Dialysis Initiation

CKD Managementmedium

A 59-year-old man with stage 5 CKD attends clinic and denies symptoms. He is hemodynamically stable with a clear chest and mild lower-limb edema, but a pericardial friction rub is heard on auscultation. His AV fistula is still maturing. Laboratory studies show markedly elevated urea and creatinine, potassium 5.1 mmol/L, and bicarbonate 19 mmol/L. Which of the following is the most appropriate next step?

  1. A.Intensify diuretic therapy
  2. B.Start sodium bicarbonate
  3. C.Start a potassium binder
  4. D.Initiate hemodialysisCorrect

Explanation

A pericardial friction rub in a patient with stage 5 CKD indicates uremic pericarditis, an absolute indication for urgent dialysis initiation regardless of the eGFR. The mild hyperkalemia and low bicarbonate are secondary; neither diuretics, oral bicarbonate, nor potassium binders treat the underlying uremia driving the pericarditis. An immature fistula does not delay urgent dialysis—temporary access (tunneled catheter) is used.

Why each option

A.
Incorrect. Diuretics address volume but not the uremic milieu causing pericarditis.
B.
Incorrect. Sodium bicarbonate corrects acidosis modestly but does not treat uremic pericarditis.
C.
Incorrect. A potassium binder addresses only the mild hyperkalemia, not the emergent uremic pericarditis.
D.
Correct. Uremic pericarditis is an absolute indication to start dialysis urgently, using temporary access while the fistula matures.

Reference: KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of CKD; Rutsky EA, Rostand SG. Treatment of uremic pericarditis and pericardial effusion. Am J Kidney Dis. 1987;10(1):2-8.

This is one of 1,100 questions in the MedBoardSA nephrology bank, with timed test mode, tutor mode, and progress tracking by topic.

Practise the full bank

More CKD Management questions

Browse other topics