Chapter 58: Electrolyte Abnormalities in Chronic Kidney Disease: Turn Down the ‘Lytes Level II

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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

• Interpret clinical and biochemical findings in patients with CKD.

• Recommend a patient-specific therapeutic plan for treating electrolyte abnormalities and chronic kidney disease-mineral and bone disorder (CKD-MBD).

• Monitor the effectiveness of the pharmacotherapeutic plan for treating electrolyte abnormalities in CKD.

• Educate patients with CKD on nonprescription medications that can worsen electrolyte abnormalities in CKD.

PATIENT PRESENTATION

Chief Complaint

“I’m just don’t feel like myself.”

HPI

Robert Wolfe is a 67-year-old man with type 2 DM, HTN, and stage 5 CKD. He receives hemodialysis three times a week with a high-flux hemodialysis membrane. His wife brought him into the ED this morning after she noticed increased confusion and lethargy, worsening over the past 2–3 days. According to his wife, the patient missed his HD session 2 days ago. She reports no other new symptoms except for increased pain in his feet from his neuropathy for which his PCP increased his gabapentin dose last week.

PMH

• Type 2 DM × 20 years

• HTN × 30 years

• Stage 5 CKD; he has been receiving HD for the past 5 years with a high-flux cellulose triacetate membrane; he has no residual renal function

• Diabetic neuropathy

• Anemia of CKD

• Dyslipidemia

• CKD-MBD

• Uremic pruritus

FH

Father with CAD; mother with DM and HTN

SH

Retired from a glass factory; on disability; past history of smoking, quit 3 years ago; (–) ETOH for the past 7 years

Meds

• Calcium acetate 667 mg, 2 PO TID

• Gabapentin 300 mg PO BID (increased last week from 300 mg PO at bedtime)

• Nephrocaps 1 PO daily

• Sodium ferric gluconate 62.5 mg IV once weekly with HD

• Metoprolol tartrate 25 mg PO BID

• Amlodipine mg PO daily

• Lipitor 10 mg PO daily

• Glipizde XL 10 mg PO daily

• Sitagliptin 25 mg PO daily

• Epogen 6000 IU IV three times a week with HD

• Calcijex 2 mcg IV three times a week with HD

• Ensure® Original Vanilla nutritional supplement, one bottle (237 mL) PO TID

All

NKDA

ROS

Increased fatigue and confusion; reduced sensation in lower extremities

PE

Gen

Patient somnolent; does not appear to be in distress

VS

BP 168/82 mm Hg, P 82 bpm, RR 14, T 36.8°C; dry body Wt 68 kg, Ht 5′11″

Skin

Normal; intact, warm and dry