An 83-year-old woman with end-stage chronic renal failure of unknown aetiology underwent a chronic haemodialysis programme in a peripheral dialysis centre since October 2004.
Personal history:
Hypercholesterolaemia, non-dyslipidaemia, non-diabetes mellitus, long-standing rheumatoid arthritis without current treatment, severe osteoporosis with vertebral fracture, and heart failure with moderate/mild diastolic dysfunction.
Since its beginning in hemodialysis, two internal arteriovenous fistulas with loss of posterior function have been performed, and currently carries a tunneled central venous catheter in the right internal jugular as vascular access.
During the last year the patient has not presented complications or hospital admissions.
During this time, its dialysis regimen has not been modified, which has been sessions of 240 minutes three days/week, with high permeability dialyzer and 2m2 of surface, and adequate Qb of 350 kg/min with adequate dialysis.
Current situation:
Approximately from the beginning of summer, the patient has poor tolerance to achieving end-tidal episodes of hypotension practically in all dialysis sessions, which required fluid infusion for stabilization, and weight reprogramming.
Therefore, on August 8, 16, patient was transferred to the dialysis hospital unit for better patient control during hemodialysis.
Upon arrival to the unit, the patient presents evident signs of fluid overload, with pre-hemodialysis arterial hypertension, predialysis weight of 47.5 kg, which indicates an overweight of 4.2 kg over her previous dry weight, very intense apnea.
In the anamnesis, the patient reported that since the summer heat began, she practically did not eat anything, and highlighted in the analytical albuminemia 2.6 g/dl and total serum proteins 5.5 g/dl reillement 10 days ago.
During the first two weeks of their stay in the hospital unit, it is unsuccessful to achieve the patient's dry weight due to episodes of intradialytic hypotension.
Even gained 1 in this period, despite putting into practice different strategies such as limiting ultra-hour bath and 300-400 ml Na, performing sequential dialysis sessions with post-hemodialysis temperature extending to a temperature of approximately 140 kg above concentration.
During this time, we review the treatment of the patient with withdrawal of all hypotensive medication. Echocardiogram was performed ruling out worsening of heart failure, and ulcerative colitis associated with antibiotic treatment of severe ulcerative colitis associated with wound healing
In the fourth week of treatment in the unit due to intolerance to supplements, there is an ultraconfirmed consultation with albuminID, in order to limit as much as possible an excessive overweight between sessions, the patient undergoes daily hemodialysis, with prescription of 6 weekly sessions
Although in principle Endocrinology ruled out the prescription of parenteral nutrition, consider that the patient had the possibility of oral feeding, and proposed follow-up dietetics maintaining the high volume nutritional supplements at week 900 that described oral supplementation.
From the beginning of the PNID, which is the unit well established by the patients weight without additional insulin requirements due to hyperglycemias, the patient presents good tolerance to hospital discharge, keeping the patients levels close to week (43.3 Kg).
In the eighth week, the prescription of the NPID is reviewed, lowering the volume to be infused in each session to 700 ml, edemas in the lower limbs persist even though they are almost inapprehensible after dialysis.
Therefore, it was decided to reduce the number of weekly sessions to five, and to continue decreasing the dry weight slowly until reaching 42 Kg, which is achieved in the tenth week.
From this week on, the patient became stable and hemodynamically stable during the hemodialysis sessions, without presenting difficulties to arrive at the ultra-scarring regimen to achieve total dry weight at the end of the sessions, and maintain the NPID complete
