Management of Patients Receiving Dialysis

Introduction

All patients receiving dialysis should be immediately highlighted to the renal on-call to allow uninterrupted dialysis. Where possible patients should be admitted to the primary clinical team and dialysis facilitated through the Renal Unit.

Assessment / Monitoring

Haemodialysis

Inpatient dialysis may take time to organise - early renal involvement is paramount.
Transfer of care to the Renal Unit is not always in the best interest of the patients (e.g. broken limb). All cases must be discussed.

Clinical history

Ask about timing of last dialysis session, symptoms of fluid overload and if they still pass urine (i.e. do they have residual renal function?).
Breathlessness in a dialysis patient is pulmonary oedema until proven otherwise.

Clinical examination

Review patient observations.
Examine for evidence of fluid overload: peripheral oedema / jugular venous pressure (JVP) and pulmonary oedema.
If sepsis is suspected examine dialysis access: line sepsis may have erythema or pus at the exit site or be tender over the tunnelled portion. Fistulae infection is uncommon, presenting as thrombophlebitis / cellulitis.

Investigations

Be wary of arteriovenous (AV) access; do not take BP measurements or bloods from a limb with a fistula.
Obtain bloods early in all admissions.
An ECG is essential if K+ > 5.5mmol/L.
Peripheral blood cultures must be obtained in suspected sepsis. Do not access a dialysis line for blood sampling or cultures.
Do not catheterise for the purpose of monitoring urine output.

Peritoneal Dialysis (PD)

PD is a home-based treatment carried out by the patient. There is no outreach service and thus PD patients may require early transfer.

Clinical history

Ask about timing of last dialysis session, if they still have PD in situ, the appearance of their fluid (e.g. clear or cloudy), symptoms of fluid overload and if they still pass urine (i.e. do they retain residual renal function?).

Clinical examination

Review patient observations.
Examine for evidence of fluid overload; peripheral oedema / JVP and pulmonary oedema.
Suspect PD peritonitis in those with abdominal pain, cloudy effluent or pyrexia.

Investigations

If indicated, examine the PD catheter site for erythema, pus, crusting or pain.
Obtain bloods early in all admissions.
An ECG is essential if K+ > 5.5mmol/L.
Do not catheterise for the purpose of monitoring urine output.
In suspected PD peritonitis ask the patient to drain out the fluid and send for microbiology. If no fluid is in situ or the patient is unable to perform a PD exchange DO NOT delay antibiotics.

Management

General Principles

Dialysis patients usually follow a low potassium diet. Ensure this is requested.
Dialysis patients are commonly prescribed a phosphate binder (e.g. calcium acetate, lanthanum, sevelamer) which should be given with meals to bind dietary phosphate. These are not required if the patient is fasting.

Fluid and electrolytes

Many patients on dialysis are anuric and fluid restricted. Diuretics will be ineffective.
In the context of acute illness or in attempt to correct hypotension, intravenous fluid remains an appropriate treatment. Renal advise 250ml boluses with immediate reassessment. It is unusual to require more than 2000ml.
Routine use of maintenance fluids is not appropriate, even in fasting patients.
IV drug administration can provide a large cumulative volume: discuss each case with a pharmacist to ensure safe lowest-possible volume is used.
Do not replace potassium without discussing with renal.

Blood Transfusion

If blood transfusion is necessary, the risk of hyperkalaemia and fluid overload can be minimised by giving blood during a scheduled dialysis session.
With the exception of live-saving emergencies, blood transfusion should be discussed with renal on-call.

Post-Operative Care

All dialysis patients should have a repeat set of U&Es and FBC immediately following surgery.

Remember: routine use of maintenance fluids is discouraged, even in fasting patients.

Drug Therapy / Treatment Options

General Advice

Incorrect or inappropriate prescribing in end-stage renal disease (ERSD) can lead to significant morbidity. Consult The Renal Drug Handbook or access the online Renal Drug Database (login required), or speak to a pharmacist.
All newly prescribed drugs should be adjusted where appropriate.
Important drug considerations are listed in table 1.

Table 1: Important drug considerations

Drugs	Issues	Advice
Analgesia	Increased risk of opioid toxicity particularly with codeine, morphine or long-acting opioid preparations. Increased risk of GI ulceration, bleeding, hyperkalaemia and loss of residual renal function with NSAID use.	Dose reduce and extend period between doses. Use of alfentanil SC 50-200micrograms for acute pain. Minimise or avoid NSAID use.
Antibiotics	Trimethoprim induced hyperkalaemia. Increased risk of penicillin neurotoxicity. Persistence of vancomycin / gentamicin with repeated doses. Intraperitoneal antibiotic use for PD patients.	Avoid trimethoprim (and nitrofurantoin, ineffective at eGFR <30ml/minute). Dose adjust penicillin. Vancomycin and gentamicin are dialysed. Levels should be monitored pre-dialysis and dosed following dialysis. Intravenous antibiotics are an appropriate alternative in the absence of PD training.
Contrast-based imaging	Iodinated (CT) contrast is nephrotoxic. This has the potential to reduce residual renal function. It is essentially harmless in those without residual function. Gadolinium-based (MRI) contrast is toxic in those with eGFR <30ml/minute and capable of causing nephrogenic systemic fibrosis, which can be fatal.	If residual function remains, follow guidance given in Management of Acute Kidney Injury. Completely avoid gadolinium administration in ESRD.

Other information

Contact the renal on-call on discharge to ensure follow-up and ongoing dialysis (including transport) is re-established.

Guideline reviewed: April 2023

Page last updated: June 2023