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End stage renal disease (ESRD) patients are followed closely by nephrology as
outpatients. Therefore, many of the manifestations of ESRD are managed long-term in
the outpatient setting. The following "guidelines" will be useful in caring for these
patients while they are inpatients at UMMC. (Epoetin alfa and calcitriol dosing is done
by nephrology. Intact PTH, aluminum levels, and iron studies are checked quarterly.
These values may be obtained by calling the patient’s dialysis center.)
1) Assume a creatinine clearance < 5 mL/min for hemo- and peritoneal dialysis
patients.
2) Refer to your pharmacist (8-5644) to ensure appropriate renal dosing of all
medications.
B. Anemia:
C. Secondary Hyperparathyroidism:
1) Calcium phosphate product > 65-70: results in soft tissue and vascular
calcification/deposition.
2) Phosphate binders must be given with meals and bedtime snacks to bind
dietary phosphate. Hold phosphate binders if patient is NPO.
a) Calcium phosphate product < 65-70: Give calcium carbonate 650
-1300 mg PO with meals and bedtime snack
b) Calcium phosphate product > 65-70: Give aluminum hydroxide 1920 –
3840 mg(30-60 cc) PO with meals and bedtime snack
c) If calcium phosphate product is > 65-70 and the patient has
symptomatic hypocalcemia: give aluminum hydroxide PO with meals
and treat the hypocalcemia with CaCO3 500 mg elemental calcium
PO TID with meals or IV calcium gluconate as needed.
d) Hold phosphate binder if serum PO4 < 3.
3) Calcitriol:
a) if PTH < 3 X normal: do not give calcitriol
b) if PTH > 3 X normal: administer calcitriol 0.25 - 0.5 mcg PO daily
c) Hold calcitriol when calcium phosphate product > 65-70 and/or if
patient is hyperphosphatemic.
D. Miscellaneous:
1) All dialysis patients should receive Nephro-vite one tablet PO daily for
vitamin supplementation.
2) Pain Relief: try acetaminophen first before non-steroidal anti-inflammatory
agents or aspirin because of increased risk of bleeds with these agents.
AVOID Meperidine (Demerol ): accumulation of active metabolite will result in
SEIZURES.
3) Goal Albumin: > 3.5 gm/dl
4) AVOID antacids, etc... containing aluminum and/or magnesium since they will
accumulate in ESRD patients.
5) AVOID potassium supplements or high sodium content products. However,
CAPD patients may often require potassium supplementation.