A 38-year-old man with end-stage renal disease (ESRD), on hemodialysis, presents by EMS with shortness of breath. He states he has missed dialysis for the past week due to shortness of breath.

You Might Also Like

• 8 Pitfalls in Recognition and Management of Acetaminophen Toxicity
• The Current Status of Continuous-Seizure Management
• Updated Guidelines on Atrial Fibrillation Management

Explore This Issue

ACEP Now: Vol 43 – No 10 – October 2024

Clinical questions:

1) What diagnostic tests should be ordered?

2) How should missed dialysis be managed?

Treatment adherence is a significant problem among patients with ESRD on hemodialysis. There seems to be a gap in understanding and compliance with hemodialysis between health care workers and patients. Why might patients fail to adhere to a lifesaving therapeutic intervention?

The medical literature offers some explanations. Contributing factors to nonadherence with hemodialysis may include fatigue, depression, transportation challenges, poor health literacy, lack of trust, cognitive impairment, and lack of family and social support.^1–10

Complications of nonadherence may be significant and even life-threatening, including pulmonary edema, hyperkalemia, uremia, heart failure, and other cardiovascular events.^11–17

When attending to patients who have not been adherent to hemodialysis regimens, care should include a medical evaluation and initiation of treatment. Diagnostic studies may include ECG, chest X-ray, serum chemistries, and complete blood count. Initiation of treatment for emergent conditions such as pulmonary edema or hyperkalemia should be undertaken immediately. Arrangement for inpatient or outpatient hemodialysis is crucial to prevent additional complications.

Equally important is identification of barriers to compliance with outpatient hemodialysis to prevent future readmissions and complications of ESRD. Care coordination with primary care, nephrology, home health, and outpatient services, such as transportation, may be of value in improving adherence to hemodialysis.

Case Conclusion

Following stabilization of airway, breathing, and circulation, diagnostic tests included serum chemistries notable for potassium of 7.5 and a chest radiograph that demonstrated pulmonary edema. Treatment was initiated with intravenous calcium gluconate, glucose and insulin, sodium bicarbonate, patiromer, and nebulized albuterol. The patient was admitted for emergent inpatient hemodialysis.

Following stabilization, care coordination was initiated with social work, primary care, and nephrology. Transportation was identified as a barrier to outpatient hemodialysis, and reliable transportation for future outpatient hemodialysis was arranged.

Disclaimer

This article is not a comprehensive review of diagnosis and treatment of ESRD but an overview of management of nonadherence. Authoritative sources should be used for diagnostic and treatment decisions.

Dr. Marco is professor of emergency medicine at Penn State Health-Milton S. Hershey Medical Center and associate editor of ACEP Now.

References

1. Sharif-Nia H, Marôco J, Froelicher ES, Barzegari S, Sadeghi N, Fatehi R. The relationship between fatigue, pruritus, and thirst distress with quality of life among patients receiving hemodialysis: a mediator model to test concept of treatment adherence. Sci Rep. 2024 May 1;14(1):9981.
2. Al-Khattabi GH. Adherence of Hemodialysis Patients to Fluid, Diet, Medications, and Hemodialysis Sessions, Makkah, Saudi Arabia. Saudi J Kidney Dis Transpl. 2023 Dec 1;34(Suppl 1):S31-S43.
3. Zhang S, Xu Y, Xia Y. The efficacy and safety of sertraline in maintenance hemodialysis patients with depression: A randomized controlled study. J Affect Disord. 2024 May 1;352:60-66.
4. Chen C, Zheng J, Liu X, Liu J, You L. Role of health literacy profiles in fluid management of individuals receiving haemodialysis: A cross-sectional study. J Adv Nurs. 2024 Jun;80(6):2325-2339.
5. Bayram R, Budak S, YIldIz H. The effect of non-compliance with diet and liquid restriction on fatigue in dialysis patients. Rev Esc Enferm USP. 2024 May 24;58:20230251.
6. Mechta Nielsen T, Marott T, Hornum M, Feldt-Rasmussen B, Kallemose T, Thomsen T. Non-adherence, medication beliefs and symptom burden among patients receiving hemodialysis -a cross-sectional study. BMC Nephrol. 2023 Oct 27;24(1):321.
7. Inanaga R, Toida T, Aita T, Kanakubo Y, Ukai M, Toishi T, Kawaji A, Matsunami M, Okada T, Munakata Y, Suzuki T, Kurita N. Trust, Multidimensional Health Literacy, and Medication Adherence among Patients Undergoing Long-Term Hemodialysis. Clin J Am Soc Nephrol. 2024 Apr 1;19(4):463-471.
8. Metzger M, Benloukil S, Sharma B, Abdel-Rahman EM. Prevalence of Cognitive Impairment and Relationships with Other Factors in Patients with End Stage Kidney Disease Receiving Hemodialysis. Nephrol Nurs J. 2024 Jan-Feb;51(1):69-75.
9. Alhamad MA, Almulhim MY, Alburayh AA, Alsaad RA, Alhajji AM, Alnajjar JS, Alhashem SS, Salah G, Al Sahlawi M. Factors Affecting Adherence to Hemodialysis Therapy Among Patients With End-Stage Renal Disease Attending In-Center Hemodialysis in Al-Ahsa Region, Saudi Arabia. Cureus. 2023 Oct 9;15(10):e46701.
10. Tian FF, Hall YN, Griffin S, Kranze T, Marcella D, Watnick S, O’Hare AM. The Complex Patchwork of Transportation for In-Center Hemodialysis. J Am Soc Nephrol. 2023 Oct 1;34(10):1621-1627.
11. Sinnathamby ES, Banh KT, Barham WT, Hernandez TD, De Witt AJ, Wenger DM, Klapper VG, McGregor D, Paladini A, Ahmadzadeh S, Shekoohi S, Kaye AD, Varrassi G. Hyperkalemia: Pharmacotherapies and Clinical Considerations. Cureus. 2024 Jan 26;16(1):e52994.
12. Costa D, Patella G, Provenzano M, Ielapi N, Faga T, Zicarelli M, Arturi F, Coppolino G, Bolignano D, De Sarro G, Bracale UM, De Nicola L, Chiodini P, Serra R, Andreucci M. Hyperkalemia in CKD: an overview of available therapeutic strategies. Front Med (Lausanne). 2023 Jul 31;10:1178140.
13. Xu D, Zhou B, Zhang J, Li C, Guan C, Liu Y, Li L, Li H, Cui L, Xu L, Liu H, Zhen L, Xu Y. Prediction of hyperkalemia in ESRD patients by identification of multiple leads and multiple features on ECG. Ren Fail. 2023 Dec;45(1):2212800.
14. Collister D, Pyne L, Bhasin AA, Smyth B, Herrington W, Jardine M, Mark PB, Badve S, Rossignol P, Dember LM, Wanner C, Ezekowitz J, Devereaux PJ, Parfrey P, Gansevoort R, Walsh M. Heart failure events in randomized controlled trials for adults receiving maintenance dialysis: a meta-epidemiologic study. Nephrol Dial Transplant. 2024 Jul 10:gfae156.
15. Hallgren C, Svensson CJ, Ullerstam T, Olin M, Dezfoolian H, Kashioulis P, Oras J. Validating a Simplified Lung Ultrasound Protocol for Detection and Quantification of Pulmonary Edema in Patients With Chronic Kidney Disease Receiving Maintenance Hemodialysis. J Ultrasound Med. 2023 Sep;42(9):2013-2021.
16. Gan T, Guan H, Li P, Huang X, Li Y, Zhang R, Li T. Risk prediction models for cardiovascular events in hemodialysis patients: A systematic review. Semin Dial. 2024 Mar-Apr;37(2):101-109.
17. Zhao X, Gan L, Niu Q, Hou FF, Liang X, Chen X, Chen Y, Zhao J, McCullough K, Ni Z, Zuo L. Clinical Outcomes in Patients on Hemodialysis with Congestive Heart Failure. Kidney Dis (Basel). 2023 Mar 3;9(4):306-316.