What is the best course of action for a patient with end-stage renal disease (ESRD), pulmonary edema, and cardiac strain, who has a history of missing dialysis appointments due to transportation issues and has been hospitalized multiple times, currently taking medications including losartan (angiotensin II receptor antagonist), atorvastatin (HMG-CoA reductase inhibitor), and metoprolol succinate (beta blocker), and presenting with normal vital signs, but requiring ongoing dialysis and oxygen therapy at 3L?

Immediate Priority: Establish Reliable Dialysis Access Through Facility Transfer

This patient requires immediate transfer to a dialysis facility with in-house transportation services or consideration for home dialysis modalities, as transportation failure is directly causing life-threatening complications including pulmonary edema with cardiac strain (elevated troponin) and encephalopathy. 1

Critical Context: Transportation Barriers and Mortality Risk

• Transportation failure represents the most common barrier to dialysis attendance and is associated with a 3.98-fold increased risk of hospitalization within 2 days of a missed treatment 1
• Missed dialysis treatments directly increase mortality risk (HR 1.68), cardiovascular mortality, sudden death/cardiac arrest, and hospitalization rates 2
• The pattern of recurrent hospitalizations from missed dialysis demonstrates that current transportation arrangements have failed catastrophically and will continue to fail without systemic intervention 1

Primary Recommendation: Facility Transfer with Integrated Transportation

Transfer this patient to a dialysis center that provides reliable in-house transportation services as the definitive solution. 3

Implementation Steps:

• Identify dialysis facilities in the region with dedicated transportation programs before discharge 3
• Coordinate with social work to arrange facility transfer within 1 week
• Document that current transportation arrangements have resulted in multiple life-threatening hospitalizations requiring immediate intervention 1
• Ensure accepting facility has capacity and willingness to manage this patient's complex medical needs including oxygen requirements 3

Alternative: Home Dialysis Modalities

If facility transfer with transportation is unavailable, peritoneal dialysis represents the superior alternative for this patient. 3

Rationale for Peritoneal Dialysis:

• Eliminates transportation barriers entirely by allowing home-based treatment 3
• Provides more gradual fluid removal with smaller hemodynamic shifts, reducing risk of hypotension and cardiac strain 3
• Avoids repeated ischemic insults to organs compared to intermittent hemodialysis 3
• Reduces hospitalization days when properly managed 3

Prerequisites for Home Dialysis:

• Patient must demonstrate cognitive capacity (currently A&O x4) and physical ability to perform exchanges 3
• Requires supportive home dialysis program willing to train and monitor patient 3
• Need assessment of home environment and caregiver availability 3
• Patient must understand that missing peritoneal dialysis exchanges carries similar mortality risk as missed hemodialysis 4

Medication Management During Transition

Continue current cardiovascular medications but implement monthly medication reconciliation per CMS requirements. 3

Critical Medication Considerations:

• Losartan 50mg: Monitor renal function closely as ARBs can worsen kidney function in volume-depleted states; however, discontinuation is not indicated in stable ESRD on dialysis 5
• Metoprolol succinate 100mg: Continue for cardiac protection given elevated troponin history 3
• Sevelamer carbonate 800mg: Verify adherence as phosphate control is essential; inadequate dialysis leads to hyperphosphatemia 2
• Dialysis patients average 2-3 medication discrepancies per reconciliation; pharmacist involvement improves accuracy 3

Oxygen and Respiratory Management

• Continue home oxygen at 3L to maintain SpO2 >92% 3
• Strictly prohibit smoking in apartment as this patient has chronic respiratory failure with hypoxia and history of pulmonary edema
• Monitor for signs of fluid overload between dialysis sessions (increased oxygen requirement, orthopnea, peripheral edema)

Emergency Education: Non-Negotiable Return Precautions

Educate patient that the following require IMMEDIATE emergency department presentation:

1. Missing ANY scheduled dialysis session - this is a medical emergency with 3.98x hospitalization risk within 48 hours 1
2. Altered mental status or worsening confusion (uremic encephalopathy) 6
3. Severe shortness of breath or chest pain (pulmonary edema, cardiac strain) 3
4. Inability to maintain oxygen saturation on home oxygen
5. Muscle weakness, palpitations, or irregular heartbeat (hyperkalemia) 6

Dietary Management

• Strict low-potassium diet to prevent life-threatening hyperkalemia between dialysis sessions 7
• Maintain adequate protein intake (1.2 g/kg/day for hemodialysis patients) to prevent malnutrition 7
• Fluid restriction based on residual urine output and interdialytic weight gain targets 3
• Phosphate restriction with meals to reduce cardiovascular calcification risk 7

Higher Level of Care Consideration

If transportation and home dialysis options both fail, assisted living facility placement with dialysis transportation services is medically necessary. 1

Justification:

• Current living situation has resulted in multiple preventable hospitalizations with life-threatening complications
• Pattern demonstrates inability to access life-sustaining treatment independently
• Mortality risk increases exponentially with continued missed treatments 2
• This represents failure of outpatient management requiring escalation of care setting

Common Pitfalls to Avoid

• Do not assume backup transportation plans will work - this patient has already demonstrated transportation failure; only systemic solutions (facility transfer or home dialysis) will succeed 1
• Do not delay intervention - each missed treatment carries immediate mortality risk; waiting for "one more chance" with current arrangements is medically inappropriate 1, 2
• Do not focus solely on laboratory values - this patient's clinical trajectory (recurrent hospitalizations, pulmonary edema, encephalopathy) demonstrates inadequate dialysis regardless of current stable vital signs 7
• Do not overlook medication reconciliation - ESRD patients average 2-3 medication discrepancies that contribute to hospitalizations; monthly reconciliation is now a CMS quality metric 3