Dear Unregistered,
The use of diuretics may still have value in many patients even after starting dialysis if they have residual renal function. The US uses less diuretics than in Japan and Europe. Some studies have shown reduced interdialytic weight gains as well as lower levels of potassium thus reducing episodes of hyperkalemia. However, in anuric dialysis patients, it has no means of action to work any longer, but it can be an effective treatment to augment dialysis treatments in those patients that still have enough renal function. There is also a suggestion of benefit with reduced cardiac specific mortality by as much as 14% in some studies in those patients continued on diuretics. As in all aspects of medical therapy, it must be considered in conjunction with all of the medications and conditions that a patient has while under the care of a multidisciplinary team headed by a nephrologist. As with all patients on diuretics, controlling salt intake is paramount in maximizing the effectiveness of any diuretic used. Nevertheless, the majority of American nephrologists appear to discontinue diuretics within 90 days of starting dialysis, but in patients with residual renal function, continuing diuretics may have a significant benefit on a case by case basis.
Ascites is a complex condition based on many factors especially that of protein/calory malnutrition where patients have very low albumin levels. This is quite common in many dialysis patients and leads to high mortality especially from sudden cardiac death. Ascites in dialysis patients is fortunately not common and can be further controlled with more frequent dialysis as well as improving albumin levels to increase plasma oncotic pressures. Since ascites has many different conditions that can cause this third space fluid retention, a complete examination of the ascitic fluid is usually performed to eliminate any secondary causes of ascites beyond that of fluid overload from poorly controlled ESRD. That is the world of medicine to always consider what other processes may be masquerading as a common complication. In general, in well dialyzed patients, there should never been any patient with ascites.
Ascites can be a symptom of the uremic syndrome but fluid around the heart sac called a pericardial effusion is more common and more dangerous in that it can cause a condition called cardiac tamponade which is a medical emergency. Fortunately, with effective chronic and emergency treatments for ESRD, the incidence of developing pericardial effusions or ascites is becoming very uncommon. It should never occur in a well managed dialysis patient monitored for proper dry weights, dietary salt restrictions and adequate protein intake to keep albumin levels higher than 4.0. While diuretics may have a place in patients with residual renal function, proper dialysis prescriptions and dietary compliance is the most important factors in maintaining fluid hemostasis in dialysis patients.