DIFFICULT MANAGEMENT PROBLEMS IN DIALYSIS .2. REFRACTORY CHF AND MODEST RENAL-FAILURE

This 72-year-old white woman with diabetes mellitus (Type II) and isch emic cardiomyopathy was referred for evaluation on the day she was dis charged from hospital, November 10, 1992. She was referred by her card iologist for help managing recurrent episodes of congestive heart fail ure (CHF) complicated by moderate renal failure, both due to diabetes. In the preceding five months, control of heart failure required multi ple visits to the cardiologist and five hospital admissions, for a tot al of 32 hospital days. The interval between admissions was becoming p rogressively shorter-the last two just 10 days apart. In spite of bume tanide 4 mg qid, metolazone 10 mg gid, Lanoxicaps 0.05 mg qd, hydralaz ine 25 mg qid, clonidine 0.2 mg tid, and Procardia 60 mg XL qd, the pa tient would leave the hospital only to experience rapid return of edem a, progressive dyspnea on exertion and a nonproductive cough. She alwa ys slept on three pillows and was never able to life flat. Review of s ystems disclosed no symptoms of uremia except perhaps a poor appetite. Past medical history included Type II diabetes mellitus, since 1967; coronary artery bypass grafts in 1983 and 1988; left hemicolectomy for adenocarcinoma, Duke's grade C, 1990 with normal colonoscopy July 199 2. Because of a neurogenic bladder, the patient performed self cathete rization intermittently. In the more distant past she also had a chole cystectomy, appendectomy, and total abdominal hysterectomy. Physical e xamination revealed an elderly individual whose neck veins were visibl e to the angle of the jaw when sitting. Her weight was 66.8 kg, height 165 cm, and blood pressure 150/72 supine and after 2 min of standing. The lungs were clear to auscultation. No pericardial rub was present. The liver span was 15 cm. No bruit was present and the spleen was not palpable or percussable. Well healed right subcostal, right paramedia n and infraumbilical (umbilicus to pubis) scars marked her previous su rgical procedures. Marked edema was present to above both knees. No as terixis, myoclonus, or fetor uremicus were detected. Laboratory result s: April 9, 1992-BUN 95 mg/dl, creatinine 4.3 mg/dl, sodium 138 mEq/l, potassium 4.1 mEq/l, chloride 102 mEq/l, total CO2 28 mEq/l; April 4, 1992-albumin 3.2 g/d, total protein 6.4 g/d, cholesterol 173 mg/d, WB C 5,400, lymphocytes 17%, total lymphocyte count 900 cells/mcl. The ad vantages and disadvantages of hemodialysis and peritoneal dialysis wer e discussed with the patient and her family. Continuous Ambulatory Per itoneal Dialysis (CAPD) was encouraged because of the continuous ultra filtration. The potential difficulty in placing the catheter because o f multiple prior surgical procedures was explained. The patient electe d to try CAPD. A single cuff curled Tenckhoff peritoneal dialysis cath eter was placed laparoscopically by a surgeon in the operating room on November 18, 1992. The catheter placement went without incident and t he patient was discharged the same day. Intermittent peritoneal dialys is was started the next day and continued for about 8 hr/day thrice we ekly with 1 then 1.5 l exchanges to allow time for wound healing while providing help with volume control. CAPD training was carried out fro m December 7 to 10. By December 16, her weight was down to 57.3 kg, a loss of 10 kg. As of her clinic visit of April 23, 1993, she had no ho spital admissions since November 10, 1992, except for the dialysis cat heter insertion. Although she still sleeps on three pillows, the neck veins are flat at a head elevation of 30 degrees and there is no ortho pnea or change in respiratory rate lying flat. Ankle edema is again 4 + at 68 kg. Appetite has improved and she attributes part of her incre ased weight to increased (or