Week 13: Symptoms Associated with Renal and Hepatic Disease

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Symptoms Associated with Renal and Hepatic Disease
Case Study
November 23, 2013

Week 13: Symptoms Associated with Renal and Hepatic Disease

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Renal Case Study Introduction
Glenda is a 41 year old woman with end stage renal disease related to polycystic kidney disease. She has been on dialysis for ten years while waiting for a donor. She has recently made the choice to stop her dialysis sessions and her medications. She acknowledges this will mean the end of her life, but she has come to feel that she has no quality. She has come to discuss what you can do for her current symptoms and what death might look like.

Glenda tells you she is chronically fatigued, has diminished appetite and is always

constipated. She reports getting a little foggy before her dialysis and sometimes has neuropathy in her fingers and feet. She goes crazy from the uremia. She is currently on an ACE inhibitor to control her blood pressure, calcium carbonate PO TID to bind phosphate, docusate 100 mg TID for constipation.
Medication and Dosing Considerations
Since Glenda has chosen to stop her dialysis treatments as well as her medications, I would first review the medical treatments that Glenda is currently receiving and discontinue those that will not improve her quality of life while dying (
Davison & Rosielle 2012). any
M
drugs that were previously cleared by dialysis may need to be dose adjusted or discontinued.

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Treatment plans should be frequently reevaluated, with particular attention to the use of scheduled medications (
Davison & Rosielle 2012).
With an expected survival rate of approximately 8 days unless she has significant residual kidney function (
Holley 2012), i t would be appropriate for Glenda to stop her ACE inhibitor to control her blood pressure. I would discontinue the calcium carbonate PO TID as it can increase constipation, nausea, and vomiting (Davis n.d.). Continuing her docusate 100 mg TID may help relieve pain and discomfort cause by her constipation. Adding lactulose may be beneficial.
Lactulose works by relieving constipation through a number of different methods. Lactulose is made up of sugar molecules and is partly broken down by the bacteria that live in the lower part of the gut. This leads to the contents of the gut becoming more acidic because there are carboxylic acids among its metabolites , which are not absorbed from the lower bowel. That in turn causes to be retained in the lower bowel. This increases the amount of water in the water stools, softening them and making them easier to pass. The added volume of gas and flatulence caused by fermentation the lactulose adds to the volume of the fecal material, of and makes it easier to expel. The slightly acidic condition of the colon caused by the presence of acids leads to active peristalsis The combined effect of all of these processes relieves
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constipation in a very effective manner. Until the intestinal contents are emptied, the fermentation process causes periodic surges that can barely be retained and often lead to a panicky effort to reach toilet facilities. Excess amounts can lead to an uncontrollable, explosive, violent diarrhea. In sensitive individuals, such as people with reduced kidney function, excess

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lactulose dosage can result in dehydration electrolytic disturbances such as sodium and high levels (Wikipedia 2013), but at this point the benefits may outweigh the negative side effects.
Clarification of treatment limitations including resuscitation (code) status should be addressed as well as provide emotional/psychological, spiritual, social work, and bereavement support services to Glenda and her family (
Davison & Rosielle 2012).
Survival rate and Expectations
Glenda might experience the following symptoms after discontinuing her dialysis treatments and should be counselled about these symptoms and reassured that they can be adequately treated, although drugs with sedating side effects may be necessary to ensure comfort. (
Davison & Rosielle 2012):
➢ confusion/agitation
➢ pain
➢ dyspnea
➢ nausea
➢ twitching/seizures
➢ anxiety/psychological distress
➢ pruritus
➢ peripheral edema

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Depending on the presence and degree of residual kidney function, survival after stopping dialysis is often measured in days; in patients with no significant residual kidney function, death occurs in a mean of 8 days after the last dialysis treatment. Patients with some endogenous kidney function may live for prolonged periods of time after stopping dialysis. This needs to be discussed with Glenda and her family as well as hospice and primary care providers who will continue to care for the patient after dialysis is withdrawn. In order for patients to receive optimal care after stopping dialysis, enrollment in hospice should be encouraged. Symptom management, attention to the patient’s spiritual needs, and bereavement care for the Glenda’s family will all be provided if the patient is enrolled in hospice (
Holley 2012).
For pain management acetaminophen is the agent of choice for mild pain. Fentanyl and methadone are considered safe after dialysis discontinuation, although methadone should only be initiated by clinicians familiar with it (Holley 2012). If Glenda experiences shortness of breath oxygen, positioning, and opioids are the mainstays of therapy and I would also recommend continuing fluid restriction (