Quality of Life in Patients on Dialysis - Dissertation Example

INTRODUCTION CASE LOG Patient History M is a 72 year-old widow with neprohritic syndrome, temporal arthritis, osteoporosis, severe hypertension and Myeloma. M has two daughters however she lives on her own. Her present complaints are: - itching, poor appetite, nausea, lower back pain and lethargy. She is still passing some urine about 1500mls per day. Prescribed drugs are: - Amlodipine 10mg P.O daily, Calicichew, Omeprozole 20mg, Prednisolone 15mg IM q 12 hours , and Cyclizine. Physical Examination M weighs 64.3kgs, She presented with oedema, pulse rate 92 b.p.m. and blood pressure of 202/103 mmHg. Investigations Recent blood results: - Sodium 136 mmol/l Within normal limits Potassium 5.3 mmol/l Within normal limits Urea 59.1 mmol/l Elevated Creatinine 938 mol/l Elevated Haemoglobin 9.0 g/dl Reduced Calcium 2.1 mmol/l Within normal limits Phosphate 2.47 mmol/l Elevated White cell count 12.1 x 109/l Elevated GFR (Modification MDR) 4 ml/min Reduced Diagnosis/Differential Diagnosis Acute renal failure (ARF) Treatment M was receiving 2 hours Haemodialysis (HD); haemodialysis consists of the perfusion of blood and a physiologic salt solution on opposite sides of a semi permeable membrane. Multiple substances such as, water, urea, creatinine, uremic toxins, and drugs move from the blood into the dialysate, thus facilitating removal from the blood. Solutes are transported across the membrane by either passive diffusion or ultrafiltration. M also received 7 sessions of Plasma Exchange. Plasma Exchange is a procedure in which blood is separated into different parts: red cells, white cell, platelets and plasma. The plasma is removed from the blood and a plasma substitute replaced. M had chemotherapy. Chemotherapy is the treatment which uses anti-cancer drugs to kill cancer (Myeloma) cells. Myeloma is the cancer that affects cells in the bone marrow called plasma cells leading to damage to the kidney. Haemodialysis and Plasma Exchange will correct M's blood chemistry and therefore relieve her present symptoms. Modifiable risk factors as a result of ARF and treatment regime. Hypertension M is hypertensive due to fluid overload or as a result of the failure of the kidneys. The Management of M's hypertension will have the highest priority. As Redmond and McClelland (2006) noted prompt recognition and treatment of hypertension are essential because cardiovascular disease including coronary artery disease, atherosclerosis, stroke and left ventricular hypertrophy are the most common cause of death in patients with kidney disease. Risk reduction measures to prevent cardiovascular disease may delay the progression of kidney disease (in ARF or is the effect here Reno protective). ACE inhibitors or angiotensin receptor blockers (ARBs) are the drug of choice (Thomas 2004); however deterioration in renal function may follow initiation of treatment with these medications (DOH 2005, BNF 2006). Since hypertension can have deleterious effects on both cardiovascular and kidney functions, the long-term protection provided by ACE inhibitors (or ARBs) out weighs the risk they pose (Thomas 2004) (this is for ERF is it the same for ARF - CHECK). Because acute renal failure is a catabolic state, the patient can become nutritionally deficient. Total caloric intake should be 30 to 45 kcal (126 to 189 kJ) per kg per day, most of which should come from a combination of carbohydrates and lipids. In patients who are not receiving dialysis, protein intake should be restricted to 0.6 g per kg per day. Patients who are receiving dialysis should have a protein intake of 1 to 1.5 g per kg per day (Agrawal 2000). Hyperphosphatemia The patient has hyperphosphatemia. Phosphate is normally excreted by the kidney and phosphate retention and hyperphosphatemia may occur in ARF. Phosphate - binding agents may be used to retain phosphate ion in the gut. The most common agent is calcicihew, although M is on this drug she needs education on when to take the tablets or maybe increase the dosage. Uremia Caloric intake should come primarily from carbohydrates. Protein intake should be balanced to minimize nitrogenous waste production while limiting starvation ketosis and subsequent production of ketoacids. This balance is achieved best with a protein intake of 0.6 g per kg per day (Needham2005). Since uremia causes anorexia, nausea and vomiting total parental nutrition should be considered at an early stage. In order to reduce symptoms of uremia, haemodialysis treatment is appropriate. However, EDTNA/ERCA (2002) noted that haemodialysis process contributes to the requirements for dietary protein as dialysate losses of protein including amino acids. Drugs Chemotherapy-platinum-based therapies are nephrotoxic (BNF 2006) but an adequate fluid intake can decrease their effects on the renal tubules by dilution (Rang et al 2004). CASE LOG 2 Patient History P is a 66 year old lady, She is diabetic, hypertensive recently diagnosed with breast cancer a year ago and she had a myomectomy. She is still passing urine of 1000 liters. M's present complaints are lethargy, anemia. Prescribed drugs are Ramipril, frusemide, levothyron sodium, Thiamine, folic acid, loperamide, metformin, tamoxifen hydroxocdalonun. Physical Examination P's weight is 97.9 kgs, blood pressure is 189/101 mmHg, Pulse is 89 b.p.m and irregular, she is lethargic, and short of breath. Her respiratory rate is 20. Investigations Recent blood results: - Sodium 134 mmol/l Within normal limits Potassium 4.4 mmol/l Within normal limits Urea 17.3 mmol/l Elevated Creatinine 131 mol/l Elevated Haemoglobin 6.0 g/dl Reduced Calcium 2.24 mmol/l Within normal limits Phosphate 1.94mmol/l Elevated White cell count 8.2 x 109/l Within normal limits Hbaic 5.9 GFR (Modification MDR) 13 ml/min Reduced Diagnosis/Differential Diagnosis Chronic kidney diseases secondary to diabetes mellitus, hypertension and Anemia Treatment The patient P has been commenced on hemodialysis and is to have 3 units of blood. Hemodialysis consists of the perfusion of blood and a physiologic salt solution on opposite sides of a semi permeable membrane. Multiple substances such as, water, urea, creatinine, uremic toxins, and drugs move from the blood into the dialysate, thus facilitating removal from the blood. Solutes are transported across the membrane by either passive diffusion or ultra filtration (Dipiro 2005). P is recently diagnosed with breast cancer and she had a myomectomy a year ago. Myomectomy is the surgical procedure done to remove fibroids from the uterus and leaving the uterus intact. Modifiable risk factors as a result of ARF and treatment regime. Diabetes Mellitus Patient P requires effective control of blood glucose in order to reduce the renal complications of diabetes. Meticulous control of blood glucose has been conclusively shown to reduce the development of microalbuminuria by 35% in type 1 diabetes (diabetes control and complications trial 1995) and in type 2 diabetes (United Kingdom prospective diabetes study1998). In diabetic CKD patients on regular hem dialysis, poor glycemic control is an independent predictor of prognosis. This finding by Oomichi et al (2006) indicates the importance of careful management of glycemic control even after initiation of hemodialysis. P should be provided education on diabetes self-care monitoring/management, and motivational coaching since such a program of intensive diabetes education and care management in a dialysis unit was found effective in providing significant improvements in patient outcomes, glycemic control, and better quality of life in patients with diabetes mellitus (Murray 2002). Hypertension According to Toto (2005), hypertension contributes to progression of kidney disease toward end stage (ESRD) as well as to cardiovascular events such as heart attack and stroke. Treatment of hypertension is therefore imperative in patient P. The National Kidney Foundation clinical practice guidelines recommend a blood pressure goal of Read More