Patient Profile:
M.C. is a 49-year-old Caucasian female with a 41-year history of insulin dependent diabetes. In addition, she has had hypertension, coronary artery disease (CAD), nephropathy, and mild diabetic retinopathy. M.C. also has a positive family history for both Type I diabetes and kidney failure. Her father was on dialysis for many years and her two sisters have Type I diabetes. M.C. is a teacher and has home schooled her children. Her husband is a minister and counselor. A nephrologist has followed M.C. for several years and an AV fistula was placed in her left forearm 5 months earlier. During a work up for kidney/pancreas transplantation approximately 6 months prior to the current admission, it was discovered that M.C. had severe CAD. She underwent coronary artery bypass surgery at that time. For several months her kidney function remained stable; however, the vein harvest area in her left leg never healed completely and she was admitted for treatment of cellulitis. She also presented with a serum creatinine of  9.2 mgm/dl and a 3-day history of nausea and vomiting.

1. The patient will be discharged with cellulitis under control.
   
2. The patient will adjust to a dialysis treatment regimen while waiting for a kidney/pancreas transplant.
   

Discussion:
Diabetes and hypertension are the two main causes of chronic kidney disease (CKD) and are responsible for complications involving many body systems (United States Renal Data System [USRDS], 2004). In addition, a long history of insulin dependent diabetes is associated with nephropathy, retinopathy, and neuropathy (USRDS, 2004). In recent years there have been efforts to improve the care of patients with CKD long before they reach end stage renal disease (ESRD). The National Kidney Foundation (NKF)-sponsored Kidney Dialysis Outcomes Quality Initiative (K-DOQI) has recently established practice guidelines for the care of these patients (NKF, 2001). Their recommendations include early identification of the disease by using estimated glomerular filtration rates (eGFR), advance placement of vascular access before the need for dialysis, and control of anemia and calcium/phosphorous/PTH levels. Moreover, the administration of angiotensin converting enzyme (ACE) inhibitors in the presence of microalbuminuria has been shown to significantly slow the progression of CKD, as has adequate blood pressure and blood glucose control (Diabetes Control and Complications Trial Research Group, 1993; Lewis, Berl, Bain, Rohde, & Lewis, 1999; Lewis, Hunsicker, Bain, & Rohde, 1993). One formula used to estimate GFR is the Cockcroft-Gault Formula (NKF, 2000), which takes into account the patient’s serum creatinine, as well as height, weight, age, and gender (see Table 1).
 
In the case of M.C., the guidelines were followed and most of the right things were done. She had an AV fistula placed, her anemia was under control, and she was on Rocaltrol® and phosphorous binders. There was no evidence, however, that eGFRs had been done or if she had ever been on ACE inhibitors.
 
M.C. was reluctant to start dialysis because she had seen the difficulty her father had in coping with it. After a long talk with the nephrologist, she agreed to begin treatments. Even though a fistula had been placed, it never worked well and was found to be non-functioning on admission. A right perm-cath was placed and dialysis begun. After the initial three treatments, M.C. began to feel somewhat better and remained on IV antibiotics for the cellulitis. Although the swelling diminished, two toes appear cyanotic in spite of Doppler studies indicating the presence of pedal pulses. It will be important for M.C. to have follow-up care and monitoring of arterial flow to her left leg. She appeared to be adjusting well to dialysis, has a positive attitude about it, and will continue to pursue transplantation as planned.

Summary
The intended patient outcomes have been largely met in this patient, however, a great deal of diligence will be required to prevent limb loss and to have a successful kidney/pancreas transplant.
 
In spite of efforts to control the progress of CKD, the frequency and severity of complications in a patient with long-term Type I diabetes presents problems that are difficult to overcome. The presence of peripheral and coronary vascular disease has implications for co-morbidities and for the success of vascular access placement. In this case, the use of eGFR may have given a more accurate picture of renal failure progression than simply using serum creatinine levels and 24-hour creatinine clearance studies. Further work needs to be done to facilitate use of the K-DOQI Practice Guidelines for CKD, including the use of ACE inhibitors, and to reduce the fear that patients have regarding the initiation of dialysis.

References

Diabetes Control and Complications Trial Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329, 977-986.

Lewis, E.J., Hunsicker, L.G., Bain, R.P., & Rohde, R.D. (1993). The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. New England Journal of Medicine, 329, 1456-1462.

Lewis, J.B., Berl, T., Bain, R.P., Rohde, R.D., & Lewis, E.J. for the Collaborative Study Group. (1999). Effect of intensive blood pressure control on the course of type 1 diabetic nephropathy. American Journal of Kidney Disease, 34, 809-817.

National Kidney Foundation (NKF). (2001).  K/DOQI clinical practice guidelines for chronic   kidney disease. American Journal of Kidney Disease, 37(Suppl. 1), 137-181. Retrieved from www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
  
United States Renal Data System (USRDS). (2004). Chronic kidney disease. Annual Data Report. Retrieved from www.usrds.org/2004/pdf/01_ckd_04.pdf