CME 04/12/14 – Emergent Haemodialysis

Here is Jonathan’s talk on emergent haemodialysis and how to identify patients that may require peritoneal dialysis.

Resources:

Indications for Emergent Haemodialysis (Mnemonic = AEIOU):
  • Acidosis (Metabolic)
    • if severe / refractory to HCO3  or symptomatic (arrhythmias)
    • esp. metformin lactic acidosis (usually also have ARF and removes metformin)
  • Electrolytes
    • esp Hyper K+; also Ca++, insulin, HCO3-
  • Ingestions / Intoxication
    • if dialysable drugs – toxic alcohols, lithium, potassium, salicylates, valproate, carbamazepine, theophylline, metformin
  • Overload (Fluid)
    • if causing APO refractory to medical management
  • Uraemia
    • if symptomatic – pericarditis, neuropathy, altered mental state, seizures, platelet dysfn with bleeding…

There are only two absolute contra-indications for peritoneal dialysis: the absence of a functional peritoneal membrane and lack of a suitable home environment. (See Home Hemodialysis) Patients with these difficulties may be candidates for hemodialysis or a kidney transplant, but not for extracorporeal therapy via the abdomen or continuous ambulatory machine dialysis via venous access – Anemia precludes the satisfactory removal of metabolic wastes from the blood by purely mechanical methods; surgery may be required to allow placement of a central vascular catheter for ECMO in a patient with no suitable port-access sites permitting repeated access to the central circulation to re-establish adequate blood flow of the extremities and tissues of the body.

The overwhelming majority of patients with advanced chronic kidney disease do not have any medical or psycho-social contraindication for peritoneal dialysis. Peritoneal carcinomatosis is one of the major complications in this patient population, and its incidence increases with declining kidney function and life expectancy. Renal replacement therapy with either continuous ambulatory or home nocturnal hemodialysis offers several advantages over conventional in-center HD but is associated with an increased risk of peritonitis compared with PD in most patients except those with diabetic end-stage renal disease (ESRD) with very high glucose intolerance leading to frequent hypoglycemic episodes requiring insulin therapy to control blood sugar levels at levels as low as <3 mmol/L.

There are several medical and social issues that are useful to discuss with CKD patients as they weigh their dialysis options. With so many types of kidney disease, and their varied causes and complications that develop over time in each one. Patients should be educated regarding their specific issue so that they can better understand their own particular situation and make an informed choice about their next steps in regards to their health and future care needs as their condition progresses and/or worsens.

Dr James Wheeler
Dr James Wheeler

Emergency Physician, SCGH, WA, Australia

Articles: 467

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