Nephrology

PCP submission

Hi, I have this 63 yo Caucasian female patient I see at the home due to homebound status. Patient gets dialysis 3x/week.

PMH: Chronic renal failure, Respiratory failure after having covid pneumonia, amyloidosis, anemia, anxiety, hypothyroidism, chronic thrombocytopenia, hypertension and depression

CURRENT MEDICATIONS BASED ON REHAB DISCHARGE LIST:

Amlodipine 5 mg 1 tab via PEG TUBE daily

AnaManle HC cream 3-.5% apply to the rectum topically three times a day

Carvedilol 12.5 mg give 1 tab by mouth twice via PEG tube

Cholecalciferol tablet 1000 Unit give 2 tablets by mouth once daily

Darbepoetin Alfa solution 25 MCG/ML use 1 ml intravenously one time a day every Friday

Docusate sodium 100 mg give 1 tab by mouth twice a day PRN constipation

Dulcolax suppository 10 mg insert 1 suppository rectally every 24 hours as needed for constipation

Gabapentin Capsule 100 mg give 1 capsule by mouth TID

Guaifenesin Liquid 100 mg/5ML give 10 ml via PEG TUBE every 6 hours as needed

Hydralazine 25 mg give 3 tabs every 8 hours for a total of 75mg via PEG tube

Ipratropium Albuterol Solution .5-2.5 mg/3M, 3 ml inhaled orally every 4 hours as needed for SOB

Levothyroxine 25 mcg give 1 tab one tab a day

Loperamide 2 mg give 1 tab via PEG TUBE every 4 hours as needed

Melatonin 5 mg give 1 tab by mouth QHS

Midodrine HCL 10 give 1 tab via PEG TUBE every 24 hours as needed for hypotension

Milk of Magnesia 2400 mg/30 ml give 30 ml via PEG TUBE PRN for constipation

Ocean Nasal spray solution 1 spray in both nostrils every 6 hours as needed

Omeprazole DR 20 mg give 1 tab via PEG TUBE one time a day for GERD

Renal vitamin .8 mg 1 tab via PEG TUBE once daily

Sertraline 100 give 2 tablets via PEG TUBE once daily

Sevelamer Carbonate packet .8 GM give 1 packet via GTUBE with water

Trazodone 150 mg give 1 tab orally at bedtime

Tylenol 325 mg give 2 tabs every 4 hours as needed via PEG TUBE

Tramadol 50 mg 1 tab PO daily PRN

The concern that the patient has is lack of sleep.

She is up all night and takes random naps during the day.

Patient has tried all OTC sleeping meds but has some restrictions due to her kidney failure.

Melatonin and Trazodone are ineffective.

What do you recommend for sleep for this patient?

I attached labs for your reference.

1) What do you recommend for sleep for this patient with regards to medications?

2) Would you also suggest a sleep study?

Specialist response

Thanks for sharing this case. I suggest the following- 

1. Sleep disturbances are, unfortunately, highly prevalent (~45%) in dialysis patients. Possible causes include restless leg syndrome, periodic limb movement, sleep apnea, metabolic factors, including uremia, anemia, hypercalcemia, bone pain, and pruritus; anxiety and depression; circadian rhythm disorders, such as delayed-sleep phase syndrome, the use of medications that prevent sleep and poor sleep hygiene, including frequent napping during daytime dialysis. 
2. In addition to evaluation for sleep apnea, careful history to be ascertained regarding the following factors- -whether patient has unpleasant sensation in the legs accompanied by an urge to move them, typically in the evening or early part of the night (restless leg syndrome) -if rehab staff has observed jerky movements during sleep (periodic limb movement disorder) -pruritus -anxiety, depression -pain separate treatments for the above conditions are available e.g. restless leg syndrome may respond to ropinirole, pruritus may respond to phosphate control, korsuva (will be soon available),etc. Further specific treatments can be discussed in further detail depending on the history above. 
3. Hyperphosphatemia, hyperkalemia may be indicative of inadequate dialysis. If possible consider dialysis duration to 4 hour sessions to further optimize uremia correction 
4. First shift HD patients are more likely to have insomnia. If possible dialyze patient on second or third shifts if currently on the first shift 
5. Pharmacotherapy is frequently ineffective. However, in addition to what you have tried so far empiric ropinirole may be considered as the next step. No renal dose adjustment is necessary and drug is not removed by dialysis 
6. Separately, there is no role for cholecalciferol in dialysis patients so this can be stopped. Gabapentin is typically not to be used at a dose higher than 100 mg/day in a dialysis patient, so consider reducing the dose. If trazodone, melatonin, is not effective then stop. Pill burden is very high in this patient.