What is the plan of care for a patient with uncontrolled hypertension, end-stage renal disease, cirrhosis with ascites, seizure disorder, SLE, anxiety, and pancytopenia?

From the Guidelines

The plan of care for this complex patient requires a multidisciplinary approach addressing each condition while considering medication interactions, prioritizing management of uncontrolled hypertension, end-stage renal disease, cirrhosis with ascites, seizure disorder, SLE, anxiety, and pancytopenia to minimize morbidity, mortality, and improve quality of life. For uncontrolled hypertension, I recommend starting with amlodipine 5-10mg daily as it's generally well-tolerated in renal disease and cirrhosis 1.

Key Considerations:

• For end-stage renal disease, the patient needs regular dialysis (3-4 times weekly), strict fluid restriction (typically 1-1.5L daily), and renal diet (low potassium, phosphorus, and sodium).
• The cirrhosis with ascites requires spironolactone 100mg with furosemide 40mg daily (adjusted based on response), sodium restriction (<2g daily), and periodic paracentesis if ascites becomes tense, as recommended by the American Association for the Study of Liver Diseases 1.
• For seizure disorder, levetiracetam 500mg twice daily is preferred as it has minimal hepatic metabolism and doesn't require dose adjustment in renal failure.
• SLE management should include hydroxychloroquine 200mg daily (with ophthalmologic monitoring every 6-12 months) and prednisone 5-10mg daily for maintenance (higher doses during flares).
• Anxiety can be treated with buspirone 5mg twice daily, gradually increasing to 10mg twice daily as needed, avoiding benzodiazepines due to hepatic impairment.
• For pancytopenia, weekly complete blood counts are essential, with erythropoietin-stimulating agents for anemia, dose adjustments of potentially myelosuppressive medications, and infection precautions.

Medication Interactions and Adjustments:

• The patient's current medications, including Phenytoin Sodium Extended Capsule, 100 MG, and prednisone 10 mg daily, should be reviewed and adjusted as necessary to minimize interactions and optimize disease control.
• The patient's anuric status and lack of renal function should be considered when adjusting medication doses, with careful monitoring of electrolyte levels and renal function.

Multidisciplinary Approach:

• The patient should be referred to a nephrologist, hepatologist, and rheumatologist for ongoing management of end-stage renal disease, cirrhosis, and SLE.
• Regular follow-up appointments with the primary care physician and specialists are crucial to monitor disease progression, adjust treatment plans, and address any concerns or complications that may arise.

Quality of Life Considerations:

• The patient's quality of life should be prioritized, with consideration of their symptoms, functional status, and overall well-being.
• The patient's anxiety and depression should be closely monitored, with adjustments to treatment plans as needed to optimize mental health and quality of life.

From the Research

Plan of Care

The patient has multiple chronic conditions, including uncontrolled hypertension, end-stage renal disease, cirrhosis with ascites, seizure disorder, SLE, anxiety, and pancytopenia. A comprehensive plan of care is necessary to manage these conditions effectively.

• Hypertension Management: The patient's blood pressure is elevated, and she has not taken her BP medications today. According to 2, antihypertensive medications alone may not adequately control blood pressure in hemodialysis patients. Therefore, dietary salt and fluid restriction in combination with reduction of dialysate sodium concentration may be considered.
• End-Stage Renal Disease (ESRD) Management: The patient continues to receive hemodialysis three times a week. As stated in 2, optimal blood pressure in dialysis patients is not different from recommendations for the general population. Regular monitoring of blood pressure and adjustment of hemodialysis treatment as needed is crucial.
• Cirrhosis and Ascites Management: The patient has a history of cirrhosis with ascites and is following up with a GI doctor. According to 3, the treatment of ascites is currently based on the management of fluid overload, and in selected patients, long-term albumin use, norfloxacin prophylaxis, and transjugular intrahepatic portosystemic shunt may reduce the risk of further decompensation and improve survival.
• Seizure Disorder Management: The patient is on Phenytoin Sodium Extended Capsule and has not had any seizures. Regular monitoring of the patient's seizure activity and adjustment of medication as needed is necessary.
• SLE Management: The patient is on a low dose of prednisone and does not see a rheumatologist. According to 4, comprehensive assessment, evidence-based care planning, and monitoring are essential for managing chronic conditions like SLE.
• Anxiety Management: The patient's anxiety is well-controlled on medication. Regular monitoring of the patient's anxiety and adjustment of medication as needed is necessary.
• Pancytopenia Management: The patient has a low white blood cell count, red blood cell count, and platelet count. According to 5, patients with cirrhosis are at risk of hematologic derangements, and regular monitoring of blood counts is necessary.

Coordination of Care

The patient has multiple healthcare providers, including a nephrologist, GI doctor, and primary care physician. As stated in 4, coordination of professionals in care of the patient is essential for effective management of chronic conditions. Regular communication and collaboration among healthcare providers are necessary to ensure comprehensive care.

• Patient Engagement: The patient should be encouraged to take an active role in their care, including monitoring their blood pressure, adhering to medication regimens, and attending follow-up appointments.
• Care Planning: A comprehensive care plan should be developed, taking into account the patient's goals, preferences, and values. The plan should include strategies for managing hypertension, ESRD, cirrhosis, seizure disorder, SLE, anxiety, and pancytopenia.

By following this plan of care, the patient's chronic conditions can be effectively managed, and their quality of life can be improved 4, 6.