End stage renal disease(ESRD) is defined as the state or condition in which there is irreversible loss of renal function. It is the condition that gradually develops overtime and is categorized as the stage five of chronic kidney disease(GFR<15).
Functions of kidney
- Fluid and electrolyte balance
- Elimination of nitrogenous waste
- Production of erythropoietin
- Acid base balance
- Activation of vitamin D
As the above mentioned functions gets deranged in the patients with ESRD which eventually might lead to various problems . Some of the common problems encountered in emergency settings are discussed below
As there is impairment of sodium and water balance there will be retention of water leading to fluid overload which may present as congestive cardiac failure, pulmonary edema and dilutional hyponatremia. Among which pulmonary edema is an emergency condition where there is accumulation of fluid in the interistial space of lungs. It presents as acute onset shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, pink frothy sputum.
In physical examination the patient might appear anxious. There will be pallor and excessive sweating and basal crepitations could be heard on on auscultation. Investigation of choice is chest x-ray, the findings of which are prominence of pulmonary vasculature, kerley lines, peribronchial cuffing, perihilar haze and pleural effusion.
Emergency treatment includes keeping the patient in propped up position which enables the fluid to be settled down. Giving high flow oxygen and using loop diuretics such as Frusemide (50-100 mm of Hg)
Uremia is defined as the state with clinical signs and symptoms associated with the elevation of urea and creatinine levels related with decrease in GFR. It simply means the condition with clinical presentation due to the accumulation of waste products failed to be excreted by kidney. Uremia has wide range of presentation such as
Gastrointestinal manifestation, neurological manifestation, skin disorders, sexual dysfunction etc. Among those there are two serious emergency conditions
The early symptoms of uremic encephalopathy are anorexia, restlessness, drowsiness, diminished ability to concentrate, slowed cognitive function. The late symptoms are vomiting, emotional volatility, decreased cognitive function, disorientation, confusion, bizarre behavior.
In the physical examination there will be hyperreflexia, asterxis, clonus, papilledema, altered gait and the patient might also present in coma. Investigations that need to be sent are complete blood count (infection), renal function test (ESRD), liver function tests (hepatic encephalopathy), Serum electrolytes (electrolyte imbalance), toxicology screening (poisoning), MRI, encephalography.
Management of this condition is supportive. First the airway, breathing and circulation should be maintained and the patient should be sent for emergency dialysis.
Another emergency condition due to uremia is uremic pericarditis. Where the patient presents with the complain of retrosternal pain radiating to shoulders and neck. The pain gets aggravated by deep breathing, change in position and movement. Pericardial friction rub could be heard upon auscultating the chest. The investigation of choice is ECG, the findings of which include ST elevation and the characteristic feature is wide spread PR interval depression.
The management of this condition includes analgesics for pain management (avoid NSAIDs as they are nephrotoxic) and preparation of the patient for immediate dialysis.
Hyperkalemia is defined as the condition where the serum potassium level is greater than 5.5 mmol/l. if it is greater than 6.5 mmol/ l then it requires urgent treatment as it increases the risk of arrhythmia.
The patient presents with the complain of tingling sensation of hands and feet, muscle weakness, flaccid paralysis, loss of tendon jerks, abdominal distention or illeus and syncope or collapse.
Among the various investigations that could be sent one is plasma potassium level which will be increased and ECG as it has been already been discussed that hyperkalemia leads to arrhythmia. The ECG findings includes of
Mild hyperkalemia:- Tall T waves
Moderate hyperkalemia:- Prolonged PR interval/ absent P waves
Severe hyperkalemia:- Wide QRS, sine wave pattern
- Stop K supplements
- 10 ml of 10% Calcium gluconate IV over 5 mins
- If severe calcium carbonate
- 50 ml of 50% of dextrose with 10 units of insulin
- Loop diuretics Frusemide
- 50-100 ml of 1.26% of Sodium bicarbonate IV
- Calcium resonium 15 gm orally in 50 ml of 20% sorbitol TID
Condition where plasma bicarbonate level <24 mmol/L and Blood pH <7.35 The patient might have presentation characterized by acidotic breathing/ kussmaul breathing, confusion, stupor, coma, history of renal disease, hypotension, anemia and edema.
Immediate Investigations to be sent are arterial blood gas analysis, renal function test, plasma electrolytes, anion gap, osmolar gap and urinary anion gap. The management is by bicarbonate therapy and by immediate dialysis.
End stage renal disease has wide range of presentation of which some are life threatening emergencies. Whatever the presentation might be, once the patient is stabilized immediate dialysis should be done as it is the mainstay of the treatment.
- The Washington Manual of Medical Therapeutics 34th Edition
- Brenner & Rector’s – The Kidney 8th Edition
- Harrison’s Principles of Internal Medicine 19th Edition
- Tintinalli’s Emergency Medicine 7th Edition
ABOUT THE AUTHOR
Dr. Subhash Shrestha (Dr. Jack) has recently completed one months of rotation in emergency care setting where he encountered many life threatening renal emergencies. He started his medical career an intern doctor in Orthopedics managing life threatening acute traumatic cases. He is currently working in Department of Pediatrics and Neonatology.
Apart from Medicine, his interests include writing, music, traveling, cooking and painting. He is also an Associate Editor at Update Medicine.