Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

ESRD & Dialysis Complications

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In one line

·When kidneys fail completely, the body cannot clean the blood or balance fluids and minerals—only dialysis or a transplant can do that job.

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Normal physiology

·The kidneys are two fist-sized filters in your lower back that clean your blood 24/7, pull out waste and extra water, balance minerals and acid, and make hormones that control blood pressure, red blood cell production, and bone strength—every drop of your blood passes through them about 40 times a day.

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What goes wrong

·In end-stage renal disease, the nephrons (the tiny kidney filters) die off until fewer than 15% are left working—so the kidneys cannot clean waste, balance potassium or acid, pull off extra fluid, or make the hormones that control blood pressure, red blood cells, and bones.

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Hallmark signs

·Swelling in the legs, ankles, or face
·Shortness of breath
·Feeling very tired and weak all the time (fatigue)
·Itching all over (uremic itching (pruritus))
·Nausea, vomiting, or loss of appetite
·Trouble thinking clearly or concentrating (brain fog)
·Muscle cramps, especially during or after dialysis
·Chest pain or irregular heartbeat (arrhythmia)

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Red flags · escalate now

·Sudden severe shortness of breath or chest pain — may mean fluid in the lungs or a heart problem and needs emergency care right away.
·Fever with chills, especially with redness, warmth, or drainage at the dialysis catheter or fistula site — may be a blood infection (sepsis) and needs antibiotics and urgent evaluation.
·New confusion, severe headache, seizure, or trouble staying awake — may mean toxins are affecting the brain (uremic encephalopathy) or there is bleeding in the brain and needs immediate attention.
·Irregular heartbeat, palpitations, or feeling like the heart is racing or skipping beats — may be dangerously high potassium and needs an ECG and emergency treatment to protect the heart.

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Workup

·Basic metabolic panel (BMP): sodium, potassium, chloride, bicarbonate, BUN, creatinine, glucose
·Hemoglobin and hematocrit
·Calcium, phosphate, and intact parathyroid hormone (PTH)
·Albumin
·Ferritin and transferrin saturation (TSAT)
·Electrocardiogram (EKG)
·Chest X-ray
·Ultrasound of vascular access (Doppler flow study)

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Treatment

·Hemodialysis (typically 3 times per week, 4 hours per session) or peritoneal dialysis (daily exchanges at home)
·Create and maintain vascular access (arteriovenous fistula preferred, then arteriovenous graft, then tunneled dialysis catheter as last resort)
·Phosphate binders (calcium carbonate, sevelamer, lanthanum) taken with meals, plus calcitriol (active vitamin D) or calcimimetics (cinacalcet) to control parathyroid hormone
·Erythropoiesis-stimulating agent (ESA: epoetin alfa or darbepoetin alfa injected weekly or every 2 weeks) plus intravenous iron supplementation
·Dietary restriction: potassium < 2–3 grams/day, sodium < 2 grams/day, fluid intake limited to urine output plus 1 liter per day (most ESRD patients make little to no urine)
·Blood pressure control: optimize dry weight (target weight after dialysis removes all extra fluid), ACE inhibitor or ARB if residual kidney function remains, and other antihypertensives (beta-blockers, calcium channel blockers) as needed
·Kidney transplant evaluation and listing (for appropriate candidates)

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NCLEX trap

·In ESRD the kidneys are nearly dead — they cannot respond to water pills at all. The only way to pull the fluid off is dialysis. Giving a water pill wastes precious time, and it can poison the remaining kidney tissue even more. Start dialysis NOW.
·Low blood pressure during dialysis usually means fluid is coming off too fast OR the patient was already dry before you started. The fix is to SLOW the ultrafiltration rate (the speed at which the machine pulls fluid) and give a small IV fluid bolus DURING the session to stabilize blood pressure. Do NOT stop dialysis — the toxins and extra potassium still need to come out.
·Fever PLUS a vascular access (fistula, graft, or catheter) in ESRD means bloodstream infection (bacteremia) until proven otherwise. Draw two sets of blood cultures from separate sites RIGHT NOW, before any antibiotic. Access infections can seed the heart valves (endocarditis) and kill within days. Treat every fever as serious.
·High potassium can stop the heart with NO warning on the EKG. Check potassium before and after every dialysis session. If the level is above 6.0 mEq/L OR if you see peaked (tall, pointy) T-waves on the EKG, give calcium gluconate (protects the heart), insulin with dextrose (drives potassium into cells), and albuterol (also drives it in), and arrange URGENT dialysis. Do not wait for symptoms.
·Tiredness and confusion in ESRD come from FOUR things working together: anemia (low red blood cells), severe waste buildup in the blood (uremia) (poison waste building up because kidneys are broken), high potassium (slows the brain), and fluid overload (low oxygen). Check potassium, fluid status, and when the last dialysis happened FIRST. Transfusion alone will NOT fix the problem — you must remove the toxins with dialysis AND treat the anemia over time with erythropoietin (a hormone shot that tells bone marrow to make red cells).
·You MUST feel for the thrill yourself every shift. A clotted access means NO dialysis can happen — and toxins and potassium will pile up in hours and can kill the patient. If the thrill is gone, page the surgeon and interventional radiology immediately. This is a dialysis emergency.

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