A 50-year-old man comes to the office for a routine follow-up visit. He has hypertension, diabetes mellitus, depression, secondary hyperparathyroidism, and end-stage renal disease. The patient has been on hemodialysis for the past 3 years. He was admitted 3 months ago for catheter-related infection, which was treated with antibiotics. The patient also had a right below-the-knee amputation 2 years ago following a nonhealing foot ulcer. Physical examination shows a right carotid bruit. Over the next 5 years, this patient is at greatest risk of death from which of the following?

Question

A 50-year-old man comes to the office for a routine follow-up visit.  He has hypertension, diabetes mellitus, depression, secondary hyperparathyroidism, and end-stage renal disease.  The patient has been on hemodialysis for the past 3 years.  He was admitted 3 months ago for catheter-related infection, which was treated with antibiotics.  The patient also had a right below-the-knee amputation 2 years ago following a nonhealing foot ulcer.  Physical examination shows a right carotid bruit.  Over the next 5 years, this patient is at greatest risk of death from which of the following?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d4d8_133f_bc81_73ae4e729769_MD0003_00 Cardiovascular disease (CVD) (eg, coronary artery disease, stroke) is the most common cause of death in patients with end-stage renal disease (ESRD), accounting for approximately 50% of deaths even in younger patients. Traditional cardiovascular risk factors including hypertension (96% of patients), dyslipidemia, diabetes mellitus, left ventricular hypertrophy, sedentary lifestyle, and advanced age (average age of dialysis initiation is >60 years) are highly prevalent in patients on dialysis. In addition, chronic kidney disease is an independent risk factor for CVD, likely due to factors related to renal dysfunction and/or renal replacement therapy, including the following: Metabolic abnormalities (eg, hyperphosphatemia) and increased calcium load (eg, vitamin D supplementation) cause arterial calcification, coronary artery stiffening/narrowing, and left ventricular hypertrophy (diastolic dysfunction). Uremia and renal replacement therapy cause oxidative stress, resulting in accelerated atherogenesis and inhibition of nitric oxide synthesis. Anemia, which is common in patients with ESRD, is a risk factor for CVD and is associated with worse outcomes in acute coronary syndrome. CVD also accounts for significant morbidity in patients with ESRD; peripheral artery disease with extensive vascular calcification and poor arterial supply can lead to nonhealing foot ulcers and result in amputation. Because of the increased morbidity and mortality, patients with ESRD require aggressive management of both traditional and renal-specific cardiovascular risk factors. (Choice B) Infection is the second most common cause of death in patients with ESRD, accounting for approximately 15%-20% of deaths. Dialysis catheter-related infections are common; mortality can be reduced with appropriate antibiotic treatment and replacement of infected catheters. (Choice C) Patients with ESRD are at increased risk for psychiatric conditions (prevalence of up to 70%), especially depression and anxiety. The incidence of death by suicide is higher than in the general population but much lower than death from CVD. (Choice D) The risk of venous thromboembolism in patients with ESRD is twice that for the general population, but death attributable to CVD is much higher. (Choice E) Although some elderly patients with poor functional status and quality of life may withdraw from dialysis, this is an uncommon outcome in a 50-year-old patient. Educational objective: Cardiovascular disease is the most common cause of death (up to 50%) in patients with end-stage renal disease (ESRD). Contributing factors include an increased prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes) and ESRD-related risks (eg, anemia, oxidative stress). Aggressive risk-factor modification is required to reduce mortality.

A 50-Year-Old Man Comes to the Office for a Routine