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cardio.acute-hf.end-stage-renal-disease.v1

Acute HF — HD-dependent ESRD

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — ADHF in HD-dependent ESRD specialization. IV loop diuretic USELESS if anuric → ULTRAFILTRATION (HD or SCUF) primary modality. BB metoprolol succinate preferred (minimally HD-removed). SGLT2i AVOID if eGFR <20 / dialysis. MRA DEBATED — DOHAS (PMID 24722440) signal but RALES excluded HD; only if K reliably <5.0 + post-HD-only schedule. ARNI/ACEi acceptable with K-binder (patiromer/SZC) support. Statin secondary prevention only (4D + AURORA showed no primary benefit). ICD/CRT case-by-case + shared decision per DanISH-CKD/MADIT-II subgroup. Vascular access protection (bedside sign, NO BP/IV in access arm). High-output HF screen if AVF flow >2 L/min. Severity triggers: IDH, hyperK from GDMT, AVF/AVG flow worsening HF, missed dialysis triggers volume overload. Mandatory nephrology + dialysis-center coordination at every transition. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (ESRD-HD specifics documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • history
    ESRD on chronic HD + acute volume overload (inter-dialytic weight gain >5% dry weight + dyspnea/orthopnea) → ADHF in dialysis-dependent patient
    esrd_on_hd_with_volume_overload
  • lab_abnormality
    Missed ≥1 HD session + pulmonary edema (most common ADHF trigger in HD; mortality risk especially after long inter-dialytic interval)
    missed_dialysis_with_pulm_edema
  • symptom
    Intradialytic hypotension (IDH) episodes + worsening NYHA → flag for HF-dialysis prescription review
    intradialytic_hypotension_with_hf_decompensation
  • imaging
    AVF/AVG flow >2 L/min on access US + features of high-output HF (cardiac index >4) → consider access banding/ligation eval
    avf_flow_above_2lpm_with_high_output_failure

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Age affects ICD/CRT decision in dialysis (less benefit per DanISH-CKD); transplant candidacy
  • dialysis_modality_schedule_dry_weightrequired
    history • used at CONTEXT
    In-center HD vs home HD vs PD; thrice-weekly schedule; documented dry weight + access type/site essential for fluid management
  • urine_output_residual_renal_functionrequired
    history • used at CONTEXT
    Anuric (UOP <100 mL/day) → IV loop USELESS; oliguric (UOP 100-500) → IV loop may have residual benefit; preserves residual renal function → less aggressive UF needed
  • access_type_avf_avg_tdc_and_arm_protectionrequired
    history • used at CONTEXT
    AVF/AVG arm: NO BP cuff, NO IV access, NO blood draws — protect access; TDC site informs antibiotic stewardship + bacteremia screen
  • sbp_pre_and_post_dialysisrequired
    vital • used at CONTEXT
    Pre-HD SBP guides UF tolerability; post-HD SBP <90 = IDH; trend across sessions informs dry weight + UF rate adjustment
  • potassium_pre_dialysisrequired
    lab • used at CONTEXT
    HD patients often hyperK pre-HD (4.5-6.5 typical) — alters ARNI/ACEi/MRA decisions and emergency K management
  • phosphorus_pthrequired
    lab • used at CONTEXT
    Hyperphosphatemia + secondary hyperPTH drive vascular calcification + LV remodeling; CKD-MBD bundle
  • troponin_baseline_chronically_elevatedrequired
    lab • used at INITIAL_WORKUP
    Chronic troponin elevation common in HD; trend (delta) more useful than absolute for ACS rule-in
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    NT-proBNP ALWAYS elevated in HD baseline (renal cleared); trend + dry-weight comparison rather than absolute
  • echo_with_lvef_and_diastolicrequired
    imaging • used at INITIAL_WORKUP
    HFrEF vs HFpEF in dialysis; calcific valve + uremic cardiomyopathy assessment; AVF flow effect on cardiac output
  • access_ultrasound_for_flow
    imaging • used at BRANCHING_WORKUP
    AVF/AVG flow measurement when high-output HF suspected (flow >2 L/min); supports banding/ligation discussion

12-phase flow (10)

  1. 1FRAME
    ADHF in HD-dependent ESRD — IV loop diuretic USELESS if anuric → ULTRAFILTRATION primary; IDH dominant complication; SGLT2i avoid if eGFR <20; access protection mandatory
    inputs: dialysis_modality_schedule_dry_weight, urine_output_residual_renal_function
    advance: ESRD-HD framing + anuria status confirmed
  2. 2ENTRY
    Recognize ADHF in HD: orthopnea + crackles + inter-dialytic weight gain >5% dry weight + missed-HD trigger common; check K + access; coordinate URGENT HD if missed-session or hyperK
    inputs: sbp_pre_and_post_dialysis, potassium_pre_dialysis
    advance: urgent HD coordinated OR scheduled session brought forward
  3. 3CONTEXT
    Dialysis modality (in-center vs home), thrice-weekly schedule, documented dry weight, access type/site/arm, residual urine output, prior IDH episodes, transplant status, GoC/advance directives
    inputs: age, dialysis_modality_schedule_dry_weight, access_type_avf_avg_tdc_and_arm_protection, urine_output_residual_renal_function, phosphorus_pth
    advance: context complete
  4. 4RED_FLAGS
    Severe hyperK (>6.5 with EKG changes) → emergent HD; intradialytic hypotension severe (SBP <80 with sx) → halt UF; missed dialysis ≥2 sessions → check for hyperK + acidosis + uremic encephalopathy; bacteremia from TDC; access bleeding/thrombosis
    inputs: potassium_pre_dialysis, sbp_pre_and_post_dialysis
    actions: cardiogenic_shock
    advance: red flags screened
  5. 5INITIAL_WORKUP
    BMP (K, phos, HCO3, Mg, Cr, BUN), CBC (anemia common; Hb target 10-11 per KDIGO), troponin trend (chronic elevation baseline), NT-proBNP trend, blood cultures × 2 if TDC/fever, ECG (LVH/peaked T common), CXR, lung US for B-lines, echo for LVEF + diastolic + valve calcification + AVF flow effect
    inputs: troponin_baseline_chronically_elevated, nt_probnp, echo_with_lvef_and_diastolic
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented
  6. 6BRANCHING_WORKUP
    If anuric + volume overload → ULTRAFILTRATION primary; if oliguric → trial IV loop (160-320 mg furosemide IV) but expect minimal effect; if AVF flow >2 L/min on US + high-output features → vascular surgery for banding/ligation eval; if IDH recurrent → bioimpedance, sodium profiling, dialysate temp adjust, midodrine pre-HD
    inputs: urine_output_residual_renal_function
    advance: volume removal modality decided + IDH plan documented
  7. 7TREATMENT
    ULTRAFILTRATION via HD or SCUF as primary volume removal (anuric); IV loop only if residual UOP. RAAS BLOCKADE: ARNI/ACEi acceptable if K controlled (need K-binder + close monitor); HOLD if K >5.5. BB: METOPROLOL SUCCINATE preferred (minimally HD-removed) over carvedilol (HD removal variable) and atenolol (highly HD-removed). MRA: DEBATED in HD — small studies (DOHAS) suggest benefit; only if K reliably <5.0 + careful schedule (e.g., 12.5 mg post-HD only). SGLT2i: AVOID if eGFR <20 / dialysis. Statin: 4D + AURORA showed NO mortality benefit for primary prevention in HD; continue for ASCVD secondary only. Phosphate binders, ESA per Hb target, calcium-channel blockers for HTN, midodrine pre-HD for IDH
    inputs: potassium_pre_dialysis, sbp_pre_and_post_dialysis
    advance: UF modality + drug adjustments + IDH prevention documented
  8. 8DISPOSITION
    Floor with telemetry for arrhythmia (uremic cardiomyopathy + electrolyte shifts during HD); CICU if shock or refractory pulmonary edema awaiting urgent HD; coordinate access protection bedside sign; nephrology mandatory consult
    advance: unit + access sign + nephrology arranged
  9. 9MONITORING
    Pre/post-HD weight + BP, daily K + phos + HCO3 + Cr, daily access exam (thrill + bruit), telemetry for arrhythmia (especially during/after HD), daily echo if shock, NT-proBNP trend (use change not absolute)
    inputs: potassium_pre_dialysis, sbp_pre_and_post_dialysis
    actions: panel.renal
    advance: ESRD-aware monitoring active
  10. 10FOLLOWUP
    Coordinate with home dialysis center (in-center 3×/wk vs home), nephrology + HF clinic shared visits, dry-weight reassessment q3 mo, AVF surveillance US annually, transplant evaluation if not done, statin secondary prevention only, ICD/CRT case-by-case + shared decision per DanISH-CKD/MADIT-II
    advance: shared dialysis-HF clinic + transplant eval booked