From the Guidelines
The laboratory criteria for emergent hemodialysis include symptoms or signs attributable to kidney failure, such as neurological signs and symptoms attributable to uremia, pericarditis, anorexia, medically resistant acid-based or electrolyte abnormalities, intractable pruritus, serositis, and acid-base or electrolyte abnormalities, as outlined in the KDIGO 2024 clinical practice guideline 1. When evaluating a patient for emergent hemodialysis, it's essential to consider a composite assessment of their symptoms, signs, quality of life, preferences, level of GFR, and laboratory abnormalities, as recommended in Practice Point 5.4.1 of the KDIGO 2024 guideline 1. Some key laboratory abnormalities that may indicate the need for emergent hemodialysis include:
- Severe hyperkalemia
- Severe metabolic acidosis
- Uremic encephalopathy
- Uremic pericarditis
- Refractory fluid overload causing respiratory distress It's crucial to note that the decision to initiate emergent dialysis should be based on the patient's overall condition, rather than isolated laboratory values, and should take into account their symptoms, signs, and quality of life, as well as their level of GFR and laboratory abnormalities, as outlined in Practice Point 5.4.2 of the KDIGO 2024 guideline 1. In general, treatment should not be delayed when these criteria are met, as they represent life-threatening conditions requiring immediate intervention. The KDIGO 2024 guideline also recommends considering planning for preemptive kidney transplantation and/or dialysis access in adults when the GFR is <15–20 ml/min per 1.73 m2 or risk of KRT is >40% over 2 years, as outlined in Practice Point 5.4.3 1.
From the Research
Laboratory Criteria for Emergent Hemodialysis
The decision to initiate emergent hemodialysis is often based on the presence of severe hyperkalemia, among other factors. According to the studies, the following laboratory criteria may indicate the need for emergent hemodialysis:
- Serum potassium levels ≥ 6.0 mEq/l, as this threshold is associated with a substantially increased risk of mortality 2
- Serum potassium levels ≥ 5.7 mEq/l, as this is associated with an increased risk of all-cause mortality 2
- Serum potassium levels ≥ 5.5 mEq/l, as this defines hyperkalemia and is associated with increased morbidity and mortality 3, 2
Hyperkalemia Management
The management of hyperkalemia in patients with end-stage renal disease (ESRD) involves several strategies, including:
- Dialysis, which is the primary treatment for hyperkalemia in ESRD patients 4, 5
- Dietary potassium restriction, which can help prevent hyperkalemia 5
- Avoidance of medications that increase the risk of hyperkalemia 5
- Use of potassium-binding agents, such as patiromer and sodium zirconium cyclosilicate, which can help reduce serum potassium levels 6, 5