What do I do for a patient with Chronic Kidney Disease (CKD) stage 5 who is not voiding and is on Intravenous (IV) fluids?

Management of CKD Stage 5 Patient Who Is Not Voiding and on IV Fluids

For a CKD stage 5 patient who is not voiding and is on IV fluids, urgent hemodialysis should be initiated to prevent life-threatening complications of fluid overload and uremic toxicity.

Initial Assessment

When managing a CKD stage 5 patient who is not voiding and is on IV fluids, the following urgent steps are needed:

1. Assess for signs of fluid overload and uremia:

   • Check for pulmonary edema, peripheral edema, hypertension
   • Evaluate for uremic symptoms: altered mental status, nausea, vomiting
   • Assess vital signs with special attention to blood pressure

2. Laboratory evaluation:

   • Serum electrolytes (particularly potassium)
   • BUN and creatinine
   • Arterial blood gas if respiratory distress is present

Management Algorithm

Step 1: Stop IV Fluids

• Immediately discontinue or significantly reduce IV fluid administration to prevent worsening fluid overload 1

Step 2: Diuretic Trial (if not already attempted)

• Consider IV furosemide 40-80 mg (if not already tried)
• For patients with CKD stage 5, higher doses may be needed due to reduced kidney function 2
• Monitor response carefully, but expect limited efficacy in advanced CKD

Step 3: Urgent Dialysis Initiation

• If the patient shows no response to diuretics or has signs of volume overload or uremic symptoms, initiate urgent hemodialysis 1
• The decision to initiate dialysis should be based primarily on clinical assessment of signs/symptoms of uremia, evidence of protein-energy wasting, and inability to safely manage metabolic abnormalities or volume overload with medical therapy 1

Specific Considerations

Vascular Access

• If no permanent access is in place, place a temporary dialysis catheter
• For longer-term management, plan for creation of permanent vascular access (AV fistula or graft)

Dialysis Prescription

• Initial dialysis session should be gentle (shorter duration, lower blood flow) to avoid dialysis disequilibrium syndrome
• Target ultrafiltration based on estimated fluid overload

Monitoring During Treatment

• Close monitoring of vital signs, particularly blood pressure
• Watch for hypotension during fluid removal
• Monitor for electrolyte shifts, particularly potassium

Long-Term Management

After the acute situation is managed:

1. Evaluate for permanent renal replacement therapy options:

   • Maintenance hemodialysis (in-center or home)
   • Peritoneal dialysis
   • Kidney transplantation evaluation 1

2. Patient education:

   • Patients who reach CKD stage 5 should receive education about kidney failure treatment options 1
   • Include family members and caregivers in education 1

3. Volume management:

   • Implement fluid restriction appropriate to residual kidney function
   • Regular assessment of volume status 1
   • Salt restriction to help manage fluid balance

Common Pitfalls to Avoid

1. Delaying dialysis initiation when clinical indications are present can lead to increased morbidity and mortality from complications of uremia and fluid overload

2. Excessive ultrafiltration during initial dialysis sessions can cause hemodynamic instability and increased risk of complications

3. Neglecting residual kidney function - even minimal remaining function should be preserved when possible

4. Overlooking conservative management as an option for certain patients, particularly those with multiple comorbidities or advanced age who may not benefit from dialysis 1

Remember that while GFR estimation guides decision-making, the timing of dialysis initiation should be primarily based on clinical assessment of symptoms and the ability to manage metabolic abnormalities and volume status medically 1.