What is the initial approach for a Chronic Kidney Disease stage 5 (CKD-5) patient on Maintenance Hemodialysis (MHD) presenting with abdominal hardness and a tense, nontender abdomen the day before dialysis?

Management of Abdominal Hardness in CKD-5 MHD Patient

This patient most likely has fluid overload with interdialytic weight gain causing abdominal distension, and should receive urgent hemodialysis with aggressive ultrafiltration to remove excess fluid, rather than waiting until the scheduled session the next day.

Immediate Assessment

The clinical presentation of a tense but nontender abdomen with preserved bowel sounds in a hemodialysis patient the day before dialysis is highly suggestive of fluid overload rather than an acute surgical abdomen 1. Key distinguishing features to confirm:

• Volume status assessment: Check for peripheral edema, jugular venous distension, pulmonary crackles, and compare current weight to dry weight 2
• Interdialytic weight gain: Calculate weight gain since last dialysis session (typically should be <5% of dry weight between sessions) 1
• Absence of peritoneal signs: The nontender abdomen with present bowel sounds argues against peritonitis, bowel obstruction, or ischemia 3
• Vital signs: Assess for hypertension and respiratory distress as markers of volume overload 2

Primary Management Strategy

Urgent dialysis with ultrafiltration is the definitive treatment for fluid overload in this clinical scenario 1, 2:

• Do not wait until the scheduled dialysis session the next day if the patient is symptomatic with significant volume overload
• Target ultrafiltration volume should equal the excess interdialytic weight gain plus any additional fluid accumulation 1
• Monitor hemodynamic stability during aggressive fluid removal 4

Differential Considerations to Exclude

While fluid overload is most likely, rapidly assess for conditions requiring different management 2:

• Constipation/ileus: Common in dialysis patients due to phosphate binders, fluid restriction, and uremia; however, bowel sounds are present which makes complete obstruction less likely 3
• Ascites: The examination specifically notes no ascites, but if uncertain, bedside ultrasound can confirm 1
• Uremic gastroparesis: Can cause abdominal distension but typically presents with upper GI symptoms (nausea, vomiting, early satiety) 3
• Peritoneal dialysis-related complications: Not applicable as patient is on hemodialysis 1

Supportive Measures

While arranging urgent dialysis 1:

• Restrict fluid and sodium intake immediately to prevent further accumulation 2
• Hold or reduce antihypertensives if blood pressure is elevated due to volume overload (will improve with ultrafiltration) 2
• Assess nutritional status: Use this opportunity to evaluate for protein-energy wasting, as abdominal examination findings should be documented 1
• Review dialysis adequacy: Recurrent significant interdialytic weight gain may indicate inadequate patient education about fluid restriction or need for dialysis prescription adjustment 1

Post-Dialysis Monitoring

After ultrafiltration 1, 2:

• Reassess abdominal examination to confirm resolution of distension
• Verify achievement of dry weight target
• Monitor for hypotension or cramping from excessive fluid removal
• Reinforce dietary sodium and fluid restriction education to prevent recurrence
• Consider more frequent dialysis sessions if patient consistently has excessive interdialytic weight gain 1

Critical Pitfall to Avoid

Do not delay dialysis in a symptomatic volume-overloaded patient simply because their next scheduled session is the following day. Severe fluid overload can lead to pulmonary edema, hypertensive crisis, and cardiac complications with significant morbidity and mortality 2, 4. The tense abdomen represents significant third-spacing and total body fluid excess requiring urgent intervention 1.