How to manage an infected arterial ulcer in a patient with severe kidney compromise and impaired renal function, who is refusing dialysis?

Management of Infected Arterial Ulcer in Severe Kidney Compromise Without Dialysis

In a patient with severe kidney compromise refusing dialysis who has an infected arterial ulcer, prioritize aggressive infection control with renally-adjusted broad-spectrum antibiotics and local wound management, while recognizing this represents a palliative care scenario with high mortality risk where limb salvage may be unachievable. 1, 2, 3

Immediate Infection Control

Antimicrobial Therapy

• Initiate broad-spectrum antibiotics immediately within 1 hour of recognizing infection, as survival benefit outweighs nephrotoxicity concerns even in severe renal impairment 1, 4
• Start with vancomycin plus piperacillin-tazobactam as empiric coverage for polymicrobial infection typical of arterial ulcers 1
• Vancomycin dosing in severe renal impairment (CrCl <30 mL/min): Initial loading dose of 15 mg/kg regardless of renal function, followed by maintenance dosing of 250-1000 mg every several days based on levels; in anuria, 1000 mg every 7-10 days 5
• Piperacillin-tazobactam dosing in severe renal impairment (CrCl ≤40 mL/min): Reduce dose according to degree of renal impairment; standard dosing carries increased risk of neurotoxicity and seizures 6
• Obtain blood cultures before antibiotic administration but do not delay antibiotics for culture results 1, 4

Avoid Additional Nephrotoxins

• Each additional nephrotoxin increases acute kidney injury odds by 53%, and combining 3 or more nephrotoxins doubles AKI risk 7, 4
• Avoid NSAIDs, aminoglycosides (unless no alternative exists), and contrast agents for imaging 7, 4
• Adjust all renally-cleared medications for decreased GFR 4

Local Wound Management

Wound Care Without Revascularization

• Perform daily wound inspection with palpation through dressings to assess for worsening infection 1
• Use 0.5% chlorhexidine preparation with alcohol for wound cleansing before dressing changes 1
• Apply maximal sterile barrier precautions during any wound manipulation including cap, mask, sterile gown, sterile gloves 1
• Remove obviously necrotic tissue only if it can be done without causing bleeding, as hemostasis will be impaired 1

Recognize Futility of Revascularization

• Patients with severe renal insufficiency refusing dialysis have 1-year mortality of 44% even with aggressive treatment 3
• Renal disease is a more important predictor of poor outcome after revascularization than commonly expected, with typical limb salvage rates of only 50% even among survivors 2
• Persistent ischemia, extensive infection, forefoot/heel gangrene, and dialysis-dependent renal failure all adversely affect outcomes 2
• Contrast-based vascular imaging carries prohibitive risk of further renal deterioration in this population 2

Supportive Care and Symptom Management

Hemodynamic Support if Septic

• If patient develops septic shock, administer at least 30 mL/kg isotonic crystalloids targeting mean arterial pressure ≥65 mmHg 1, 4
• Use norepinephrine as first-line vasopressor if needed 1, 4
• Do not use sodium bicarbonate to improve hemodynamics if pH ≥7.15 1, 7, 4

Glucose Control

• Target blood glucose ≤180 mg/dL using protocolized insulin therapy; avoid tight control (≤110 mg/dL) 1, 4
• Monitor glucose every 1-2 hours until stable, then every 4 hours 1

Anemia Management

• Monitor hemoglobin levels closely as anemia is nearly universal in ESRD patients 8
• Consider erythropoietin and blood transfusion for severe anemia (hemoglobin <8.5 g/dL) 1
• Be aware that iron overload from excessive IV iron can occur and should be monitored 8

VTE and Stress Ulcer Prophylaxis

• Provide pharmacologic VTE prophylaxis with low-molecular-weight heparin unless contraindicated by bleeding risk 1, 4
• Use proton pump inhibitor or H2-receptor antagonist for stress ulcer prophylaxis given GI bleeding risk factors 1, 4

Palliative Care Framework

Acknowledge Conservative Management Context

• Conservative kidney management (CKM) is a holistic, proactive treatment for kidney failure that for elderly comorbid patients can improve symptom burden and align with quality-of-life goals 9
• This patient's refusal of dialysis represents a selection related to life or death that must be respected 10
• Time between initial counseling and outcome (urgent dialysis or death) averages 115 days in patients refusing dialysis 10

Symptom-Focused Approach

• Prioritize symptom burden assessment as ESRD patients have high physical symptom burden requiring ongoing palliative care approaches 8
• A palliative care perspective is appropriate for ESRD patients with severely limited life expectancy, focusing on symptom management rather than definitive surgical intervention 8
• Nephrologists should remain actively involved through end-of-life care 9

Pain Management

• Provide adequate analgesia for ulcer pain, adjusting opioid doses for renal impairment
• Monitor for uremic symptoms including nausea, pruritus, and altered mental status

Monitoring Parameters

• Serial creatinine and electrolytes every 4-6 hours if septic, otherwise daily 4
• Vancomycin trough levels to guide dosing adjustments 5
• Complete blood count to monitor for anemia and thrombocytopenia 1
• Bleeding time if considering any invasive procedures, as bleeding times >10-15 minutes indicate high hemorrhage risk 1
• Daily wound assessment for progression of infection or necrosis 1

Critical Prognostic Information

• Severe renal insufficiency (GFR <30 mL/min) increases odds of death 2.97-fold in patients with critical limb ischemia 3
• Patients with gangrene or ischemic ulceration have 87% prevalence in severe renal insufficiency versus 70% in normal renal function 3
• High 1-year mortality of 38-44% must be considered when discussing treatment goals 2, 3
• Without dialysis, progressive uremia will develop with severe symptoms typically within 3-4 months 10