What adjustments should be made to the management of a long-term care resident with end-stage renal disease (ESRD), severe anemia, hyperphosphatemia, and metabolic acidosis, who declined dialysis and has impaired renal function, as evidenced by a low estimated glomerular filtration rate (eGFR) and elevated blood urea nitrogen (BUN) and creatinine levels?

Management of ESRD Patient Who Declined Dialysis

This patient requires immediate initiation of sodium bicarbonate therapy for severe metabolic acidosis (CO₂ 11 mmol/L), urgent optimization of phosphate binders for hyperphosphatemia (5.3 mg/dL), and consideration of erythropoiesis-stimulating agents for severe anemia (Hgb 8.9 g/dL), while simultaneously preparing for either dialysis initiation or palliative care depending on capacity evaluation.

Immediate Medical Management Priorities

Severe Metabolic Acidosis (CO₂ 11 mmol/L)

• Initiate sodium bicarbonate supplementation immediately to correct the severe metabolic acidosis, as acidosis at this level contributes to protein catabolism, bone disease, and cardiovascular complications 1
• Target serum bicarbonate of 22-30 mmol/L through oral sodium bicarbonate (typically 650-1300 mg three times daily, titrated to effect) 1
• Monitor for volume overload with sodium bicarbonate administration given the patient's ESRD and already compromised fluid status 1

Hyperphosphatemia (5.3 mg/dL)

• Intensify phosphate binder therapy immediately, as hyperphosphatemia contributes to secondary hyperparathyroidism, vascular calcification, and increased cardiovascular mortality in ESRD 2, 3
• Ensure phosphate binders are being taken with meals for maximum efficacy, as compliance is frequently challenging 4
• Implement dietary phosphate restriction with focus on avoiding phosphate additives in processed foods, which are almost completely absorbed and can add 1,000 mg daily to phosphate intake 4
• The calcium-phosphorus product should be calculated and maintained below recommended thresholds to prevent extraosseous calcification 3

Severe Anemia (Hemoglobin 8.9 g/dL)

• Evaluate iron status immediately (ferritin, transferrin saturation) to distinguish absolute from functional iron deficiency before initiating therapy 4
• If iron deficient, initiate intravenous iron supplementation, which is more efficient than oral iron in CKD patients, particularly with chronic deficiency 4
• Consider erythropoiesis-stimulating agents (ESA) when hemoglobin is below 10 g/dL after addressing iron deficiency 4
• The MCV of 100 fL suggests adequate red cell size, making iron deficiency less likely but not excluded 4

Hyperchloremia (122 mmol/L) with Low Anion Gap (8)

• The hyperchloremia with normal anion gap and severe metabolic acidosis is consistent with non-anion gap metabolic acidosis typical of advanced CKD 1
• This pattern reinforces the urgency of bicarbonate supplementation 1

Dialysis Initiation Considerations

Current Clinical Status Assessment

• The patient meets absolute criteria for dialysis initiation with eGFR 16.1 mL/min/1.73m² and multiple uremic complications (severe acidosis, hyperphosphatemia, anemia) 1
• Dialysis should be strongly recommended when eGFR is ≤15 mL/min/1.73m² or when uremic complications are present and refractory to medical management 1
• The severe metabolic acidosis (CO₂ 11 mmol/L) represents a refractory complication that will be difficult to manage medically without dialysis 1

If Dialysis is Initiated After Capacity Evaluation

• Use gentle, abbreviated initial dialysis sessions (2 hours maximum, reduced blood flow rates, less efficient dialyzer) to prevent dialysis disequilibrium syndrome given the severe uremia (BUN 74 mg/dL, creatinine 3.09 mg/dL) and metabolic acidosis 5
• Dialysis disequilibrium syndrome occurs when dialysis removes urea faster from blood than brain, causing cerebral edema with symptoms ranging from nausea/headache to seizures, coma, and death 5
• Increase dialysis frequency rather than duration initially, gradually extending treatment time to standard 3-4 hours over the first week 5
• Monitor closely for neurological symptoms during and after initial treatments 5

Palliative Care Pathway (If Patient Maintains Decision-Making Capacity and Declines Dialysis)

Integrated Palliative Care Initiation

• All patients who decide not to undergo dialysis should receive integrated palliative care immediately, focusing on symptom management and quality of life 1
• The palliative approach should be patient- and family-centered, with emphasis on reducing symptom burden and improving well-being rather than renal replacement 1
• This decision should occur through shared decision-making in open and empathetic discussions about severely limited life expectancy and low quality of life 1

Symptom Management Without Dialysis

• Control uremic symptoms including fatigue, sleep disturbances, dyspnea, anxiety, pruritus, nausea, and xerostomia through pharmacologic and non-pharmacologic interventions 1
• Continue medications that improve quality of life and provide symptom relief, even if they don't address the underlying renal failure 6
• Supplemental oxygen can be used for comfort if dyspnea develops 6

Hospice Referral Criteria

• Consider immediate hospice referral if the patient confirms desire for comfort-oriented care rather than life-prolonging interventions 6
• Hospice eligibility requires joint certification by treating physician and hospice medical director of terminal prognosis with life expectancy likely less than 6 months, plus written patient agreement 6
• Document functional deterioration, increasing healthcare utilization, unintentional weight loss, declining ability to perform activities of daily living, and symptom burden 6
• Do not delay referral due to prognostic uncertainty, as this is the most common barrier to timely hospice enrollment 6
• Earlier referral (when prognosis is months to weeks, not days to hours) is associated with better outcomes and improved symptom control 6

Additional Management Adjustments Beyond Current Orders

Medication Review and Adjustments

• Review all current medications for appropriateness in ESRD and adjust dosing for eGFR 16 mL/min/1.73m² 1
• Ensure renin-angiotensin system blockers (if prescribed) are continued if tolerated, as they slow CKD progression even at this stage, while monitoring potassium closely 1
• The current potassium of 4.8 mmol/L is acceptable, but monitor closely with any medication changes 4

Nutritional Assessment and Intervention

• Obtain formal nutritional assessment given the low albumin (3.2 g/dL), which indicates either malnutrition or uremic protein loss 1
• Balance protein intake recommendations (adequate to prevent malnutrition) with phosphate restriction (challenging since protein sources contain phosphate) 4
• Emphasize plant-based protein sources when possible, as phosphate from vegetables is less absorbed than from animal sources or additives 4

Monitoring Intensification

• Increase laboratory monitoring frequency to weekly initially given the severe metabolic derangements and need for medication titration 1
• Monitor electrolytes (especially potassium, bicarbonate, calcium, phosphorus), renal function, and hemoglobin weekly until stabilized 1, 4
• The respiratory assessments and vital signs monitoring QID already ordered are appropriate given risk of uremic complications 1

Critical Pitfalls to Avoid

• Do not delay bicarbonate supplementation while awaiting nephrology follow-up, as severe acidosis (CO₂ 11 mmol/L) requires immediate intervention 1
• Do not initiate full-intensity dialysis if dialysis is started, as this will cause dialysis disequilibrium syndrome given the severe uremia and acidosis 5
• Do not assume the patient lacks capacity simply because they declined dialysis—many patients make informed decisions to pursue conservative management 1
• Do not withhold palliative care if the patient has capacity and confirms desire to avoid dialysis, as this represents a legitimate treatment choice requiring supportive care 1, 6
• Do not require DNR status for hospice eligibility if that pathway is chosen—this is illegal under the Patient Self-Determination Act 6