In a 60-year-old African American male with end-stage renal disease who has refused hemodialysis and presents with right-sided chest pain, normal basic metabolic panel and troponin, and a markedly elevated pro‑brain natriuretic peptide of 12,182, what is the recommended management?

Management of ESRD Patient Who Refused Dialysis with Chest Pain and Elevated Pro-BNP

This patient requires immediate supportive care focused on symptom management and hospice referral, as withdrawal from dialysis is ethically acceptable after shared decision-making, and the markedly elevated pro-BNP reflects both volume overload and cardiac dysfunction that cannot be adequately managed without dialysis. 1

Immediate Clinical Assessment

Address the Chest Pain

• Rule out acute coronary syndrome (ACS) despite normal troponin, as troponin interpretation in ESRD is complex and patients often present atypically for ACS 2
• Normal troponin does not exclude cardiac ischemia in ESRD patients, who may have microinfarctions, left ventricular hypertrophy, or unrecognized heart failure contributing to symptoms 2
• Consider ECG and clinical assessment for other causes of right-sided chest pain including pulmonary embolism, pericarditis, or pleuritic pain 2

Interpret the Markedly Elevated Pro-BNP

• Pro-BNP of 12,182 pg/mL is extremely elevated even for ESRD patients on hemodialysis, where levels are typically elevated but average around 2,000-4,000 pg/mL 3, 4, 5
• This level indicates severe volume overload and/or significant cardiac dysfunction (heart failure, left ventricular hypertrophy) 4, 5
• Pro-BNP at this magnitude is a strong predictor of mortality in ESRD patients 4
• Without dialysis, this pro-BNP level cannot be effectively reduced, as hemodialysis typically decreases pro-BNP by only 30-40% per session, and the underlying cardiac pathology requires ongoing management 4, 6

Management Framework

Respect Patient Autonomy Regarding Dialysis Refusal

• Withdrawal from dialysis is ethically and clinically acceptable after shared decision-making 1
• Before accepting the refusal as final, address potentially remedial factors:
  • Screen for depression, as this may be contributing to the refusal 1
  • Assess for inadequately treated pain or other symptoms 1
  • Evaluate for reversible social factors (financial concerns, transportation issues, family support) 1
• Ensure the patient has decision-making capacity and is making a fully informed, voluntary choice 1

Provide Comprehensive Conservative Care

• Initiate aggressive symptom management focused on quality of life rather than life prolongation 1
• For volume overload and dyspnea:
  • Administer intravenous loop diuretics (furosemide starting at 20 mg bolus or 3 mg/h infusion, doubling doses until symptom relief or maximum 160 mg bolus/24 mg/h infusion) 1
  • Recognize that diuretic efficacy will be limited given ESRD and refusal of dialysis 1
  • Consider ultrafiltration or hemofiltration if patient reconsiders dialysis for symptom control 1

Address Cardiac Dysfunction

• The combination of elevated pro-BNP and right-sided chest pain suggests possible right ventricular dysfunction or acute cor pulmonale 4, 5
• Echocardiography would help assess left ventricular ejection fraction, left ventricular hypertrophy, and volume status, though management options are limited without dialysis 4, 5
• Optimize blood pressure control if hypertensive, using agents that don't require renal clearance 1

Initiate Hospice and Palliative Care

• Ensuring access to appropriate supportive and/or hospice care is an integral part of care following a decision to withdraw dialysis 1
• Without dialysis, this patient will develop progressive uremia, volume overload, and electrolyte abnormalities leading to death within days to weeks 1
• Focus on:
  • Pain management for chest pain
  • Dyspnea management with opioids and oxygen as needed
  • Management of nausea, pruritus, and other uremic symptoms
  • Psychosocial and spiritual support 1

Critical Pitfalls to Avoid

• Do not assume the elevated pro-BNP is "just from renal disease" – this level indicates severe cardiac pathology requiring attention 4, 5
• Do not dismiss normal troponin as excluding cardiac disease in ESRD patients who often have chronically elevated troponin and atypical presentations 2
• Do not proceed with conservative management without first addressing reversible factors (depression, pain, social issues) that may be influencing the dialysis refusal 1
• Do not delay hospice referral once the decision to forgo dialysis is confirmed, as quality of life rapidly deteriorates 1

Prognosis Without Dialysis

• The extremely elevated pro-BNP (12,182 pg/mL) is strongly predictive of mortality even in patients receiving dialysis 4
• Without dialysis, death will occur from progressive uremia, volume overload, hyperkalemia, or cardiac complications within approximately 1-2 weeks 1
• The right-sided chest pain and markedly elevated pro-BNP suggest this patient may have acute cardiac decompensation that could lead to death within days 4, 5