Chronic kidney disease - Revision history

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Medication Safety in the ED

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	*Caution: sodium bicarbonate can worsen volume overload and cause [[hypocalcemia]] (ionized calcium drops as pH rises)		*Caution: sodium bicarbonate can worsen volume overload and cause [[hypocalcemia]] (ionized calcium drops as pH rises)

	===Medication Safety ~~in the ED~~===		===Medication Safety===
	'''''Critical drug dosing considerations in CKD:'''''		'''''Critical drug dosing considerations in CKD:'''''
	*[[NSAIDs]]: '''Avoid''' in CKD G3-5 — worsen renal function, cause hyperkalemia, fluid retention, GI bleeding		*[[NSAIDs]]: '''Avoid''' in CKD G3-5 — worsen renal function, cause hyperkalemia, fluid retention, GI bleeding

Ostermayer: /* Clinical Features */

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Clinical Features

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	*Dialysis access complications — thrombosed fistula/graft, access infection, dialysis catheter malfunction, steal syndrome		*Dialysis access complications — thrombosed fistula/graft, access infection, dialysis catheter malfunction, steal syndrome
	*Medication-related adverse effects — drug accumulation due to impaired clearance		*Medication-related adverse effects — drug accumulation due to impaired clearance

	~~===Uremic Syndrome===~~
	~~''Consider when eGFR <15 or BUN >80-100 mg/dL; however, symptoms correlate poorly with lab values''~~
	*GI: nausea, vomiting, anorexia, uremic fetor (ammonia breath), metallic taste, GI bleeding
	*Neurologic: [[altered mental status]], lethargy, [[asterixis]], myoclonus, [[seizures]], peripheral neuropathy, restless legs
	*Cardiovascular: [[pericarditis]] / [[pericardial effusion]] (uremic pericarditis — friction rub; '''indication for emergent dialysis'''), [[hypertension]], accelerated atherosclerosis
	*Hematologic: platelet dysfunction (uremic bleeding), anemia
	*Dermatologic: pruritus, uremic frost (rare, late finding), sallow/yellow skin color
	*Immune: impaired cellular immunity → increased susceptibility to infection

	==Differential Diagnosis==		==Differential Diagnosis==

Ostermayer: /* Reasons CKD Patients Present to the ED */

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Reasons CKD Patients Present to the ED

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	==Clinical Features==		==Clinical Features==
	~~===Reasons CKD Patients Present to the ED===~~
	*Volume overload / [[congestive heart failure]] — dyspnea, edema, hypertensive emergency		*Volume overload / [[congestive heart failure]] — dyspnea, edema, hypertensive emergency
	*[[Hyperkalemia]] — medication-related (ACEi, ARB, SGLT2i, spironolactone, trimethoprim), dietary, missed dialysis, metabolic acidosis		*[[Hyperkalemia]] — medication-related (ACEi, ARB, SGLT2i, spironolactone, trimethoprim), dietary, missed dialysis, metabolic acidosis

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Ostermayer: Created page with "==Background== Chronic kidney disease (CKD) is defined as abnormalities in kidney structure or function present for '''≥3 months''' with implications for healthKidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314. Affects ~37 million adults in the United States; the majority are unaware of thei..."

2026-03-10T00:59:17Z

Created page with "==Background== *Chronic kidney disease (CKD) is defined as abnormalities in kidney structure or function present for '''≥3 months''' with implications for health<ref name="KDIGO2024">Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.</ref> *Affects ~37 million adults in the United States; the majority are unaware of thei..."

New page

==Background==
*Chronic kidney disease (CKD) is defined as abnormalities in kidney structure or function present for '''≥3 months''' with implications for health<ref name="KDIGO2024">Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.</ref>
*Affects ~37 million adults in the United States; the majority are unaware of their diagnosis<ref name="KDIGO2024"/>
*Most common causes: [[diabetes mellitus]] (~40%), [[hypertension]] (~30%), glomerulonephritis, polycystic kidney disease
*CKD is a '''major independent risk factor for cardiovascular disease''' — most patients with CKD die of cardiovascular events, not kidney failure
*CKD patients present to the ED frequently — often for complications of CKD rather than the kidney disease itself

===KDIGO Staging===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Stage'''
| align="center" style="background:#f0f0f0;"|'''eGFR (mL/min/1.73m²)'''
| align="center" style="background:#f0f0f0;"|'''Description'''
|-
| G1 || ≥90 || Normal or high (CKD if other markers of kidney damage present)
|-
| G2 || 60-89 || Mildly decreased
|-
| G3a || 45-59 || Mildly to moderately decreased
|-
| G3b || 30-44 || Moderately to severely decreased
|-
| G4 || 15-29 || Severely decreased
|-
| G5 || <15 || Kidney failure (may require dialysis or transplant)
|}

*CKD also staged by '''albuminuria category:''' A1 (<30 mg/g), A2 (30-300 mg/g), A3 (>300 mg/g)
*Both eGFR and albuminuria predict risk of progression and cardiovascular events
*'''KDIGO 2024 update:''' Recommends creatinine-based eGFR (CKD-EPI 2021 equation without race); add cystatin C when eGFR creatinine may be inaccurate (extremes of muscle mass, amputation, cirrhosis)<ref name="KDIGO2024"/>

==Clinical Features==
===Reasons CKD Patients Present to the ED===
*'''Volume overload / [[congestive heart failure]]''' — dyspnea, edema, hypertensive emergency
*'''[[Hyperkalemia]]''' — medication-related (ACEi, ARB, SGLT2i, spironolactone, trimethoprim), dietary, missed dialysis, metabolic acidosis
*'''Uremic symptoms''' — nausea, vomiting, anorexia, fatigue, pruritus, [[altered mental status]], [[seizures]], pericarditis
*'''Infections''' — CKD patients are immunocompromised; UTI, [[pneumonia]], vascular access infections, [[peritonitis]] (peritoneal dialysis)
*'''[[Acute kidney injury]]''' (AKI on CKD) — dehydration, nephrotoxins, obstruction, sepsis
*'''Cardiovascular events''' — [[acute coronary syndrome]], [[stroke]], peripheral vascular disease (risk 2-10× higher than general population)
*'''Electrolyte disorders''' — [[hyperkalemia]], [[hyperphosphatemia]], [[hypocalcemia]], [[metabolic acidosis]]
*'''Anemia exacerbation''' — GI bleeding, erythropoietin deficiency, iron deficiency
*'''Dialysis access complications''' — thrombosed fistula/graft, access infection, dialysis catheter malfunction, steal syndrome
*'''Medication-related adverse effects''' — drug accumulation due to impaired clearance

===Uremic Syndrome===
''Consider when eGFR <15 or BUN >80-100 mg/dL; however, symptoms correlate poorly with lab values''
*'''GI:''' nausea, vomiting, anorexia, uremic fetor (ammonia breath), metallic taste, GI bleeding
*'''Neurologic:''' [[altered mental status]], lethargy, [[asterixis]], myoclonus, [[seizures]], peripheral neuropathy, restless legs
*'''Cardiovascular:''' [[pericarditis]] / [[pericardial effusion]] (uremic pericarditis — friction rub; '''indication for emergent dialysis'''), [[hypertension]], accelerated atherosclerosis
*'''Hematologic:''' platelet dysfunction (uremic bleeding), anemia
*'''Dermatologic:''' pruritus, uremic frost (rare, late finding), sallow/yellow skin color
*'''Immune:''' impaired cellular immunity → increased susceptibility to infection

==Differential Diagnosis==
''When evaluating a CKD patient with acute decompensation, consider:''
*'''AKI on CKD''' — reversible causes should always be sought (dehydration, obstruction, nephrotoxins, sepsis)
*'''Volume overload:''' [[Congestive heart failure]], nephrotic syndrome, cirrhosis, medication non-compliance
*'''[[Hyperkalemia]]:''' Medication-related, dietary, missed dialysis, tissue breakdown, metabolic acidosis
*'''Infection/[[sepsis]]:''' UTI, pneumonia, dialysis access infection, peritonitis (PD patients)
*'''Cardiovascular:''' [[Acute coronary syndrome]] (CKD patients may have atypical presentations), [[hypertensive emergency]], [[pericardial effusion and tamponade|uremic pericarditis/tamponade]]
*'''Uremic encephalopathy:''' Diagnosis of exclusion — rule out other causes of AMS ([[hypoglycemia]], [[stroke]], [[sepsis]], drug toxicity, [[electrolyte abnormalities]])
*'''Drug accumulation/toxicity:''' Medications not dose-adjusted for renal function (opioids, gabapentin, antibiotics, metformin, lithium, digoxin)
*'''GI bleeding:''' Platelet dysfunction + anticoagulant use + angiodysplasia (common in CKD)

==Evaluation==
===Workup===
;Standard Labs:
*'''BMP''' — creatinine (compare to baseline), BUN, potassium, bicarbonate, calcium, glucose
*'''CBC''' — anemia (normocytic, from erythropoietin deficiency), platelet count
*'''Magnesium, phosphorus''' — hyperphosphatemia and hypomagnesemia are common
*'''[[VBG]] or [[ABG]]''' — assess for [[metabolic acidosis]] (non-anion gap from impaired H⁺ excretion ± anion gap from uremic toxins)
*'''[[Urinalysis]]''' — proteinuria, hematuria, casts (assess for active glomerulonephritis or UTI)
*'''[[Lactate]]''' — if concern for sepsis or tissue hypoperfusion
*'''Coagulation studies''' — if bleeding, uremic platelet dysfunction, or DIC suspected
*'''[[Troponin]]''' — chronic elevation is common in CKD (especially on dialysis); interpret '''in the context of symptoms and trending''' rather than a single value

;If AKI on CKD Suspected:
*'''Renal [[ultrasound]]''' — assess kidney size (small echogenic kidneys = chronic disease), hydronephrosis (obstruction), renal vein thrombosis
*'''Bladder scan / post-void residual''' — if obstruction suspected
*'''Fractional excretion of sodium (FENa)''' or FEUrea (if on diuretics) — prerenal vs. intrinsic
*'''Urine electrolytes, urine protein-to-creatinine ratio'''

;Targeted:
*'''[[ECG]]''' — '''mandatory in all CKD presentations''' — evaluate for [[hyperkalemia]] (peaked T waves, widened QRS, sine wave), ischemia, pericarditis (diffuse ST elevation)
*'''[[CXR]]''' — pulmonary edema, pleural effusion, pericardial effusion, pneumonia
*'''[[Blood cultures]]''' — if febrile (low threshold for blood cultures in dialysis patients and those with indwelling catheters)

===Diagnosis===
*CKD itself is usually an established diagnosis — the ED role is to identify '''acute complications''' and '''reversible causes of decompensation'''
*'''Always compare creatinine to baseline''' — a patient with baseline creatinine 3.0 who presents at 3.2 is very different from one presenting at 6.0
*Determine if the patient has a '''nephrology provider''' and whether they are '''on dialysis''' (and when their last session was)
*'''CKD is confirmed''' (not just diagnosed in the ED) when kidney damage or decreased function has been present for ≥3 months — a single elevated creatinine may represent AKI, not CKD<ref name="KDIGO2024"/>

==Management==
===Life-Threatening Emergencies===
;[[Hyperkalemia]] (K⁺ >5.5 mEq/L):
*'''ECG changes present or K⁺ >6.5:'''
**'''Calcium gluconate''' 10% 10 mL (or calcium chloride via central line) IV over 2-3 min — '''cardiac membrane stabilization''' (does not lower K⁺)
**'''Regular [[insulin]]''' 10 units IV + '''[[dextrose]]''' 25g (D50W) IV — shifts K⁺ intracellularly
**'''Albuterol''' 10-20 mg nebulized — additional K⁺ shift
**'''[[Sodium bicarbonate]]''' 50-100 mEq IV — if concurrent metabolic acidosis (effect on K⁺ is modest)
**'''Kayexalate''' (sodium polystyrene sulfonate) 15-30g PO or '''Patiromer''' or '''Sodium zirconium cyclosilicate (Lokelma)''' — true K⁺ elimination (delayed onset)
**'''Emergent [[dialysis]]''' — definitive treatment for severe/refractory hyperkalemia in CKD/ESRD
*See [[Hyperkalemia]] for full management

;Uremic Pericarditis:
*Friction rub + chest pain + uremia = '''indication for emergent dialysis'''
*'''Avoid anticoagulation''' (risk of hemorrhagic pericardial effusion → tamponade)
*If hemodynamic compromise → evaluate for [[pericardial effusion and tamponade|tamponade]] → [[pericardiocentesis]] if indicated

;Pulmonary Edema / Volume Overload:
*'''[[NIV]]''' ([[BiPAP]]) for respiratory distress
*'''IV [[nitroglycerin]]''' for afterload reduction if hypertensive
*'''IV [[furosemide]]''' — CKD patients require higher doses (start 40-80mg IV for CKD G3-4; 80-200mg IV for G5/ESRD); may be ineffective in ESRD
*'''Emergent [[dialysis]]''' (ultrafiltration) if refractory to medical management or anuric
*See [[Congestive heart failure]]

;Severe Metabolic Acidosis:
*'''Sodium bicarbonate''' IV if pH <7.1 or bicarbonate <8-10 mEq/L with hemodynamic instability
*'''Dialysis''' for severe refractory acidosis
*Caution: sodium bicarbonate can worsen volume overload and cause [[hypocalcemia]] (ionized calcium drops as pH rises)

===Medication Safety in the ED===
'''''Critical drug dosing considerations in CKD:'''''
*'''[[NSAIDs]]:''' '''Avoid''' in CKD G3-5 — worsen renal function, cause hyperkalemia, fluid retention, GI bleeding
*'''[[Metformin]]:''' Contraindicated when eGFR <30; hold when eGFR 30-45 if acutely ill; risk of [[lactic acidosis]]
*'''Opioids:''' [[Morphine]] — '''avoid''' (active metabolite accumulates → prolonged sedation/respiratory depression); use [[fentanyl]] or [[hydromorphone]] (safer in CKD). [[Meperidine]] — '''avoid''' (normeperidine accumulation → seizures)
*'''[[Gabapentin]]/[[pregabalin]]:''' Dose reduce; accumulation causes sedation, [[altered mental status]], myoclonus
*'''Antibiotics:''' Many require dose adjustment — particularly [[vancomycin]] (dose by levels/AUC), aminoglycosides (avoid if possible), [[nitrofurantoin]] (ineffective and neurotoxic in CKD G4-5)
*'''[[Enoxaparin]]:''' If eGFR <30, use '''unfractionated heparin''' instead, or reduce enoxaparin dose (1 mg/kg daily instead of BID) with anti-Xa monitoring
*'''Contrast:''' IV iodinated contrast can be given when clinically indicated (e.g., CT angiography for PE, stroke) — '''do not withhold life-saving imaging''' for CKD; hydrate with IV crystalloid before and after; hold metformin for 48h after contrast if eGFR <30
*'''ACEi/ARB:''' Hold during acute illness, dehydration, or AKI ("sick day rules"); do not start or uptitrate in the ED during acute presentations
*'''Potassium-sparing medications:''' Review and hold [[spironolactone]], [[amiloride]], [[triamterene]], [[trimethoprim]] if hyperkalemic

===Dialysis-Specific Considerations===
*Determine '''modality''' (hemodialysis vs. peritoneal dialysis), '''schedule''', and '''when last session occurred'''
*'''Missed dialysis:''' Common ED presentation; check K⁺, bicarbonate, volume status; arrange urgent dialysis
*'''Dialysis access:'''
**'''Do not''' use an AV fistula or graft for blood draws, IV access, or blood pressure measurement
**'''Do not''' place a blood pressure cuff on the access arm
**Assess fistula/graft for '''thrill''' (palpable) and '''bruit''' (auscultate) — absence suggests thrombosis → vascular surgery or interventional radiology consultation
*'''Peritoneal dialysis peritonitis:''' Cloudy PD effluent + abdominal pain ± fever; send PD fluid for cell count (WBC >100/µL with >50% neutrophils), Gram stain, and culture; initiate empiric IP antibiotics (typically IP vancomycin + IP ceftazidime or gentamicin per local protocol) after consulting nephrology
*'''Dialysis catheter infection:''' Blood cultures from catheter AND peripheral site; empiric IV [[vancomycin]] + gram-negative coverage; consult nephrology regarding catheter removal vs. salvage

==Disposition==
===Admit===
*'''Hyperkalemia''' with ECG changes, K⁺ >6.5, or refractory to ED treatment
*'''Pulmonary edema/volume overload''' requiring dialysis or not responding to diuretics
*'''Uremic pericarditis''' or pericardial effusion with hemodynamic concern
*'''Uremic encephalopathy''' or severe uremic symptoms
*'''Severe metabolic acidosis''' (pH <7.2, bicarbonate <10)
*'''AKI on CKD''' with significant creatinine rise from baseline and no readily reversible cause
*'''Sepsis''' or serious infection (especially dialysis access infection, PD peritonitis)
*'''Need for emergent or urgent dialysis'''
*'''New diagnosis of ESRD''' requiring dialysis initiation

===Discharge with Close Follow-Up===
*Mild hyperkalemia (K⁺ 5.5-6.0, no ECG changes) corrected in ED with dietary counseling, medication adjustment, and follow-up within 24-48 hours
*Stable CKD with minor medication-related issue (dose adjustment made)
*Mild volume overload responsive to diuretic adjustment
*'''Ensure:''' Nephrology follow-up arranged, medication list reconciled, "sick day rules" reviewed (hold ACEi/ARB, metformin, NSAIDs, diuretics during acute illness/dehydration)

==See Also==
*[[Acute kidney injury]]
*[[Hyperkalemia]]
*[[Metabolic acidosis]]
*[[Congestive heart failure]]
*[[Dialysis complications]]
*[[Pericardial effusion and tamponade]]
*[[Hypertensive emergency]]
*[[Uremic encephalopathy]]

==External Links==
*[https://www.kidney-international.org/article/S0085-2538(23)00766-4/fulltext KDIGO 2024 CKD Guideline (Full Text)]
*[https://www.mdcalc.com/calc/43/creatinine-clearance-cockcroft-gault-equation MDCalc - Cockcroft-Gault Equation]
*[https://www.mdcalc.com/calc/3939/ckd-epi-equations-glomerular-filtration-rate-gfr MDCalc - CKD-EPI eGFR Calculator]

==References==
{{reflist|2}}

[[Category:Renal]]

[[Category:Renal]]

← Older revision		Revision as of 09:36, 22 March 2026
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	==Background==		==Background==
	*Chronic kidney disease (CKD) is defined as abnormalities in kidney structure or function present for ~~'''~~≥3 months~~'''~~ with implications for health<ref name="KDIGO2024">Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.</ref>		*Chronic kidney disease (CKD) is defined as abnormalities in kidney structure or function present for ≥3 months with implications for health<ref name="KDIGO2024">Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2024;105(4S):S117-S314.</ref>
	*Affects ~37 million adults in the United States; the majority are unaware of their diagnosis<ref name="KDIGO2024"/>		*Affects ~37 million adults in the United States; the majority are unaware of their diagnosis<ref name="KDIGO2024"/>
	*Most common causes: [[diabetes mellitus]] (~40%), [[hypertension]] (~30%), glomerulonephritis, polycystic kidney disease		*Most common causes: [[diabetes mellitus]] (~40%), [[hypertension]] (~30%), glomerulonephritis, polycystic kidney disease
	*CKD is a ~~'''~~major independent risk factor for cardiovascular disease~~'''~~ — most patients with CKD die of cardiovascular events, not kidney failure		*CKD is a major independent risk factor for cardiovascular disease — most patients with CKD die of cardiovascular events, not kidney failure
	*CKD patients present to the ED frequently — often for complications of CKD rather than the kidney disease itself		*CKD patients present to the ED frequently — often for complications of CKD rather than the kidney disease itself

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	\|}		\|}

	*CKD also staged by ~~'''~~albuminuria category:~~'''~~ A1 (<30 mg/g), A2 (30-300 mg/g), A3 (>300 mg/g)		*CKD also staged by albuminuria category: A1 (<30 mg/g), A2 (30-300 mg/g), A3 (>300 mg/g)
	*Both eGFR and albuminuria predict risk of progression and cardiovascular events		*Both eGFR and albuminuria predict risk of progression and cardiovascular events
	*KDIGO 2024 update: Recommends creatinine-based eGFR (CKD-EPI 2021 equation without race); add cystatin C when eGFR creatinine may be inaccurate (extremes of muscle mass, amputation, cirrhosis)<ref name="KDIGO2024"/>		*KDIGO 2024 update: Recommends creatinine-based eGFR (CKD-EPI 2021 equation without race); add cystatin C when eGFR creatinine may be inaccurate (extremes of muscle mass, amputation, cirrhosis)<ref name="KDIGO2024"/>
Line 62:		Line 62:
	*[[Lactate]] — if concern for sepsis or tissue hypoperfusion		*[[Lactate]] — if concern for sepsis or tissue hypoperfusion
	*Coagulation studies — if bleeding, uremic platelet dysfunction, or DIC suspected		*Coagulation studies — if bleeding, uremic platelet dysfunction, or DIC suspected
	*[[Troponin]] — chronic elevation is common in CKD (especially on dialysis); interpret ~~'''~~in the context of symptoms and trending~~'''~~ rather than a single value		*[[Troponin]] — chronic elevation is common in CKD (especially on dialysis); interpret in the context of symptoms and trending rather than a single value

	;If AKI on CKD Suspected:		;If AKI on CKD Suspected:
Line 71:		Line 71:

	;Targeted:		;Targeted:
	*[[ECG]] — ~~'''~~mandatory in all CKD presentations~~'''~~ — evaluate for [[hyperkalemia]] (peaked T waves, widened QRS, sine wave), ischemia, pericarditis (diffuse ST elevation)		*[[ECG]] — mandatory in all CKD presentations — evaluate for [[hyperkalemia]] (peaked T waves, widened QRS, sine wave), ischemia, pericarditis (diffuse ST elevation)
	*[[CXR]] — pulmonary edema, pleural effusion, pericardial effusion, pneumonia		*[[CXR]] — pulmonary edema, pleural effusion, pericardial effusion, pneumonia
	*[[Blood cultures]] — if febrile (low threshold for blood cultures in dialysis patients and those with indwelling catheters)		*[[Blood cultures]] — if febrile (low threshold for blood cultures in dialysis patients and those with indwelling catheters)

	===Diagnosis===		===Diagnosis===
	*CKD itself is usually an established diagnosis — the ED role is to identify ~~'''~~acute complications~~'''~~ and ~~'''~~reversible causes of decompensation~~'''~~		*CKD itself is usually an established diagnosis — the ED role is to identify acute complications and reversible causes of decompensation
	*~~'''~~Always compare creatinine to baseline~~'''~~ — a patient with baseline creatinine 3.0 who presents at 3.2 is very different from one presenting at 6.0		*Always compare creatinine to baseline — a patient with baseline creatinine 3.0 who presents at 3.2 is very different from one presenting at 6.0
	*Determine if the patient has a ~~'''~~nephrology provider~~'''~~ and whether they are ~~'''~~on dialysis~~'''~~ (and when their last session was)		*Determine if the patient has a nephrology provider and whether they are on dialysis (and when their last session was)
	*CKD is confirmed (not just diagnosed in the ED) when kidney damage or decreased function has been present for ≥3 months — a single elevated creatinine may represent AKI, not CKD<ref name="KDIGO2024"/>		*CKD is confirmed (not just diagnosed in the ED) when kidney damage or decreased function has been present for ≥3 months — a single elevated creatinine may represent AKI, not CKD<ref name="KDIGO2024"/>

Line 85:		Line 85:
	;[[Hyperkalemia]] (K⁺ >5.5 mEq/L):		;[[Hyperkalemia]] (K⁺ >5.5 mEq/L):
	*ECG changes present or K⁺ >6.5:		*ECG changes present or K⁺ >6.5:
	**Calcium gluconate 10% 10 mL (or calcium chloride via central line) IV over 2-3 min — ~~'''~~cardiac membrane stabilization~~'''~~ (does not lower K⁺)		**Calcium gluconate 10% 10 mL (or calcium chloride via central line) IV over 2-3 min — cardiac membrane stabilization (does not lower K⁺)
	**Regular [[insulin]] 10 units IV + ~~'''~~[[dextrose]]~~'''~~ 25g (D50W) IV — shifts K⁺ intracellularly		**Regular [[insulin]] 10 units IV + [[dextrose]] 25g (D50W) IV — shifts K⁺ intracellularly
	**Albuterol 10-20 mg nebulized — additional K⁺ shift		**Albuterol 10-20 mg nebulized — additional K⁺ shift
	**[[Sodium bicarbonate]] 50-100 mEq IV — if concurrent metabolic acidosis (effect on K⁺ is modest)		**[[Sodium bicarbonate]] 50-100 mEq IV — if concurrent metabolic acidosis (effect on K⁺ is modest)
	**Kayexalate (sodium polystyrene sulfonate) 15-30g PO or ~~'''~~Patiromer~~'''~~ or ~~'''~~Sodium zirconium cyclosilicate (Lokelma)~~'''~~ — true K⁺ elimination (delayed onset)		**Kayexalate (sodium polystyrene sulfonate) 15-30g PO or Patiromer or Sodium zirconium cyclosilicate (Lokelma) — true K⁺ elimination (delayed onset)
	**~~'''~~Emergent [[dialysis]]~~'''~~ — definitive treatment for severe/refractory hyperkalemia in CKD/ESRD		**Emergent [[dialysis]] — definitive treatment for severe/refractory hyperkalemia in CKD/ESRD
	*See [[Hyperkalemia]] for full management		*See [[Hyperkalemia]] for full management

	;Uremic Pericarditis:		;Uremic Pericarditis:
	*Friction rub + chest pain + uremia = ~~'''~~indication for emergent dialysis~~'''~~		*Friction rub + chest pain + uremia = indication for emergent dialysis
	*Avoid anticoagulation (risk of hemorrhagic pericardial effusion → tamponade)		*Avoid anticoagulation (risk of hemorrhagic pericardial effusion → tamponade)
	*If hemodynamic compromise → evaluate for [[pericardial effusion and tamponade\|tamponade]] → [[pericardiocentesis]] if indicated		*If hemodynamic compromise → evaluate for [[pericardial effusion and tamponade\|tamponade]] → [[pericardiocentesis]] if indicated
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	*IV [[nitroglycerin]] for afterload reduction if hypertensive		*IV [[nitroglycerin]] for afterload reduction if hypertensive
	*IV [[furosemide]] — CKD patients require higher doses (start 40-80mg IV for CKD G3-4; 80-200mg IV for G5/ESRD); may be ineffective in ESRD		*IV [[furosemide]] — CKD patients require higher doses (start 40-80mg IV for CKD G3-4; 80-200mg IV for G5/ESRD); may be ineffective in ESRD
	*~~'''~~Emergent [[dialysis]]~~'''~~ (ultrafiltration) if refractory to medical management or anuric		*Emergent [[dialysis]] (ultrafiltration) if refractory to medical management or anuric
	*See [[Congestive heart failure]]		*See [[Congestive heart failure]]

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	===Medication Safety===		===Medication Safety===
	~~'''~~''Critical drug dosing considerations in CKD:~~'''~~''		''Critical drug dosing considerations in CKD:''
	*[[NSAIDs]]: ~~'''~~Avoid~~'''~~ in CKD G3-5 — worsen renal function, cause hyperkalemia, fluid retention, GI bleeding		*[[NSAIDs]]: Avoid in CKD G3-5 — worsen renal function, cause hyperkalemia, fluid retention, GI bleeding
	*[[Metformin]]: Contraindicated when eGFR <30; hold when eGFR 30-45 if acutely ill; risk of [[lactic acidosis]]		*[[Metformin]]: Contraindicated when eGFR <30; hold when eGFR 30-45 if acutely ill; risk of [[lactic acidosis]]
	*Opioids: [[Morphine]] — ~~'''~~avoid~~'''~~ (active metabolite accumulates → prolonged sedation/respiratory depression); use [[fentanyl]] or [[hydromorphone]] (safer in CKD). [[Meperidine]] — ~~'''~~avoid~~'''~~ (normeperidine accumulation → seizures)		*Opioids: [[Morphine]] — avoid (active metabolite accumulates → prolonged sedation/respiratory depression); use [[fentanyl]] or [[hydromorphone]] (safer in CKD). [[Meperidine]] — avoid (normeperidine accumulation → seizures)
	*[[Gabapentin]]/[[pregabalin]]: Dose reduce; accumulation causes sedation, [[altered mental status]], myoclonus		*[[Gabapentin]]/[[pregabalin]]: Dose reduce; accumulation causes sedation, [[altered mental status]], myoclonus
	*Antibiotics: Many require dose adjustment — particularly [[vancomycin]] (dose by levels/AUC), aminoglycosides (avoid if possible), [[nitrofurantoin]] (ineffective and neurotoxic in CKD G4-5)		*Antibiotics: Many require dose adjustment — particularly [[vancomycin]] (dose by levels/AUC), aminoglycosides (avoid if possible), [[nitrofurantoin]] (ineffective and neurotoxic in CKD G4-5)
	*[[Enoxaparin]]: If eGFR <30, use ~~'''~~unfractionated heparin~~'''~~ instead, or reduce enoxaparin dose (1 mg/kg daily instead of BID) with anti-Xa monitoring		*[[Enoxaparin]]: If eGFR <30, use unfractionated heparin instead, or reduce enoxaparin dose (1 mg/kg daily instead of BID) with anti-Xa monitoring
	*Contrast: IV iodinated contrast can be given when clinically indicated (e.g., CT angiography for PE, stroke) — '''do not withhold life-saving imaging''' for CKD; hydrate with IV crystalloid before and after; hold metformin for 48h after contrast if eGFR <30		*Contrast: IV iodinated contrast can be given when clinically indicated (e.g., CT angiography for PE, stroke) — '''do not withhold life-saving imaging''' for CKD; hydrate with IV crystalloid before and after; hold metformin for 48h after contrast if eGFR <30
	*ACEi/ARB: Hold during acute illness, dehydration, or AKI ("sick day rules"); do not start or uptitrate in the ED during acute presentations		*ACEi/ARB: Hold during acute illness, dehydration, or AKI ("sick day rules"); do not start or uptitrate in the ED during acute presentations
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	===Dialysis-Specific Considerations===		===Dialysis-Specific Considerations===
	*Determine ~~'''~~modality~~'''~~ (hemodialysis vs. peritoneal dialysis), ~~'''~~schedule~~'''~~, and ~~'''~~when last session occurred~~'''~~		*Determine modality (hemodialysis vs. peritoneal dialysis), schedule, and when last session occurred
	*Missed dialysis: Common ED presentation; check K⁺, bicarbonate, volume status; arrange urgent dialysis		*Missed dialysis: Common ED presentation; check K⁺, bicarbonate, volume status; arrange urgent dialysis
	*Dialysis access:		*Dialysis access:
	**'''Do not''' use an AV fistula or graft for blood draws, IV access, or blood pressure measurement		**'''Do not''' use an AV fistula or graft for blood draws, IV access, or blood pressure measurement
	**'''Do not''' place a blood pressure cuff on the access arm		**'''Do not''' place a blood pressure cuff on the access arm
	**Assess fistula/graft for ~~'''~~thrill~~'''~~ (palpable) and ~~'''~~bruit~~'''~~ (auscultate) — absence suggests thrombosis → vascular surgery or interventional radiology consultation		**Assess fistula/graft for thrill (palpable) and bruit (auscultate) — absence suggests thrombosis → vascular surgery or interventional radiology consultation
	*Peritoneal dialysis peritonitis: Cloudy PD effluent + abdominal pain ± fever; send PD fluid for cell count (WBC >100/µL with >50% neutrophils), Gram stain, and culture; initiate empiric IP antibiotics (typically IP vancomycin + IP ceftazidime or gentamicin per local protocol) after consulting nephrology		*Peritoneal dialysis peritonitis: Cloudy PD effluent + abdominal pain ± fever; send PD fluid for cell count (WBC >100/µL with >50% neutrophils), Gram stain, and culture; initiate empiric IP antibiotics (typically IP vancomycin + IP ceftazidime or gentamicin per local protocol) after consulting nephrology
	*Dialysis catheter infection: Blood cultures from catheter AND peripheral site; empiric IV [[vancomycin]] + gram-negative coverage; consult nephrology regarding catheter removal vs. salvage		*Dialysis catheter infection: Blood cultures from catheter AND peripheral site; empiric IV [[vancomycin]] + gram-negative coverage; consult nephrology regarding catheter removal vs. salvage
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	*AKI on CKD with significant creatinine rise from baseline and no readily reversible cause		*AKI on CKD with significant creatinine rise from baseline and no readily reversible cause
	*Sepsis or serious infection (especially dialysis access infection, PD peritonitis)		*Sepsis or serious infection (especially dialysis access infection, PD peritonitis)
	*~~'''~~Need for emergent or urgent dialysis~~'''~~		*Need for emergent or urgent dialysis
	*New diagnosis of ESRD requiring dialysis initiation		*New diagnosis of ESRD requiring dialysis initiation