When you encounter a patient who has end-stage renal disease and is on dialysis, there are a few questions you should make sure to answer that will help in your management:
- What is their dialysis schedule? Have they missed any sessions recently?
- Does the patient have anemia? Many dialysis patients have anemia of chronic disease due to decreased EPO production. Do they receive EPO during their dialysis sessions?
- Does the patient have hypertension? If so, is this because they are volume-overloaded? Excess fluid can be removed in dialysis as tolerated. In the meantime, you should make sure to keep their blood pressures carefully controlled (and not too low).
- Do they have evidence of bone disease? Many patients with ESRD have tertiary hyperparathyroidism (click on the link for a brief pathophys reminder). They may be on cinacalcet (calcimimetic that decreases calcium and phos levels) or sevelamer (phos binder).
- Are their medications renally dosed? It seems like a no-brainer, but you’d be surprised. Also, are there specific medications that they do receive during dialysis? This is especially important for timing of medications like antibiotics.
- What is their access? Where is their fistula? Or do they have a tunneled cath? They cannot have IVs in the same arm as a fistula.
- Nutrition: one of the areas that we as clinicians tend to gloss over, but is extremely important to our patients (have you ever ordered from the renal menu? It SUCKS). Make sure they are on a low K/phos/sodium diet; patient should also be taking nephrocaps (vitamin B and C).