NephroTube Dialysis Module Mini Exam (1)

2.

A radiocephalic A-V access was created in your 60-year-old African American diabetic woman 4 weeks ago and iscurrently not maturing. Which one of the following variables is associated with failure of fistula maturation(primary failure) is CORRECT?

Age > 65 years
Coronary artery disease (CAD)
Peripheral vascular disease (PVD)
Hyperlipidemia
All of the above

Correct Answer

A. All of the above

Explanation

The answer is E
A Canadian study by Lok et al. showed that all of the above variables are associated with primary failure of the
native fistula by univariate analysis (E is correct). Although diabetes was found to be associated with primary
failure of the fistula by univariate analysis, it was not significant by multivariate analysis. However, other studies
found that diabetes is a risk factor for maturation of the fistula. In the study of Lok et al., male gender and white
race were found to decrease the risk for maturation.
By using age, CAD and PVD, and other variables, Lok et al. developed a predictive risk score system to assess
the most appropriate choice of access for an individual patient. They classified the risk categories into low risk
(score

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3.

Your patient has a central venous catheter for HD, and the infection rate is much higher than an A-V graft. Infection ofthe catheter results from which one of the following sources of contamination is CORRECT?

Catheter connectors
Catheter lumen during dialysis
Infused solutions
Migration of patient’s skin flora into the cannulation site
All of the above

Correct Answer

A. All of the above

Explanation

The answer is E
Venous catheters can be infected from several sources, including the above despite following the best practice
guidelines proposed by the Centers Disease Control and KDOQI. Also, catheters can colonize infective organisms
from recently treated bacteremia.

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4.

In your patient with CKD 4 (eGFR 22 mL/min), you plan to place a native arterio-venous (A-V) fistula. Which one ofthe following is the MOST preferred fistula for your patient?

Radiocephalic fistula
Brachiocephalic fistula
Brachiobasilic transposition fistula
A-V graft
Any one of the above

Correct Answer

A. Radiocephalic fistula

Explanation

The answer is A
Currently there are several options for creation of vascular accesses at different anatomical locations of the body.
In general, the preferred initial site is the wrist in a nondominant arm. Therefore, the radiocephalic access is the
preferred A-V fistula for any patient (A is correct). Once distal sites are exhausted, creation of a fistula in the
upper arm should be considered, and brachiocephalic or brachiobasilic fistulas are placed. The A-V graft has less
survival compared to the fistula, and is not the preferred access in most of the patients. The concept of FISTULA
FIRST is introduced because of superior outcomes with a fistula compared to a graft.

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5.

The above patient has radiocephalic fistula, and he comes to your office 4 weeks after fistula creation. Which one of thefollowing measurements suggests that the fistula is functioning properly and will be ready in 3 months forcannulation?

Vein diameter 2 mm and access flow rate 300 mL/min
Vein diameter 3 mm and access flow rate 400 mL/min
Vein diameter 4 mm and access flow rate 450 mL/min
Vein diameter 6 mm and access flow rate 600 mL/min
Vein diameter 2.8 mm and access flow rate 350 mL/min

Correct Answer

A. Vein diameter 6 mm and access flow rate 600 mL/min

Explanation

The answer is D
Generally 28–53%of A-V accesses never mature adequately to be usable for dialysis. When mature, the median
time for maturity is 98 days. The KDOQI guidelines defined the “rule of 6s” as the criteria for maturation of the
fistula, which include (1) vein diameter of 6 mm, (2) access flow rate of 600 mL/min, and (3) access depth of 6 mm
below the skin. According to the study of Robbin et al. the vein diameter >4 mm and access flow rate
>500 mL/min are highly predictive of fistula maturation and adequate for cannulation. Based on these criteria,
choice D is correct, suggesting that the fistula is maturing properly. Other choices are incorrect.

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6.

You have been dialyzing a patient with a graft with a blood flow of 400–500 mL/min for 6 months without anycomplications. One day you get a call from your nurse that the venous pressure is high and she needs to reduce bloodflow to 300 mL/min, and the nurse suspects thrombosis of the graft. Which one of the following methods of vascularaccess surveillance would have prevented the thrombus of the graft?

Measurement of monthly access flow
Measurement of monthly static venous dialysis pressures
Monthly duplex ultrasound
Monthly physical examination by qualified personnel
None of the above

Correct Answer

A. Monthly physical examination by qualified personnel

Explanation

The answer is D
Of all of the above choices, monthly physical examination and clinical assessment are the keys to access
maintenance. Although the most common screening tests are access flow and dialysis venous pressure
measurements, a review of vascular access surveillance suggests the physical examination and clinical assessment
are the first line assessment than hemodynamic studies. Thus, D is correct. Follow-up of other measures have not
consistently shown any improvements in outcomes of graft function. Also, there is only limited evidence that
surveillance reduces thrombosis in native fistulas.

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7.

Hemodiafiltration (HDF) combines both diffusion and convection. Which one of the following clinical benefits of HDF is FALSE?

HDF removes middle molecules more efficiently than high-efficiency and high-flux dialysis
Phosphate removal is much higher than high-efficiency and high-flux dialysis
Removal of inflammatory cytokines is better or higher with HDF than high-efficiency and high-flux dialysis
Preservation of residual renal function is much better with HDF than high-efficiency and high-flux dialysis
Improvement in albumin and other markers of nutrition is better with HDF than high-efficiency and high-flux dialysis

Correct Answer

A. Improvement in albumin and other markers of nutrition is better with HDF than high-efficiency and high-flux dialysis

Explanation

The answer is E
HDF is a modality that combines both diffusion and convection. This technique requires large ultrapure volumes
of replacement fluid. This fluid can be infused pre-, post-, or mixed dilution modes. Because of convection, many
uremic toxins that have a molecular weight up to 40,000 Da can be removed. As a result, many biochemical
abnormalities associated with ESRD or uremia can be improved. Removal of middle molecules such as
β2-microglobulin is 30–40 % higher with HDF compared to high-flux dialysis. Similarly removal of phosphate
mass with HDF is 15–20 % higher than other HD modalities. It has been shown that cytokine removal is much
higher with HDF, and preservation of residual renal function is prolonged with HDF. However, most studies did
not find any significant benefit of HDF in improving nutritional, as measured by either albumin or prealbumin
concentrations. Thus, E is false.
HDF has been shown to improve β2-microglobulin-associated amyloidosis and carpal tunnel syndrome. Also,
some studies have shown reduced incidence of intradialytic hypotensive episodes. However, most studies showed
no effect of HDF on the usage of erythropoietic stimulating agents and anemia.

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8.

A 60-yr-old man with ESRD because of multiplemyeloma complains of progressive backpain. Hb level last mo was 10.8 g/dl, at whichtime you had increased erythropoietin from10,000 IU two times weekly to 10,000 IU threetimes weekly administered subcutaneously.Now, you note Hb level of 8.2 g/dl and serumalbumin level of 2.2 g/dl. You consult hematology.They recommend therapy with dexamethasone,thalidomide, and cyclophosphamide.Free light chain concentration was 17,000 mg/L.Which ONE of the following therapies isMOST likely to result in effective reductionin free light chain until chemotherapy becomeseffective?

Dialysis with a high-flux dialyzer, molecular cutoff 20 kD
Plasma exchange with albumin replacement
Dialysis with “super” flux dialyzer, molecular cutoff 10 KD
Dialysis with high molecular weight cutoff dialyzer, molecular cutoff 45 kD
Switch to peritoneal dialysis (PD)

Correct Answer

A. Dialysis with high molecular weight cutoff dialyzer, molecular cutoff 45 kD

Explanation

Correct answer is D: Dialysis with high molecular weight cutoff dialyzer, molecular
cutoff 45 kD
The patient has high load of free light chains and is most likely to benefit from dialysis with
high cutoff dialyzer. These dialyzers have a molecular weight cutoff of 45 kd and can
effectively remove free light chains till chemotherapy becomes effective.

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9.

A 24-year-old woman with a long-standinghistory of lupus is diagnosed with heparininducedthrombocytopenia.Regarding alternatives to therapy, whichONE of the following therapies is the MOSTappropriate anticoagulation strategy?

Enoxaparin
Epoprostenol
Tinzaparin
Clopidogrel
Heparinization of dialyzer with reversal

Correct Answer

A. Epoprostenol

Explanation

Answer B: Epoprostenol
Epoprostenol can effectively anticoagulate during dialysis. Enoxaparin is low molecular weight heparin
and can provoke heparin-induced thrombocytopenia. Likewise heparinization is not recommended.
Tinzaparin and clopidogrel are likely less effective than epoprostenol.

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10.

Protein-bound uremic solutes are poorly removedby current dialysis therapies. Recently,one such toxin, p-cresol, was associated withincreased mortality in dialysis patients.Which ONE of the following strategies isMOST likely to result in effective removalof protein-bound uremic solutes?

Maintenance of residual renal function
Switching to PD
Hemodiafiltration
Gut lavage with nonreabsorbable solutes
High-flux dialysis

Correct Answer

A. Maintenance of residual renal function

Explanation

Correct answer is A: Maintenance of residual renal function
Residual renal clearance is 4 to 9 times more effective in clearing protein bound solutes
compared to peritoneal clearance. Peritoneal dialysis patients do have greater protein-bound
uremic toxin clearance compared to hemodialysis patients.

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Nephrotube Dialysis Module Mini Exam (1)

As medical director of a dialysis facility, you noticed that one of your colleague’s patients has consistently low eKt/V of1.1 despite a 4-h session 3 times a week on a high-flux dialyzer and a functioning A-V fistula. Which one of thefollowing factors can affect delivered Kt/V?

Quiz Preview

A radiocephalic A-V access was created in your 60-year-old African American diabetic woman 4 weeks ago and iscurrently not maturing. Which one of the following variables is associated with failure of fistula maturation(primary failure) is CORRECT?

Your patient has a central venous catheter for HD, and the infection rate is much higher than an A-V graft. Infection ofthe catheter results from which one of the following sources of contamination is CORRECT?

In your patient with CKD 4 (eGFR 22 mL/min), you plan to place a native arterio-venous (A-V) fistula. Which one ofthe following is the MOST preferred fistula for your patient?

The above patient has radiocephalic fistula, and he comes to your office 4 weeks after fistula creation. Which one of thefollowing measurements suggests that the fistula is functioning properly and will be ready in 3 months forcannulation?

Hemodiafiltration (HDF) combines both diffusion and convection. Which one of the following clinical benefits of HDF is FALSE?

A 24-year-old woman with a long-standinghistory of lupus is diagnosed with heparininducedthrombocytopenia.Regarding alternatives to therapy, whichONE of the following therapies is the MOSTappropriate anticoagulation strategy?

Protein-bound uremic solutes are poorly removedby current dialysis therapies. Recently,one such toxin, p-cresol, was associated withincreased mortality in dialysis patients.Which ONE of the following strategies isMOST likely to result in effective removalof protein-bound uremic solutes?