Managing Diabetic Patients on Dialysis: The Nurse and Practitioners Role in Multidisciplinary Team Essentials
Submitted by Dr. Gary D. Goldberg, PhD
Diabetic patients on dialysis -
The chronic state of diabetes mellitus (DM) mainly type II, is an increasingly common cause of end stage renal disease (ESRD) in all countries, accounting for 51% of dialysis patients in the U.S. and 39% in Europe.  Patient survival is much worse than for non-diabetic patients, with a large proportion of patients dying within the first 3 months of dialysis (excluded from USRDS data). See: Hypertension, dialysis and clinical nephrology at http://www.hdcn.com//.  In North America, chronic diabetes (e.g., poorly controlled), has shown as a major cause of death associated with cardiovascular diseases.  Usually the outcome is better for transplanted patients.
Many of the non-renal complications of diabetes will continue to progress after initiation of dialysis, including:
- coronary artery disease
- Cerebrovascular disease
- Peripheral vascular disease
- Autonomic dysfunction
- Moreover, notable depression.
Many times discussion is made on an individual basis, but continuous ambulatory peritoneal dialysis (CAPD) is frequently the preferred option. There are advantages and disadvantages similar to other dialysis patients. As a nurse or practitioner, you will learn the disadvantages of haemodialysis (HD) also; vascular instability and increased cardiac risk, difficulty creating vascular access, increased hypotension on dialysis, and an increased hypoglycaemia may accrue.
In addition, CAPD offers no cardiac instability or need for access, but increased glucose loads, weight gain and sometimes difficulties with diabetic control will accrue. In some patients, visual disturbances may impair the ability to perform CAPD exchanges, but can usually be overcome. In the outpatient clinic setting, the nurse can teach the patient proper techniques and waste handling.
Approaching patients on haemodialysis -
Chronic renal failure affects every aspect of a person’s life. Patients will experience complex physical, psychological, and social problems. It can be very difficult to come to terms with receiving haemodialysis (HD) treatment three or four times each week. Nurses and practitioners should be sensitive to the needs of patients and stresses caused by end stage renal disease (ESRD).
The relationship between the nurse and patient will take on a unique role and will continue through several different treatments modalities. The most important aspect in maintaining the trust between the nurse and the patient is developing a partnership in care. It is essential that the nurse explains and discusses all aspects of HD treatment with the patient. Without this involvement, patients can experience loss of control and increased dependence on the nursing staff.
Specific concerns experienced by patients on HD are often centered on:
- Cannulation problems –
- Being cannulated by inexperienced nurses –
- Complications during dialysis –
- Fluid removal during treatment resulting in hypovolaemia or fluid overload –
- Machine problems/alarms and backups –
- Unexplained changes or poor communication in treatment regiment –
- Length of time spent waiting for machines.
Acute renal failure can result in an uncertain future for the patient. The nurse and/or practitioner must be aware of the anxiety and distress which this can cause. During this period, the patient will need support and understanding. In addition, there must be complete confidence with trust on part of the complete nursing team.
Clinical features for the nurse and/or practitioner to be aware of while the patient is undergoing treatment should include ̕  (Note: these are general findings and must be tailored to the needs of the individual patients).
- Intravascular volume overload (IVO): salt (1-2 g/d) and H²o (usually <1 L/d) restriction. Diuretics (usually loop blockers + thiazide) –
- Hyponatremia: restriction of enteral free water intake (<1 L/d) –
- Hyperkalemia: restriction of dietary K⁺ intake (usually <40 mmol/d) -
- Sodium bicarbonate (Na HCO₃): (usually 50-100 mmol) –
- Calcium (Ca²⁺) gluconate: (10 mL of 10% solution over 5 min) –
- Metabolic acidosis: restriction of dietary protein (usually 0.6 g/kg per day of high biologic values) and sodium bicarbonate (maintain serum bicarbonate >15 mmol.L or arterial pH>7.2) –
- Hyperphosphatemia: restriction of dietary phosphate (PO₄³ ˉ) intake (usually <800 mg/d), Phosphate binding agents (calcium carbonate and aluminum hydroxide) –
- Hypocalcemia: calcium carbonate if symptomatic or if sodium bicarbonate may be administered –
- Hypermagnesemia: discontinue (Mg²⁺₋)containing antacids –
- Hyperuricemia: treatment may not be necessary if <890 μmol/L (<15 mg/dL) –
- Nutrition Values: restriction of dietary protein (˜0.6 g/kg per day) and carbohydrate (˜100 g/d) –
Clinical manifestations of the Chronic Diabetic in HD –
Two major risk factors that seem to be at the forefront are hypertension (HTN) and the other factor appears to be blood-pressure control management.  HTN complicates most types of renal disease and a major contributor to the rate of progression of renal damage whatever the original cause. Untreated or poorly controlled HTN can directly damage the kidneys causing hypertensive nephropathy. HTN, both on its own and by causing left ventricular hypertrophy (LVH), plays a major role in the increased risk of cardiovascular death in patients with renal failure.
It is essential that you target the suggested guidelines (see: Am H Assoc plus Brit Hyper Soc) of <140/80 in diabetics. HD patients have a similar increased risk of cardiovascular disease to diabetics; hence, 140/80 is an appropriate target P/B.
Guidelines for achieving B/P control in HD –
- Have a target weight, then aim to bring your patient to their dry weight by bring their weight down slowly over several dialyses, (e.g., 0.5 – 1 kg/week).
- Minimize symptomatic hypotensive episodes so patients will tolerate weight reduction; also possibly minimize the use of anti-hypertensive drugs, as these may contribute to hypotension on dialysis.
- Educate your patients about the importance of B/P control management. Encourage your patients to restrict weight gains between dialyses to < 2 kg by limiting salt and water intake.
- ACE inhibitors and angiotensin II blockers both can cause dramatic hypotension with volume depletion. Anaphylactic reactions can also occur when ACE inhibitors are used in patients dialyzing on polyacryonitrile (PAN) membranes. These drugs must be used with great care, only when B/P control cannot be achieved by any other means.
All nursing staff including the NP should pay close attention to the B/P, fundoscopy findings, and precordial examination. In addition, examine the abdomen for bruits and palpable renal masses. Also, important would be the visual extremity examination for edema, and the probability of neurologic presences of asterixis (i.e., muscle weakness and/or tremor of the wrist when extended). It isessential and through evidence-based investigation that the nursing teams work together, to slow down the progression of chronic renal disease (CRD) only complicated through abnormal metabolic syndrome X.
Short Bio of Dr. Gary D. Goldberg, PhD
Over 30 years experience in the Medical field, At UCLA and Pacific Hospital of the Valley, as a Chief Technologist and Analyst, Visiting Professor and Instructor for continuing education at UCLA School of Nursing and Writer/Speaker at the School of Medicine from 1995-2008.
From 2003-2008 Dr. Goldberg has collaborated and published through Blackwell Publishing Co. (Medical Division), and Journal of American College of Cardiology plus 15, published abstracts through UCLA Dept. of Internal Medicine and the Dept. of Cardiology.
Current title: Clinical Professor of Medical Education with Angeles College of Nursing, in Los Angeles, CA. Funded through the State Dept. of California for Continuing Nursing Education.
Dr. Goldberg has written two major academic course textbooks for Angele College of Nursing and has represented advanced nursing education course curriculum approved by the ANA for CEU(s) and the AMA CMU Level 1 Credit for physicians.
To reach Dr. Gary D. Goldberg, for comments and/or consultation, please use e-mail address: [email protected] or cell phone contact: 818-610-9017.
 U.S. Renal Data System. USRDS 2010, Annual Data Report. Atlas of end-stage renal disease in the United States. Bethesda MD: National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2007. Available from URL: http://www.usrds.org/atlas 2010.htm.
 Schrier RW, Masoum A, Elhassan E. Clin J Am Soc Nephrol (Jun) 5: 1132-1140, 2010
 _____et al: Acute renal failure, in Brenner and Rector’s The Kidney, 6th ed., BM Brenner (ed). Philadelphia, Saunders, 2000, pp.1201-1262. Also, see: Xue JL, Ma JZ, Louis TA, Collins AJ. Forecast of the number of patients with end-stage renal disease in the United States to year 2010. J Am Soc Nephrol (2004) 2:1012-1016 revised March 15, 2004.
 Star RA: Treatment of acute renal failure. Kidney Int (54): 1817, 1998 review. Cited again in 2000 ed. Management of Ischemic and Nephrotoxic Acute Renal Failure. Brenner and Rector’s The Kidney, 6th ed. Philadelphia, Saunders, 2000. pp 1201-1210.
 Thadhani R et al: Acute renal failure. N Engl J Med (334): 1448, 1996.
 Kaplan N: Systemic hypertension: Mechanisms and diagnosis, in Heart Disease, 6th ed. E. Braunwald et al (eds.). Philadelphia, WB Saunders, 2001.