Free nephrology board questions: Hemodialysis

A 50-year-old man with ESKD undergoing HD thrice weekly for the past 4 years presents to the outpatient dialysis unit with persistent large interdialytic weight gain (IDWG). He has received counseling on dietary fluid restriction, and his dialysis treatment time was increased 2 months ago. IDWG is typically 3–4 kg during the mid-week intervals and 6–8 kg over the long interdialytic interval. He estimates his urine output to be 100 mL/d. Current HD prescription includes 4-hour treatment, blood flow rate (BFR) of 450 mL/min, dialysate flow rate of 700 mL/min, and a dialysate composition that includes sodium concentration of 140 mEq/L, bicarbonate concentration of 35 mEq/L, and potassium concentration of 2 mEq/L. He dialyzes via an arteriovenous fistula (AVF) and most recent Kt/V is 1.82 (reference range, >1.2). Current medications include torsemide, lisinopril, calcium acetate, and calcitriol. On examination prior to HD, BP is 158/86 mm Hg and heart rate is 86/min. His lungs are clear, a right forearm AVF has a strong thrill, and trace bilateral lower extremity edema is present. What is the MOST appropriate next best step in the management of this patient’s large IDWG?

A 52-year-old man receives thrice-weekly 3.5-hour hemodialysis with dialysate sodium 140 mEq/L. He urinates about 100 mL/day and inconsistently follows sodium and fluid restriction. Dry weight is 70 kg, predialysis weight averages 76 kg, and predialysis BP averages 170/95 mm Hg. He has no intradialytic hypotension. He cannot extend treatment time or attend extra sessions, and unit policy caps ultrafiltration at 13 mL/kg/h (goal 3.1 L per treatment). He has elevated jugular venous pressure, bibasilar crackles, and moderate pretibial edema. Predialysis sodium is 135 mEq/L. Which intervention is most likely to decrease his interdialytic weight gain?

A 52-year-old woman is evaluated in the dialysis unit to discuss her anemia. Her history includes ESKD secondary to IgA nephropathy, anemia, hyperphosphatemia, well-compensated alcohol-associated liver cirrhosis, and hypertension. She has been receiving in-center HD three times per week for the past 5 months via a brachiocephalic arteriovenous fistula, and she is actively listed for kidney transplantation. A review of systems is only notable for fatigue, and she denies any signs of bleeding. Her medications include carvedilol and sevelamer. Four weeks ago, her hemoglobin was noted to be 6.9 g/dL, and she was prescribed epoetin alfa, 3500 units three times per week. On current examination, BP is 138/72 mm Hg, heart rate is 92/min, and weight is 75 kg. She is somewhat lethargic but able to answer all questions, and the remainder of the examination is unremarkable. Laboratory data (4 weeks ago, current; reference): hemoglobin 6.9, 7.1 g/dL (12–16); transferrin saturation 39%, 35% (20–50); ferritin 920, 725 ng/mL (24–307); serum aspartate aminotransferase 48, 61 U/L (10–40); serum alanine aminotransferase 32, 47 U/L (10–40). Additional laboratory testing, including thyroid function, B₁₂, folate, PTH, and peripheral blood smear are normal. Current single-pool Kt/V is 1.5 (reference range >1.2). Which ONE of the following is the MOST appropriate next step in the management of this patient’s anemia?

A 57-year-old man on hemodialysis presents immediately after dialysis with a painful, enlarged arteriovenous fistula. The fistula has enlarged progressively over several weeks, and after his last few treatments he needed 7–10 minutes of compression for hemostasis. Staff cannulate with 16-gauge needles using the rope-ladder technique. He takes apixaban for atrial fibrillation. The arterial anastomosis of the left arm fistula is expanded and pulsatile, and the overlying skin is blanched and tight with several needle puncture sites. What is the best next step?

A 61-year-old man with CKD stage 5 from ADPKD and heart failure is admitted with anorexia, nausea, vomiting, and weight loss. A left forearm arteriovenous fistula was placed 6 months ago. He takes lisinopril, furosemide, and atorvastatin. He is afebrile, with oxygen saturation 94% on room air, bibasilar crackles, 3+ pretibial edema, and asterixis. HD is started for uremia. Before outpatient placement, hepatitis B serologies and tuberculin skin testing (TST) are ordered. He declines TST, explaining that he was raised in Morocco and has tested positive since childhood because of vaccination. What is the most appropriate next step?

A 75-year-old man with type 2 diabetes, hypertension, and hyperlipidemia started HD 4 months ago and tolerates treatments well. Total cholesterol 230 mg/dL, HDL 30 mg/dL, LDL 145 mg/dL, triglycerides 201 mg/dL. What is the next best step?

A 54-year-old man with ESRD from diabetes and hypertension, on hemodialysis for 2 years, reports fatigue and weakness. Medications include insulin, antihypertensives, aspirin, atorvastatin, sevelamer, and erythropoietin. Predialysis BP is 112/82 mm Hg. Cardiac and lung examinations are normal; he has trace leg edema. Values 3 months ago and now: albumin 3.9 and 3.4 g/dL; total CO₂ 25 and 22 mEq/L; calcium 8.7 and 8.1 mg/dL; intact PTH 400 and 600 pg/mL (dialysis target 130–585); single-pool Kt/V 1.5 and 1.43. TSH is 5.0 µU/mL with free T₄ 0.9 ng/mL (0.8–1.8). Which strategy best addresses his fatigue and weakness?