What labs are recommended for a patient refusing dialysis?

Laboratory Monitoring for Patients Refusing Dialysis

For patients with end-stage renal disease who refuse dialysis, focus laboratory monitoring on electrolytes (sodium, potassium, calcium, magnesium, chloride, bicarbonate), renal function markers (BUN, creatinine), and parameters that guide symptom management rather than dialysis adequacy metrics.

Core Laboratory Tests

Electrolyte Panel

• Monitor sodium, potassium, calcium, magnesium, chloride, and bicarbonate to identify life-threatening imbalances that may require urgent intervention or inform palliative care decisions 1, 2
• Potassium levels are particularly critical, as hyperkalemia (>5.0 mEq/L) is associated with increased mortality risk and may cause cardiac arrhythmias requiring emergency management 3
• Check bicarbonate levels to assess metabolic acidosis severity, which commonly develops in ESRD and contributes to symptoms 2, 4
• Note that hyperchloremia occurs in 46% of ESRD patients at presentation, contrary to older assumptions about electrolyte patterns 4

Renal Function Markers

• Measure BUN and creatinine to track disease progression and inform prognosis discussions with the patient and family 1, 2
• Calculate eGFR using the 2009 CKD-EPI equation rather than relying on creatinine alone for more accurate assessment 2
• Recognize that a single abnormal result is insufficient; persistence of abnormalities helps confirm chronic progression 2

Mineral Metabolism Parameters

• Monitor phosphorus levels, as hyperphosphatemia (>5.5 mg/dL) is associated with increased mortality risk even without dialysis 1, 3
• Check calcium levels to identify hypercalcemia or hypocalcemia that may contribute to symptoms 1
• Measure intact PTH if progressively rising or persistently elevated, as this may guide treatment of bone pain or other symptoms related to CKD-mineral bone disorder 1, 5

Anemia Assessment

• Measure hemoglobin to assess anemia severity, which contributes significantly to fatigue and quality of life 6
• Check serum ferritin and transferrin saturation if considering erythropoiesis-stimulating agents or iron supplementation for symptom management 1, 6
• Target transferrin saturation ≥20% and ferritin >100 ng/mL if treating anemia 6

Monitoring Frequency

• Frequency should be guided by symptom burden and goals of care rather than rigid dialysis protocols 2
• For patients with rapidly declining function (GFR category G5 <15 mL/min/1.73m²), more frequent monitoring may be warranted to anticipate complications 2
• Consider checking labs every 1-2 weeks initially, then adjust based on rate of change and clinical status 2

Tests to Avoid

• Do not routinely measure dialysis adequacy metrics (Kt/V, urea reduction ratio) as these are irrelevant without dialysis 6
• Avoid routine cardiac biomarkers (troponin, BNP) unless specifically evaluating acute symptoms, as chronic elevation is expected in ESRD 6

Palliative Care Context

• All laboratory monitoring should serve the goal of optimizing comfort and quality of life rather than prolonging survival 1
• Results should inform discussions about symptom management options (dietary modifications, medications for hyperkalemia, treatment of uremic symptoms) 1
• Involve hospice or palliative care specialists in interpreting results and making treatment recommendations aligned with patient goals 1

Important Caveats

• Certain medications can interfere with creatinine measurements, affecting eGFR accuracy 2
• Uremic symptoms typically manifest when BUN exceeds 300 mg/dL, which may guide discussions about expected symptom trajectory 1
• Laboratory abnormalities in ESRD patients refusing dialysis will inevitably worsen; the goal is managing complications rather than normalizing values 1, 4