ESRD Patients in the PCP Office

Patients are living longer and doing more with end organ damage than ever before. They live in the community, work, socialize and generally live their lives. However, they do get sick and then seek care thru their primary care provider. Here are some tips for caring for end stage renal disease patients. Nurses Announcements Archive Article

ESRD Patients in the PCP Office

So, you have finished your MSN or DNP, passed your certification exam, landed your first job in primary care and voila....you are seeing patients all by yourself.

Congratulations!

Patients being seen by primary care providers (PCPs) are more complex than ever. Hypertension (HTN) and diabetes are two of the more common comorbidities. Then, you add in congestive heart failure (CHF), connective tissue disease, Lupus and end stage renal disease (ESRD). Mix it up with depression and post-traumatic stress disorder (PTSD) and you have your new patient base.

The patients I'm going to discuss are ESRD patients on dialysis who are being seen by PCPs.

I've been a nephrology APRN since 2006. I work in a very large 19 MD practice. And... they have 19 different ways of practicing nephrology! For some, they want to be the PCPs, for others, they see themselves as the nephrologist only. Makes for some exciting situations to say the least. To this end, what YOU find in your area might differ somewhat from what I see. This is general information.

Caring for and prescribing for dialysis patients can be daunting and I thought I would share some tips that I've learned over the years to help ease the new APRN into a comfort zone.

It is very important to use a solid reference. There are many prescribing references out there to choose from. I have used the MPR Nurse Practitioner Drug reference and Epocrates, but I prefer UpToDate as the name speaks for itself. In addition to prescribing information, UpToDate includes evidence based practice, guidelines and protocols. You might want to negotiate for it when you get hired if not already offered. If you work within a hospital system, call your pharmacist for guidance. For private practices, seek out a willing retail pharmacist and cultivate a relationship. (Posted links at end of article)

Almost all medications prescribed to dialysis patients need to be renally dosed. Renal dosing is done by adjusting for the patient being on either intermittent hemodialysis (IHD), peritoneal dialysis (PD), or continuous renal replacement therapy (CRRT).

Once a patient reaches ESRD, or chronic kidney disease (CKD) stage V, the glomerular filtration rate (GFR) is

Some ways that medications are dose adjusted include:

  1. Decreasing the total amount given
  2. Increasing the interval between doses
  3. Timing of medication related to type of dialysis (dialyzability)
  4. Some meds are contraindicated with an ESRD diagnosis
  5. Warfarin needs to be monitored very closely as the absorption rate can be unpredictable. Many times, if the patient is on hemodialysis, the nephrology practice will want to monitor and adjust dosage. This is usually done on a weekly basis

Other general caveats when caring for ESRD patients:

  1. When an ESRD patient has gastroenteritis or volume loss due to nausea, vomiting, diarrhea, it is important to be mindful of the amount of fluid you give the patient. And, before I get blasted for stating the obvious, our patients frequently get fluid overloaded by their other providers. ESRD patients can have GENTLE hydration but start with 250-500ml.
  2. For fluid overloaded patients, first ask if they urinate and then ask how much. At some point (and it varies with the patient), diuretics do no good. Dialysis is the best way to handle fluid overload in ESRD patients. Call the nephrologist and try to get them in for an extra treatment if they are on hemodialysis or adjust their PD bath. Brain natriuretic peptide (BNP) is not the best way to determine fluid status in an ESRD patient. Look to clinical exam such as pedal or facial edema, hypertension, shortness of breath or activity intolerance. Most dialysis patients live in a state of at least mild fluid overload so unless a BNP is >2000, they are not MORE fluid overloaded then they are usually.
  3. ESRD patients have various dialysis accesses. These can include fistulas or grafts which lie below the skin usually in an upper extremity. Grafts can also be placed in the thigh. Then there are catheters which are usually tunneled and can be placed in the internal jugular or translumbar into the inferior vena cava. There are also peritoneal catheters which lie in the peritoneum. Your friendly area nephrology APRN or PA is a good resource if you have questions.

As nephrology APRNs/PAs, we work very hard to educate our patients and make them the best advocate for their own health. These patients are all very fragile and frequently require medical care. Together, the PCP and nephrologist work together to provide the best outcome.

What's been your experience with ESRD patients in your practice?

References:

Dialysis of Drugs (2013) Retrieved January 8, 2015 from http://renalpharmacyconsultants.com/assets/2013dodbooklet.pdf

Epocrates (2014) Retrieved January 8, 2015 from Point of Care Medical Applications | Epocrates

MPR Drug Reference (2014) Retrieved January 8, 2015 from Subscription Info (Nurse Practitioners) - MPR

Peritoneal Dialysis Catheter Placement (2013) Retrieved January 9, 2015 fromMedscape: Medscape Access

Placement of Translumbar Catheter (2010). Retrieved January 9, 2015 from

UpToDate (2015) Retrieved January 8, 2015 from Evidence-Based Clinical Decision Support at the Point of Care | UpToDate

Trauma Columnist

14-yr RN experience, ER, ICU, pre-hospital RN, 12+ years experience Nephrology APRN. allnurses Assistant Community Manager. Please let me know how I can help make our site enjoyable.

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ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

My experience has been a total lack of advance life care planning with every ESRD resident I have encountered in LTC.It is NEVER addressed outside the nursing home and we end up with a family in crisis,a resident CTD and rolling out to dialysis as a full code with end stage dementia.This may just be a characteristic of our local unit...If your experience is something g different please share it.

Trauma Columnist

traumaRUs, MSN, APRN

88 Articles; 21,249 Posts

Specializes in Nephrology, Cardiology, ER, ICU.

Very interesting observation. I practice in IL and our legislature just passed a law allowing APRNs and PAs to sign the POLST form.

I am a firm believer in advanced directives and getting them signed PRIOR to the acute need. It is so upsetting for the families for their first encounter with me to be presenting them with an end of life decision.

Thank you for your perspective.

Do you have a palliative care service available to your LTC?

allnurses Guide

BostonFNP, APRN

2 Articles; 5,581 Posts

Specializes in Adult Internal Medicine.

Great article.

I have a few on my panel and I often call our local nephrology NP with med questions.

Sent from my iPhone.

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.
Very interesting observation. I practice in IL and our legislature just passed a law allowing APRNs and PAs to sign the POLST form.

I am a firm believer in advanced directives and getting them signed PRIOR to the acute need. It is so upsetting for the families for their first encounter with me to be presenting them with an end of life decision.

Thank you for your perspective.

Do you have a palliative care service available to your LTC?

We do have a palliative care program ,first in this area.

ktwlpn, LPN

3,844 Posts

Specializes in LTC,Hospice/palliative care,acute care.

One of our PCP's in our LTC informed one of our staff nurses last week that "anyone on dialysis has to be 'full code'.....

Trauma Columnist

traumaRUs, MSN, APRN

88 Articles; 21,249 Posts

Specializes in Nephrology, Cardiology, ER, ICU.

That's crazy. What's their rationale?

AtomicWoman

1,747 Posts

Thanks so much for this article. My biggest frustration as a primary care NP in treating ESRD patients is that once they are on dialysis, the nephrologists stop communicating with us. A note every 6 months, plus a copy of recent labs, would be very helpful, so that we know what is going on with the patient. They seem to forget that we have treated the patients for years while their kidney function was better than it is now. I recently saw a dialysis patient, who is doing well. But I found out he had had a lot of trouble with the vasculature in his access arm and had multiple procedures, consults, etc. Keeping our practice "in the loop" would have been appreciated and I would have called him to touch base. That said, I am extremely cautious in what I prescribe for these patients and if I have any question that I can't find the answer to, I call the nephro. Better safe than sorry.

Trauma Columnist

traumaRUs, MSN, APRN

88 Articles; 21,249 Posts

Specializes in Nephrology, Cardiology, ER, ICU.

Thanks AtomicWoman.

We are seeing that we are the primary care provider for more and more pts. With Obamacare, few of our dialysis patients can even get into see a PCP anymore. I've been doing healthcare education/preventive exams, etc. for over two years now.

I do agree that we don't communicate much with our pts PCPs. For the most part, in my practice, I handle the acute stuff like HTN, DM, CHF, wounds, etc., all on my own. I see these pts every week so its easy for me to care for them as issues arise.