Chronic Kidney Disease and Comprehensive Dialysis Patient Management Notes

Overview: Dialysis patient management and lifestyle adjustments

• End-stage kidney disease leads to the need for lifelong dialysis; patients will remain on dialysis long-term and require ongoing lifestyle changes beyond the dialysis itself.
• dialysis can fix many problems caused by kidney failure, but lifestyle modifications are essential to optimize outcomes.
• Typical dialysis schedule mentioned: 3 times per week (e.g., Monday, Wednesday, Friday).
• Patients on dialysis often undergo additional systemic changes and require multidisciplinary care (diet, medications, psychosocial support, case management for transplant evaluation).

Body-system impacts when urination ceases (anuria) and the corresponding management

• Neurologic system

  • Potential issues such as seizures if electrolyte or metabolic disturbances occur.
  • Dialysis can help correct many electrolyte and toxin imbalances that contribute to neurologic symptoms.
  • Management consideration: anticonvulsants may be needed if seizures occur; not used prophylactically.

• Respiratory system

  • Fluid overload in the lungs can cause crackles, shortness of breath, and pulmonary edema.
  • Without functioning kidneys, diuretics like Lasix are ineffective; diuretics require some residual kidney function.
  • Immediate management: address fluid overload with dialysis to remove excess fluid; consider airway support (e.g., CPAP as needed) for some patients.
  • Long-term strategy: fluid restriction to prevent fluid accumulation; monitoring and optimizing pulmonary status.

• Cardiovascular system

  • Hypertension is common due to increased renin release when perfusion is reduced; hypertension is a leading cause of death in dialysis patients.
  • Dialysis helps manage fluid status but many patients still require multiple antihypertensive medications (beta-blockers, calcium channel blockers, etc.).
  • Dialysis can help reduce some cardiovascular risk factors, but dyslipidemia may worsen with dialysis, particularly triglycerides.
  • Hypertriglyceridemia: dialysis can increase triglyceride levels; often treated with lipid-lowering therapy (e.g., statins).

• Gastrointestinal and nutritional status

  • Anorexia and poor dietary intake are common in end-stage kidney disease.
  • Diet becomes highly restricted to manage electrolytes, fluid, and waste products; patients may experience diet noncompliance due to the restrictive nature.
  • Supplemental nutrition: Nepro (renal-specific supplement with lower sodium, potassium, and phosphorus) is often used to help meet nutritional needs.

• Hematologic system

  • Anemia is universal in end-stage kidney disease due to reduced erythropoietin production by diseased kidneys.
  • Erythropoiesis-stimulating agents (e.g., erythropoietin alfa) address anemia and are often given with dialysis visits; typically administered subcutaneously, about 3 times per week, and may take 2-3 weeks to show effect.
  • If anemia is severe or acute, blood transfusions may be required (transfusion carries risks; efforts aim to avoid transfusions when possible).
  • Iron stores are necessary for effective RBC production; iron supplementation is common.
  • Pruritus from elevated salts and skin changes can occur; patients may have edema-prone skin and skin breakdown risk.

• Dermatologic and skin integrity considerations

  • Edematous, itchy skin (pruritus) is common; scratching can lead to skin breakdown.
  • Good hygiene and skin care reduce complications: plain, fragrance-free soaps; simple, fragrance-free lotions; Vaseline or petrolatum-based products.

• Electrolyte and metabolic balance

  • Key electrolytes affected: ext{Sodium}, ext{ Potassium}, ext{ Calcium}, ext{ Phosphorus}.
  • Metabolic acidosis often develops and may remain compensated with dietary management and bicarbonate supplementation.
  • Diet aims to maintain electrolyte balance and minimize cramping and bone pain due to shifts in electrolytes.
  • Diet strategy: avoid “double jeopardy” foods that are high in potassium and phosphorus; prefer foods lower in these minerals and higher in calcium.

Dietary and metabolic management of dialysis patients

• Dietary restrictions are extensive and personalized; DaVita’s dietary guide is commonly referenced for guidance on potassium and phosphorus limits and calcium needs.
• Major dietary goals:
  • Low potassium (to prevent arrhythmias and muscle dysfunction)
  • Low phosphorus (to prevent bone disease and vascular calcification)
  • Adequate calcium (often with calcium supplements and vitamin D)
  • Vitamin D (cholecalciferol) to enhance calcium absorption and bone health
  • Iron intake or supplementation to support erythropoiesis
  • Bicarbonate or other agents to help manage metabolic acidosis and electrolyte shifts
• Phosphorus binders are commonly prescribed to limit phosphate absorption from the gut.
• Calcium supplementation is often used, along with vitamin D, to support bone health.
• Vitamin D and iron are important for RBC production and overall metabolic balance.
• Compensated metabolic acidosis may require buffering with bicarbonate supplements; diet and electrolyte management help minimize cramping and bone pain due to shifts.
• Nepro and other renal-specific supplements provide nutrition with controlled levels of sodium, potassium, and phosphorus to support patients who struggle with oral intake.

Exercise and transplant considerations

• All patients on dialysis are typically evaluated for kidney transplantation; case management helps determine eligibility for the transplant list.
• National waiting list context (as of May 2025):
  • kidneys: 91{,}000 people on the waiting list
  • liver: about 9{,}000 on the waiting list (next closest organ)
• Organ scarcity: kidney failure is more common than liver failure; a significant portion of patients rely on dialysis because organ availability lags far behind demand.
• Ethical and practical implications:
  • Dialysis sustains life and enables near-normal activity compared to other organ failure scenarios, but it is not curative; transplantation offers a potential cure but is limited by donor availability.
  • The large waiting list underscores the ethical imperative to improve organ donation rates and access to transplantation, while providing high-quality dialysis care in the interim.

Dialysis access: Central venous catheters

• Two common central venous catheter types discussed:

  • Non-tunneled catheter (nontunneled): quick bedside access, can be used immediately after radiographic confirmation of correct placement, higher infection risk.
  • Tunneled catheter (PermCath): surgically implanted in a sterile environment (OR); tunneled under the skin to reduce infection risk, more stable for long-term use; still requires confirmation by imaging before use.

• Insertion sites and principles:

  • Catheters typically end in the superior vena cava (SVC) with the tip in the central venous system; placement is confirmed by X-ray before use.
  • Non-tunneled catheters have a higher risk of infection due to an external segment near the exit site (dressings may not adhere well and can lead to contamination).
  • Tunneled catheters have a lower infection risk because the catheter travels under the skin before entering the venous system.

• Practical considerations and pros:

  • Both types provide reliable, large-volume access for hemodialysis.
  • Pros of a catheter: rapid placement and immediate usability once imaging confirms proper placement.
  • Pros of a PermCath: greater stability and lower infection risk due to tunneling; more suitable for longer-term use.
  • The choice between catheter types depends on the expected duration of use, infection risk, and clinical setting; some patients require urgent access, while others are bridged to arteriovenous fistula or graft planning.

• Typical nursing and clinical considerations:

  • Ensure correct tip location (in the SVC) with radiographic confirmation before first use.
  • Manage exit-site care and dressing changes to minimize infection risk; monitor for signs of infection.
  • Recognize that large-volume dialysis requires reliably functioning catheters and proper care to prevent complications.

• Summary practical distinctions:

  • BasCath (often a non-tunneled catheter): quick, bedside access; higher infection risk; short-term use.
  • PermCath (tunneled catheter): longer-term access, more stable, lower infection risk; requires surgical placement but can be used after imaging confirms placement.
  • Both provide large-volume dialysis access; patient safety hinges on proper site care and timely removal when a permanent access (fistula or graft) is available.

Quick practical takeaways for patient management

• Dialysis is lifesustaining but not curative; transplant status is commonly pursued, with case management assisting in listing.
• Expect comprehensive care beyond dialysis: dietary modification, pharmacotherapy for anemia and electrolyte management, infection prevention, and psychosocial support.
• Understand the rationale behind common interventions:
  • Antihypertensive and lipid-lowering therapies to address cardiovascular risk.
  • Erythropoietin alfa and iron to manage anemia; avoid unnecessary transfusions when possible.
  • Vitamin D and calcium management to preserve bone health in the setting of secondary hyperparathyroidism and metabolic bone disease.
  • Phosphorus binders and dietary phosphorus restriction to prevent hyperphosphatemia and vascular calcification.
  • Bicarbonate to maintain acid-base balance; dietary strategies to minimize electrolyte shifts and cramping.
• When weighing dialysis access options, balance immediacy, infection risk, and long-term stability; tunneled catheters provide safer long-term access but require surgical placement, while non-tunneled catheters offer rapid access for short-term needs.
• Patient education emphasis: adherence to fluid restrictions, dietary restrictions, and scheduled dialysis sessions; encourage questions and active participation in care planning.
• Real-world relevance: dialysis enables many patients to maintain a relatively normal lifestyle with proper planning, yet ongoing management challenges persist, including cardiovascular risk, anemia, mineral bone disease, and access-related complications.