End-Stage Renal Failure / DialysisUrgent

CKD stage 5 (eGFR 8), not yet on dialysis; 1 week of vomiting, itching and breathlessness; K⁺ 6.8, HCO₃ 12, urea 260 mg/dL; pericardial rub

• K⁺ ≥6.5 / ECG changes
• Pericardial rub or hypotension
• Seizures, asterixis
• Pulmonary oedema

• Acute-on-chronic AKI (reversible cause)
• Obstruction
• Heart failure
• Sepsis

• Admit: Uraemic emergency, hyperkalaemia, overload, pericarditis, encephalopathy, access failure
• ICU: Pulmonary oedema needing ventilation, tamponade, hyperkalaemia with arrhythmia, unstable for intermittent HD
• Dialysis: AEIOU indications
• CRRT: Haemodynamically unstable: citrate anticoagulation, effluent 20–25 mL/kg/h

• Fatigue alone is not a dialysis indication.
• Uraemic pericarditis can tamponade — examine for rub and pulsus paradoxus daily.
• Hepatitis B vaccination before dialysis; fistula creation 6–12 months before expected start.

• Place a subclavian dialysis line when a jugular site is available
• Start dialysis with a long, high-flow first session (disequilibrium)
• Use heparin with uraemic pericarditis
• Give unadjusted doses of renally cleared drugs

• Missing AEIOU indications
• Unadjusted drug doses
• Subclavian lines
• Aggressive first dialysis

Ward/HDU with urgent dialysis; ICU if unstable. Chronic dialysis unit and access surgery.