Diagnosis of Anasarca in ESRD Patients Who Missed Dialysis
The diagnosis is volume overload (or fluid overload/hypervolemia) secondary to end-stage renal disease (ESRD), not a separate named syndrome. This represents acute decompensation of chronic kidney disease due to inadequate renal replacement therapy.
Understanding the Clinical Entity
- Anasarca in the context of missed dialysis is a clinical manifestation, not a distinct diagnostic entity 1
- The underlying diagnosis remains end-stage renal disease (ESRD) with acute volume overload as the presenting complication 2
- ESRD is defined as either GFR <15 mL/min per 1.73 m² with uremic symptoms or the need for kidney replacement therapy (dialysis or transplantation) 2
Pathophysiology of Volume Overload in Missed Dialysis
- Inadequate dialysis leads to accumulation of uremic toxins and failure to remove excess fluid, resulting in progressive volume expansion 1
- The kidneys in ESRD patients cannot maintain fluid and electrolyte balance, making regular dialysis essential for preventing fluid accumulation 1
- Missed or delayed dialysis exchanges cause fluid overload, leading to hypertension and cardiovascular complications 1
Clinical Presentation
When ESRD patients miss dialysis, they develop:
- Generalized edema (anasarca) from inability to excrete sodium and water 3
- Uremic symptoms including nausea and vomiting from toxin accumulation 1
- Potential progression to multiple organ failure requiring intensive care, mechanical ventilation, and continuous renal replacement therapy in severe cases 3
- Respiratory compromise from pulmonary edema and pleural effusions 4
Diagnostic Terminology in Clinical Practice
The appropriate diagnostic formulation should be:
- Primary diagnosis: End-stage renal disease (ESRD) 2
- Acute complication: Volume overload with anasarca 1
- Contributing factor: Non-adherence to dialysis regimen 1
This is distinct from other causes of anasarca in ESRD patients, such as:
- TAFRO syndrome (a rare entity with thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly) 3
- Nephrotic syndrome from primary glomerular disease 5
- Cardiac failure or hepatic disease 6
Clinical Management Implications
- The treatment priority is urgent dialysis to remove excess fluid and uremic toxins 1, 4
- Continuous renal replacement therapy (CRRT) may be required in critically ill patients with severe volume overload and hemodynamic instability 3
- Patients must adhere to their prescribed dialysis schedule to prevent recurrent volume overload 1
- The adequacy of dialysis should be monitored with target Kt/V ≥1.2 to ensure adequate clearance 7
Prognostic Considerations
- Dialysis-dependent ESRD patients who progress to requiring dialysis have high mortality rates, with mean life expectancy of only 2.7 years in patients older than 65 2
- Regular adherence to dialysis is essential for survival, as inadequate dialysis leads to uremia affecting multiple organ systems 1
- Patients on dialysis must be educated about the life-threatening consequences of missing treatments 1