COMMENTARY

Patient Transition to Dialysis: Advice to Providers and Pharmacists

Lynda Szczech, MD, MSE

Disclosures

February 21, 2018

Hello. My name is Lynda Szczech. I am a practicing nephrologist in Durham, North Carolina.

Today I want to talk about the transition of patients with chronic kidney disease (CKD) to dialysis. This is a time in the life of a patient that I think is a very vulnerable one. It is very emotionally challenging and requires a team approach to care—the team being the patient, their family, primary care provider (PCP), nephrologist, pharmacist—everyone involved in the patient's care.

The reasons that I chose this topic are twofold. First, [the transition of a patient to dialysis] is one that is near and dear to my heart. When I walk into a dialysis unit and meet someone for whom it is his or her first dialysis session, I am struck by the emotions openly expressed in front of so many complete strangers. At such a critical time as this in a person's life, I try to be there to support them.

The second reason that I am bringing this point up now is because there are new chapters added to the United States Renal Data System (USRDS) Annual Data Report.[1,2] The USRDS is a Congress-mandated annual data review of all patients undergoing dialysis in the United States, and it is available online at usrds.org. The first of these two volumes reports on patients with CKD who do not require dialysis, and the second volume focuses on patients with CKD who do need dialysis [ie, end-stage renal disease].[1,2]

The two new chapters, chapters 8 and 9, recently added to volume 1 of the USRDS were primarily driven by a good friend of mine at UC Irvine, Dr Kam Kalantar-Zadeh. Both of these chapters detail the experience of CKD patients making the transition to dialysis.

Monitor Patients for Congestive Heart Failure and Weight Gain

[Chapter 8 of the USRDS report discusses the increased rate of hospitalizations.] Unfortunately, when someone is making that transition, from not requiring dialysis to requiring dialysis, his or her risk for hospitalization goes way up. The most important and frequent cause for hospitalization is congestive heart failure.

Congestive heart failure can develop prior to dialysis, as kidney function slowly declines and there is a decrease in sodium excretion. It can also develop after dialysis due to changes in patients' medications and the removal of systemic salt and water through the dialysis machine. Both of these causes are very important.

Patients, their family members, and PCPs need to keep track of the patient's weight over time. If there is an upward trend in weight gain, let someone know. Congestive heart failure and sodium retention can lead to bad hospitalizations and are associated with increased risks for mortality.[1]

Review the Patients' Medications and Adjust Doses if Needed

The other big-picture item that I want to talk about is changes and/or adjustments that may need to be made to the patient's medications.[1] As patients make the transition from nondialysis-dependent CKD to dialysis, their kidney function changes and medication doses may need to be adjusted. Since dialysis affects the ability of the kidneys to excrete sodium, potassium, and phosphorus, patients may require additional medications to address this issue.

Usually patients who are just starting dialysis, or who are already on dialysis, are on eight to 10 medications. As I mentioned in a previous video, the opportunity for medication errors occurring in these patients is quite significant.[3] If you are a PCP or another healthcare provider caring for dialysis patients in the hospital, it is important that you review the patients' medications with them before they are discharged back to their nephrologist for care.

[With respect to patient medications], are dialysis patients on diuretics? Patients with CKD who don't need dialysis are usually taking diuretics to assist the kidneys in eliminating sodium to prevent buildup of fluid in the body. More often than not, patients who start dialysis will no longer need to take diuretics.

[Pharmacists, however, should not advise patients to discontinue diuretics because there are some dialysis patients who may need to take diuretics.] Instead, tell them to talk to their nephrologist to see if diuretics are still indicated. Patients are often—but not always—tapered off of diuretic medications.

As kidneys fail and patients get closer to the need for dialysis, the effective amount of certain drugs may increase in their bloodstream. Once patients start dialysis, the dialysis machine itself may dialyze out medications. These are the next two points I would like to talk about: [renal clearance and the effect of dialysis on certain medications].

[Regarding the effect of dialysis and renal drug clearance], I think the best example of this (though not the only one) is seen in diabetes medications. In chapter 8 of the USRDS, you will see a beautiful graph showing a decline in glucose levels as patients approach the need for dialysis.[1] For people with diabetes, that's a good thing. It means better blood sugar control. From a safety perspective, that can mean unexpected drops in blood sugar, which can be very dangerous and sometimes deadly.

As patients who have diabetes approach the need for dialysis, keep an eye on the blood sugar levels. PCPs, if you see that someone's hemoglobin A1c which used to be the eights is now in the sixes, and they've not made any changes in medication doses, I'll bet you dollars to donuts that their estimated glomerular filtration rate (eGFR) has fallen a little bit more. Maybe their oral hypoglycemic or insulin is a little more effective, meaning it's hanging around longer. Bear in mind that better blood sugar control can occur prior to dialysis because medications aren't cleared as much.

After starting dialysis, the timing of when patients take their medication needs to be discussed on a medication-by-medication level with a pharmacists or nephrologist, because some medicines are cleared by dialysis and need to be taken after dialysis. This pertains mostly to antibiotics and similar medications. Some medications aren't cleared by dialysis, and you wouldn't want to take a big dose of antihypertensive medicine right before dialysis, where we might be trying to remove fluid from your body as a part of the dialysis procedure.[4] It can get very complicated. Therefore, patients starting dialysis must understand the appropriate timing of their medications.

Questions Patients May Ask You About Dialysis

There are a number of questions that patients frequently ask me. PCPs should also be prepared to answer them.

"Will I still make urine? Will I still pee?"

The answer to that is: probably not in the long term, but some patients will continue to produce urine over quite a long period of time. Over time, in terms of months and years, the kidney function of dialysis patients will continue to decrease, and patients will in turn produce less and less urine. It will depend on the individual and the length of time that they are on dialysis. Bear in mind that if a patient goes from a lot of urine output to less urine output, it gets back to that weight—ie, the kidneys' ability to eliminate sodium and water. Again, keep an eye on the patient's weight.

"Will I need to be on dialysis forever?"

The short answer to this question is probably yes. Although there are anecdotal instances of patients who started dialysis due to a small change in their kidney function, perhaps from an acute injury that reversed, and then came off of dialysis, this is not a common scenario.

I am reminded of the saying "Hope for the best but plan for the worst." What I mean by "plan for the worst" is, dialysis may be your ticket to enjoying the rest of your life, but that's the key. It is your ticket to enjoying the rest of your life, and it's not the end of your life. It's the beginning of a different chapter.

Here's my little pep talk: "This is your chapter to learn about and take control over. The things that you need to learn about are managing your weight and how dialysis affects your weight, blood pressure, and the salt levels in your blood. What you need to do is help dialysis help you."

I hope that this video has brought some insight into the important points in the transition of patients with CKD to dialysis. Please let me know your comments and thoughts on this topic, and also if there are other topics you would like to learn more about.

This is Lynda Szczech, a practicing nephrologist in Durham, North Carolina, who loves her patients and who wishes to make this time a less traumatic one for them. Have a great night.

Follow Medscape Nephrology on Twitter for more Nephrology news @MedscapeKidney .

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....