eMedicine Specialties > Emergency Medicine > Genitourinary

Renal Failure, Chronic and Dialysis Complications

Author: Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Contributor Information and Disclosures

Updated: Jun 9, 2009

Introduction

Background

Chronic renal failure (CRF) requiring dialysis or transplantation is known as end-stage renal disease (ESRD). In the United States, diabetic nephropathy is the most common and hypertension the second most common cause. Along with glomerulonephritis, these cause approximately 75% of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy. Genetic kidney disease such as polycystic kidney disease is a common cause in young adults.¹

Patients with end-stage renal disease (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 using continuous ambulatory peritoneal dialysis (CAPD) are also common. Patients who have undergone renal transplantation may experience a variety of transplant-related conditions.

Patients with chronic renal failure often 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 approximately 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. Measuring GFR requires a timed urine collection as well as measurement of serum creatinine. However, it can be accurately estimated from a patient's age, weight, gender, and serum creatinine level. Online calculators are available to automate the calculation.²

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:

Systemic signs

Malaise, weakness, and fatigue are very common.

Gastrointestinal signs

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

Neurological signs

Peripheral neuropathy and restless legs syndrome are the most common neurologic complications of CRF. Seizures may occur due to uremia, and the prevalence of stroke is increased.

Hematologic signs

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.

Dermatologic signs

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

Metabolic/endocrine signs

Volume overload occurs when salt and water intake exceeds losses and excretion. This causes congestive heart failure (CHF) and exacerbates hypertension. 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.

Cardiac signs

Volume overload may cause CHF and pulmonary edema. Hypertension contributes to cardiovascular disease. Dyslipidemia is a primary risk factor for cardiovascular disease and a common complication of ESRD. Uremia may also lead to pericardial effusion and, in rare cases, pericardial tamponade. Cardiovascular mortality is 10-20 times higher in dialysis patients than in the normal population.
 
Vascular signs

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).

Dialysis catheters

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.

Infection/immunologic

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 end-stage renal disease (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. During 2004, the last year with complete data availability, 104,364 patients (approximately 0.03% of the US population) began renal replacement therapy, an adjusted incidence rate of 339 per 1,000,000. As of 2005, more than 485,000 patients were receiving treatment for ESRD in the United States. As a result, patients with ESRD are encountered on a regular basis in US emergency departments.

International

Resources allocated for treatment of ESRD vary throughout the world, and the treatments are expensive. Untreated ESRD is rapidly fatal, and treatment is too expensive for most individuals to purchase privately. Consequently, very few patients with ESRD are encountered in countries where ESRD treatment is not funded by the government.

The morbidity and mortality of dialysis patients is much higher in the United States compared with most other countries. This is probably a consequence of selection bias. Due to liberal criteria for receiving government-funded dialysis in the United States and rationing (both medical and economic) in most other countries, US patients receiving dialysis are on the average older and sicker than those in other countries.

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 end-stage renal disease (ESRD) is hyperkalemia, which is often encountered in patients after missed dialysis or 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.
• Cardiovascular mortality is 10-20 times higher in dialysis patients than in the normal population.
• Anemia results in fatigue, reduced exercise capacity, decreased cognition, and impaired immunity.
• Renal transplant patients are prone to infection, especially in the immediate post-transplant period.

Race

Etiology of end-stage renal disease (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.
 
In the United States, racial and ethnic discrepancies in ESRD exist, with 2006 rates in the African American and Native American populations 3.6 and 1.8 times greater, respectively, than the rate among whites, and the rate in the Hispanic population 1.5 times higher than that of non-Hispanics.³

Sex

Presentation and treatment of chronic renal failure (CRF) and end-stage renal disease (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 rather than dialysis because of a relatively greater long-term benefit compared to that of adults, and due to difficulties related to vascular access for dialysis.

Clinical

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.

• Chronic renal failure (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. Sepsis is a serious cause of hypotension.
• Myocardial ischemia or infarction is common in patients with ESRD; consider this diagnosis in hypotensive patients along with other conditions, such as GI bleeding.
• Dialysis dysequilibrium syndrome is a common neurologic complication seen in dialysis patients.
  • 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 continuous ambulatory peritoneal dialysis (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 access. 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). Life-threatening bleeding may occur.

Physical

• Chronic renal failure (CRF) produces no specific physical findings.
• Patients with an arteriovenous fistula or graft should have the site examined regularly. Abnormal findings include loss of palpable thrill, overlying erythema, or active bleeding from the incisional wound of a newly placed fistula or graft.
• Physical findings of chronic renal failure 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 chronic renal failure (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.

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