What are the indications for hemodialysis (HD) in patients with leptospirosis and severe acute kidney injury (AKI) or renal failure?

Indications for Hemodialysis in Leptospirosis

Initiate hemodialysis emergently in leptospirosis patients with AKI when life-threatening complications develop, including severe hyperkalemia with ECG changes, refractory metabolic acidosis, uremic complications (encephalopathy, pericarditis, bleeding), or pulmonary edema unresponsive to diuretics. 1

Absolute Indications for Emergent Dialysis

The standard life-threatening indications for RRT apply to leptospirosis-associated AKI:

• Severe hyperkalemia with ECG changes or rapidly rising potassium levels requires immediate hemodialysis 1
• Severe metabolic acidosis with impaired compensation or refractory to medical management 1
• Uremic complications including encephalopathy, pericarditis, or uremic bleeding 1
• Pulmonary edema unresponsive to diuretics or severe fluid overload causing respiratory compromise 1
• Anuria or oliguria with progressive volume overload 1

Leptospirosis-Specific Considerations

Unique Clinical Features Affecting Dialysis Decisions

Leptospirosis-induced AKI has distinct characteristics that influence dialysis management:

• Nonoliguric AKI with hypokalemia is typical in leptospirosis, contrasting with most other causes of AKI 2, 3, 4
• Tubular dysfunction precedes GFR decline, with increased distal potassium secretion and impaired proximal sodium reabsorption 2, 3
• Pulmonary hemorrhage risk is exceptionally high in severe leptospirosis (Weil's disease), requiring careful fluid management during dialysis 2, 3, 4

Critical Timing and Frequency Recommendations

For critically ill leptospirosis patients with Weil's disease requiring dialysis, initiate prompt and daily hemodialysis rather than alternate-day treatment. 5, 3, 4

The evidence strongly supports aggressive dialysis strategies:

• Daily hemodialysis significantly reduces mortality compared to alternate-day dialysis (16.7% vs 66.7% mortality) in critically ill leptospirosis patients 5
• Door-to-dialysis time should be minimized; prompt initiation improves outcomes 5
• Alternate-day hemodialysis is no longer appropriate for critically ill patients with Weil's disease 5

Modality Selection

Intermittent Hemodialysis vs CRRT

Use daily intermittent hemodialysis as the preferred modality for leptospirosis-associated AKI, even in critically ill patients, due to disease-specific considerations. 2, 5, 3

Key modality considerations:

• Daily hemodialysis is specifically recommended for critically ill leptospirosis patients 2, 3, 4
• CRRT may be considered for hemodynamically unstable patients requiring vasopressor support, following general AKI principles 6, 7
• Intermittent HD is preferred for rapid correction of severe hyperkalemia when present 1, 7

Special Precautions During Dialysis

Maintain low daily net fluid intake during dialysis due to the high risk of pulmonary hemorrhage in leptospirosis. 2, 3, 4

Critical management points:

• Restrict fluid administration aggressively because of pulmonary hemorrhage risk 2, 3, 4
• Lung-protective ventilation strategies (low tidal volumes, high PEEP after recruitment maneuvers) should accompany dialysis in severe cases 2, 3
• Monitor for thrombocytopenia (common in leptospirosis) which increases bleeding risk during dialysis 8

Clinical Algorithm for Dialysis Initiation

Step 1: Assess for Absolute Indications

• Life-threatening hyperkalemia with ECG changes → Immediate HD 1
• Severe metabolic acidosis refractory to medical therapy → Immediate HD 1
• Uremic complications (encephalopathy, pericarditis, bleeding) → Immediate HD 1
• Pulmonary edema unresponsive to diuretics → Immediate HD 1

Step 2: Evaluate Disease Severity

• Weil's disease (jaundice + AKI + pulmonary involvement) → Plan for daily HD 5, 3, 4
• Hemodynamic instability requiring vasopressors → Consider CRRT 6, 7
• Mechanical ventilation for ARDS → Ensure daily HD with fluid restriction 5, 3

Step 3: Implement Leptospirosis-Specific Protocol

• Daily hemodialysis sessions (not alternate-day) 5, 3, 4
• Minimize door-to-dialysis time once indication established 5
• Strict fluid restriction to prevent pulmonary hemorrhage 2, 3, 4
• Continue for approximately 3 weeks until renal function recovery 8, 4

Common Pitfalls to Avoid

• Do not use alternate-day dialysis in critically ill leptospirosis patients; this approach is associated with 66.7% mortality versus 16.7% with daily dialysis 5
• Do not liberalize fluids during dialysis despite nonoliguric AKI; pulmonary hemorrhage risk remains high 2, 3, 4
• Do not delay dialysis waiting for oliguria to develop; leptospirosis typically causes nonoliguric AKI 2, 3, 4
• Do not assume hypokalemia precludes dialysis need; other indications (acidosis, uremia, fluid overload) still apply 2, 3, 4

Expected Outcomes

• Renal function typically recovers over 3 weeks with appropriate management 8, 4
• Mortality in leptospirosis-associated AKI is approximately 22% overall, but significantly lower (16.7%) with prompt daily dialysis 5, 4
• Most patients achieve creatinine <200 μmol/L by 2 months post-recovery 8