An 80-year-old male with acute-on-chronic kidney disease presents with severe oliguria, asterixis, pericardial friction rub, blood urea nitrogen (BUN) 140 mg/dL, serum creatinine 9.2 mg/dL, and serum potassium 7.6 mEq/L refractory to medical therapy. What is the definitive life-saving management?

Answer and explanation

Correct answer: C. Emergent Hemodialysis

  1. Step 1: The patient meets multiple absolute emergency indications for renal replacement therapy (the classic 'AEIOU' mnemonic):
  2. Step 2: A - Refractory Acidosis; E - Refractory Electrolytes (severe hyperkalemia K > 6.5); I - Intoxications; O - Volume Overload refractory to diuretics; U - Uremic complications (uremic pericarditis, uremic encephalopathy/asterixis).
  3. Step 3: Uremic pericarditis and refractory hyperkalemia carry imminent mortality from tamponade or arrest, requiring emergent hemodialysis.
Answer
Emergent Hemodialysis.
Why not the others: 'Oral sodium bicarbonate' cannot correct severe refractory uremic pericarditis or severe hyperkalemia; 'Loop diuretics' are ineffective in oliguric end-stage renal failure; 'Exchange transfusion' does not clear uremic toxins or restore electrolyte balance.

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