What is the management approach for a patient with impaired renal function on hemodialysis (HD) 4 times a week presenting with sepsis?

Sepsis Management in Hemodialysis Patients

Initial Resuscitation and Fluid Management

Administer at least 30 mL/kg of crystalloid fluid within the first 3 hours of sepsis recognition, targeting a mean arterial pressure (MAP) ≥65 mmHg, even in patients on hemodialysis 4 times weekly. 1

The Surviving Sepsis Campaign guidelines make no distinction for ESRD patients regarding initial fluid resuscitation, and recent evidence supports this approach:

• Aggressive fluid resuscitation (≥30 mL/kg) in ESRD patients on HD does not increase rates of volume overload, urgent dialysis, intubation, or mortality compared to conservative fluid strategies 2
• In a case-control study, only 23% of ESRD patients received guideline-concordant fluid resuscitation (≥30 mL/kg) compared to 60% of non-ESRD patients, yet aggressive resuscitation appeared safe with no difference in adverse outcomes 2
• A separate study comparing <20 mL/kg versus ≥20 mL/kg found no significant difference in ICU admission rates, length of stay, volume overload, intubation rates, or need for urgent dialysis 3

Common pitfall: Physicians often withhold adequate fluid resuscitation in ESRD patients due to unfounded fears of volume overload, which may worsen outcomes by perpetuating hypoperfusion and organ dysfunction 2, 4

Source Control and Antimicrobial Therapy

Obtain blood cultures before antibiotics, then initiate broad-spectrum empiric antibiotics within 1 hour of sepsis recognition. 1

For HD patients, consider these infection sources in order of frequency:

• Vascular access (HD catheter) infections are the most common source 4
• Lower respiratory tract infections 4
• Urinary tract infections (less common in anuric patients)
• Intra-abdominal sources

Antibiotic dosing must be adjusted for renal impairment and dialysis clearance:

• For piperacillin-tazobactam in patients with CrCl <20 mL/min or on hemodialysis: administer 2.25 grams every 12 hours for most indications, or 2.25 grams every 8 hours for nosocomial pneumonia 5
• Following each hemodialysis session, administer an additional 0.75 grams (0.67 grams piperacillin/0.08 grams tazobactam) as hemodialysis removes 30-40% of the administered dose 5
• Vancomycin should not be withheld due to nephrotoxicity concerns in severe sepsis, as treatment of infection takes priority over potential kidney injury 6
• Ensure adequate resuscitation before attributing worsening renal function to vancomycin, as volume depletion and hypoperfusion are major contributors to sepsis-associated AKI 6

Vasopressor Support

If hypotension persists after initial fluid resuscitation, initiate norepinephrine as the first-line vasopressor targeting MAP ≥65 mmHg. 1

• Norepinephrine was the most commonly used vasopressor in HD patients with sepsis (used in 22 of 30 patients requiring vasopressors) 4
• Do not use low-dose dopamine for "renal protection"—this practice is obsolete and not recommended 7

Renal Replacement Therapy Considerations

Continue the patient's scheduled hemodialysis regimen, but consider transitioning to continuous renal replacement therapy (CRRT) if hemodynamically unstable. 1

• Intermittent hemodialysis and CRRT are equivalent in terms of mortality in septic patients with acute kidney injury 1
• Use CRRT to facilitate fluid balance management in hemodynamically unstable patients (those requiring high-dose vasopressors or with persistent hypotension) 1
• Do not initiate RRT solely for elevated creatinine or oliguria without other definitive indications (severe acidosis pH <7.15, hyperkalemia >6.5 mEq/L, uremic complications, or refractory volume overload) 1, 6
• For patients already on chronic HD, maintain or increase dialysis frequency as needed for volume and electrolyte management 1

Metabolic Management

Implement protocolized glucose control, initiating insulin when two consecutive blood glucose levels exceed 180 mg/dL, targeting an upper limit ≤180 mg/dL. 1

• Monitor blood glucose every 1-2 hours until stable, then every 4 hours 1
• Use arterial blood rather than capillary blood for point-of-care glucose testing if arterial catheters are present 1

Avoid sodium bicarbonate therapy for lactic acidemia with pH ≥7.15, as it does not improve hemodynamics or reduce vasopressor requirements. 1

Venous Thromboembolism Prophylaxis

Administer pharmacologic VTE prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). 1

Critical consideration for HD patients: Since creatinine clearance is <30 mL/min:

• Use dalteparin (preferred LMWH with low renal metabolism) 1
• Alternatively, use another LMWH with low renal metabolism 1
• Or use UFH 1
• Combine pharmacologic prophylaxis with mechanical prophylaxis (intermittent pneumatic compression devices) whenever possible 1

Additional Supportive Care

Minimize nephrotoxin exposure, as each additional nephrotoxin increases AKI odds by 53%. 6, 8

• Avoid NSAIDs entirely 8
• Carefully review and adjust all medication dosages for renal impairment 1
• Monitor for drug accumulation, particularly with renally cleared antibiotics 1

Initiate early enteral nutrition within 48 hours if tolerated, starting with low-dose feeding (up to 500 calories/day) and advancing as tolerated. 1

Address goals of care within 72 hours of ICU admission, incorporating palliative care principles where appropriate. 1

Prognostic Considerations

• Sepsis-associated acute renal failure carries a 70% mortality rate 1
• In this HD population, in-hospital mortality was 26.6% with 28-day out-of-hospital mortality of 25.6% 4
• The presence or absence of ≥2 SIRS criteria did not significantly predict mortality in HD patients with sepsis 4