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According to one study, the United States has one of the highest rates of missed dialysis treatment at 24% [33]. Younger patients consistently are found to have higher rates of compliance issues. As these patients require dialysis to sustain life, the patient who has missed a session (or several) is at higher risk for deterioration with increased rates of all‐cause hospitalization, all‐cause mortality, cardiovascular mortality, and sudden cardiac death [35].

When a patient who admits to having missed dialysis sessions presents to EMS, the more likely pathophysiology and required treatments can be inferred. Patients with respiratory distress are likely to have fluid overload. Management may be multimodal. Noninvasive positive‐pressure ventilation can be implemented in the awake patient to improve oxygenation [28]. Nitroglycerin is an option to facilitate fluid shifts by increasing venous capacitance. In the setting of uncomplicated fluid overload from dialysis noncompliance, the patient should be hypertensive and tolerate nitrates well [36]. Should the patient be exhibiting signs of cardiogenic shock, consideration should be given to pericardial tamponade [17].

Diuretics such as furosemide can be used in the renal disease patient, provided he or she makes urine. Careful assessment of the patient’s volume status should be made, as giving diuretics to an intravascularly depleted patient can worsen renal function. In the euvolemic or hypervolemic patient, higher than average doses of diuretic will be needed to overcome renal dysfunction [37].