A 63-year-old woman with a long history of type 2 diabetes mellitus is being evaluated for a progressive decline in renal function. She has no new complaints except for occasional tiredness and lower back pain. Her other medical problems include hypertension, obesity, mild diabetic retinopathy, and peripheral neuropathy. One year ago, she was evaluated for atypical chest pain and had a negative exercise stress test. She is a lifetime non-smoker. Her current medications include insulin, amlodipine, and low-dose aspirin. She was treated with lisinopril, which has been stopped recently due to renal dysfunction and hyperkalemia.
Her current eGFR is 15 ml/min, potassium is 5.1 mEq/L, and hemoglobin is 10.2 g/dL.
Which of the following would provide the highest survival benefit in this patient?

Question

A 63-year-old woman with a long history of type 2 diabetes mellitus is being evaluated for a progressive decline in renal function.  She has no new complaints except for occasional tiredness and lower back pain.  Her other medical problems include hypertension, obesity, mild diabetic retinopathy, and peripheral neuropathy.  One year ago, she was evaluated for atypical chest pain and had a negative exercise stress test.  She is a lifetime non-smoker.  Her current medications include insulin, amlodipine, and low-dose aspirin.  She was treated with lisinopril, which has been stopped recently due to renal dysfunction and hyperkalemia.
Her current eGFR is 15 ml/min, potassium is 5.1 mEq/L, and hemoglobin is 10.2 g/dL.
Which of the following would provide the highest survival benefit in this patient?

Quizplus · Accepted Answer

Diabetes mellitus is the most common cause of end-stage renal disease (ESRD) requiring dialysis, and the 5-year survival for these patients on hemodialysis is around 30-40% (> 50% deaths from cardiovascular disease). Studies show diabetics with ESRD receiving kidney transplant had a 5-year survival of 67-77% and better quality of life. As a result, renal transplant should be offered to all eligible diabetics with ESRD. While a living related donor transplant is the best option, cadaveric transplant also offers increased survival in diabetic patients. Improved survival in diabetics following a cadaveric kidney transplant is maximal in younger age groups but is seen in all age groups, including patients > age 70. (Choices B & D) The optimal time to start dialysis is debated. Studies have shown no difference in outcomes between preemptive dialysis (GFR of 10-15 ml/min/1.73m² without symptoms of uremia) and dialysis at either the onset of uremic symptoms or when the glomerular filtration rate is < 10 ml/min/1.73m². (Choice C) Erythropoietin offers symptomatic relief from anemia of renal failure and indirectly improves cardiovascular morbidity and mortality, but renal transplant offers a higher survival benefit. (Choice E) Peritoneal dialysis is an option for maintenance dialysis in diabetics with stable cardiovascular dynamics, no severe vascular disease, or without advanced neuropathy. Survival with chronic peritoneal dialysis is generally comparable to chronic hemodialysis, but is not better than renal transplant. Educational objective: Diabetics with end-stage renal disease (ESRD) treated with either a living related or cadaveric donor kidney transplant (compared to dialysis) have better survival, quality of life, and rehabilitation. Infections are the most common cause of death in the early post-transplant period. __________ References: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation and recipients of a first cadaveric transplant. (http://www.ncbi.nlm.nih.gov/pubmed/10580071) A randomized, controlled trial of early versus late initiation of dialysis. (http://www.ncbi.nlm.nih.gov/pubmed/20581422)

A 63-Year-Old Woman with a Long History of Type 2