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Chapter 20: Cardiovascular Disease in Chronic Kidney Disease

A 61-year-old man presents to the nephrology clinic for evaluation of a recently diagnosed stage III Chronic Kidney Disease (CKD). He has a history of long-standing hypertension, gout, and diabetes. He denies history of heart disease. He had an appendectomy at age 17. He is presently asymptomatic and is in the clinic at the request of his primary care physician. His vital signs show a blood pressure (BP) of 135/72, heart rate (HR) 74, respiratory rate (RR) of 14, oxygen saturation of 99%. His physical examination is notable for clear sclera, regular heart rate with no murmurs, clear lungs, nondistended nontender abdomen and trace bilateral lower extremity edema. He takes amlodipine, allopurinol, metformin, and over the counter vitamin D. Outpatient blood work shows the following: sodium 141 mEq/L, potassium 4.2 mEq/L, chloride 97 mmol/L, CO2 25 mmol/L, glucose 97 mg/dL, blood urea nitrogen 34 mg/dL, creatinine 1.45 mg/dL with an MDRD-estimated glomerular filtration rate (eGFR) of 55 mL/min. Urinary testing reveals a urinary albumin/creatinine ratio (UACR) of 252 mg/g. Which of the following is accurate regarding his prognosis?

A. His mortality risk is similar to the general population because his blood pressure and diabetes are well controlled.

B. His risk of progression to ESRD requiring dialysis is higher than his risk of death.

C. His mortality risk is similar to the general population because his UACR is less than 300 mg/g.

D. He should not be worried about his CKD because his eGFR is very close to 60 mL/min.

E. His risk of progression to end-stage renal disease (ESRD) requiring dialysis is lower than his risk of death.

The answer is E. Patients with impaired kidney function are more likely to die than to progress to ESRD requiring renal replacement therapy. Additionally, both decrease in GFR and increase is albuminuria >30 mg/g are associated with an increased risk of all-cause mortality and cardiovascular event.

You are rounding in the dialysis unit and you meet one of your new patients. She is a 73-year-old woman with end stage renal disease secondary to hypertension and was started on dialysis a week ago. Her past medical history is notable for smoking, hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, and remote stroke with residual right hemiparesis. She takes aspirin, carvedilol, losartan, atorvastatin, hydralazine, and isosorbide mononitrate. Her physical examination reveals a thin elderly woman with pale conjunctivas. Heart sounds are irregularly irregular without murmurs. She has mild ronchi at bilateral lung bases with 1+ bilateral peripheral edema. Abdomen is supple, nontender with normal bowel sounds. She has a right brachiocephalic arteriovenous fistula with ...

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