Abstract: PUB145
Acute PD in ESKD Jehovah's Witness Patient With Severe Anemia and Uremic Bleeding
Session Information
Category: Dialysis
- 702 Dialysis: Home Dialysis and Peritoneal Dialysis
Authors
- Ganesan, Lakshmi, Loma Linda University School of Medicine, Loma Linda, California, United States
- Abdi Pour, Amir, Loma Linda University School of Medicine, Loma Linda, California, United States
- Infante, Sergio, Loma Linda University School of Medicine, Loma Linda, California, United States
Introduction
Due to high mortality associated with severe anemia and hemodialysis, anemia is aggressively managed with iron and ESA therapy in chronic HD patients. Severe anemia is generally managed first with transfusion. In patients who refuse transfusion, anemia management can pose a challenge. We present a case of changing modality to PD in Jehovah's Witness patient to allow for improvement of uremic bleeding, and stabilization of hemoglobin without transfusion.
Case Description
39 yo M Jehovah’s Witness with ESRD 2/2 DM2 on HD, PAD on DAPT (and h/o BLE angioplasty) admitted with LLE necrotizing fasciitis. Admission hemoglobin was 9.2g/dL. He received 5 HD treatments before his BKA on day 9. Due to symptomatic post-op anemia (5g/dL, nadir 4.2g/dL), he was too unstable for HD. Pt had ongoing bleeding attributed to blood thinners, surgery and uremic platelet dysfunction. Patient's volume status and mentation worsened. On day 17, Quinton catheter was placed and CCPD started. BUN was at 167mg/dL at start of PD. Due to bleeding from prior Veress access site, patient had two revisions before PD was successful. On day 21, pt completed full PD. He tolerated 6 days of 24hr/day of PD, 11 cycles, fill volume 500mL, increased to 1000mL. Repeat labs showed BUN 110mg/dL and Hgb 9.6g/dL. Anemia was managed with aggressive ESA dosing - Epogen 40K units qHS, started day 16. Respiratory status and mentation improved. He was transitioned back to HD on day 27 at patient’s behest due to ongoing scrotal edema and hydrocele. He tolerated resuming HD, though Hgb was 7-8g/dL on HD even with higher dose ESA. He was discharged from hospital to resume outpatient HD.
Discussion
To date, there is no reported case of converting dialysis modality for anemia in Jehovah’s Witness patients who are too unstable for HD. There is a reported case of using acute PD post-laparotomy. They do not cite anemia or ongoing bleeding as an indication in this case, but rather related to patient’s advanced directive against autologous procedures. They acknowledge peritoneal dialysis superiority where cardiovascular instability and bleeding risk are concerned. While our patient experienced further bleeding after catheter placement, he still had improvement in his hemoglobin over one week of PD. This supports using acute PD when ESRD patients may be too unstable for HD due to severe anemia.