Hemodialysis Case

Presentation

Kyle Starkus, PharmD

08/18/2021
Patient RS
CC

Pain of the left forearm and hand

HPI

RS is a 45 y/o male with a PMH significant for ESRD on HD MWF, T2DM,

hyperlipidemia, and HTN who presented to the ED with swelling, mild redness,
and pain of the left forearm and hand. US revealed noncompressibility of the left
anterior brachial vein and a heparin drip was initiated.
Patient RS
● PMH
○ ESRD on HD MWF
○ T2DM
○ Hyperlipidemia
○ HTN
● SH
○ (-) Smoking
○ (-) EtOH
○ (-) Illicit drug use
○ Unknown FH
○ Unknown Diet
● ALL
○ NKDA
Objective
● Patient RS is 65” and 68.1kg with a BMI of 25.0
● Vitals: 97 / 149/70 / 65 / 20 / 99% RA

8/11 8/11 8/12 8/13 8/17

WBC 9.3 8.9 5.9 7.2 6.5

RBC 3.11 3.69 3.51 3.43 3.22

Hbg 10.1 12.0 11.4 11.1 10.5

Plt 214 214 220 190 226

Objective Cont.
8/11 8/11 8/12 8/13

Na 136 132 135 134

Cl 103 93 96 97

K 5.1 3.7 4.1 4.5

CO2 15 27 26 19

BUN 107 35 45 71

SCr 16.62 8.46 10.18 13.10

Ca 7.3 8.9 7.7 6.9

Phosphorus 8.3 9.7

Albumin 3.6 4.2 3.2

Prior To Admission Medications

Drug Strength Directions Indication

Insulin Detemir 5 units SubQ qhs T2DM

Hydralazine 50mg 1 tab PO TID HTN

(hold SBP < 110)

Carvedilol 12.5mg 1 tab PO BID HTN

Amlodipne 10mg 1 tab PO daily HTN

Furosemide 80mg 1 tab PO daily HTN

Aspirin 81mg 1 tab PO daily HLD

Inpatient Medications

Drug Strength Directions Indication

Levemir 5 units SubQ qhs T2DM

Novolog Variable Correction scale T2DM

Heparin Variable Per Protocol DVT

Warfarin Variable Pharmacy to dose DVT

Furosemide 80mg 1 tab PO daily HTN

Amlodipine 10mg 1 tab PO daily HTN

Hydralazine 50mg 1 tab PO daily HTN

(hold if SBP < 110)
Inpatient Medications Cont.

Drug Strength Directions Indication

Melatonin 6mg 1 tab PO daily Insomnia

Calcium Acetate 2000mg 1 cap PO TID with Electrolyte

meals imbalance

APAP 650mg 1 tab PO q4h PRN Headache / Fever

Ferric Gluconate 62.5mg IV qw Anemia

Cholecalciferol 1000 IU 1 tab PO daily Vit D

Paricalcitol 5 mcg 5mcg IV qMWF Vit D

Chronic Kidney Disease
● Chronic kidney disease (CKD)
○ Gradual loss of kidney function over time
○ CKD poses numerous clinical challenges such as:
■ Mineral and Bone disorders (CKD-MBD)
● Fractures
● Cardiovascular disease
● Increased mortality
■ Hormonal abnormalities
● Vitamin D
● Parathyroid hormone (PTH)
● Erythropoietin
■ Electrolyte abnormalities
● Potassium
● Calcium
● Phosphorous
Chronic Kidney Disease Cont.
● CKD risk factors:
○ Smoking
○ Obesity
○ Advanced age
● Causes of CKD:
○ Diabetes mellitus
○ HTN
○ Pyelonephritis
● CKD comorbid cardiovascular conditions:
○ HF
○ IHD
○ Peripheral vascular disease
○ Left ventricular hypertrophy
Chronic Kidney Disease Cont.
● One unique clinical challenge CKD patients face is that they are at increased
risk of developing both blot clots and bleeding
● Bleeding
○ Platelet dysfunction
■ Activation / recruitment / adhesion / aggregation
○ Anemia
○ Hemodialysis
● Clotting
○ Increased procoagulants
■ Increased cystatin C, CRP, IL-6, TNF, fibrinogen, etc.
○ Hyperhomocysteinemia - folic acid for methionine conversion as prevention?
○ Hemodialysis (low BP)
Stage of CKD

GFR Term GFR Category (KDIGO

2012)

>90 + kidney damage Normal or high G1

60-89 + kidney damage Mild decreased G2

45-59 Mild to moderate decrease G3a

30-44 Moderate to severe G3b
decrease

15-29 Severe decrease G4

<15 or dialysis dependent Kidney failure G5

Stage of CKD Cont.
Degree of albuminuria

ACR (mg/g) or Term Albuminuria category

AER (mg/24hr) (KDIGO 2012)

<30 Normal to mild increase A1

(normoalbuminuria)

30-300 Moderate increase A2

(microalbuminuria)

>300 Severe increase A3

(macroalbuminuria
ACR - albumin to creatinine ratio

AER - albumin excretion rate

Pathophysiology
Overview
Hyperphosphatemia
● High phosphate levels increase PTH levels
● Treatment
○ Restriction of dietary phosphates
■ Dairy, cola, chocolate
○ Phosphate binders
■ Aluminum-based
● Aluminum hydroxide (high toxicity)
■ Calcium-Based
● Calcium acetate (hypercalcemia)
■ Aluminum-free, calcium-free
● Ferric citrate (iron absorption)
■ Not systemically absorbed
● Sevelamer (risk of bowel obstruction + reduces absorption of not just PO4)
Vitamin D Deficiency & Secondary Hyperparathyroidism
● Vitamin D
○ Activated by the kidneys (impaired in CKD)
■ 1,25-dihydroxy vitamin D
■ Vitamin D3 - cholecalciferol (skin via UV light)
■ Vitamin D2 - ergocalciferol (plant sterols)
● Both high PO4 and low Ca cause increased release of PTH
○ Increased PTH results in bone demineralization
○ Prevented in CKD by:
■ Decreasing serum PO4
■ Increasing serum calcium
■ Increasing the sensitivity of calcium receptors on the parathyroid gland
Treatment of Secondary Hyperparathyroidism
● Vitamin D analogs
○ Results in increased calcium absorption
○ Calcitriol (Rocaltrol)
○ Paricalcitol (Zemplar)

● 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.