What is the best approach to manage an 88-year-old female patient with end-stage renal disease (ESRD) on dialysis, monoclonal gammopathy, and a corneal ulcer, who has recently declined neurologically and has multiple comorbidities?

Management of an 88-Year-Old ESRD Patient on Dialysis with Neurological Decline and Corneal Ulcer

Your primary focus should be ensuring adequate dialysis delivery to manage her metabolic derangements and uremic symptoms, while simultaneously treating the corneal ulcer with dose-adjusted antimicrobials appropriate for her renal function. 1

Immediate Dialysis Management

Your patient's neurological decline with jerking, twitching, and poor dialysis tolerance during afib with RVR represents acute uremic encephalopathy compounded by inadequate dialysis clearance. 1

• Schedule her for dialysis today as planned - persistent uremic symptoms including encephalopathy are absolute indications for urgent dialysis 1
• Monitor for and aggressively manage hyperkalemia during the session, as her anuria places her at high risk - use insulin (0.1 units/kg) plus glucose (25% dextrose 2 mL/kg) if hyperkalemia develops acutely 1
• Ensure ECG monitoring throughout dialysis given her history of afib with RVR and risk of electrolyte shifts 1
• Consider more frequent dialysis sessions (potentially daily or every other day temporarily) until her neurological status stabilizes, as intensive hemodialysis regimens improve uremic symptom control 1

Antimicrobial Dose Adjustments for ESRD

Your current valacyclovir dosing is critically incorrect for an anuric ESRD patient and may be contributing to her neurological symptoms.

• Valacyclovir must be dose-reduced to 500 mg once daily after each dialysis session (not three times daily) in ESRD patients, as standard dosing causes neurotoxicity manifesting as confusion, tremors, and encephalopathy 2
• Tobramycin ophthalmic drops are safe to continue as topical administration has minimal systemic absorption 2
• Verify the "IM injection antibiotic" dose is appropriate for ESRD - many injectable antibiotics require significant dose reduction or extended intervals in anuric patients 2

Monoclonal Gammopathy Considerations

Her monoclonal gammopathy requires specific attention as it may be contributing to her renal disease and overall decline. 3, 4

• Determine if this is monoclonal gammopathy of renal significance (MGRS) - review whether her original ESRD was caused by the monoclonal protein (cast nephropathy, light chain deposition disease, or amyloidosis) 3, 4
• If MGRS is present, her neurological decline could represent progression of paraprotein-related complications beyond the kidney 3
• Coordinate with hematology if not already involved, as treatment targeting the plasma cell clone may be indicated even in advanced age if it improves quality of life 4

Metabolic Derangement Correction

Since her delirium previously resolved with metabolic correction, focus on optimizing her dialysis prescription. 1

• Target adequate small solute clearance with Kt/V ≥1.2 per session 2
• Address volume overload aggressively, as her lack of urine output means all fluid removal must occur during dialysis 1
• Monitor and correct severe metabolic acidosis during dialysis sessions, as this is an indication for urgent dialysis 1

Cardiac Management During Dialysis

Her afib with RVR complicating dialysis requires specific attention. 1

• Coordinate dialysis timing with rate control - ensure her ventricular rate is controlled before initiating dialysis to prevent hemodynamic instability
• Use slower ultrafiltration rates to minimize hemodynamic stress during fluid removal 1
• Consider cooler dialysate temperature (35-36°C) to improve hemodynamic tolerance during sessions 1

Infection Control

With negative blood cultures but ongoing intensive topical antimicrobial therapy for corneal ulcer:

• Continue the ophthalmology-directed regimen for the corneal ulcer as prescribed 2
• Avoid nephrotoxic antibiotics (aminoglycosides systemically, NSAIDs) that could eliminate any residual renal function 2, 5
• Monitor for signs of systemic infection given her immunocompromised state from ESRD and monoclonal gammopathy 2

Critical Pitfalls to Avoid

• Do not continue valacyclovir at three times daily dosing - this is causing iatrogenic neurotoxicity in an anuric patient 2
• Do not attribute all neurological symptoms to "just uremia" without considering drug toxicity from renally-cleared medications 2
• Do not skip or shorten dialysis sessions because she tolerates them poorly - instead, modify the prescription (slower rates, cooler temperature, more frequent shorter sessions) 1
• Do not overlook that her monoclonal gammopathy may require hematologic treatment to prevent further organ damage 3, 4

Prognosis Discussion

At 88 years old with ESRD, monoclonal gammopathy, and multiple comorbidities, she meets criteria for patients who may not live longer with dialysis than without it (age ≥75 years, multiple comorbidities, functional impairment). 2

• Ensure goals of care discussions have occurred with the patient (if she regains capacity) and family regarding the intensity of interventions 2
• Offer integrated palliative care to control symptoms including fatigue, dyspnea, and anxiety regardless of whether dialysis continues 5
• Systematic symptom assessment should be implemented to improve quality of life 2