What are the recommendations for a patient with end-stage renal disease, pulmonary edema, and chronic respiratory failure who missed multiple dialysis appointments due to transportation issues?

Recommendations for Follow-Up: ESRD Patient with Missed Dialysis and Acute Decompensation

Immediate Priority: Ensure Reliable Dialysis Access

This patient requires immediate establishment of a reliable transportation system to prevent future missed dialysis sessions, as missing treatments directly increases mortality risk and has already resulted in life-threatening pulmonary edema. 1

Transportation Solutions

• Contact the dialysis facility social worker immediately to arrange guaranteed medical transportation through Medicare/Medicaid-covered services 1
• Document transportation as a medical necessity given the recent hospitalization for missed treatments 1
• Establish backup transportation plans (family, friends, or alternative transport services) for when primary transport fails 1
• Consider scheduling dialysis at times when transportation is most reliable 1

Critical Clinical Monitoring

Cardiovascular and Volume Status

• Monitor for recurrent pulmonary edema given the recent episode with elevated troponin, which indicates cardiac strain from volume overload 2, 3
• Assess volume status at each visit: check for JVD, peripheral edema progression, lung sounds, and oxygen requirements 3
• The nonpitting bilateral lower extremity edema noted on exam suggests chronic volume overload that requires aggressive ultrafiltration at dialysis 3
• Blood pressure control is adequate at 115/60, but continue current antihypertensive regimen 4

Medication Review - Critical Safety Concern

• Discontinue losartan 50 mg immediately 4
  • Angiotensin receptor blockers are contraindicated in ESRD patients as they can precipitate anuria and acute pulmonary edema 4
  • This patient already experienced pulmonary edema; losartan may have contributed to hemodynamic instability 4
  • Blood pressure is currently controlled on metoprolol, amlodipine, and other agents 4

Dialysis Adequacy Assessment

• Measure dialysis adequacy within 1 month using Kt/Vurea to ensure adequate solute clearance 2
• Target total Kt/Vurea ≥1.7 per week (combining peritoneal and residual renal function if applicable) 2
• Assess for uremic symptoms: nausea, vomiting, appetite suppression, encephalopathy 2
• The documented encephalopathy and generalized weakness may indicate inadequate dialysis from missed sessions 2

Nutritional Status

• Check serum albumin and normalized protein nitrogen appearance (nPNA) at next dialysis adequacy measurement 2
• Current medications include Aranesp for anemia management, which is appropriate 2
• Monitor for protein-energy wasting given generalized weakness and recent acute illness 2

Respiratory Management

Chronic Respiratory Failure

• Patient is oxygen-dependent (97% on 3L) with chronic respiratory failure and history of pulmonary edema 2
• Continue home oxygen therapy at current rate 2
• Ensure adequate ultrafiltration at each dialysis session to prevent fluid accumulation and recurrent pulmonary edema 2, 3
• Albuterol inhaler is appropriate for bronchodilation 2

Hyperkalemia Prevention

Dietary and Medical Management

• Provide education on low-potassium diet given ESRD and risk of life-threatening hyperkalemia between dialysis sessions 2
• Ensure patient has access to potassium-binding resins (e.g., sodium polystyrene sulfonate) at home for emergencies 2
• Educate on fluid restriction (typically 1-1.5L/day for anuric patients) to prevent volume overload 2
• Instruct patient to seek emergency care immediately if experiencing muscle weakness, palpitations, or chest pain (signs of hyperkalemia) 5

Skeletal Health

Spinal Stenosis and Pathologic Fracture Management

• Patient has thoracic spinal stenosis with pathologic thoracic fracture, requiring wheelchair for mobility 2
• Continue ergocalciferol (vitamin D2) 50,000 units for bone health 2
• Sevelamer carbonate 800 mg is appropriate for phosphate binding 2
• Monitor calcium and phosphate levels regularly 2

Noncompliance Risk Mitigation

Patient Education and Support

• Schedule education session with dialysis nurse to reinforce understanding of risks from missed treatments 1
• Explain that missing dialysis increases risk of sudden cardiac death, stroke, and pulmonary edema 1
• The patient appears to understand dialysis is necessary (went to ER when transport failed), but needs reinforcement 1
• Consider peer support mentorship by pairing with adherent dialysis patient to improve motivation 1

Psychosocial Assessment

• Patient is alert, oriented x4 with appropriate affect, but has history of noncompliance 1
• Assess for depression, which commonly affects dialysis adherence 1
• Evaluate whether "lack of motivation" is contributing to missed appointments 1
• Consider palliative care consultation given multiple comorbidities and symptom burden 6

Follow-Up Schedule

Short-Term (Within 2 Weeks)

• Confirm reliable transportation is established and functioning 1
• Verify patient is attending all scheduled dialysis sessions 1
• Remove losartan from medication list and confirm discontinuation 4

Medium-Term (Within 1 Month)

• Measure dialysis adequacy (Kt/Vurea) and nutritional parameters 2
• Reassess volume status and oxygen requirements 3
• Check troponin if any cardiac symptoms develop 3

Ongoing Monitoring

• Monthly assessment of dialysis attendance, volume status, and nutritional markers 2
• Quarterly evaluation of vascular access function (if applicable) 7
• Annual reassessment of goals of care given multiple comorbidities 8

Red Flags Requiring Emergency Evaluation

• Missed dialysis sessions - patient should go directly to emergency department 2
• Severe shortness of breath or chest pain (pulmonary edema, hyperkalemia) 5, 3
• Altered mental status beyond baseline encephalopathy 2
• Inability to maintain oxygen saturation on home oxygen 2