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