Podcast 1022: Emergent Dialysis

Sep 21, 2026

A practical guide to deciding when missed dialysis becomes a true emergency. The discussion covers refractory acidosis, dangerous potassium levels and ECG changes, dialyzable toxins, fluid overload, pulmonary edema, and uremic complications such as altered mentation and tamponade. It also explains why creatinine alone cannot determine the need for urgent dialysis.

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INSIGHT

Missed Dialysis Requires Complication-Based Triage

Missed dialysis does not automatically require admission; clinicians must decide whether complications demand treatment before the next scheduled session.
Most patients follow Monday-Wednesday-Friday or Tuesday-Thursday-Saturday schedules.

ADVICE

Dialyze Refractory Acidosis After Treating Causes

Dialyze acidosis when metabolic derangements remain uncorrectable and cause altered mentation or hemodynamic instability.
Treat reversible causes first, including sepsis, DKA, fluids, antibiotics, or bicarbonate.

ADVICE

Let ECG Changes Guide Hyperkalemia Dialysis

Evaluate hyperkalemia using the ECG and response to treatment rather than potassium alone.
Dialysis patients may tolerate chronically higher potassium, but persistent elevation or ECG changes require escalation.

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Contributor: Taylor Lynch, MD

Educational Pearls:

When a patient who missed dialysis presents to the emergency department, our clinical concern is who needs to be admitted to the hospital for emergent dialysis and who can wait for their next regularly scheduled session.

Dialysis sessions typically occur on Monday, Wednesday, and Friday, or Tuesday, Thursday, and Saturday.

Acronym for indications for emergent dialysis: AEIOU

Acidosis

Patients may have an underlying cause for acidosis such as sepsis or DKA.
Treat the underlying cause, but if the acidosis is unable to be corrected, the patient needs dialysis.

Electrolytes

Most commonly elevated is potassium.
In general, dialysis patients tend to have higher potassium levels, so don't just treat the number.
Look for potassium greater than 6.5 or if EKG changes are present.

Ingestion

Intoxication with substances such as Lithium, Ethylene Glycol, Methanol, Salicylates.

Overload

Patients may present with evidence of fluid overload such as new oxygen requirement or pulmonary edema.
If they are making urine, treat with diuretics, but if unresponsive to medical therapy, they will require dialysis.

Uremia

Build-up of nitrogenous waste products in the blood, which is indicated by an elevated BUN.
Patients may develop complications such as altered mentation or pericardial effusions and subsequent cardiac tamponade.

Keep in mind creatinine itself is not an indication for emergent dialysis.

Serves as a surrogate marker of kidney function.
Can be high or low depending on muscle mass or kidney filtration, and the patient may or may not need dialysis.

References:

Jentzer JC, Bihorac A, Brusca SB, et al. Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives. J Am Coll Cardiol. 2020;76(9):1084-1101. doi:10.1016/j.jacc.2020.06.070

Summarized by Ashley Lyons, OMS4 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P

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