What are the follow-up recommendations for a patient with End Stage Renal Disease (ESRD) and noncompliance with renal dialysis, presenting with Pulmonary Edema and Elevated troponin, after missing dialysis appointments due to transportation issues?

Follow-Up Recommendations for ESRD Patient with Dialysis Non-Adherence

Immediate Priority: Transportation Reliability

This patient requires an immediate, formalized backup transportation plan with multiple redundancy layers, as missed dialysis treatments directly increase mortality risk and have already resulted in life-threatening pulmonary edema with cardiac strain (elevated troponin). 1, 2

Transportation Solutions (Implement All)

• Establish primary and secondary transportation services with written confirmation of scheduled pickup times for all dialysis appointments, as transportation failure is the most common barrier to dialysis attendance and associates with 3.98 times increased risk of hospitalization within 2 days of a missed treatment 2

• Create emergency transportation protocol including taxi vouchers, ride-share accounts, or dialysis facility transport services as backup when primary transport fails 3, 4

• Document all transportation arrangements in the patient's chart with contact numbers for both primary and backup services, and provide the patient with a written card containing these emergency numbers 3

• Consider facility transfer to a dialysis center with more reliable in-house transportation services if current arrangements continue to fail 4

Critical Clinical Monitoring

Dialysis Adequacy Assessment

• Measure Kt/Vurea within 1 month to ensure adequate solute clearance with target total Kt/Vurea ≥1.7 per week, as inadequate dialysis directly contributes to the patient's encephalopathy and generalized weakness 1, 5

• Assess for uremic symptoms at each visit including nausea, vomiting, appetite changes, and worsening encephalopathy, and check serum albumin and normalized protein nitrogen appearance (nPNA) at next dialysis adequacy measurement 1

Cardiovascular and Fluid Management

• Monitor for recurrent pulmonary edema given this patient's recent episode with elevated troponin indicating cardiac strain from volume overload 1

• Ensure adequate ultrafiltration at each dialysis session to prevent fluid accumulation, as this patient is at high risk for recurrent pulmonary edema 1

• Continue home oxygen at 3L for chronic respiratory failure, ensuring adequate supply and backup concentrator in case of equipment failure 1

Hyperkalemia Prevention

• Provide intensive education on low-potassium diet with written materials and dietary consultation, as missed dialysis sessions place this patient at extreme risk for life-threatening hyperkalemia 1

• Ensure patient has emergency supply of potassium-binding resin (sodium polystyrene sulfonate) at home with clear instructions on when to use 1

• Instruct patient to seek emergency care immediately for muscle weakness beyond baseline, palpitations, or chest pain, which may indicate hyperkalemia 1

Patient Education and Adherence Support

Risk Communication

• Educate patient on specific mortality risk of missed treatments using positive framing: emphasize that attending all scheduled dialysis sessions improves survival and well-being, rather than focusing on negative outcomes 5, 3

• Explain that missing even one treatment increases hospitalization risk by nearly 4-fold and emergency room visits by 2-fold within 48 hours 2

• Review dialysis adequacy results with patient at each measurement, ensuring she understands target Kt/V values and their clinical significance for preventing her symptoms of encephalopathy and weakness 5

Psychological Assessment

• Screen for depression, anxiety, and motivation barriers at this visit, as psychiatric conditions including depression and negative attitudes predict non-compliance in dialysis patients 5, 3

• Assess for financial barriers affecting transportation access, as socioeconomic factors are major contributors to dialysis non-adherence 4

• Consider peer support mentorship by connecting patient with adherent dialysis patients, as relationships with other dialysis patients facilitate treatment attendance 3

Red Flag Education

Instruct patient that the following situations require going directly to the emergency department, not waiting for scheduled dialysis: 1

• Missing any scheduled dialysis session due to transportation or other barriers
• Altered mental status beyond her baseline encephalopathy
• Inability to maintain oxygen saturation on home oxygen
• Severe shortness of breath or chest pain
• Muscle weakness, palpitations, or irregular heartbeat

Medication Optimization

• Continue current medication regimen including Aranesp for anemia management, ergocalciferol for bone health given pathologic thoracic fracture, and sevelamer carbonate for phosphate binding 1

• Review anticoagulation status given patient is on clopidogrel and aspirin, ensuring dialysis staff are aware due to bleeding risk during access procedures 6

Follow-Up Schedule

• Schedule next home visit within 1 week to verify transportation arrangements are functioning and patient attended scheduled dialysis sessions 5

• Coordinate with dialysis facility to receive immediate notification if patient misses any treatment, triggering same-day outreach 5, 7

• Arrange monthly monitoring of hospitalization frequency and dialysis adequacy measurements as outcome measures 5