End-Stage Renal Disease (ESRD)

• End-stage renal disease (ESRD) can manifest with a metallic taste accompanied by nausea and vomiting.
• Muscle wasting and cramping are also common manifestations of ESRD.
• Skin-related symptoms include bruising and cramping.
• Vital signs in ESRD may show elevated heart rate (HR), blood pressure (BP), and respiratory rate (RR), along with decreased pain sensation.

Pathophysiology of ESRD

• ESRD involves increased levels of toxins, urea, uric acid, and nitrogenous waste products in the blood.
• Azotemia occurs when the kidneys can't eliminate nitrogen metabolites, leading to urea accumulation.
• Uncontrolled diabetes or hypertension are frequent causes of ESRD.

Lab Values in ESRD

• Oliguria, defined as urine output less than 30 mL per hour, is an expected finding.
• In ESRD, the glomerular filtration rate (GFR) is 15 or less (normal GFR is above 90).
• Critical creatinine levels are above 1.3 mg/dL.
• BUN levels exceeding 20 mg/dL are indicative of ESRD.
• High magnesium levels are observed, which can lead to respiratory depression.
• High potassium levels result in peaked T waves and widened QRS complexes on ECG.
• Kayexalate increases fecal potassium excretion by binding potassium in the gastrointestinal tract.

ESRD Medications

• Calcium acetate (PhosLo) is used as a calcium binder to lower phosphate levels.
• Sevelamer (Renagel) is a phosphate binder that binds phosphate in the GI tract to lower dietary phosphate absorption.
• Epoetin Alpha is administered to treat anemia.
• Benzodiazepines and phenytoin (Hydantoin) are used as anticonvulsants.
• Digoxin (cardiac glycoside) and dobutamine (beta receptor agonist) are used as inotropes.
• Diuretics are used to manage fluid overload.
• Gentamicin and other anti-infectives require monitoring of BUN and creatinine levels.

Medications to Hold Before Hemodialysis (HD)

• Any medication affecting blood pressure should be held, including -prils, -sartans, -osins, -lols, -dipines, diuretics, digoxin, and antiarrhythmics.

Diet for ESRD

• A renal diet is high in calories and low in sodium, potassium, and protein.
• Potassium intake should be low, avoiding foods like potatoes, citrus fruits, oranges, avocados, cantaloupe, coffee, and salt substitutes.
• Phosphorous intake should be restricted.
• Sodium intake should be less than 2-3 grams.
• Protein intake should be low (0.6-0.8 g/kg/day).
• Vitamin supplements are necessary.
• Fluid intake is limited.
• Good food choices include apples, berries, cauliflower, broccoli, eggplant, and eggs.
• Assess for weight changes.
• Monitor labs such as electrolytes, BUN, creatinine, protein, transferrin, and iron.
• Assess patient history, preferences, and calorie count.
• Assess for anorexia, N/V, depression, unpalatable diet, lack of understanding, and stomatitis.
• Schedule medication administration to avoid right before meals.

HD Complications

• Metabolic acidosis (normal PaO2)
• Disturbances of lipid metabolism can be accelerated, contributing to cardiovascular complications.
• Cardiovascular diseases remain the leading cause of death in patients receiving dialysis as well as for patients with CKD.
• Anemia due to ESKD is compounded by blood loss during HD.
• Gastric ulcers may result from the physiologic stress of chronic illness, medication, and preexisting medical conditions.
• Metallic taste and nausea are common in patients with uremia.
• Vomiting may occur during HD treatment due to fluid shifts and hypotension.
• Disordered calcium metabolism and renal osteodystrophy can result in bone pain and fractures.
• Calcification of major blood vessels has been linked to hypertension and other vascular complications.
• Phosphorus deposits in the skin can cause itching.
• Sleep problems are a common complication.
• Shortness of breath can occur as fluid accumulates between dialysis treatments.
• Hypotension may occur during treatment, with common signs including nausea, vomiting, diaphoresis, tachycardia, and dizziness.
• Painful muscle cramping may occur, usually late in dialysis.
• Exsanguination may occur if blood lines separate or dialysis needles become dislodged.
• Arrhythmias may result from electrolyte and pH changes or removal of antiarrhythmic medications during dialysis.
• Air embolism is rare due to venous air detectors but can occur if air enters the vascular system.
• Chest pain may occur in patients with anemia or arteriosclerotic heart disease.
• Dialysis disequilibrium results from cerebral fluid shifts, with signs and symptoms including headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is more likely to occur in AKI or when BUN levels are very high.
• Expected outcome is lower HR and BP
• High HR and Low BP Requires call to DR
• Assess for thrill bleeding and bruit at access site.
• Hypotension is not a normal finding and can indicate dehydration.

Manifestations & Complications of Fluid Overload in ESRD

• Pericarditis, pericardial effusion, pleural friction rub, and cardiac tamponade can occur, requiring emergency dialysis.
• Signs of fluid overload are JVD, weight gain, dependent edema, and adventitious breath sounds.
• Notify the doctor for findings such as JVD, pulmonic infiltrates, crackles, seizure, confusion, weakness, rapid weight gain, decreased peripheral pulses, hypervolemia, and dysrhythmias.