AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

Section 2 of 11  

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• Follow-up
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Background

Chronic renal failure (CRF) requiring dialysis or transplantation is known as end-stage renal disease (ESRD). In the United States, diabetic nephropathy, hypertension, and glomerulonephritis cause approximately 75% of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy.

Patients with ESRD are commonly encountered in the ED with problems related to the metabolic complications of their renal disease or dialysis complications. Various problems related to vascular access in patients on hemodialysis and to abdominal catheters in patients taking continuous ambulatory peritoneal dialysis (CAPD) are also common. Patients who have undergone renal transplantation may experience a variety of transplant-related conditions.

Patients with CRF may present to the ED with an unrelated condition. In these cases, the level of renal function may have important implications for diagnosis and treatment.

Pathophysiology

All major organ systems are affected by renal failure. Prevalence of symptoms is a function of the glomerular filtration rate (GFR), which averages 120 mL/min in a healthy adult. As the GFR falls to less than ~20% of normal, symptoms of uremia may begin to occur. They almost are invariably present when the GFR decreases to less than 10% of normal.

Signs and symptoms of renal failure are due to overt metabolic derangements resulting from inability of failed kidneys to regulate electrolyte, fluid, and acid-base balance; they are also due to accumulation of toxic products of amino acid metabolism in the serum. Signs and symptoms include the following:

Malaise, weakness, and fatigue are very common.

GI disturbances include anorexia, nausea, vomiting, and hiccups. Peptic ulcer disease and symptomatic diverticular disease are common in patients with CRF.

Peripheral neuropathy and restless legs syndrome are the most common neurologic complications of CRF.

Anemia is inevitable in CRF because of loss of erythropoietin production. Abnormalities in white cell and platelet functions lead to increased susceptibility to infection and easy bruising.

Pruritus is a common dermatologic complication assumed to be secondary to accumulation of toxic pigments (urochromes) in the dermis.

Volume overload, a common cardiovascular complication of renal failure, occurs when salt and water intake exceeds losses and excretion. Hyperkalemia is the most common immediately life-threatening metabolic complication of renal failure and may develop suddenly when GFR is severely reduced. Anion gap acidosis results from decreased hydrogen ion excretion and may exacerbate hyperkalemia. Hypocalcemia is potentially life threatening and results from loss of vitamin D and increased parathyroid hormone levels. Hypermagnesemia also may occur.

Vascular access complications are similar to those seen in any patient with a vascular surgical procedure (eg, bleeding, local or disseminated intravascular infections, vessel [graft] occlusion).

A peritoneal dialysis catheter subjects patients to the risks of peritonitis and local infection. The catheter acts as a foreign body and provides a portal of entry for pathogens from the external environment.

Patients who have received renal transplants may experience recurrent renal failure due to rejection or other graft complications. In addition, chronic immunosuppression makes them prone to infection.

Frequency

United States

The government of the United States funds treatment of ESRD universally for US citizens. As a consequence, the population of patients receiving dialysis or who have had a renal transplant in the United States is large. Approximately 150 cases of CRF per million persons are newly diagnosed per year in the United States. Approximately half of these patients go on to require dialysis or transplantation. As a result, patients with ESRD are encountered on a regular basis in most US EDs.

International

Resources allocated for treatment of ESRD vary throughout the world. Very few patients with ESRD are encountered in countries where ESRD treatment is not funded by the government because of the high mortality rate when dialysis or transplantation is not widely available.

Mortality/Morbidity

Patients in renal failure are prone to all of the complications of any underlying condition, such as diabetes and hypertension. In addition, renal failure causes a variety of metabolic and physiologic derangements.

• The most common cause of sudden death in patients with ESRD is hyperkalemia, which is often encountered in patients who have missed dialysis or commit dietary indiscretion. Serum potassium also rises when the serum is acidemic, even though total body potassium is unchanged. Hyperkalemia is usually asymptomatic and should be treated empirically when suspected and when arrhythmia or cardiovascular compromise is present.
• Iatrogenic complications related to fluid administration (fluid overload) or medications are frequently encountered in patients in renal failure.

Race

Etiology of ESRD differs among racial groups primarily because of the prevalence of predisposing conditions, such as diabetes and hypertension. In populations with problematic access and utilization of primary medical care for treatment of predisposing conditions, ESRD often is encountered in relatively young patients. While the costs of treatment for ESRD are borne by the entire population (through government funding), relatively inexpensive preventive treatments often are funded poorly. Diseases such as diabetes and hypertension are much less likely to lead to renal failure when appropriately treated. The cost of primary care for these conditions is far lower than for dialysis or transplantation, yet primary care remains poorly funded while ESRD treatment is reimbursed completely by the government. This conundrum is reflective of the often illogical and capricious nature of health care spending in the United States.

Sex

Presentation and treatment of CRF and ESRD do not differ significantly between men and women. Differences in causes of renal failure are related to the types of underlying conditions prevalent in men and women.

Age

While the etiology of CRF differs among age groups, the presentations and nature of complications are similar. Young children with ESRD often are treated with transplantation because of difficulties related to vascular access for dialysis.

CLINICAL

Section 3 of 11  

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History

Renal failure produces no symptoms early in the course of the disease. At this stage, symptoms of the underlying illness may bring the patient to medical attention and renal insufficiency is noted on laboratory testing.

• CRF potentially affects all organ systems. History for the presenting disorder is similar to that encountered when the same disorder exists in patients without renal failure.
• The following presentations are seen frequently in CRF. Moreover, some problems are unique to patients with CRF/ESRD; many of these are related to treatments, such as dialysis or transplantation.
• Electrolyte abnormalities include life-threatening hyperkalemia, which is usually asymptomatic.
• • Dilutional hyponatremia may cause mental status changes or seizures.
  • Hypocalcemia or hypermagnesemia may cause weakness and life-threatening dysrhythmias.
  • Neuromuscular irritability is seen with hypocalcemia and may present as tetany or paresthesia.
  • Hypermagnesemia causes neuromuscular depression with weakness and loss of reflexes.
  • Acidosis may present as shortness of breath due to the work of breathing from compensatory hyperpnea.
• Pericarditis and asymptomatic pericardial effusion are common in patients with ESRD. Cardiac tamponade may occur but is rare. Presentation of pericarditis and tamponade are typical, with pleuritic chest pain being the most common presentation.
• • Tamponade presents as fatigue, weakness, syncope, or dyspnea.
  • Hypotension is usually present, and, if advanced, frank shock and cardiovascular collapse occur.
• Hypotension with postural weakness or syncope may occur as a complication of fluid shifts from dialysis or from any other cause.
• Myocardial ischemia or infarction is common in patients with ESRD; consider this diagnosis in hypotensive patients along with other conditions, such as GI bleeding.
• A common neurologic complication seen in dialysis patients is dialysis dysequilibrium syndrome.
• • Syndrome is characterized by weakness, dizziness, headache, and in severe cases, mental status changes. Diagnosis is one of exclusion.
  • A prime characteristic of the syndrome is that it is nonfocal.
• Peritonitis is common in patients being treated with CAPD, occurring approximately once per patient year. Patients present with abdominal pain, which may be mild, or complain of a cloudy effluent. Fever often is absent.
• Infection at the catheter exit site manifests as expected local pain, erythema, warmth, and/or fluctuance.
• Other abdominal conditions, such as appendicitis, pancreatitis, or diverticulitis, should be considered when patients present with abdominal pain, especially if signs and symptoms are localized.
• Vascular access problems include infections, which are usually manifest with typical signs and symptoms such as local pain, redness, warmth, or fluctuance. Fever may be present without local signs.
• • Clotting of the vascular access presents as loss of normal bruit or thrill. There may be signs or symptoms of distal limb ischemia.
  • Patients may present after dialysis or minor trauma with bleeding from their vascular acces. Bleeding usually can be controlled with elevation and firm but nonocclusive pressure. In the immediate postdialysis period, protamine may be needed to reverse the effect of heparin (routinely used in dialysis to prevent clotting).

Physical

• CRF produces no specific physical findings.
• Physical findings of CRF complications generally are those expected with the specific complication and do not differ from those encountered when the condition occurs in patients with normal renal function.
• Certain complications are very common in renal failure.
• CAPD-associated peritonitis
• • Abdominal pain and tenderness usually are generalized and relatively mild.
  • Localized pain and tenderness suggest a local process, such as incarcerated hernia or appendicitis.
  • Severe generalized peritonitis may be due to a perforated viscus as in any other patient.
• Transplant-related problems: Pain and tenderness over a transplanted kidney may be due to infection (pyelonephritis), obstruction (stone or extrinsic compression), or graft rejection.
• Vascular access aneurysms or pseudoaneurysms
• • These present as localized swelling, which may be pulsatile, and are often chronic.
  • A rapid increase in size may indicate active bleeding.

Causes

Once CRF has occurred, treatment options and complications are largely independent of the cause.

• In terms of broad categories of disease, glomerulonephritis and interstitial nephritis are the most common causes of CRF in adults and children.
• Chronic upper urinary tract infection causes CRF in all age groups.
• CRF also is encountered in children because of congenital anomalies such as chronic hydronephrosis, which is caused by anatomic defects that obstruct urine flow or allow reflux from the bladder (vesicoureteral reflux).
• Kidneys may be congenitally hypoplastic.
• Hereditary nephropathies also exist.
• In adults, diabetic and hypertensive nephropathies are the most common specific causes of CRF.
• Polycystic disease, renal vascular disease, and analgesic nephropathy also are common.
• In certain geographic areas, HIV-related renal disease is becoming common.
• Certain diseases such as some of the types of glomerulonephritis tend to recur in transplanted kidneys. In these cases, dialysis is the preferred treatment option.
• Consider renal transplant patients to be mildly to moderately immunosuppressed.
• • In the immediate posttransplant period or during a rejection episode, intensive immunosuppression puts patients at considerable risk of infection, including disseminated viral infections such as herpes zoster.
  • Degree of immunosuppression is less late in the posttransplant course when corticosteroids alone may be used.

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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WORKUP

Section 5 of 11  

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• Follow-up
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Lab Studies

• Because of the primacy of the kidney in regulating metabolism, the concentrations of many chemical constituents of the body are abnormal in patients with CRF. The hematologic system is affected and thus the cellular components of the blood. Knowledge of the expected abnormalities and of the patient's baseline is necessary in evaluating patients with CRF. The following are the most important and frequently encountered abnormalities:
• Hyperkalemia is the most common clinically significant electrolyte abnormality in CRF.
• • It is often asymptomatic until potentially lethal dysrhythmias occur.
  • Hyperkalemia is uncommon when patients with ESRD are compliant with treatment and diet, unless an intercurrent illness such as acidosis or sepsis develops.
  • Serum potassium usually should be measured in patients with CRF/ESRD who present with a systemic illness or major injury.
  • History of hyperkalemia requiring treatment should lower the threshold for ordering a potassium level.
• BUN and serum creatinine are elevated chronically in patients with CRF and ESRD.
• • In patients who are not on dialysis, the degree of elevation is loosely reflective of the degree of renal impairment.
  • In patients with ESRD, the degree of elevation reflects the intensity and frequency of dialysis. Elevations of BUN and creatinine alone in patients with ESRD do not require emergency treatment.
  • BUN and creatinine elevations above baseline may be a sign of rejection in renal transplant patients and of deterioration in renal function in patients with predialysis CRF.
  • When such patients with residual renal function present with any suspected serious illness or urinary complaint, measure the BUN and creatinine and compare to baseline. Patients often are aware of their baseline BUN and creatinine.
• Baseline anion gap metabolic acidosis is typical in patients with CRF, who have a decreased ability to excrete acid. These patients are very prone to developing severe acidosis when under physiologic stress (eg, sepsis, myocardial infarction [MI], trauma).
• • Dialysis is necessary if the patient has severe acidosis.
  • Treat patients with significant chronic acidosis with oral alkalinizing agents to prevent bone loss.
  • Shortness of breath in patients with CRF may be due to respiratory compensation for acidosis.
• Anemia is invariable in patients with CRF patients. This is primarily due to loss of erythropoietin production. Comparison with baseline values often is useful for evaluation of anemia.
• Abnormal bleeding, primarily due to abnormal platelet function, is common on patients with CRF. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) usually are normal. When necessary, measurement of bleeding time is the best way to determine hemostatic competency.
• CAPD-associated peritonitis is a diagnosis supported by culture of effluent dialysate (ie, peritoneal fluid), which should be ordered prior to empiric treatment. Presumptive diagnosis is based on a peritoneal fluid WBC count of more than 100/mL or a positive Gram stain. The effluent is often cloudy when peritonitis is present.
• Pancreatitis occurs with increased frequency in patients with ESRD. Since renal insufficiency may elevate amylase levels falsely, measurement of serum lipase may be preferable.
• Total creatine phosphokinase (CPK) measurements may be elevated falsely in patients in renal failure. Tests for cardiac-specific markers, such as CPK-MB mass assays or cardiac troponins (I and T), may be more useful when MI is suspected. These specific markers are not falsely elevated in renal failure.
• Infection should be suspected in patients who present with febrile illness. Patients are at increased risk of infection because of immunosuppressive effects of antirejection drugs (ie, transplant patients) or impaired immune function from uremia (ie, other patients with ESRD). Consider blood cultures when these patients present with febrile illnesses.

Imaging Studies

• Imaging studies in patients with CRF are ordered as indicated by the presenting complaint.
• Studies involving intravenous (IV) contrast may proceed in patients with ESRD who have no residual renal function.
• Contrast material given orally and or in retrograde urologic studies is not nephrotoxic and may be used in patients with CRF or ESRD.
• • Nephrotoxic effects of IV contrast must be considered in patients who are not yet on dialysis or who have received a transplant.
  • Consultation with a radiologist or nephrologist is advisable before giving IV contrast to such patients; consider alternatives to contrast.

Other Tests

• Electrocardiography (ECG) may be useful in diagnosis of suspected hyperkalemia.
• • Findings of severely peaked T waves are a relatively specific although not very sensitive test for hyperkalemia in the setting of CRF.
  • Similar "hyperacute" T-waves may be seen early in acute MI.

Procedures

• Peripheral hemodialysis access sites may be used to draw blood or infuse medications and fluids in an emergency when no other access is available.
• A central venous access device may be used with the usual precautions.
• The following procedure may be used when hemodialysis access is used in an emergency:
• • Do not use a tourniquet.
  • Avoid puncturing the back wall of the vessel.
  • Carefully secure all IV catheters; infusions may need to be under pressure because of relatively high pressures at the access site.
  • Apply firm but nonocclusive pressure for 10-15 minutes after accessing a peripheral hemodialysis access site.
  • Document presence of a thrill before and after procedure.
• A patient with ESRD who has no residual urine output may have a lower urinary tract infection (a pus filled bladder is known as pyocystis).
• • Consider bladder catheterization in patients with ESRD who present with fever or lower abdominal pain.
  • If purulent material is obtained, send it for culture.

TREATMENT

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Prehospital Care

• In an immediately life-threatening emergency, prehospital personnel may use a hemodialysis access site for IV access with the precautions noted in Procedures. The site should not be used for routine IV access.
• IV fluids should not be administered except for cases of frank shock. When used, the preferred regimen is small bolus doses (~200-250 mL) with reevaluation for effect between doses. Lactated Ringer solution should not be used because of the potassium content.
• Most medications used in prehospital care are used in the usual dosages.
• Do not give diuretics in the field to dialysis patients with ESRD. They usually are not effective and may have more than the usual toxicity.
• Cardiac arrest in a patient with CRF or ESRD may be due to hyperkalemia. Consider treatment with IV calcium and IV bicarbonate.

Emergency Department Care

Emergencies in patients with CRF or ESRD or in transplant recipients generally are treated as in all other patients. Certain conditions are unique to this group of patients, and others occur more commonly than in patients with normal renal function.

• Cardiac arrest in patients with CRF or ESRD may be due to hyperkalemia. In most medical arrests, treat hyperkalemia empirically with IV calcium and bicarbonate while awaiting laboratory confirmation.
• Consider pericardial tamponade, especially in the setting of pulseless electrical activity (PEA). Consider pericardiocentesis if tamponade is suspected.
• Pulmonary edema is frequent in renal failure and usually is due to volume overload. Also consider myocardial dysfunction.
• • Volume overload is best treated by hemodialysis or by use of hypertonic dialysate in CAPD patients.
  • Nitrates administered by the sublingual, topical, or IV routes are effective in the usual doses.
  • Loop diuretics (eg, furosemide) may be effective at promoting diuresis in patients with residual renal function. They also may be effective because of a pulmonary venodilation effect. Ototoxicity is potentially increased because of delayed excretion and higher blood levels.
  • IV morphine is useful for its vasodilating effects. Take care to avoid precipitating respiratory depression.
• Hypertension in patients with renal failure (as in other patients) usually requires no treatment in and of itself.
• • When indications for treatment exist, such as myocardial ischemia or hypertensive encephalopathy, usual treatments may be used with appropriate dosage adjustment.
  • Dialysis may be needed if hypertension is due to volume overload.
  • Nitroprusside may be used to treat severe hypertension in patients with renal failure. Risk of thiocyanate toxicity is increased and levels must be monitored in cases of prolonged infusion.
• Hypotension in dialysis patients may be due to any of the causes encountered in any other patient. Consider serious causes such as bleeding, cardiac dysfunction, and sepsis. The most common cause is dialysis. After more serious causes are ruled out, IV isotonic saline in small bolus doses (~200 mL) may be used for treatment.
• Bleeding may be due to uremic coagulopathy or from anticoagulation during hemodialysis. In the latter case, the heparin effect may be reversed with protamine.
• • Desmopressin (DDAVP) by nasal, subcutaneous, or IV routes and cryoprecipitate are effective in correction of uremic coagulopathy.
  • Applying firm but nonocclusive pressure for 10-15 minutes best treats bleeding from a vascular access site.
• CAPD-associated peritonitis is treated with a loading dose of parenteral antibiotic followed by a period of intraperitoneal antibiotics. Most institutions that treat CAPD patients have a standard protocol for treatment.
• Cutaneous herpes zoster infection in renal transplant patients should be treated with systemic antiviral therapy to prevent or ameliorate possible dissemination.

Consultations

Consider consultation with a nephrologist and/or vascular surgeon for the following problems:

• Need for urgent dialysis
• Signs of transplant rejection, infection, or obstruction
• Significant deterioration from baseline renal function
• CAPD-associated peritonitis or catheter-associated infection
• Infection, obstruction, or expanding aneurysm/pseudoaneurysm of the vascular access

MEDICATION

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Most medications are used with the same indications as in patients without CRF. Initial dosages usually are unchanged, with adjustments made in dosage or frequency of subsequent treatments to account for changes in metabolism and excretion secondary to renal disease.

When medications are prescribed for transplant patients or those with residual renal function, consider the drug's effect on the kidney.

Patients with renal insufficiency are often on multiple medications; consider possibility of drug interactions.

Drug Category: Electrolyte supplements

These agents are used to reduce potassium levels. Hyperkalemia is the most common life-threatening emergency in patients with ESRD.

Drug Category: Antidiabetic agent

Insulins are used to shift potassium intracellularly and reduce potassium levels.

Drug Category: Beta-adrenergic agonist

This agent stimulates the ATPase pump, thereby shifting potassium into the intracellular compartment through activation of cyclic AMP.

Drug Category: Antidote

This agent is used to remove potassium from the body.

Drug Category: Phosphate binders, oral

These agents decrease GI phosphate absorption.

Drug Category: Recombinant human erythropoietins

Stimulate development of erythroid progenitor cells. Used in the treatment of anemia associated with chronic renal failure.

FOLLOW-UP

Section 8 of 11  

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Further Inpatient Care

• Inpatient care depends upon the underlying condition that brought the patient to the ED.

Further Outpatient Care

• Outpatient care for patients with renal failure depends upon the underlying condition.

In/Out Patient Meds

• Medications to be ordered depend upon the condition being treated. Consult references regarding dosage adjustments related to renal function.

Transfer

• Transfer patients who need dialysis to a facility with dialysis capability if it is not available at the presenting hospital.
• Patients with serious transplant-related problems may require transfer to a facility whose staff is familiar with renal transplantation.

Deterrence/Prevention

• Avoiding dehydration and nephrotoxic drugs may minimize further declines in renal function in patients with preexisting renal insufficiency or with a renal transplant.
• Refer patients found to have incidental conditions, such as hypertension, to an appropriate source of primary care.

Complications

• Anemia
• Changes in calcium and phosphorous metabolism, hyperkalemia, hyponatremia, acidosis
• Lipid disorders
• Pericarditis
• Serositis
• Gout, pseudogout
• Hypothyroidism, seizures, fractures
• Accelerated hypertension
• Infertility, impotence, spontaneous abortion
• Bleeding, GI mucosal ulcerations, arteriovenous malformations

Prognosis

• Mortality rate is approximately 20% despite careful attention to fluid and electrolyte balance or other treatment.

Patient Education

• For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article, Chronic Kidney Failure.

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• Failure to consider nephrotoxicity when prescribing medications (especially IV contrast) or other treatments to patients with renal disease
• Failure to consider or treat hyperkalemia. The following drugs are among those which may cause hyperkalemia: trimethoprim, heparin, potassium-sparing diuretics, pentamidine, angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs).
• Use of inappropriate technique in cannulating a hemodialysis site
• Failure to consider surgical disease in a CAPD patient with abdominal pain
• Failure to consider serious causes of hypotension in a patient with ESRD

MULTIMEDIA

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Media file 1:  Renal failure, chronic and dialysis complications. The tracing shows a wide QRS and very large T waves. In the setting of a minimally symptomatic patient with renal failure, this must be treated as hyperkalemia until the potassium level is not elevated. Hyperkalemia may be completely asymptomatic until a lethal arrhythmia occurs. Calcium salts are the most rapid acting of the agents used to treat hyperkalemia.
	View Full Size Image
Media type:  Rhythm Strip

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
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• Bennett WM. Guide to drug dosage in renal failure. Clin Pharmacokinet. Nov 1988;15(5):326-54. [Medline].
• Brenner BM, Rector FC Jr, eds. The Kidney. 6th ed. WB Saunders;1999.
• Ifudu O. Care of patients undergoing hemodialysis. N Engl J Med. Oct 8 1998;339(15):1054-62. [Medline].
• Pastan S, Bailey J. Dialysis therapy. N Engl J Med. May 14 1998;338(20):1428-37. [Medline].
• Perazella MA. Acute renal failure in HIV-infected patients: a brief review of common causes. Am J Med Sci. Jun 2000;319(6):385-91. [Medline].
• Piraino B. Peritonitis as a complication of peritoneal dialysis. J Am Soc Nephrol. Oct 1998;9(10):1956-64. [Medline].
• Steiner RW, Halasz NA. Abdominal catastrophes and other unusual events in continuous ambulatory peritoneal dialysis patients. Am J Kidney Dis. Jan 1990;15(1):1-7. [Medline].
• United States Renal Data System. III. Treatment modalities for ESRD patients. Am J Kidney Dis. Aug 1999;34(2 Suppl 1):S51-62. [Medline].
• Wolfson AB, Singer I. Hemodialysis-related emergencies--Part 1. J Emerg Med. Nov-Dec 1987;5(6):533-43. [Medline].
• Wolfson AB, Singer I. Hemodialysis-related emergencies--Part II. J Emerg Med. Jan-Feb 1988;6(1):61-70. [Medline].
• Yu HT. Progression of chronic renal failure. Arch Intern Med. Jun 23 2003;163(12):1417-29. [Medline].

Article Last Updated: Jun 13, 2006