Internal Medicine Correlations and Clinical Scenarios (CCS) USMLE Step 3

CASE 5: End-Stage Renal Failure and Dialysis

Setting: office

CC: “My kidneys are failing, do I need dialysis?”

VS: BP: 152/92 mm Hg; P: 64 beats/minute; T: 98°F; R: 22 breaths/minute

HPI: A 67-year-old man with a history of hypertension and diabetes who has had renal insufficiency for several years now comes to the office for evaluation of his kidneys. The patient is obese and has had difficulty controlling both his diabetes and high BP. He is adherent to diet and tries to exercise.

PMHX:

Image Hypertension for 12 years

Image Diabetes for 8 years

Image Tobacco in the past; quit 15 years ago

Medications:

Image Lisinopril

Image Nifedipine

Image Sitagliptin

Image Glyburide

PE:

Image General: tired, but comfortable

Image Extremities: edema present

Image Chest: basilar rales bilaterally

Image Cardiovascular: S4 gallop; no murmurs

Initial Orders:

Image CHEM-7

Image UA

Image Complete blood count (CBC)

Which is not an indication for dialysis?

a. Fatigue

b. Hyperkalemia

c. Fluid overload

d. Encephalopathy

e. Metabolic acidosis

f. Pericarditis

Answer a. Fatigue

Everyone is fatigued or tired. This is too nonspecific a finding. All the others, potassium, fluid, pericarditis, acidosis, and encephalopathy are definitely indications for immediate dialysis. Despite control of BP and diabetes, many people have worsening renal dysfunction that will need dialysis. Your job is to detect who is having worsening creatinine clearance (<30 mL/minute) and will need dialysis before their condition gets bad enough to have metabolic acidosis and these other findings.

As usual, the patient returns in 1 to 2 weeks for evaluation of his laboratory test results.

Reports:

Image CHEM-7: BUN 48 g/dL; creatinine 4 mg/dL; potassium 4.9 mEq/L; bicarbonate 19 mEq/L

Image UA: protein 2+

Image CBC: hematocrit 32%; mean corpuscular volume (MCV) 85 fL

Renal failure decreases erythropoietin level, resulting in anemia (Figure 6-3).

Image

Figure 6-3. Regulation of red blood cell production by erythropoietin. If the ability of blood to carry oxygen decreases because of a fall in numbers of red blood cells (e.g., normal cell death, pathological destruction of red blood cells, bleeding, etc.), the kidney senses lower partial pressure of oxygen (PO2) levels and increases the levels of erythropoietin (EPO). EPO then signals the bone marrow to increase production of red blood cells. (Reproduced with permission from Kibble JD, Halsey CR: The Big Picture: Medical Physiology, 1st ed. New York: McGraw-Hill; 2009.)

Orders:

Image Vascular access placement (arteriovenous [AV] graft)

Image Phosphate level

Image Calcium level

Image Nephrology evaluation

Acid production: 1 mEq/kg per day

There is no other way to excrete it than through the kidneys.

What is the most common cause of death with ESRD over time, even on dialysis?

a. Infection

b. Coronary disease

c. Sodium disorder

Answer b. Coronary disease

Renal insufficiency greatly accelerates the process of atherosclerosis.

The patient is seen by a vascular surgeon to place an AV graft. The patient is tired, but otherwise not significantly different than usual.

Reports:

Image Calcium level low

Image Phosphate level high

The calcium level is low from decreased levels of 1,25 dihydroxyvitamin D.

Replace calcium and vitamin D in renal failure.

Hyperparathyroidism from low calcium levels damages bone.

Orders:

Image Oral vitamin D and calcium carbonate replacement

Image CBC

Image CHEM-7

Move the clock forward 4 to 6 weeks. It takes this long to place an AV fistula and to allow it time to epithelialize and “mature” enough to be usable for dialysis.

In ESRD, always get a chemistry level every time you see a patient. Nephrology is a laboratory specialty. There is no significant physical finding to follow.

Report:

Image Chemistry: BUN 54 g/dL; creatinine 4.5 mg/dL

Image CBC: hematocrit 29%

Image Phosphate: elevated

Phosphate-lowering medications bind phosphate in the bowel:

• Calcium carbonate

• Lanthanum

• Sevelamer

Lanthanum and sevelamer are “rare earths” that bind phosphate in the bowel without affecting calcium levels. Once you get to the level of needing oral phosphate binders, patients definitely need dialysis. This is true even if pericarditis, encephalopathy, dangerous hyperkalemia, or fluid overload have not yet occurred. Do not wait for these dangerous developments on CCS.

Orders:

Image Phosphate binders

Image Calcium

Image Vitamin D

Image Dialysis

Image Erythropoietin

The only anemia of chronic disease treated with dialysis is ESRD.

After 6 weeks, the graft of the AV fistula should be sufficiently mature to allow vascular access. You should expect every patient on dialysis to be on:

Image Calcium replacement

Image Vitamin D

Image Oral phosphate binder (calcium carbonate, sevelamer, lanthanum)

Image Erythropoietin

Image BP and lipid control

This treatment should continue permanently.



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