The influence of end-stage renal failure on the management of critically ill patients has been asked about in several SAQs:
The college's model answer was so good, that it would have been a waste not to reproduce it here.
Low/no urine output
Metabolic and Endocrine:
o Abnormal Ca++
Need for dialysis determines fluid prescribing, feeding and any protein restriction
Hypertension very common
Prone to pulmonary oedema
Polyneuropathy and myopathy
Impaired gastrointestinal motility
Increased risk of bleeding related to gastric ulceration
Increased risk of infection
Altered clearance of medications that have predominant renal excretion
Fistulas used for dialysis may complicate CVC and arterial access
To this, one might add a note regarding nutrition. A normal or slightly increased daily protein intake may be required to compensate for amino acid losses into the circuit, and for the hypercatabolic state of critical illness. In contrast, intermittent haemodialysis patients tend to benefit from low protein and low sodium diet so as to decrease their urea load.
LITFL take this answer, and build wonderfully upon it. Specifically, they quote an editorial by Szamosfalvi and Yee (2013), which is the single most useful published resource on this topic.
Issues specific to ESRD raised in this article include:
- 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
The all-cause in-ICU mortality of ESRD patients admitted to ICU seems to be over double that of patients without renal failure (11% vs 5%), though it is lower than the mortality of patients with acute renal failure (23%).