Emergency Dialysis

Introduction to Emergency Dialysis

• The Kidney International guidelines recommend rationing dialysis resources, prioritizing patients with potentially fatal conditions such as severe hyperkalemia, pulmonary edema, or severe metabolic acidosis 1
• In situations with multiple victims, dialysis resources should be rationed, prioritizing patients with life-threatening conditions, such as severe hyperkalemia, pulmonary edema, or metabolic acidosis, as recommended by the Kidney International guidelines 1

Patient Management

• For patients with crush syndrome, the Kidney International guidelines suggest an infusion of saline solution at 1 L/h, continuing at a reduced rate if extraction lasts more than 2 hours, and monitoring urine production to adjust hydration 1
• The following protocol should be followed for victims of disasters with crush syndrome:
• Patients undergoing emergency dialysis should be monitored for hemodynamic stability, electrolyte abnormalities, acid-base status, signs of bleeding, and catheter function and signs of infection, as recommended by the American Society of Nephrology and the Journal of the American Society of Nephrology guidelines 2, 3
• Patients receiving ribavirin should have their hemoglobin levels frequently evaluated, and the medication should be discontinued if severe anemia occurs, as suggested by the International Society of Nephrology 2
• For patients with acute coronary syndrome, the timing of dialysis in the first 48 hours should consider volume status, electrolyte disturbances, and bleeding risk, as recommended by the American Journal of Kidney Diseases guidelines 4

Infection Control and Prevention

• The American Journal of Kidney Diseases recommends performing cultures and endotoxin analysis of water and dialysate monthly, and notifying the medical director to take immediate action if bacterial or endotoxin levels exceed typical action levels 5
• The American Journal of Kidney Diseases guidelines suggest implementing strict hand hygiene measures, disinfecting the catheter exit site with chlorhexidine alcohol, and disinfecting the catheter connector with antiseptic when accessing or disconnecting 5

Indications for Emergency Dialysis

• Patients with severe hyperkalemia and electrocardiographic changes or resistant to medical treatment should undergo emergency dialysis to prevent life-threatening complications, as recommended by the American Society of Nephrology and the European Renal Association 2
• Patients with volume overload and pulmonary edema unresponsive to diuretics should be initiated on emergency dialysis to alleviate symptoms and prevent further complications, as suggested by the European Renal Association 2
• Patients with severe metabolic acidosis refractory to medical treatment should undergo emergency dialysis to correct acid-base imbalance and prevent organ damage, as recommended by the International Society of Nephrology 2
• Patients with symptomatic uremia should be initiated on emergency dialysis to alleviate symptoms and prevent further complications, as suggested by the National Kidney Foundation 2
• Hemodynamically unstable patients should receive continuous renal replacement therapy (CRRT) to provide better hemodynamic stability and avoid significant osmotic changes, as recommended by the American College of Cardiology and the Kidney International guidelines 2, 6
• Stable patients should receive intermittent hemodialysis, as it is a more suitable option for patients with stable blood pressure and volume status, as suggested by the European Society of Cardiology and the Journal of the American Society of Nephrology guidelines 2, 3
• CRRT is the first choice for emergent dialysis, providing better hemodynamic stability, avoiding major fluid or osmotic shifts, and reducing the risk of worsening intracranial pressure, as stated in the Kidney International guidelines 6
• Peritoneal Dialysis (PD) is a second choice if CRRT is unavailable, as it does not require vascular access or systemic anticoagulation, according to the Nature Reviews Nephrology guidelines 7
• For patients with hyperammonemia, CRRT is preferred over intermittent HD due to reduced risk of rebound hyperammonemia, according to the Nature Reviews Nephrology guidelines 7

Vascular Access and Initiation of Dialysis

• For patients requiring emergent dialysis, immediate vascular access should be established with an uncuffed non-tunneled dialysis catheter of appropriate length and gauge, followed by prompt initiation of CRRT for hemodynamically unstable patients or intermittent hemodialysis for stable patients, as recommended by the Kidney International guidelines 6
• Within 30 days of urgent dialysis start with a CVC, establish an ESKD Life-Plan with a permanent dialysis access plan, including planning for AV access creation or PD catheter placement, as recommended by the American Journal of Kidney Diseases guidelines 8

Conflict Resolution and Patient Care

• If there is conflict between the medical team and the patient or legal representative regarding the need for emergency dialysis, dialysis should be provided while the conflict is resolved, to ensure timely and appropriate treatment, as recommended by the American Society of Nephrology and the Kidney International guidelines 3, 2

Prognosis and Outcomes

• Patients requiring emergency dialysis have a substantial risk of mortality, with approximately 75% mortality at 2 years after acute events such as myocardial infarction, highlighting the importance of prompt and appropriate intervention, as reported by the National Kidney Foundation and the American Journal of Kidney Diseases guidelines 2, 4
• Patients with acute kidney injury (AKI) or end-stage renal disease (ESRD) who require emergency dialysis have a higher risk of mortality and hospitalization compared to those who initiate dialysis in a planned manner, emphasizing the need for prompt and effective treatment, as supported by the Kidney International guidelines 1
• The mortality risk for patients requiring emergent dialysis is substantial, highlighting the importance of prompt and appropriate intervention, according to the American Journal of Kidney Diseases guidelines 4