Ebola hemorrhagic fever, which is accompanied by hematemesis, melena, hematuria, epistaxis, and vaginal bleeding, might remind us of a scary apocalyptic movie in which victims ooze blood from every orifice.
The nature of Ebola hemorrhagic fever is such that nephrologists need to be more engaged in the management of the ensuing fluid and electrolyte disarrays that often precedes terminal acute kidney injury (AKI).
Ebola victims may need 10 to 20 liters of daily fluid replacement because of massive blood and fluid loss. Depletional hyponatremia may ensue which may be difficult to manage given ongoing fluid and electrolyte losses. Other electrolyte abnormalities, such as profound hypokalemia, hypomagnesemia, and hypophosphatemia, will often confound the condition and are major contributors to the development of dysrhythmias, cardiac arrest, and death. In my opinion, an astute nephrologist is the second most important physician next to the infectious disease specialist when it comes to the management of patients with Ebola hemorrhagic fever.
Some experts believe dialysis therapy in any form is futile, citing the irreversibility of the disease state and imminent death following development of oligoanuric AKI. Despite a seemingly low likelihood of improvement at this stage of Ebola hemorrhagic fever, I believe dialysis should be offered to any Ebola patient who needs it.
The terminal cases with death outcome despite dialysis referred to by some experts to substantiate their view that dialysis therapy is futile have occurred mostly in African countries. In the U.S. we apparently had two Ebola cases in whom dialysis therapy was used, including one who died and one who survived.
The Liberian national who came to the U.S. to visit relatives after having contracted Ebola hemorrhagic fever in Africa died at a Dallas hospital shortly after dialysis initiation. While the use of dialysis in this case seemed to make little or no difference in the patient’s survival, nephrologists and other clinicians should not be deterred from offering all patients RRT if they need it, even if they only have a small chance of survival.
With respect to which type of RRT should be used—conventional intermittent hemodialysis (HD) or continuous RRT such as continuous venovenous hemodiafiltration (CVVHDF)—this depends on patient condition. As oligoanuric AKI occurs in terminal and the most severe stages of multiple organ failure with high likelihood of mortality independent of the underlying etiology, patients are often less stable for conventional HD. For these patients, CVVHDF may be the better option.
Notwithstanding that Ebola hemorrhagic fever—for which there is currently no approved treatment and which is associated with a high case fatality rate—most Ebola patients treated in the U.S. have survived thus far. Supportive care appears to influence the odds of survival.
It is here that the expertise and training of American nephrologists, and the resources they have available, can potentially make a big difference in Ebola outcomes.