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Hemodialysis Case Presentation
Hemodialysis Case Presentation
Presentation
HPI
Cl 103 93 96 97
CO2 15 27 26 19
BUN 107 35 45 71
● Calcimimetic
○ Results in decreased PTH -- decreased calcium leaching from bones
○ Cinacalcet (Sensipar)
Patient RS - Vitamin D Deficiency / Hypocalcemia
● No vitamin D level measured
● Cholecalciferol 1000 units daily
○ Appropriate dose
○ Appropriate agent for residual renal function
○ Could titrate dose with Vitamin D level
● Paricalcitol 5 mcg IV qMWF
○ Appropriate dose
○ Appropriate agent of HD patient
Patient RS - Hypertension
● Amlodipine
○ More effective when plasma volume is expanded
○ Little dialyzability
○ Unaltered PK in HD patients
● Furosemide
○ Reduce hyperkalemia with residual renal function
○ Favourable impact on cardiac remodeling
○ Minimizes interdialytic weight gain
● Hydralazine
○ Not removed with HD
○ Half life data with HD (7-16 hours)
● Carvedilol
○ Independent cardiovascular benefits
Patient RS - DVT
● Heparin bridging with heparin infusion
○ Continue for 24 hours after INR in goal
● Warfarin therapy
○ Strong data for HD patients
○ Goal INR of 2-3
○ Will continue for at least 3 months
● Adherence
○ Pt. has history of missing HD sessions
○ Extrapolation to missed coumadin clinic appointments could justify the use of apixaban
■ If apixaban were to be used - 2.5mg BID
Patient RS - Hyperlipidemia
● Currently not on therapy
● Statin use in HD patients
○ Evidence does not clearly answer the clinical decision to use a statin
○ Evidence appears to suggests risk of cardiac death is still reduced in HD patients with statin
use
○ Evidence appears to suggests safety profile is relatively equivalent to non-HD patients with
statin use
○ Ultimately provider discretion
Patient RS - Type 2 Diabetes Mellitus
● Currently on insulin detemir 5 units SubQ qhs home dose
● A1c 4.8%
○ 01/13/2021
● Goal A1c <7%
Patient RS - Hyperphosphatemia / Hyperparathyroidism
● This patient is currently not on therapy for hyperphosphatemia
○ Sevelamer carbonate not ideal option as this will increase pill burden for patient
■ TID dosing, folic acid supplementation, vitamin D/E/K
○ Ferric citrate may be best option to help with anemia
● PTH levels have not been measured
○ Adjust for hyperphosphatemia and hypocalcemia
Questions?
Works Cited
Cianciolo G, De Pascalis A, Di Lullo L, Ronco C, Zannini C, La Manna G: Folic Acid and Homocysteine in Chronic Kidney Disease and
Cardiovascular Disease Progression: Which Comes First. Cardiorenal Med 2017;7:255-266. doi: 10.1159/000471813
Kaw D, Malhotra D. Platelet dysfunction and end-stage renal disease. Semin Dial. 2006 Jul-Aug;19(4):317-22. doi:
10.1111/j.1525-139X.2006.00179.x. PMID: 16893410.
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-84. doi:
10.1159/000339789. Epub 2012 Aug 7. PMID: 22890468.
Lu, H. Y., & Liao, K. M. (2018). Increased risk of deep vein thrombosis in end-stage renal disease patients. BMC nephrology, 19(1),
204. https://doi.org/10.1186/s12882-018-0989-z
Malliara M. (2007). The management of hypertension in hemodialysis and CAPD patients. Hippokratia, 11(4), 171–174.
Shapiro, K., Bombatch, C., Garrett, S. D., Veverka, A., & RxPrep (Firm). (2021). RxPrep course book: 2021 Naplex course book.
The Use of Furosemide in Patients on Dialysis - Full Text View.” Full Text View - ClinicalTrials.gov,
clinicaltrials.gov/ct2/show/NCT01815892.