Question 8

Outline the pathophysiological changes associated with end-stage kidney disease (dialysis dependent) that may impact on the management of critically ill patients.

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College answer

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Low/no urine output

Metabolic and Endocrine:
o   Hyperkalaemia
o   Abnormal Ca++
o   Hyperphosphataemia
Need for dialysis determines fluid prescribing, feeding and any protein restriction

Hypertension very common
Atherosclerosis common
Pericarditis common

Prone to pulmonary oedema

Dialysis disequilibrium

Polyneuropathy and myopathy

Fragile skin

Platelet dysfunction

Impaired gastrointestinal motility
Increased risk of bleeding related to gastric ulceration

Increased risk of infection

Altered clearance of medications that have predominant renal excretion

Vascular access:
Fistulas used for dialysis may complicate CVC and arterial access

Other issues specific to ESRD: 

  • The central veins draining the access arm with the fistula should be protected from venous
  • Diet should be potassium- and phosphate-restricted
  • An AV fistula should not be accessed for CRRT or SLEDD, because the sessions are long and the risk of needle dislodgement and lifethreatening haemorrhage is thus greatly increased.
  • In terms of small solute clearance, there is no need to change the dose of dialysis in critically ill ESRD patients when compared to their regular maintenance dose.
  • Hypotonic and hypertonic fluids should be avoided


Clermont, Gilles, et al. "Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes." Kidney international 62.3 (2002): 986-996.

Szamosfalvi, Balazs, and Jerry Yee. "Considerations in the critically ill ESRD patient." Advances in chronic kidney disease 20.1 (2013): 102-109.

Arulkumaran, N., N. M. P. Annear, and M. Singer. "Patients with end-stage renal disease admitted to the intensive care unit: systematic review." British journal of anaesthesia 110.1 (2013): 13-20.

Thompson, Stephanie, and Neesh Pannu. "Renal replacement therapy in the end-stage renal disease patient with critical illness." Blood purification 34.2 (2012): 132-137.