What are the initial steps in managing nephrology emergencies?

Initial Management of Nephrology Emergencies

The most critical first step in managing nephrology emergencies is to have an emergency plan in place that includes fluid management protocols, contact information for specialists, and clear instructions for emergency medical personnel. 1

Immediate Assessment and Stabilization

Acute Kidney Injury (AKI) and Crush Syndrome

• Fluid resuscitation:

  • Initiate aggressive fluid resuscitation with normal saline at 1000 ml/hr, then taper by 50% after 2 hours 2
  • For crush injuries, follow a structured approach:
    • Before extrication: Infuse 0.9% saline at 1 L/hr
    • During extrication: Continue 0.9% saline, reduce to ≥0.5 L/hr if extrication exceeds 2 hours
    • After extrication: Continue fluid resuscitation based on clinical response 1
  • Avoid potassium-containing balanced salt fluids due to risk of hyperkalemia 2

• Laboratory monitoring:

  • Obtain immediate electrolytes, acid-base status, creatinine, blood urea nitrogen
  • Use point-of-care devices (e.g., iStat) when standard laboratory infrastructure is unavailable 1
  • Monitor for hyperkalemia, which requires urgent treatment

Electrolyte Emergencies

• Hyperkalemia:

  • Immediate ECG to assess for cardiac effects
  • For severe hyperkalemia (>6.5 mmol/L or ECG changes):
    • IV calcium gluconate 10% (10 mL) over 2-3 minutes with ECG monitoring 3
    • Insulin (10 units regular) with glucose (25g) IV
    • Sodium bicarbonate 50 mEq IV if metabolic acidosis present
    • Consider emergency dialysis if refractory

• Hyponatremia/Hypernatremia:

  • For hyponatremia with neurological symptoms: 3% hypertonic saline
  • For hypernatremia: Calculate fluid deficit and correct gradually
  • Avoid sodium correction >8 mmol/L/day 1

Special Considerations for Specific Nephrology Emergencies

Nephrogenic Diabetes Insipidus (NDI)

• Emergency management:
  • Use 5% dextrose for intravenous rehydration 1
  • Calculate initial fluid rate to avoid sodium decrease >8 mmol/L/day 1
  • Monitor clinical status, neurological condition, fluid balance, weight, and electrolytes 1
  • Each patient should have an emergency plan including a medical alert bracelet 1

Dialysis-Dependent Patients in Disasters

• For chronic dialysis patients:
  • Implement predisaster preparation including identification of alternative dialysis facilities
  • Provide patients with medical documentation of their dialysis prescription
  • Educate patients on renal emergency diet and fluid restriction
  • Consider potassium-binding resins when dialysis is unavailable 1
  • Coordinate evacuation plans with local and national agencies 1

Acute Dialysis Needs

• Indications for emergency dialysis:

  • Life-threatening hyperkalemia unresponsive to medical management
  • Severe metabolic acidosis
  • Volume overload with pulmonary edema
  • Uremic encephalopathy or pericarditis
  • Severe drug toxicity with dialyzable agent

• Dialysis modality selection:

  • Intermittent hemodialysis is preferred for rapid correction of electrolyte disturbances 1
  • Consider continuous renal replacement therapy for hemodynamically unstable patients

Coordination of Care

• Contact specialized nephrology centers for guidance in complex cases 1
• Patients with nephrology emergencies should be treated in specialized centers with experience or under consultation with expert centers 1
• For patients undergoing anesthesia, surgery, or with acute illness, close monitoring of fluid balance and electrolytes is essential 1

Common Pitfalls to Avoid

• Fluid management errors:

  • Avoid excessive fluid administration in oliguric patients
  • Do not use potassium-containing fluids in hyperkalemic states
  • Avoid rapid correction of sodium abnormalities

• Medication errors:

  • Discontinue nephrotoxic medications
  • Adjust medication dosages based on kidney function
  • Be cautious with NSAIDs, ACE inhibitors, and contrast media in at-risk patients

• Delayed recognition:

  • Failure to recognize early signs of AKI
  • Missing hyperkalemia in patients with reduced kidney function
  • Overlooking the need for early dialysis in severe cases

By following this structured approach to nephrology emergencies, clinicians can optimize patient outcomes through prompt recognition and appropriate management of these potentially life-threatening conditions.