A 55-year-old man with a history of chronic kidney disease presents to the emergency department with shortness of breath and swelling in his legs for the past 3 days. He has missed his last two dialysis sessions. Vital signs are temperature 98.7°F (37.0°C), blood pressure 148/92 mmHg, pulse 93 beats/min, and respirations 22/min. On physical examination, he has pitting edema up to his knees, tachycardia, and crackles heard on lung auscultation. Laboratory results show a potassium level of 7.0 mEq/L, a blood pH of 7.1, and elevated blood urea nitrogen (BUN) and creatinine levels.
Which of the following is the most appropriate next step in the management of this patient?
B) Initiate emergency dialysis
Indications for dialysis in a patient with renal failure can be remembered by the AEIOU mnemonic:
- Acidosis: Severe metabolic acidosis typically with a pH <7.2
- Electrolytes: Hyperkalemia with a potassium level above 6.5 mEq/L
- Ingestion: Ingestion of a dialyzable drug or toxin
- Overload: Fluid overload
- Uremia: Symptoms of uremia such as pericarditis, encephalopathy, or severe nausea/vomiting
This patient presents with severe hyperkalemia (potassium level of 7.0 mEq/L), severe metabolic acidosis (pH of 7.1), and fluid overload, all of which are indications for emergency dialysis.
Answer choice A: Administer intravenous diuretics, is incorrect. While diuretics may help with fluid overload, they are not sufficient to address the severe hyperkalemia and acidosis in this patient.
Answer choice C: Monitor and recheck labs in 24 hours, is incorrect. This approach is inappropriate given the severity of the patient's condition, which requires immediate intervention.
Answer choice D: Prescribe oral potassium binders, is incorrect. Oral potassium binders may help lower potassium levels but are not appropriate for immediate management of severe hyperkalemia.
Answer choice E: Start bicarbonate therapy, is incorrect. Bicarbonate therapy may help with acidosis but is not sufficient to address the severe hyperkalemia and fluid overload.
Key Learning Point
Indications for dialysis in a patient with renal failure can be remembered by the AEIOU mnemonic: acidosis (a severe metabolic acidosis typically with a pH <7.2), electrolytes (hyperkalemia with a potassium level above 6.5 mEq/L), ingestion of a dialyzable drug or toxin, overload (fluid overload), and uremia.
