REFRACTORY CHF AND MODEST RENAL FAILURE: III

This 72‐year‐old white woman with diabetes mellitus (Type II) and ischemic cardiomyopathy was referred for evaluation on the day she was discharged from hospital, November 10, 1992. She was referred by her cardiologist for help managing recurrent episodes of congestive heart failure (CHF) complicated by moderate renal failure, both due to diabetes. In the preceding five months, control of heart failure required multiple visits to the cardiologist and five hospital admissions, for a total of 32 hospital days. The inttrval between admissions was becoming progressively shorter—the last two just 10 days apart. In spite of bumetanide 4 mg qid, metolazone 10 mg qod, Lanoxicaps 0.05 mg qd, hydralazine 25 mg qid, clonidine 0.2 mg tid, and Procardia 60 mg XL qd, the patient would leave the hospital only to experience rapid return of edema, progressive dyspnea on exertion and a nonproductive cough. She always slept on three pillows and was never able to life flat. Review of systems 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 1992. Because of a neurogenic bladder, the patient performed self catheterization intermittently. In the more distant past she also had a cholecystectomy, appendectomy, and total abdominal hysterectomy . Physical examination revealed an elderly individual whose neck veins were visible to the angle of the jaw when sitting. Her weight was 66.8 kg, height 165 cm, and blood pressure 150/72 supine and afier 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 paramedian and infraumbilical (umbilicus to pubis) scars marked her previous surgical procedures. Marked edema was present to above both knees. No asterixis, myoclonus, or fetor uremicus were detected . Laboratory results: 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 CO 2 28 mEq/l; April 4, 1992—‐albumin 3.2 g/d, total protein 6.4 g/d, cholesterol 173 mg/d, WBC 5,400, lymphocytes 17%, total lymphocyte count 900 cells/mcl . The advantages and disadvantages of hemodialysis and peritoneal dialysis were discussed with the patient and her family. Continuous Ambulatory Peritoneal Dialysis (CAPD) was encouraged because of the continuous ultrafiltration. The potential difficulty in placing the catheter because of multiple prior surgical procedures was explained. The patient elected to try CAPD. A single cuff, curled Tenckhoff peritoneal dialysis catheter was placed laparoscopically by a surgeon in the operating room on November 18, 1992. The catheter placement went without incident and the patient was discharged the same day. Intermittent peritoneal dialysis was started the next day and continued for about 8 hr/day thrice weekly with 1 then 1.5 l exchanges to allow time for wound healing while providing help with volume control. CAPD training was carried out from 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 hospital admissions since November 10, 1992, except for the dialysis catheter insertion. Although she still sleeps on three pillows, the neck veins are flat at a head elevation of 30 degrees and there is no orthopnea or change in respiratory rate lying flat. Ankle edema is again 4 + at 68 kg. Appetite has improved and she attributes part of her increased weight to increased (oral) calorie intake resulting from improved breathing. The dialysis catheter has continued to function well, and no catheter related complications have developed. The 2 l intraperitoneal dialysate volume has not caused any symptoms. The only cardiac or antihypertensive medications are Procardia 60 mg XL and Lanoxicaps 0.05 mg qd .