MKSAP Quiz: office evaluation of progressive chronic kidney disease
Long-term bisphosphonate treatment may increase risk of some fractures in older women
A 28-year-old female graduate student with progressive chronic kidney disease due to IgA nephropathy and hypertension is evaluated in the office.
She has fistulous Crohn disease for which she has undergone multiple abdominal surgeries, including distal ileum and proximal colon resection as well as a temporary ileostomy and subsequent ileocolic anastomosis. She has been referred to a nephrologist, nutritionist, and social worker and has discussed various methods of kidney replacement therapy, including the risks and benefits. She would prefer kidney transplantation. Medications are lisinopril, calcium acetate, and epoetin alfa. There is no family history of kidney disease. She has type O blood, and her mother and father have blood types B and A, respectively. She has no siblings.
On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 130/78 mm Hg, pulse rate is 62/min, and respiration rate is 14/min. BMI is 24. Cardiopulmonary examination is normal.
Estimated glomerular filtration rate is 23 mL/min/1.73 m2.
Which of the following is the most appropriate next step in this patient's management?
A. Begin training for peritoneal dialysis
B. Evaluate her father as a potential kidney donor
C. Evaluate her mother as a potential kidney donor
D. Plan placement of an arteriovenous fistula
MKSAP Answer and Critique
The correct answer is D) Plan placement of an arteriovenous fistula. This item is available to MKSAP 15 subscribers as item 46 in the Nephrology section.
This patient has stage 4 chronic kidney disease due to IgA nephropathy and will need kidney replacement therapy. She prefers kidney transplantation but may need to undergo dialysis before an appropriate donor kidney is available. Although she can be referred to a transplant center, she cannot accumulate time on the deceased donor transplant waiting list until her glomerular filtration rate is 20 mL/min/1.73 m2 or less. The most appropriate next step in management is therefore placement of an arteriovenous fistula and training for home hemodialysis.
Compared with peritoneal dialysis, daily home hemodialysis is associated with better control of hyperphosphatemia, blood pressure, and volume overload in patients with chronic kidney disease. Furthermore, peritoneal dialysis requires an intact peritoneum and is unlikely to succeed in a patient with a history of fistulous Crohn disease and multiple abdominal surgeries whose peritoneum is unlikely to be intact.
Evaluation of this patient's parents as potential kidney donors would not be appropriate. This patient and her parents are not ABO compatible, and kidney transplantation would most likely cause an early and immediate allograft rejection. Furthermore, most transplant programs do not perform ABO-incompatible transplants. Preemptive kidney transplantation is associated with better patient and allograft survival but often is not possible in the absence of a suitable living donor because of the long wait for a deceased donor kidney transplant.
Key Point
- Compared with peritoneal dialysis, daily home hemodialysis is associated with better control of hyperphosphatemia, blood pressure, and volume overload in patients with chronic kidney disease.