DDM 4 Case 2 Group 8
Calei Ca Angela Berry Diandra Alston Baele Dumas Alina Forshee Nia Haley
Xandria Milligan
Collect CC: Confusion
HPI: 67-year-old AA female with PMH of DM2, HTN, and Stage 5 CKD, receiving HD TIW. Brought to ED this morning by her husband, who reports increased confusion and lethargy, worsening over the past 2-3 days. According to her husband, the patient missed HD session 2 days ago. He reports no other new Sx except for increased pain in her feet from neuropathy, for which PCP increased her gabapentin dose last week.
PMH: Patient was diagnosed with type 2 diabetes in 1997 and hypertension in 1987. Patient was diagnosed with stage 5 chronic kidney disease in 2012 and placed on hemodialysis with no residual renal function. Patient has also been diagnosed with diaetic neuropathy in 2007, anemia of chronic kidney disease in 2010, dyslipidemia in 1992, and chronic kidney disease mineral and bone disorder in 2012.
Allergies: No known allergies.
FH: Father was diagnosed with coronary artery disease and is now deceased. Mother was diagnosed with diabetes mellitus and hypertension and is now deceased.
Relevant SH: Patient is married and lives with her husband. Patient is retired and is on disability pay. Patient is a former smoker, quit in 2014, and quit drinking in 2010.
ROS: (+) Increased fatigue and confusion; (+) reduced sensation in LE
Lab Test Results:
Lab values show that this patient's BUN is high, potassium level is high, bicarbonate level is low, creatinine level is very high, glucose level is high, hemoglobin level is low, hematocrit level is slightly low, albumin level is low, phosphate level is high, parathyroid hormone level is very high, and EKG showed peaked T waves. All other tested values were normal. BUN: 82
K+: 6.1
HCO₃-: 18
Cr: 8.2
Glucose: 118
Hgb: 11.2
Hct: 34.5%
Albunimum: 2.2
Phosphate: 7.4
PTHi: 140 pg/mL
ABG: HCO₃-: 20
EKG: peaked T-waves in lead V3
All other lab values are within normal range.
Physical Exam Findings:
General: Somnolent; appears to be in NAD
Vital Signs: BP 168/82 mm Hg, P 82 bpm, RR 14, T 36.8°C; dry body Wt 68 kg, Ht 5′5″
HEENT: normal
Neck/Lymph Nodes: Positive JVD
Lungs: Crackles in bases BL CV: RRR
MS/Ext: 1+ BL pedal edema
Neuro: A & O to person only; CN II–XII intact; DTRs 2+ BL
Current Medications:
· Calcium acetate 667 mg, 2 PO TID
· Gabapentin 300 mg PO BID (increased last week from 300 mg PO HS)
· Nephrocaps 1 PO daily
· Metoprolol tartate 25 mg PO BID
· Amlodipine 10 mg PO daily
· Simvastatin 40 mg PO daily
· Glipizide XL 10 mg PO daily
· Sitagliptin 25 mg PO daily
· Ensure Original Vanilla nutritional supplement 237 mL PO TID
Current Medications (verified per Outpatient Dialysis): ● Sodium ferric gluconate 62.5 mg IV once weekly with HD ● Epogen® 6000 IU IV TIW with HD ● Calcijex® 2 mcg IV TIW with HD
Assess 1. Non-compliance on Hemodialysis for CKD 2. Diabetic Neuropathy 2. Hypertension 3. Anemia 4. Vaccines Plan 1. Complete hemodialysis as schedules (CrCl is 6 mL/min)
a. Initiate Kionex immediately
b. D/C Ensure since very high in protein and recommend low protein diet
2. Decrease patient’s pain and increase her quality of life.
a. D/C Gabapentin and initiate lidocaine 5%
2. Target BP < 140/90 (Based on JNC-8 Guidelines)
a. Prevent cardiovascular events or end-organ damage
b. Reduce hypertension-related mortality
c. D/C Metoprolol and initiate Lisinopril once hyperkalemia is treated
d. D/C Simvastatin and initiate Rosuvastatin due to Amlodipine having interactions with Simvastatin
3. Increase hemoglobin level to target 12-15.5 g/dL
4. Vaccines a. Ensure patient is up to date on vaccinations to prevent risk of infections, morbidity and mortality 1. The patient must complete Hemodialysis as scheduled (TIW)
a. Educate the patient on the importance and benefits of hemodialysis compliance.
b. Find out the underlying cause as to why the patient did not attend their last hemodialysis session.
c. Initiate Kionex 15 g (60 mL) of one to four times daily. Take the medication 3 hours before or three hours after oral medications.
d. Recommend low protein diet [0.6 to 0.75 grams of protein per kilogram body weight]
2. Initiate Lidocaine 5%. Apply one patch to foot every 12 hours as needed for pain. Administer cautiously since patient has stage 5 CKD
2. Initiate Lisinopril 20 mg daily once hyperkalemia is treated
Initiate Rosuvastatin 10 mg daily and discontinue Simvastatin due to interactions between Amlodipine and Simvastatin.
3. Increase sodium ferric gluconate to 100 mg/week to improve response to ESA therapy
a. Educate the patient on increasing dietary intake of iron-rich food
4. Flu vaccine once per year
Pneumovax 23 (Pneumococcal Polysaccharide 23-valent) vaccine give first if not given already, then give prevnar13 a year later
Hepatitis B vaccination if not given already Follow-up: 1. Ensure patient is compliant on hemodialysis schedule Monitor a. Make sure patient adheres to hemodialysis schedule and and Evaluate stays on the full regimen (goes three times per week)
b. Monitor patient’s BUN, Scr, serum electrolytes, and hemoglobin and hematocrit levels before and after dialysis
c. Monitor patient’s potassium level until back to normal range (3.5-5 mEq/mL)
d. Make sure patient is adherent to low protein diet
2. Monitor application area for burning, discomfort, redness or swelling, as Lidocaine can cause these side effects. Also, monitor for lightheadedness or dizziness
2. Ensure compliance with Lisinopril
a. Monitor BP every visit to hemodialysis
b. Monitor anaphylactic reactions
c. Monitor swelling of the hands, face, mouth, or throat Ensure compliance with Rosuvastatin
a. Monitor LFT’s and for rhabdomyolysis
3. Monitor hgb and hct twice weekly, then monthly
a. Monitor hgb and hematocrit for efficacy 4. Efficacy: Immunity to the influenza virus, hepatitis B virus, and Pneumococcal infections.
Safety: ● Hypersensitivity reactions ● Injection site reactions ● Fever ● Muscle ache
References Carter, Barry L, James, Paul A, Oparil, Suzanne. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5):507-520. doi: 10.1001/jama.2013.284427. Cassagnol, M, Harisingani, R, Sadd, M. How to Manage Pain in Patients with Renal Insufficiency or End-Stage Renal Disease on Dialysis? The Hospitalist. 2013(8). DailyMed - KIONEX- sodium polystyrene sulfonate suspension. U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed November 10, 2019 Lidoderm (Lidocaine Patch 5%): Side Effects, Interactions, Warning, Dosage & Uses. RxList. https://www.rxlist.com/lidoderm-drug.htm#description. Published October 25, 2018. Accessed November 11, 2019. Ldsay, TJ, Snyder, MJ. Treating Painful Diabetic Peripheral Neuropathy: An Update. American Family Physician. 2016 Aug 1;94(3):227-234. https://www.ncbi.nlm.nih.gov/pubmed/27479625. Reference Ranges. American College of Physicians. https://annualmeeting.acponline.org/educational-program/handouts/reference-ranges-table. Accessed October 5, 2019.
Overview and Discussion of Chronic Kidney Disease (CKD)
Epidemiology of theDisease · CKD is defined as abnormalities of kidney structure or function, present for greater than 3 months, with implications for health. CKD is recognized as a significant health problem associated with: o High morbidity and mortality § Each year, kidney disease kills more people than breast or prostate cancer. In 2013, more than 47,000 Americans died from kidney disease. § Hospitalization rates decreased by 11 percent for CKD patients and by 10.1 percent for those without CKD. However, rates of both overall and cause-specific admissions increased with advancing stages of CKD. § In 2013, adjusted mortality rates remained higher for Medicare patients with CKD (117.9/1,000) than for those without CKD (47.5/1,000); and these rates increased with CKD severity. o High economic burden to health care systems. · Prevalence of CKD o The overall prevalence of CKD increased from 12 percent to 14 percent between 1988 and 1994 and from 1999 to 2004 but has remained relatively stable since 2004. o Women (15.93 percent) are more likely to have stages 1 to 4 CKD than men (13.52 percent). o African Americans (17.01 percent) and Mexican Americans (15.29 percent) are more likely to have CKD than Caucasians (13.99 percent). · Complications o Fluid retention o Hyperkalemia, which could impair your heart's ability to function and may be life-threatening o Cardiovascular disease o Weak bones and an increased risk of bone fractures o Anemia o Erectile dysfunction o Damage to your central nervous system o Decreased immune response o Pregnancy complications that carry risks for the mother and the developing fetus o End stage renal disease, eventually requiring either dialysis or a kidney transplant for survival Etiology
· Clinical factors
o Type 1 and 2 diabetes
o High blood pressure
o Glomerulonephritis
o Polycystic kidney disease o Prolonged obstruction of the urinary tract, such as enlarged prostate or kidney stones
o Vesicoureteral reflux
o Pyelonephritis
· Socioeconomic factors
o Older age
o US ethnic minority status
o Exposure to certain chemicals and environmental conditions
o Low income/education
· Classification
o Stage 1 CKD: >90 mL/min/1.73 m3 – Normal or high
o Stage 2 CKD: 60-89 mL/min/1.73 m3 – Mildly decreased
o Stage 3a CKD:49-59 mL/min/1.73 m3 – Mildly to moderately decreased
o Stage 3b CKD: 30-44 mL/min/1.73 m3 – Moderately to severely decreased
o Stage 4 CKD: 15-29 mL/min/1.73 m3 – Severely decreased
o Stage 5 CKD: < 15 mL/min/1.73 m3 – Kidney failure
Pathophysiology of the Disease
· CKD progression from category 1 through 5 occurs over time in most people, with the precise mechanism depending on the etiology of the disease
o DCKD is characterized by glomerular mesangial expansion
o Polycystic kidney disease is characterized by development and expansion of renal cysts
· In response to the decrease in nephron function, the remaining nephrons compensate through autoregulation
o Renin release from the juxtaglomerular apparatus increases, converting angiotensinogen to angiotensin I, which is then converted to angiotensin II (ATII), a potent vasoconstrictor o ATII’s vasoconstricting properties could eventually lead to the development of intraglomerular hypertension and hypertrophy and a further decline in the number of functioning nephrons
· Proteinuria may promote to the progressive loss of nephrons as a result of cellular damage.
o Filtered proteins (albumin, transferrin, ATII, cytokines and more) are toxic to kidney tubular cells, resulting in the production in inflammatory and vasoactive cytokines
o Filtered proteins can ultimately lead to the scarring of the interstitium, progressive loss of structural nephron units, and GFR reduction
Clinical Presentation
· Often symptomatic, until patient reaches stage 4 (GFR between 15-29 mL/min/1.73 ) or 5 (GFR < 15 mL/min/1.73 ) CKD
· Symptoms include fatigue, weakness, shortness of breath (SOB), mental confusion, nausea and vomiting, bleeding, loss of appetite, itching, cold intolerance, and peripheral neuropathies
· Signs include edema, weight gain, changes in urine output, “foaming” of urine, and abdominal distention
· Decreased eGFR, bicarbonate, hemoglobin (hb)/hematocrit (hct), transferrin saturation (Tsat) and/or ferritin, vitamin D levels, albumin, glucose, and calcium
· Increased serum creatinine (SCr), blood urea nitrogen (BUN), potassium, phosphorus, blood pressure, parathyroid hormone (PTH), glucose, low-density lipoprotein (LDL) and triglycerides, and calcium (moreso in CKD 5)
Diagnosis
· Blood tests o Look for level of waste products in your blood · Urine tests o Urine sediment abnormalities (hematuria, red blood cell and white blood cell casts, renal tubular epithelial cells) · Imaging tests o Detect structural abnormalities § Polycystic kidneys § Renal masses § Renal artery stenosis § Cortical scarring § Small kidneys o Types § Ultrasound § Computed tomography § Magnetic resonance imaging § Angiography · Kidney biopsy o Detect what is causing CKD o Determines if responding to therapy
Treatment guidelines and alternatives
· CKD Assessment Algorithm by Premaris the Medicare Quality Improvement Organization for Missouri 2009
· KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease 2013
Discussion of treatment options, including drugs of choice, alternatives, monitoring, and side effects
· Dosing of medications in Chronic Kidney Disease:
o Consult literature to determine whether the medication is renally cleared, which would call for dosing adjustments.
o Frequency changes are made based on the Creatinine Clearance /Glomerular Filtration Rate after consulting the literature.
· Dialysis
o Hemodialysis
§ Filters your blood to remove harmful wastes and extra fluid
§ Helps control blood pressure
§ Helps balance important minerals, such as potassium, sodium, and calcium in your blood
§ Usually done at a dialysis center three times a week, with each session lasting about 4 hours
§ Can remove protein from your body, so you will need to eat foods with high-quality protein
§ Avoiding foods such as beans, peas, nuts, tea, and colas will help you limit your phosphorus.
· May have to take a phosphate or aluminum-based binder
o Phosphate binders keep phosphorus in your food from entering your bloodstream o Most common phosphate binder is calcium carbonate, which is typically prescribed to patients with advanced chronic kidney disease, including those receiving dialysis
§ They should be prescribed in conjunction with moderate dietary phosphate restriction
§ Phosphate-rich foods with a high phosphate to protein are best avoided
§ Monitor for nausea and indigestion
o Aluminum-based binders are a second-line drugs in non-dialysis chronic Disney disease
§ Include Sevelamer, Lanthanum, and sucroferric oxyhydroxide
§ Sevelamer has a starting dose is typically 1-2 tablets three times daily with each meal
§ Monitor for nausea and indigestion o Peritoneal dialysis
§ Uses the lining of your belly to filter wastes and extra fluid from your body
§ Two types
· Continuous ambulatory peritoneal dialysis (CAPD)—An exchange takes about 30 to 40 minutes, and most people need to do four exchanges per day. You sleep with solution in your belly at night.
· Automated peritoneal dialysis, which uses a cycler to do three to five exchanges per night while you sleep.
§ Typically given a phosphate-binding drug o Kidney transplant
§ Places the kidney of a healthy individual, whether living or dead, into the body of a person who has kidney disease.
§ To keep your body from attacking the donor kidney, you will need to take immunosuppressants.
· Calcineurin Inhibitors: Tacrolimus and Cyclosporine
o Tracrolimus can cause tremors, hair loss, and headaches o Cyclosporine can cause hair growth, gum enlargement, and tremors
· Antiproliferative agents: Mycophenolate Mofetil, Mycophenolate Sodium and Azathioprine
o Normally cause stomach discomfort and swelling in your ankles or feet
· mTOR inhibitor: Sirolimus
o Sirolimus can cause rash and bone marrow problems
· Steroids: Prednisone
o Prednisone can cause bone thinning if used long term
o It can cause weight gain, water retention, diabetes, and acne
o Conservative management § Treats kidney failure without dialysis or a transplant § Your doctor can give you medicines to treat the problems of kidney failure · Anemia o Commonly occurs in people with chronic kidney disease o Ferritin and Transferrin saturation help measure iron levels
§ A ferritin score below 200 nanograms (ng) per milliliter may mean a person has iron deficiency that requires treatment
§ A transferrin saturation score below 30 percent can mean low iron levels that require treatment
o Iron can be obtained from the diet
§ 100% fortified breakfast cereal
§ Baked beans and ground beef
o Erythropoietin
§ Monitor for cardiovascular disease, such as stroke or heart attacks
§ Erythropoietin (Epogen) 50-100U/kg IV or subcutaneously three times a week; or Dacarbopoietin (Aranesp) 0.45 micrograms/kg IV or subcutaneously once a week.
§ Considered if a patient’s hemoglobin level is below 10 g/dL
o Red Blood Cell Transfusions § Can increase the percentage of the patient’s blood, which increases the amount of oxygen available to the body
o Vitamin B12 and Folic Acid Supplements
§ Can treat low levels of vitamin B12 or folic acid and help treat anemia.
§ Monitor for headache or swelling
· Hyperkalemia
o Sodium polystyrene sulfonate (SPS) and calcium polystyrene sulphonate (CPS) are currently used for hyperkalemia of CKD
§ CPS has fewer side effects that SPS
§ Monitor serum electrolytes and for nausea
· Vitamin D and Calcium
o Vitamin D plays a crucial role in calcium absorption and bone metabolism
o Active (high affinity binding to the Vitamin D Receptor [VDR]) - § 1,25(OH)2D3 (calcitriol)
§ 19 nor 1,25 dihydroxyvitamin D2 (paricalcitol) - - - § 22 oxacalcitriol (maxicalcitol) - o Inactive (lack of high affinity binding to the VDR) - § Vitamin D2 (ergocalciferol): requires activation by liver and kidney
§ Vitamin D3 (cholecalciferol): requires activation by liver and kidney
§ 25(OH)D3 (calcifidiol): requires activation by kidney
§ 1α (OH)D2 (doxercalciferol): requires activation by liver - § 1α (OH)D3 (alphacalcidol): requires activation by liver - o Monitor vitamin D drugs for kidney stones, bone pain, or muscle weakness
· Volume Overload:
o Loop Diuretics by themselves or in combination with Thiazide Diuretics, along with Sodium and fluid restriction of 2L/day. o Commonly used thiazide diuretics include chlorthalidone, hydrochlorothiazide, indapamide and metolazone.
§ The long acting nature of chlorthalidone results in better control of blood - pressure than hydrochlorothiazide
§ Chlorthalidone results in a higher risk of hypokalemia.
o Common loop diuretics, such as bumetanide, furosemide, and torsemide, should be reserved for conditions of clinically significant fluid overload
§ Monitor for hypokalemia and metabolic acidosis
References
Au, K, Chan, S, Francis, RS, Johnson, DW, Mudge, DW, Pillans, PI. Phosphate binders in patients with chronic kidney disease. Australian Prescriber. 2017 Feb; 40(1): 10–14. doi: 10.18773/austprescr.2017.002. Andress, DL. VITAMIN D IN HEALTH AND DISEASE: Vitamin D Treatment in Chronic Kidney Disease. Seminars in Dialysis. 2005 Jul; 18(4). https://doi.org/10.1111/j.1525-139X.2005.18408.x. Anemia in Chronic Kidney Disease. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/anemia. Published July 1, 2014. Accessed November 11, 2019. Chronic kidney disease. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/diagnosis-treatment/drc-2035452 7. Published August 15, 2019. Accessed November 10, 2019. Choosing a Treatment for Kidney Failure. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/choosing-treatment#options. Published January 1, 2018. Accessed November 11, 2019. Hedge, SC, Sathiyasekaran, BWC, Sha, PB, Soundararajan, P. Diuretics for people with chronic kidney disease. Cochrane Database System Review. 2017(10): CD011339. doi: 10.1002/14651858.CD011339.pub2. Hemodialysis. National Kidney Foundation. https://www.kidney.org/atoz/content/hemodialysis. Accessed November 10, 2019.