Persons with diabetes mellitus whose kidney disease progresses to end-stage requiring dialysis have poorer outcomes compared to nondiabetic patients who commence maintenance dialysis. In the diabetic patient without renal failure, sustained strict glycemic, lipid, and blood pressure (BP) control can retard or thwart diabetic complications such as retinopathy, neuropathy, coronary disease, and peripheral vascular disease. Achieving these outcomes requires multidisciplinary collaborative care. Best care of the diabetic person requires a dedicated clinician who knows the patient well, who closely follows the course of clinical problems, who provides frequent assessments and interventions, and who also directs care to other agencies, clinics, and specialized clinicians who provide expert focused evaluations and interventions aimed at specific clinical concerns. Diabetic patients who reach end-stage renal disease (ESRD) have even greater clinical need of a dedicated principal care clinician than the diabetic patient who has minimal or moderate kidney disease. The diabetic patient with ESRD exhibits greater fluctuations in glucose and BP due to dialysis-related diet patterns and fluid balances and has more active cardiovascular problems due to the combined influences of calcium, phosphorus, and lipid imbalances. These problems warrant exceptional care that includes frequent surveillance and monitoring with timely interventions if patient outcomes are to be improved. We present here a quality improvement model for optimizing care of the diabetic dialysis patient that relies on a dedicated practitioner who can evaluate and intervene on the multiple variables within and beyond the dialysis clinic that impact the patient's health. We present three detailed clinical care pathways that the dedicated clinician can follow. We believe that patient outcomes can be improved with this approach that provides customized problem-focused care, collaborates with the dialysis-provider team, and extends and directs diabetic self-care, home-care, and specialized clinical care in the challenging areas of cardiac and peripheral vascular disease, glycemic control, lipid control, infection prevention, and BP management.
A 20-year-old man presented to the emergency department with fatigue, abdominal pain, nausea, and decreased appetite with 20 lb weight loss over 3-4 weeks. He was subsequently admitted and urgently started on hemodialysis via a tunneled catheter for advanced renal failure.A week after admission, he underwent laparoscopic placement of a swan neck coiled peritoneal dialysis (PD) catheter, which the operative note recorded as being uneventful. The catheter was flushed and returned fluid with ease. At the 2-week point, an attempt was made to initiate PD. A burning sensation was reported by the patient on inflow. Dialysate inflow was extremely slow, and outflow even slower. Of 600 ml infused, only 150 ml of clear fluid returned. An abdominal X-ray (AP view only) showed the peritoneal catheter to be in the pelvis (Fig. 1); it was thought to be in correct position. Tissue plasminogen activator was instilled into the catheter to treat any potential fibrin clot obstruction. Outflow continued to be slow, blood tinged, with retention of most of the instilled fluid. The abdomen became distended and the patient complained of a sensation of fullness and pain. A palpable mass was noted near the umbilicus and an abdominal computed tomography (CT) scan with oral contrast was ordered (Fig. 2).What does the CT scan show? What is the appropriate therapy for this problem? AnswersIn Fig. 2, the CT shows that the PD catheter was located within the fascia between the rectus muscle and the peritoneum far from the peritoneal cavity (see arrows). The patient was returned to the operating room where the pre-peritoneal position of the catheter was confirmed before it was repositioned. There were no subsequent complications and he successfully started PD 2 weeks later.While PD catheter malposition is frequently reported to be one of the leading causes of catheter malfunction (occurring in 13-20% in patients), it is usually due to omental entrapment and migration (1). In our patient, an AP abdominal X-ray failed to show the malposition of the catheter with the unusual diagnosis made by CT scan. A lateral abdominal X-ray of the abdomen would probably have made the diagnosis as well.Catheter malfunction due to anterior wall insertion should be part of the differential diagnosis in patients who present with pain and anterior abdominal swellings
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.