Case 027: Chronic Kidney Disease: End Stage Renal Disease

PATIENT PRESENTATION

Chief Complaint

“Since starting hemodialysis I have been very tired.”

History of Present Illness

A 55-year-old female started on hemodialysis (HD) one month ago is experiencing fatigue and low blood pressures after HD. Other medical concerns include a review of chronic disease states of T2DM, hypertension, and dyslipidemia; and evaluation and treatment for complications of CKD including mineral and bone disorders and anemia.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. Why are patients with ESKD at risk of having anemia?

   Hint: See Consequences of CKD and ESKD in PPP

2. What are some considerations to account for when selecting an iron product to prescribe?

   Hint: See Consequences of CKD and ESKD in PPP

3. Why are patients with ESKD at risk of having mineral and bone disorders?

   Hint: See Consequences of CKD and ESKD in PPP

4. How is managing chronic disease states of type-2 diabetes mellitus, hypertension, and dyslipidemias different in patients with ESKD?

   Hint: See Treatment in PPP

5. What are the complications of receiving chronic hemodialysis?

   Hint: See Renal Replacement Therapy in PPP

FOLLOW-UP

What are some considerations when erythropoiesis-stimulating agents are used in treatment of anemia of CKD?

Hint: See Consequences of CKD and ESKD in PPP

CASE SUMMARY

Global Perspective

The primary treatment for end stage kidney disease (ESKD) is renal replacement therapy (RRT) with either hemodialysis (HD) or peritoneal dialysis (PD). HD is the most common RRT modality world-wide. More than 80% of people receiving RRT are in developed and wealthier countries. Many people in the world do not have reliable access to HD or PD modalities. Lack of geographical access and cost are factors that influence these treatments. Access to a dialysis center can be a barrier especially in rural areas. Australia has reported difficulty finding qualified staffing for centers and less than 40% of patients in rural India have a dialysis center within 50 km of their home. Cost of HD and PD can be a significant barrier in all countries, however its influence on dialysis usage is varied.