eMedicine Specialties > Emergency Medicine > Genitourinary
Renal Failure, Chronic and Dialysis Complications: Treatment & Medication
Updated: Jun 9, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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. Nebulized albuterol may also be used for temporary lowering of serum potassium levels, when appropriate.
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. Protocols involving the use of oral antibiotics also are available. Most institutions that treat CAPD patients have a standard protocol for treatment. In most cases, the patient's nephrologist should be consulted.
- 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
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.
Electrolyte supplements
These agents are used to reduce potassium levels. Hyperkalemia is the most common life-threatening emergency in patients with ESRD.
Calcium chloride
Prevents deleterious effects caused by severe hyperkalemia, as measured by ECG, pending correction of increased potassium in extracellular fluid. Fastest acting drug to treat hyperkalemia (acts within min). Antagonizes membrane effects of potassium.
Adult
10 mL of 10% solution IV q10min 3 times prn
Pediatric
0.1 mL/kg of 10% solution IV q10min 3 times prn
Digoxin may cause arrhythmias; thiazides may induce hypercalcemia; may antagonize effects of calcium channel blockers, atenolol, tetracyclines, and sodium polystyrene sulfonate
Ventricular fibrillation not associated with hyperkalemia; digitalis toxicity; hypercalcemia; renal insufficiency; cardiac disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer slowly (not to exceed 0.5-1 mL/min) to avoid extravasation; hypercalcemia may occur in renal failure; caution in respiratory failure, acidosis, or severe hyperphosphatemia
Sodium bicarbonate (Neut)
Redistributes extracellular potassium into cells within 10-15 min.
Adult
50 mEq IV q15min 2 times prn
Pediatric
1-2 mEq/kg IV q15min 2 times prn
Urinary alkalinization, induced by increased sodium bicarbonate concentrations, may cause decreased levels of lithium, tetracyclines, chlorpropamide, methotrexate, and salicylates; increases levels of amphetamines, pseudoephedrine, flecainide, anorexiants, mecamylamine, ephedrine, quinidine, and quinine
Alkalosis; hypernatremia; hypocalcemia; severe pulmonary edema; abdominal pain of unknown cause
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Rapid administration of this medication may result in paradoxical CSF, intracellular acidosis, hypokalemia, impaired oxygen delivery, and hypocalcemia; hypernatremia, overshoot alkalosis, and hyperosmolality may occur
Calcium gluconate (Kalcinate)
Indicated if hyperkalemia is accompanied by ominous ECG changes beyond peaked T waves or if ECG changes persist after bicarbonate therapy. The 10% IV solution provides 100 mg/mL of calcium gluconate that equals about 9 mg/mL (0.46 mEq/mL) of elemental calcium. Antagonizes membrane effects of potassium.
Adult
10 mL of 10% solution IV q10min 3 times prn
Pediatric
0.1 mL/kg of 10% solution IV q10min 3 times prn
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; antagonizes effects of verapamil; large intakes of dietary fiber may decrease calcium absorption and levels
Renal calculi, hypercalcemia, hypophosphatemia, renal or cardiac disease, and digitalis toxicity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in digitalized patients, respiratory failure, acidosis, or severe hyperphosphatemia
Antidiabetic agent
Insulins are used to shift potassium intracellularly and reduce potassium levels.
Insulin (Humulin, Novolin, Humalog)
Stimulates cellular uptake of potassium within 20-30 min. Glucose should be administered along with insulin to prevent hypoglycemia. Monitor blood glucose levels frequently.
Adult
25-50 g glucose followed by 10 U regular insulin IV
Pediatric
0.5-1 g/kg of glucose followed by 1 U regular insulin/3 g glucose IV
Medications that may decrease hypoglycemic effects of insulin include acetazolamide, AIDS antivirals, diltiazem, diuretics, corticosteroids, cyclophosphamide, dextrothyroxine, asparaginase, calcitonin, oral contraceptives, diazoxide, dobutamine, phenothiazines, phenytoin, nicotine, isoniazid, lithium carbonate, epinephrine, thiazide diuretics, thyroid, estrogens, ethacrynic acid, morphine sulfate, and niacin
Medications that may increase hypoglycemic effects of insulin include calcium, ACE inhibitors, beta-blockers, lithium carbonate, phenylbutazone, chloroquine, clofibrate, fenfluramine, guanethidine, alcohol, anabolic steroids, sulfonamides, tetracyclines, pyridoxine, salicylates, MAOIs, mebendazole, octreotide, pentamidine, and sulfinpyrazone
Documented hypersensitivity; hypoglycemia
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Hyperthyroidism may increase renal clearance of insulin and may increase dose of insulin needed to treat hyperkalemia; hypothyroidism may delay insulin turnover, requiring less insulin to treat hyperkalemia; monitor glucose carefully; dose adjustments of insulin may be necessary in patients diagnosed with renal and hepatic dysfunction
Beta-adrenergic agonist
This agent stimulates the ATPase pump, thereby shifting potassium into the intracellular compartment through activation of cyclic AMP.
Albuterol (Proventil, Ventolin)
Adrenergic agonist that increases plasma insulin concentrations. Increase in insulin may shift potassium into intracellular space. Promotes intracellular movement of potassium within 30 min. Average decrease in serum potassium is 0.6 mmol/L after 1 dose and 1.1 mmol/L after second dose. Especially useful if no IV access available.
Adult
5 mg nebulized; repeat in 2 h
Pediatric
2.5 mg nebulized; repeat in 2 h
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders
Antidote
This agent is used to remove potassium from the body.
Sodium polystyrene sulfonate (Kayexalate)
Exchanges sodium for potassium and binds it in gut, primarily in large intestine, and decreases total body potassium. Onset of action after PO administration ranges from 2-12 h and is longer when administered rectally.
Adult
25 g in 25 cc sorbitol PO q6h
50 g in 50 cc sorbitol as retention enema PR q6h
Pediatric
1 g/kg in sorbitol PO q6h
2 g/kg in sorbitol as retention enema PR q6h
Systemic alkalosis may occur if administered concurrently with magnesium hydroxide, aluminum carbonate or similar antacids, or laxatives
Documented hypersensitivity; hypernatremia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution when administering to patients who can be affected adversely by small increase in sodium load, such as those with severe hypertension, severe congestive heart failure, or marked edema; constipation with possibility of fecal impaction may occur and should be treated with 10-20 mL of 70% sorbitol every 2 h or as necessary to produce at least 1-2 watery stools daily
Phosphate binders, oral
These agents decrease GI phosphate absorption.
Lanthanum carbonate (Fosrenol)
Noncalcium, nonaluminum phosphate binder indicated for reduction of high phosphorus levels in patients with end-stage renal disease. Directly binds dietary phosphorus in upper GI tract, thereby inhibiting phosphorus absorption.
Adult
Initial: 250-500 mg PO tid pc (chewable tabs); adjust dose q2-3wk to target serum phosphorus level
Maintenance: 500-1000 mg PO tid pc
Pediatric
Not established
Drugs known to interact with antacids (eg, alendronate, amprenavir, ciprofloxacin, itraconazole, tetracycline, thyroid hormones) should not be administered within 2 h
Documented hypersensitivity; bowel obstruction; hypophosphatemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Deposited into developing bone, including growth plate (long-term effects unknown); common adverse effects typically diminish over time but include headache, abdominal pain, nausea, diarrhea, constipation, and vomiting; in clinical trials, dialysis graft occlusion occurred more frequently than with placebo; caution with GI motility diseases (eg, Crohn disease, ulcerative colitis) or recent GI surgery
Sevelamer hydrochloride (Renagel)
Lowers serum phosphate to near normal levels in hemodialysis patients as effectively as calcium acetate without inducing hypercalcemia or increased aluminum levels. The polymer forms ionic and hydrogen bonds with phosphates and bile acids to promote fecal excretion.
Adult
2.4-4.8 g PO divided tid with meals
Pediatric
Not established
May decrease absorption of oral medications causing a decrease in levels of antiarrhythmics and antiepileptics
Documented hypersensitivity; bowel obstruction, hypophosphatemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with dysphagia, altered GI motility or GI tract surgery; measure serum phosphate and calcium frequently to adjust dose to keep serum phosphate <6.0 mg/dL
Recombinant human erythropoietins
Stimulate development of erythroid progenitor cells. Used in the treatment of anemia associated with chronic renal failure.
Epoetin alfa (Epogen, Procrit)
Indicated for the treatment of anemia associated with chronic renal failure. Stimulates division and differentiation of committed erythroid progenitor cells; induces release of reticulocytes from bone marrow into blood stream.
Adult
50-100 U/kg IV/SC 3 times/wk initially; reduce dose by 25 U/kg when hematocrit approaches 36% or increases >4 points in any 2-wk period; increase dose if hematocrit does not increase by 5-6 points after 8 wk of therapy and hematocrit is below suggested target range (suspected range is 30-36%
Pediatric
Not established
None reported
Documented hypersensitivity; uncontrolled hypertension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in porphyria, hypertension, history of seizures; decrease dose if hematocrit increase exceeds 4 units in any 2-wk period
Darbepoetin alfa (Aranesp)
Erythropoiesis stimulating protein closely related to erythropoietin, a primary growth factor produced in kidney that stimulates development of erythroid progenitor cells. Indicated for the treatment of anemia associated with chronic renal failure. Mechanism of action is similar to that of endogenous erythropoietin, which interacts with stem cells to increase red cell production. Differs from epoetin alfa (recombinant human erythropoietin) in containing 5 N-linked oligosaccharide chains, whereas epoetin alfa contains 3. Has longer half-life than epoetin alfa (may be administered weekly or biweekly).
Adult
0.45 mcg/kg IV/SC qwk initially; adjust dose (not to exceed 3 mcg/kg/wk) or frequency (eg, q2wk); to maintain target Hgb (not to exceed 12 g/dL); do not increase dose more frequently than qmo
Switching from epoetin alfa: Base dose on total weekly erythropoietin dose and frequency of administration
Pediatric
Not established
None reported
Documented hypersensitivity; uncontrolled hypertension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Elevation in Hgb >1 g/dL/2wk increases risk of MI, neurologic events (eg, seizures, stroke) and exacerbations of hypertension, CHF, thrombosis, ischemia, and edema; adverse effects include infection, hypertension, hypotension, myalgia, headache, and diarrhea (some of adverse events may be due to chronic renal failure or dialysis); severe skin rash may occur (rare)
More on Renal Failure, Chronic and Dialysis Complications |
| Overview: Renal Failure, Chronic and Dialysis Complications |
| Differential Diagnoses & Workup: Renal Failure, Chronic and Dialysis Complications |
 Treatment & Medication: Renal Failure, Chronic and Dialysis Complications |
| Follow-up: Renal Failure, Chronic and Dialysis Complications |
| Multimedia: Renal Failure, Chronic and Dialysis Complications |
| References |
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References
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Fadem SZ. Calculators for Health Care Professionals. National Kidney Foundation. Available at http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm. Accessed 12/15/08.
United States Renal Data System. Atlas of End Stage Renal Disease. United States Renal Data System. Available at http://www.usrds.org/2008/pdf/V2_02_2008.pdf. Accessed 02/25/09.
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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].
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Further Reading
Keywords
renal failure, renal disease, chronic renal failure, CRF, uremia, kidney failure, kidney disease, end-stage renal disease, ESRD, complications of dialysis, continuous ambulatory peritoneal dialysis, CAPD, diabetic nephropathy, hypertension, hypertensive nephropathy, glomerulonephritis, renal transplantation, peripheral neuropathy, restless legs syndrome, diverticular disease, peptic ulcer disease, anemia, pruritus, hyperkalemia, hypocalcemia, hypermagnesemia, peritonitis, pericarditis, asymptomatic pericardial effusion, cardiac tamponade, myocardial ischemia, myocardial infarction, dialysis dysequilibrium syndrome, vascular access aneurysms, pseudoaneurysms, chronic hydronephrosis, vesicoureteral reflux, congenitally hypoplastic kidneys, hereditary nephropathies, polycystic disease, renal vascular disease, analgesic nephropathy, HIV-related renal disease
