A 68-year-old man with chronic kidney disease secondary to diabetic nephropathy and hypertension comes to the office for a follow-up visit. The patient has had mild fatigue but no anorexia, nausea, vomiting, chest pain, or shortness of breath. Medical history includes hyperlipidemia, coronary artery disease, and hand osteoarthritis that limits manual dexterity. The patient lives alone and has occasional help from an aide. He is compliant with medications and recommended dietary restrictions. Physical examination reveals clear lungs, no heart murmur, and trace pedal edema.
Laboratory results show hemoglobin 11.8 g/dL and serum potassium 4.9 mEq/L. Estimated glomerular filtration rate (eGFR) is 19 mL/min/1.73 m², which was 26 mL/min/1.73 m² a year ago.
After a thorough discussion, the patient is interested in renal replacement therapy. Which of the following is the most appropriate next step in management?

Question

Quizplus · Accepted Answer

Patients with advanced chronic kidney disease should be referred to a nephrologist to discuss preparations for renal replacement therapy. Studies have shown similar survival outcomes among patients started on dialysis early (glomerular filtration rate [GFR] of 10-14 mL/min/1.73 m²) versus late (GFR of 5-7 mL/min/1.73 m²). However, waiting until dialysis is emergently required (eg, hyperkalemia, volume overload, uremic symptoms) places patients at high risk for complications (eg, arrhythmias, respiratory failure) and should be avoided (Choice C). ² ² Arteriovenous (AV) fistulas are the preferred vascular access modality for chronic hemodialysis (rather than an AV graft) due to fewer complications and improved longevity (Choice B). However, maturation of a fistula takes up to 3 months. Therefore, if hemodialysis is anticipated, preemptive placement of an AV fistula (typically when GFR is 15-20 mL/min/1.73 m²) is recommended. ² (Choice D) Peritoneal dialysis requires placement of a peritoneal catheter 2 weeks before use (although it can be used immediately if needed). However, peritoneal catheters require significant daily care and are relatively contraindicated in patients unable to perform catheter care, as in this patient who has limited manual dexterity. (Choice E) Emergency dialysis via a central venous catheter should be avoided if possible, as these catheters are associated with relatively high rates of complications (especially infections) and diminished survival. Educational objective: Arteriovenous fistulas are the preferred vascular access modality for chronic hemodialysis. However, maturation of a fistula takes up to 3 months. Therefore, if hemodialysis is anticipated, preemptive placement of an AV fistula is recommended, typically when the glomerular filtration rate is 15-20 mL/min/1.73 m². ² __________

A 68-Year-Old Man with Chronic Kidney Disease Secondary to Diabetic