CLINIC:
VISIT DATE:
ATTENDING PHYSICIAN:
Pediatric Nephrology Diabetes Clinic
1/28/2009
Cynthia Wong, MD
PATIENT IDENTIFICATION: XXXXX is a 12-year-old girl with spina bifida and hydrocephalus
with a ventriculoperitoneal shunt (revised on 6/6/2008). She has end stage renal disease
secondary to reflux nephropathy with a past history of recurrent urinary tract infections
and evidence of hydronephrosis. She is hemodialysis dependent. She is now status post
bilateral native nephrectomies done on 1/13/2009 and creation of an ileal conduit in
preparation for future transplantation. Hemodialysis has been started on 6/11/2008.
INTERVAL HISTORY: XXXXX was last seen in clinic on 12/17/2008. She was admitted to the
hospital on 1/12/2009 and discharged on 1/23/2009 for her bilateral native nephrectomies
and for the creation of an ileal conduit, which were done on 1/13/2009. In the
postoperative course, she had an elevated blood pressure to 140-150 systolic. She was
initially started on nifedipine drip, which was then transitioned to Catapres patch #1,
with her blood pressure being controlled with IV hydralazine. She continued on the
Catapres patch #1, as she was discharged. Her blood pressures have remained a little bit
generous, with the mom reporting home blood pressures around the 130s. XXXXX continues to
remain on the Catapres patch #1.
XXXXX experienced a drop in her hematocrit secondary to an intraabdominal bleed and,
hence, was transfused twice during her stay in the hospital.
Since discharge, XXXXX has been overall doing well. She continues on hemodialysis 3
times a week, Monday, Wednesday and Friday; however, the mom thinks that she is a little
bit more tired. She has experienced no pain and has been generally comfortable. All of
the surgical scars have been healing.
DIALYSIS PRESCRIPTION: XXXXX is now on 3 times a week dialysis on Monday, Wednesday and
Friday. She is on 3 hours of dialysis at 6 machine, with a blood flow of 200 mL/min.
She had a right IJ catheter placed on 6/11/2008 with an arterial lumen of 2.1 mL and a
venous lumen of 2.2 mL. Locks at tPA. She is on regular dose heparin. Her dialysate
consists of 140 mEq sodium, 2 mEq/L of calcium and dextrose of 200 mg/dl.
DIET AND FEEDINGS: XXXXX has a dietary restriction of 2 grams of sodium, 1 gram of
potassium and 800 mg of phosphate. She is on a fluid restriction of 1 L a day. She is
currently getting a can of Nepro every day. XXXXX's mom reports that her appetite has
been down the last few days, especially after discharge and that she is not maintaining
her oral intake adequately.
REVIEW OF SYSTEMS: The review of systems is largely negative apart from her complaint of
tiredness after dialysis. She denies a change in weight, any fever or chills. She does
not have a runny nose or cough. She does not have any GI symptoms. She now has a bowel
movement every day and her constipation has improved. She is still on MiraLAX. She has
no headaches, no history of bruising, joint pain or swelling. She has been known to be
depressed in the past and is followed up by the psychiatrist. All other review of
systems were negative.
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MEDICATIONS:
Her current medications include:
1. Epogen 2500 units IV with each dialysis treatment.
2. Ferrlecit 62.5 mg IV every 2 weeks every Monday.
3. Tylenol 500 mg p.o. p.r.n.
4. Benadryl 25 mg p.o. p.r.n.
5. Nephro-Vite 1 tablet p.o. daily.
6. MiraLAX 17 grams p.o. daily.
7. Renagel 3 tablets with meals and 2 tablets with snacks.
8. Clonidine patch #1, to be changed every week every Monday.
9. Ranitidine 75 mg p.o. b.i.d.
10. Percocet 1 tab p.o. q.6 h. p.r.n. pain, taken at night.
11. Please discontinue the sodium bicarbonate.
FAMILY/SOCIAL HISTORY: XXXXX lives at home with the mom and dad. She does to school.
There are no major changes with the family and social history.
PHYSICAL EXAMINATION:
VITAL SIGNS: Her weight today is 47 kg and her height is 122.0 cm. Her blood pressure is
113/68, her pulse is 114 beats/minute and she was afebrile with a temperature of 37
degrees Centigrade.
GENERAL: She seemed tired but not in any acute distress. She was in a wheelchair but is
cooperative on the examination.
HEENT: Normocephalic and atraumatic with VP shunt in place. Pupils are equal, round and
reactive to light. Sclerae are anicteric. Conjunctivae are noninjected. Oropharynx and
tympanic membranes are clear. Mucous membranes are moist.
NECK: Supple with no lymphadenopathy.
CHEST: Clear with no respiratory distress. No rales, rhonchi or wheeze. Catapres patch in
place.
CARDIOVASCULAR: S1 and S2 normal. No murmur. Regular rate and rhythm.
ABDOMEN: Soft, nontender and nondistended. Bilateral nephrectomy surgical sites are well
healed. No erythema or drainage from those sites. Ileal conduit in place. Surgical site
was well healed. Bowel sounds are present. No costovertebral tenderness.
NEUROLOGIC: Wheelchair bound with paralysis of the bilateral lower limbs.
EXTREMITIES: Pink and well perfused.
SKIN: No rashes, no edema.
LABORATORY: The most recent laboratory values were on 1/26/2009 with a BUN of 46,
creatinine 7.1, sodium 135, potassium 4.9, chloride 101, CO2 23, glucose 87, calcium 8.7,
phosphorus 4.4, magnesium 2.3, total protein 7.4, albumin 2.9, cholesterol 116,
triglycerides 279, uric acid 10.2, AST/ALT 13 and 18, respectively, alkaline phosphatase
146, GGT 8, iron 24, ferritin 280, transferrin 191, index 13%, intact PTCH 99, hemoglobin
8.7, hematocrit 25.3, platelets 376, reticulocyte count 3.08, WBC count 12.3.
ASSESSMENT AND PLAN: XXXXX is a 12-year-old girl with spina bifida and hydrocephalus with
a ventriculoperitoneal shunt in place. She is being followed up by the neurological
department and Dr. Michael Edwards annually. She has end stage renal disease secondary
to reflux nephropathy and is hemodialysis dependent, which was started on 6/12/2008. She
is worked up for a living related donor renal transplant and has recently had bilateral
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nephrectomies and ileal conduit in preparation for her future transplant.
ADEQUACY OF DIALYSIS: XXXXX has been continued on 3 times a week dialysis. Her most
recent KT/V is 1.44, which demonstrates adequate dialysis. Her URN was 71%. She is on 3
hours of hemodialysis and we will plan on continuing that. However, her blood pressures
remain a little bit on the generous side with some of the systolic blood pressures going
up to the 130s despite on being on the Catapres patch #1, which is most likely due to
fluid overload, given that she has had bilateral nephrectomies now. We will continue to
challenge the dry weight over the next few weeks to see if we can pull more fluid. We
have reiterated on how important her fluid restriction is at this point to the point, and
she demonstrated understanding of XXXXX's fluid restriction to 1 liter a day.
ANEMIA: XXXXX's hemoglobin has been stable preoperatively, but postoperatively her
hemoglobin had dropped and she required blood transfusions. On account of that, she will
need blood drawn for DSA 2 weeks after the transfusion. Her hemoglobin however remains
low today with a hemoglobin of 8.7. It is concerning that even after the blood
transfusion, her hemoglobin hasn't come up, and we will recheck the hemoglobin in 3 days
to make sure that this is not continuing to drop, demonstrating she is continuing to have
some oozing from her surgical site intra-abdominally. We also think that her low
hemoglobin is secondary to iron deficiency, given her low transferrin at 13%. We decided
to replete her iron stores with an 8-dose course of IV Ferrlecit, dosed at 125 mg for 8
doses during hemodialysis and then continue it monthly at 125 mg IV doses. We will also
check a hemoglobin again in 2 weeks and will continue to monitor this. Her reticulocyte
count is adequate at 3.08 and she is currently on 2500 units of erythropoietin with her
hemodialysis treatment. We will continue her erythropoietin dose at the same right now,
but we will continue to follow the hematocrit. We will consider increasing the
erythropoietin dose if the hemoglobin does not improve despite repleting her iron stores.
RENAL OSTEODYSTROPHY: Her intact PTH was 99. She is off Calcitrol. We have not made any
changes to this. Her calcium was on the low side at 8.7, but her albumin was also low at
2.9, demonstrating her real serum calcium to be a little bit higher. Her phosphorus is
4.4 and she has continued to take her phosphorus binder. We have made no changes to this
therapy.
GROWTH AND NUTRITION: Her __________ is 1.59 and is adequate. Her albumin however is low
at 2.9. Her mom informs us that she is not having a good appetite for the last few days.
Hence, we decided to increase her Nepro to 2 cans during hemodialysis treatment and
continue to have 1 can of Nepro on non-hemodialysis days. Our nutritionist is doing to
follow up with the mom regarding her nutritional intake to make sure this is adequate.
Her most recent bicarbonate level is 23 and she is not on any bicarbonate therapy.
BLOOD PRESSURE: XXXXX's blood pressure has been recently generous and per the mom's
report, it has been running in the 130s at home, although she did not bring her blood
pressure log to the clinic today. We will continue to challenge her dry weight and
continue to give Catapres patch #1 to see if we can get her off this if possible. We
will follow up this in the hemodialysis unit.
INFECTIOUS COMPLICATIONS: There are no infectious complications.
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PSYCHOSOCIAL: XXXXX continues to be see a psychiatric monthly.
citalopram (Celebrex).
She is currently on
NEUROLOGICAL ISSUES: She is followed annually by the neurosurgical team. Overall, she
continues to do well.
STATUS OF TRANSPLANT: XXXXX's father was an identified living donor, but since he had an
abnormal glucose tolerance test, he was not a candidate for a living donor. XXXXX is now
getting a work up completed for transplantation. She will require steroid-free
immunosuppression posttransplant with daclizumab induction. Overall, XXXXX continues to
do well.
We will continue to follow up in clinic.
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