Renal Failure – ESRD

End-Stage Renal Disease (ESRD):

Dialysis (note patient’s regular dialysis schedule, consult Nephrology to set this up in house while inpatient: Dr. Tran, Dr. O’Neil, Dr. Moore).

  • Lidocaine/Prilocaine 2.5%/2.5% (Emla 2.5% cream): apply topically over the A-V Fistula site 1 hr prior to each dialysis round
  • Hibiclens wash night before Ash Cath placement for initiation of dialysis
  • When determining whether a patient needs to be started on Dialysis with Stage 5 CKD:
    1. Low appetite, nausea, unintentional weight loss from anorexia -> low albumin (malnourished) -> poorer prognosis the lower the albumin is when on dialysis.
    2. Bad taste in mouth/metallic taste in mouth
    3. Difficulty sleeping, RLS (Restless Leg Syndrome)
    4. Physical exam: Look for signs of volume overload, pericardial rub, dialysis access
  • May be on Darbepoetin (Aranesp): erythropoietin to stimulate RBC production; typically erythropoietin is made by the kidneys, but in kidney failure, the pt may lack this and therefore have anemia.
  • DVT prophylaxis: Heparin 5,000 U q12 hrs
  • Acidosis:
    • Sodium bicarbonate 650 or 1300mg PO tid with meals.
      pH < 7.0:

      • Sodium bicarbonate 8.4% injection 150mEq (3 ampules) IV X 1 dose stat
        1. 1 ampule = 50 mEq
      • Sodium bicarbonate150 mEq in D5% 859ml infusion – 100ml/hr continuous IV
    • Order an ABG to assess extent of acidosis.
  • Post-Strept glomerulonephritis: Low compliment levels
  • Calciphylaxis (calcific uremic arteriolopathy (CUA)): a serious disorder that presents with skin ischemia and necrosis and occurs most commonly, though not exclusively, in end-stage renal disease (ESRD) patients. The prognosis is poor. Clinical manifestations: livedo reticularis and/or violaceous, painful, plaque–like subcutaneous nodules. If untreated, lesions progress to ischemic/necrotic ulcers with eschars that often become superinfected. Lesions classically develop in areas with greatest adiposity, including the abdomen, buttock, and thigh. There are no specific diagnostic laboratory tests for calciphylaxis. The diagnosis is suggested by the characteristic ischemic skin lesions and their distribution. If there are no contraindications, the diagnosis should be confirmed by skin biopsy, which shows arteriolar occlusion and calcification in the absence of vasculitic change. The optimal therapy is not known.

Renal failure:


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