A 68-Year-Old Man with Chronic Kidney Disease Secondary to Diabetic

A 68-year-old man with chronic kidney disease secondary to diabetic nephropathy and hypertension comes to the office for a follow-up visit.  The patient has had mild fatigue but no anorexia, nausea, vomiting, chest pain, or shortness of breath.  Medical history includes hyperlipidemia, coronary artery disease, and hand osteoarthritis that limits manual dexterity.  The patient lives alone and has occasional help from an aide.  He is compliant with medications and recommended dietary restrictions.  Physical examination reveals clear lungs, no heart murmur, and trace pedal edema.
Laboratory results show hemoglobin 11.8 g/dL and serum potassium 4.9 mEq/L.  Estimated glomerular filtration rate (eGFR) is 19 mL/min/1.73 m², which was 26 mL/min/1.73 m² a year ago.
After a thorough discussion, the patient is interested in renal replacement therapy.  Which of the following is the most appropriate next step in management?

A) Arteriovenous fistula placement now
B) Arteriovenous graft placement when eGFR is <15 mL/min/1.73 m²
C) Maximal medical therapy until uremic symptoms appear
D) Peritoneal dialysis catheter placement now
E) Tunneled central venous catheter placement when need for dialysis is imminent

Correct Answer:

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