Influence of Chronic Renal Failure on Critical Illness

Created on Sat, 07/11/2015 - 20:35
Last updated on Thu, 06/30/2016 - 00:38

The influence of end-stage renal failure on the management of critically ill patients  has been asked about in Question 1 from the first paper of 2011 and Question 29 from the first paper of 2016. The college's model answer was so good, that I have reproduced it here.

Renal:
Low/no urine output

Metabolic and Endocrine:
Associated
o   Hyperkalaemia
o   Abnormal Ca++
o   Hyperphosphataemia
Need for dialysis determines fluid prescribing, feeding and any protein restriction

Cardiovascular:
Hypertension very common
Atherosclerosis common
Pericarditis common

Respiratory:
Prone to pulmonary oedema

Neurological:
Dialysis disequilibrium

Polyneuropathy and myopathy

Skin:
Fragile skin

Haematological:
Anaemia
Platelet dysfunction

Gastrointestinal:
Impaired gastrointestinal motility
Increased risk of bleeding related to gastric ulceration

Immunological:
Increased risk of infection

Pharmacological:
Altered clearance of medications that have predominant renal excretion

Vascular access:
Fistulas used for dialysis may complicate CVC and arterial access

To this, one might add a note regarding nutrition. A normal or slightly increased daily protein intake may be required to compensate for amino acid losses into the circuit, and for the hypercatabolic state of critical illness. In contrast, intermittent haemodialysis patients tend to benefit from low protein and low sodium diet so as to decrease their urea load.

LITFL take this answer, and build wonderfully upon it. Specifically, they quote an editorial by Szamosfalvi and Yee (2013), which is the single most useful published resource on this topic.

Issues specific to ESRD raised in this article include:

  • The central veins draining the access arm with the fistula should be protected from venous
    catheters
  • Diet should be potassium- and phosphate-restricted
  • An AV fistula should not be accessed for CRRT or SLEDD, because the sessions are long and the risk of needle dislodgement and lifethreatening haemorrhage is thus greatly increased.
  • In terms of small solute clearance, there is no need to change the dose of dialysis in critically ill ESRD patients when compared to their regular maintenance dose.
  • Hypotonic and hypertonic fluids should be avoided

The all-cause in-ICU mortality of ESRD patients admitted to ICU seems to be over double that of patients without renal failure (11% vs 5%), though it is lower than the mortality of patients with acute renal failure (23%).

 

References

Clermont, Gilles, et al. "Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes." Kidney international 62.3 (2002): 986-996.

Szamosfalvi, Balazs, and Jerry Yee. "Considerations in the critically ill ESRD patient." Advances in chronic kidney disease 20.1 (2013): 102-109.

Arulkumaran, N., N. M. P. Annear, and M. Singer. "Patients with end-stage renal disease admitted to the intensive care unit: systematic review." British journal of anaesthesia 110.1 (2013): 13-20.

Thompson, Stephanie, and Neesh Pannu. "Renal replacement therapy in the end-stage renal disease patient with critical illness." Blood purification 34.2 (2012): 132-137.