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ORIGINAL ARTICLE

Risk Factors of Emergency Hemodialysis

Yu-Wen Cheng, Min-Tsung Kao, Min-Nan Lai, Min-Yuan Chou, Shyi-Yu Chung, Chia-Sheng Chen
Department of Nephrology, China Medical College Hospital, Taichung, Taiwan, R.O.C.

O b j e c t i v e s . Emergency hemodialysis (HD) is a challenge to patients, their families and nephrologists. The majority of previous reports focused on the prognosis of acute renal failure, but acute renal failure is not the only indication for emergency HD in the emergency department (ED): chronic renal failure accounts for the majority of HD cases. The aim of this study was to analyze the risk factors of all patients who need emergency HD in ED. Methods. We retrospectively collected 90 emergency HD cases from July 1999 to August 2000. By analyzing their basic data, vital signs and laboratory data, we were able to determine the risk factors of emergency HD. Results. The mortality rate was 24.4%. The leading causes of death were septic shock, respiratory failure, and multiple organ failure. Thirty-seven patients had no history of hemodialysis, and they did not have significant mortality risk. Some of the indications for emergency HD did predict survival rate. For example, pulmonary edema was the benign factor but metabolic acidosis, uremic encephalopathy and intractable gastrointestinal upset were the predictors of mortality. Younger patients and those with a history of diabetes mellitus had good prognoses. Those who had received cardiopulmonary resuscitation (CPR) or mechanical ventilator therapy before emergency HD had poor prognoses. Metabolic acidosis, leukocytosis, high C-reactive protein and blood urea nitrogen levels were all poor prognostic factors. C o n c l u s i o n s . The main indicators of the need for patients receiving emergency HD were pulmonary edema, hyperkalemia, metabolic acidosis and uremic encephalopathy. The leading cause of death was septic shock. Risk factors of emergency HD included patients who were elderly, and those who received mechanical ventilator support and CPR; the indicators for dialysis were metabolic acidosis, uremic encephalopathy, and intractable GI upset; laboratory data indicators included leukocytosis, high C-reactive protein and blood urea nitrogen levels.
( Mid Taiwan J Med 2003;8:20-6)

Key words
emergency, hemodialysis, risk factor

INTRODUCTION

Arrangement of emergency hemodialysis (HD) is a challenge to nephrologists. They need to be able to immediately decide to arrange the procedure depending on the clinical condition regardless of whether it is a case of acute renal failure (ARF) or end stage renal failure (ESRF).
Received : August 19, 2002. Revised : October 22, 2002. Accepted : December 3, 2002. Address reprint requests to : Min-Tsung Kao, Department of Nephrology, China Medical College Hospital, 2 Yuh-der Road, Taichung 404, Taiwan, R.O.C

In clinical experience, patients with ESRF but not ARF accounted for the highest proportion of cases who needed emergency HD. However, most of the previous studies focused on acute renal failure, and analyzed the risk factors and prognoses. We knew that the mortality rate of ARF was from 46% [1] to 67.75% [2], but few articles have discussed the risk factors of all patients who received emergency HD. We aimed to evaluate the risk factors of all patients who required emergency HD in the

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Table 1. Indications of emergency hemodialysis Non-survival (N = 22) Indications n (%)

Pulmonary edema Hyperkalemia Metabolic acidosis Uremic encephalopathy Intractable GI upset Bleeding tendency Intoxication Multiple indications (%)

4 (18.2)* 10 (45.6) 13 (59.1) 14 (63.6) 3 (13.6) 1 (4.6) 0 14 (63.6)

Survival (N = 68) n (%) 39 (57.4) 23 (33.8) 18 (26.5) 15 (22.1) 4 (5.8) 4 (5.9) 3 (4.4) 26 (38.2)

0.001 NS 0.009 0.001 0.049 NS NS NS

*Data in the parentheses represent percentages. NS = not significant.

emergency department (ED) and to determine the causes of death.

MATERIALS AND METHODS

We reviewed the charts and laboratory data of 79 emergency HD patients from July 1999 to August 2000 in ED of China Medical College Hospital (Taichung, Taiwan). All patients received emergency HD and were evaluated by a nephrologist for at least one indication (Table 1). The laboratory data were collected before any therapeutic management, except for cardiopulmonary resuscitation (CPR) and oxygen supplementation. Pulmonary edema was diagnosed via chest X-ray by at least two physicians in the ED. Hyperkalemia was defined as serum potassium level > 5.5 meq/L. Metabolic acidosis was diagnosed when arterial blood gas (ABG) showed pH value < 7.35 and HCO3 20 mmol/L. Uremic encephalopathy was indicated when the Glasgow coma scale was < 15 points but the patient's consciousness was clear and there were no indications of intracranial anatomic problems. Intractable gastrointestinal (GI) upset was diagnosed when the patient presented with severe nausea and/or emesis with poor response to general medical therapy. The patients with bleeding tendency had active bleeding but normal platelet count, active partial prothromplastin time (aPTT) and international normalized ratio of prothrombin time (PT-INR). We referred to these patients who had more than one indication for emergency HD as having multiple indications.

There were two chronic HD patients who were on HD schedule due to haloperidol, or estazolam intoxication. Emergency HD was arranged for one patient with no prior history of HD because of insecticide intoxication. In this study, the patients in the survival group were discharged from our hospital without distress. The patients in the non-survival group represented those patients who died during hospitalization. Statistical significance was calculated for differences between means by unpaired t test and for observed/expected frequencies by chi-square test. P value < 0.05 was considered significant. All values are expressed as mean SE or percentage.
RESULTS

In these 79 patients, a total of 90 emergency HD were performed. One patient received emergency HD 3 times and nine patients received emergency HD twice during these 14 months. A total of 22 patients died; the mortality rate was 24.4%. The causes of mortality are shown in Fig. 1. Thirty-seven patients (41%) were new cases (had no history of HD). The others received regular dialysis; the average dialysis time was 32 months (from one week to 12 years). Only four patients recovered and needed no further renal replacement therapy during hospitalization. The chief complaints of these patients in our ED are listed in Fig. 2. Shortness of breath and change in consciousness were the major complaints. However, 22 patients had more than one simultaneous complaint. The indications for

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Risk Factors of Emergency HD

Table 2. Basic data, history and vital signs of patients

Non-survival (n = 22) Age (yr) Female DM history New HD cases Mechanical ventilator CPR in ED Systolic BP (mmHg)** Diastolic BP (mmHg)** Heart rate (/min) Body temperature (C) 70.0 13.6 13 (59.1%)* 5 (22.7%) 13 (59.1%) 11 (50.0%) 5 (22.7%) 155.1 38.2 77.3 22.3 94.9 27.8 36.1 1.2

Survival (n = 68) 60.1 14.9 45 (66.1%) 33 (48.5%) 24 (35.3%) 6 (8.82%) 0 169.5 41.6 89.0 23.8 97.8 26.2 36.1 1.5

0.012 NS 0.047 NS 0.001 0.001 NS NS NS NS

*Data in the parentheses represent percentages; **Excluded two patients whose blood pressures were undetectable in emergency department. NS = not significant.

Fig. 1. Causes of death.

Fig. 2. Chief complaints of the patients who needed emergency hemodialysis in emergency department. Others included: general weakness, legs numbness and abdominal pain.

emergency HD are listed in Table 1. The indications predicted the prognosis of the patients. The results of emergency HD due to metabolic acidosis (p = 0.009), uremic encephalopathy (p = 0.001), and intractable gastrointestinal (GI) upset (p = 0.049) were poor. Pulmonary edema usually indicated a good survival rate ( p = 0.001). Hyperkalemia, bleeding tendency, intoxication or the multiple indications did not affect the prognosis of the patients. According to the basic data (Table 2), aging was a risk factor. The difference in average age between patients in the survival and non-survival groups was as much as ten years (60.1 vs 70.0 years, p = 0.012). There was no difference between genders, and history of HD was not significant. Patients with a history of diabetes mellitus (DM) had better outcomes than those without DM ( p = 0.047). The conditions of

patients in the ED also were important. Prognosis tended to be poor if the patients had undergone CPR ( p = 0.001), or had been supported by mechanical ventilator (p < 0.001). Heart rate, blood pressure, and body temperature of the patients in ED did not provide significant information for predicting survival. According to the laboratory data (Table 3), both high C-reactive protein (CRP) (p < 0.001) and white blood cell count (WBC) (p = 0.002) were negative predictors. The ABG provided some prediction of survival of patients. Low carbon dioxide (p = 0.026) and bicarbonate levels ( p = 0.012) were both risk factors to patients undergoing emergency HD. Oxygen saturation and pH values were not predictive factors. High blood urine nitrogen (BUN) was a poor predictive factor ( p = 0.049), while creatinine was not a predictor.

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Table 3. Laboratory data of patients N 72 pH value 72 PCO2 (mmHg) 72 HCO3 (mmol/L) 72 SaO2 (%) 89 WBC (/L) 32 CRP (mg/dL) 89 Hb (g/dL) 88 Platelet (/L) 89 BUN (mg/dL) 89 Creatinine (mg/dL) 89 Potassium (meq/L)

Non-survival 7.23 0.3 26.5 11.4 13.1 8.4 94.9 5.6 15336 9007 6.5 4.6 8.5 2.2 202995 149283 112.9 51.1 9.7 4.5 5.5 1.6

Survival 7.31 0.1 34.3 14.0 17.8 6.2 92.7 7.6 10660 4518 1.0 1.2 9.3 1.9 212253 91651 89.2 47.2 9.9 4.3 5.3 1.3

NS 0.026 0.012 NS 0.002 < 0.001 NS NS 0.049 NS NS

NS = not significant.

DISCUSSION

When patients presented with critical conditions and needed emergency HD, their conditions were similar to the ARF patients regardless of previous HD. Two studies stated that the mortality rate of ARF is about 46% [1] to 67.75% [2]. The mortality rate in this study was found to be 24.4%. The mortality rate in our study was lower than others because the majority of our patients went to the ED earlier since they had undergone HD for many years and were well educated about when they should visit the ED. In studies of ARF [1,2], the patients usually had many uncontrolled underlying diseases and the majority of these patients had not been educated to visit the hospital on time. Complete differential diagnosis between acute and chronic renal failure is always difficult because sometimes there is not enough time or there are too few clues for us to make a diagnosis. For these reasons, some misdiagnoses were not preventable in our study. More aggressive diagnostic tools should be used to differentiate acute from chronic renal failure in further studies. Sacchetti et al [3] reported that common complaints of chronic HD patients in the ED included shortness of breath, chest pain, abdominal pain and vomiting. Our patients not only had the same complaints, but also complained of consciousness change. Consciousness change in renal failure patients may result from uremic encephalopathy, which usually develops because of uremic toxin

accumulation in the central nervous system which interferes with its metabolism. In our study, it was interesting to note that pulmonary edema indicated a better prognosis than other indications did. Pulmonary edema caused shortness of breath which usually made the patients very uncomfortable, and caused them to visit the hospital earlier. Metabolic acidosis and uremic encephalopathy both progressed too slowly to serve as indicators. Patients who suffered from GI upset usually visited the ED after trying many kinds of medication. Therefore, HD was delayed. Since the diseases were not controlled on time, the patients had poor prognoses. Advanced age was a poor prognostic factor for both patients with ARF [2,3] and ESRF [4-10] patients. Whether or not gender was a risk factor for long-term HD patients has still not been determined. Avram et al [7] stated that males have good prognosis because the average age of male patients in their study was younger. But Iseki et al [11] had the opposite opinion. The conclusion of Nicolucci et al [6] was that there was no difference between genders. We also found that gender was not significant to predict survival. Most studies have claimed that chronic HD patients with DM history have poor prognoses [5,9-15]. However, our results contradicted those reports. Why did the DM patients who needed emergency HD have higher survival rates in our study? We believe that chronic HD patients with DM often die due to cardiovascular disease or

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Risk Factors of Emergency HD

stroke. These diseases often develop very acutely and do not allow patients a chance to arrive at the hospital and receive HD on time. Those DM patients who have the opportunity to receive emergency HD usually have mild problems. Therefore DM history is a benign factor for emergency HD. If patients need CPR or mechanical ventilator support before HD, their conditions must be very poor, so the prediction of mortality is significant. Chertow et al [16] also found that using mechanical ventilator was associated with in-hospital mortality in ARF patients. According to the laboratory data, low bicarbonate and low carbon dioxide levels were evidence of metabolic acidosis with compensation which indicated to us that metabolic acidosis had developed for a long time in the patients. Since the diseases had been delayed, they usually had poor survival rates. Oxygen saturation was non-specific in our study because some critical patients had used oxygen before ABG was available. In a few studies, anemia was a risk factor for chronic HD because anemia increased the chance of heart failure [17-19]. However, according to our data, anemia was not a significant factor to predict survival. In our study, emergency HD usually was the result of inadequate dialysis (pulmonary edema and hyperkalemia were the leading indications) and not due to chronic uremic complications. Furthermore, some patients in our study had ARF. These patients usually were not anemic but they belonged to high-risk group. Therefore, anemia was not an important risk predictor. In our study, the average WBC count was higher than 10,000 L in both groups. Because those patients in the ED were under stress, demargination of leukocytes developed. Patients in the non-survival group had higher WBC counts and CRP levels than those in the survival group which confirmed that the leading cause of death in our study was septic shock. In chronic HD patients, high CRP levels indicated malnutrition, so high CRP levels correlated to a poor prognosis [20].

The non-survival group had higher BUN levels than those in the survival group, but the creatinine levels were not significant in either group. Yeun et al [20] reported that BUN and creatinine were not predictors of death in chronic HD because BUN and creatinine represent low molecular weight uremic toxins. Inadequate dialysis often results in high serum BUN and creatinine levels. Low creatinine levels are associated with high death risk [7,9,14,15] because they imply low lean body weight and poor nutrition. Patients with inadequate dialysis and poor nutrition visit the ED frequently and their laboratory data usually show high BUN but variable creatinine levels. Potassium was not found to be a risk factor though it was an indication for emergency HD. The main problem with hyperkalemia is arrhythmia, but medication and HD are able to control hyperkalemia rapidly. Septic shock was the major cause of death in our study, a finding similar to that made by Barretti et al [21]. They reported that the causes of death in patients with ARF were sepsis, respiratory failure, and multiple organ failure. However, 50% of chronic hemodialysis patients die of cardiovascular diseases while infection is the second cause of death. Since the majority of our patients had chronic renal failure, why were the causes of death similar to those of ARF? As previously mentioned, the development of cardiovascular diseases is usually very quick, but sepsis progresses slowly. Patients with the latter disease have time to receive HD therapy; however the chance of death by sepsis is the same. Patients with cardiovascular diseases often receive therapy too late. Furthermore, the death of some of our new HD patients who had ARF was caused by septic shock. Arbitrary selection of patients for ED HD was the limitation of this study. As a retrospective report, the only patients included were those who received emergency HD. A prospective study will be required to identify those criteria which can objectively define patients in need of hemodialysis and which can analyze those who refuse emergent HD but match the criteria.

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In conclusion, the main indications for patients receiving emergency HD were pulmonary edema, hyperkalemia, metabolic acidosis and uremic encephalopathy. The leading cause of death was septic shock. The risk factors of emergency HD were age, mechanical ventilator support, and CPR; the dialysis indications were metabolic acidosis, uremic encephalopathy, and intractable GI upset; laboratory data indications were leukocytosis, high C-reactive protein and blood urea nitrogen levels.
REFERENCES

1. Frost L, Pedersen RS, Bentzen S, et al. Short and long term outcome in a consecutive series of 419 patients with acute dialysis-requiring renal failure. Scand J Urol Nephrol 1993;27:453-62. 2. Yeh JC, Lin TS, Chen HS. Risk factors of non-hospital acquired acute renal failure-analysis of 552 cases presented as initial diagnosis at emergency room. Acta Nephrol Taiwan Soc 1999;13:9-13. 3. Sacchetti A, Harris R, Patel K, et al. Emergency department presentation of renal dialysis patients: indications for EMS transport directly to dialysis centers. J Emerg Med 1991;9:141-4. 4. Goldwasser P, Mittman N, Antignani A, et al. Predictors of mortality in hemodialysis patients. J Am Soc Nephrol 1993;3:1613-22. 5. McClellan WM, Flanders WD, Gutman RA. Variable mortality rates among dialysis treatment centers. Ann Intern Med 1992;117:332-6. 6. Nicolucci A, Cubasso D, Labbrozzi D, et al. Effect of coexistent diseases on survival of patients undergoing dialysis. ASAIO J 1992;38:291-5. 7. Avram MM, Bonomini LV, Sreedhara R, et al. Predictive value of nutritional markers (albumin, creatinine, cholesterol, and hematocrit) for patients on dialysis for up to 30 years. Am J Kidney Dis 1996; 28:910-7. 8. De Lima JJ, Sesso R, Abensur H, et al. Predictors of mortality in long-term haemodialysis patients with a low prevalence of comorbid conditions. Nephrol Dial Transplant 1995;10:1708-13.

9. Lowrie EG, Lew NL. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990;15:458-82. 10. Tomita J, Kimura G, Inoue T, et al. Role of systolic blood pressure in determining prognosis of hemodialyzed patients. Am J Kidney Dis 1995;25:40512. 11. Iseki K, Kawazoe N, Osawa A, et al. Survival analysis of dialysis patients in Okinawa, Japan (1971-1990). Kidney Int 1993;43:404-9. 12. Miles AM, Friedman EA. Dialytic therapy for diabetic patients with terminal renal failure. [Review] Curr Opin Nephrol Hypertens 1993;2:868-75. 13. Brogan D, Kutner NG, Flagg E. Survival differences among older dialysis patients in the southeast. Am J Kidney Dis 1992;20:376-86. 14. Avram MM, Mittman N, Bonomini L, et al. Markers for survival in dialysis: a seven-year prospective study. Am J Kidney Dis 1995;26:209-19. 15. Lowrie EG, Lew NL, Huang WH. Race and diabetes as death risk predictors in hemodialysis patients. Kidney Int Suppl 1992;38:22-31. 16.Chertow GM, Christiansen CL, Cleary PD, et al. Prognostic stratification in critically ill patients with acute renal failure requiring dialysis. Arch Intern Med 1995;155:1505-11. 17.Harnett JD, Kent GM, Foley RN, et al. Cardiac function and hematocrit level. Am J Kidney Dis 1995;25(4 Suppl 1):3-7. 18. Harnett JD, Foley RN, Kent GM, et al. Congestive heart failure in dialysis patients: prevalence, incidence, prognosis and risk factors. Kidney Int 1995;47:884-90. 19. Foley RN, Parfrey PS, Harnett JD, et al. The impact of anemia on cardiomyopathy, morbidity, and mortality in end-stage renal disease. Am J Kidney Dis 1996; 28:53-61. 20. Yeun JY, Levine RA, Mantadilok V, et al. C-Reactive protein predicts all-cause and cardiovascular mortality in hemodialysis patients. Am J Kidney Dis 2000; 35:469-76. 21. Barretti P, Soares VA. Acute renal failure: clinical outcome and causes of death. Ren fail 1997;19:253-7.

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1999 24.4%

2000

90 37

C
2003;8:20-6

404 2002 2002 8 12 19 3

2 2002 10 22