What is the management approach for a patient with end-stage renal disease (ESRD) presenting with fever and a positive influenza (flu) test, but no cough or shortness of breath (SOB)?

From the Guidelines

For a patient with end-stage renal failure presenting with fever and positive influenza test but no respiratory symptoms, I strongly recommend prompt antiviral treatment with oseltamivir (Tamiflu) with dose adjustment for renal function, as this can significantly reduce the risk of complications and improve outcomes 1. The patient's condition, with end-stage renal failure, places them at higher risk for influenza complications due to their immunocompromised state and underlying comorbidities, as highlighted in the guidelines for influenza treatment 1. Given the severity of renal impairment, the appropriate dose of oseltamivir should be adjusted; according to the most recent guidance, a 30 mg initial dose followed by 30 mg at every dialysis session for 5 days is recommended for patients undergoing dialysis 1. Supportive care is also crucial and should include:

• Antipyretics, preferably acetaminophen, to manage fever while avoiding NSAIDs due to renal concerns
• Adequate hydration, respecting fluid restrictions to avoid volume overload
• Close monitoring for complications, including signs of bacterial superinfection which may require antibiotics
• Continuation of dialysis as scheduled, with strict adherence to infection control measures to prevent transmission to other dialysis patients
• Education on isolation precautions to prevent the spread of influenza to others, particularly in healthcare settings Early treatment with antivirals can reduce symptom duration and prevent progression to lower respiratory involvement, which is critical in patients with end-stage renal disease 1.

From the FDA Drug Label

ESRD Patients not on Dialysis Oseltamivir phosphate for oral suspension is not recommended

The patient has end-stage renal failure and is not on dialysis. Oseltamivir phosphate for oral suspension is not recommended for this patient 2.

From the Research

Patient Management

• The patient has end-stage renal failure and is positive for flu, but does not have cough or shortness of breath.
• According to 3, patients with end-stage renal disease are more susceptible to serious morbidity and mortality associated with influenza infection.
• Proper management of patients includes vaccination, monitoring for symptoms, and isolation of potentially infected patients, as well as appropriate antiviral therapies 3.

Antiviral Therapy

• Oseltamivir is indicated for the treatment and prophylaxis of influenza infections 4, 5.
• However, oseltamivir is renally cleared, and dose reductions are advised for patients with renal impairment 4.
• The current dosing advice for oseltamivir in patients with mild to moderate renal impairment may reduce its efficacy, and timely therapeutic drug monitoring can provide invaluable dosing information to the clinician treating patients with influenza 4.
• Zanamivir is another antiviral drug that can be used for the treatment of influenza A and influenza B 5.

Renal Disease Management

• End-stage renal disease is diagnosed when kidney function is no longer adequate for long-term survival without kidney transplantation or dialysis 6, 7.
• Patients with end-stage renal disease should be monitored for signs of protein-energy wasting and malnutrition, and controlling blood pressure can improve mortality 6.
• Vaccination against seasonal influenza is advised for patients with end-stage renal disease 6, 3.