ADEQUACY/SOLUTE CLEARANCE
A 49 year old man with CKD stage 5 secondary to type II diabetes mellitus and hypertension is transitioning to peritoneal dialysis. He has completed training, feels comfortable with exchanges, and he is asking to start treatments with an evening cycler.
He asks if PD can be scheduled around his full-time job.
He weighs 70 kg, looks well without any excess fluid on exam. His urine volume is 1500 ml per day with residual weekly Kt/V of 0.5.
His labs are unremarkable and peritoneal solute transplant status is unknown.
Q1 WHAT IS THE BEST INITIAL PD PRESCRIPTION?
A. Four cycles with 2 L, 1.5% dextrose, over 9 hours. No last fill.
B. Four cycles with 2 L, 1.5% dextrose, over 9 hours with 1.5 L, 1.5% dextrose, last fill.
C. Four cycles with 2 L, 1.5% dextrose, over 9 hours with 1.5 L, 1.5% dextrose, last fill plus midday exchange.
D. Four cycles with 2 L, 1.5% dextrose, over 9 hours with 1.5 L, icodextrin, last fill.
Click here for answer, explanation, and additional reading
He adapts to PD well and has no major issues. However, six months late he says to be feeling progressively more tired with morning nausea. There is no signs of infection or recent illnesses. He has noticed steady decrease in urine output and his renal weekly Kt/V is now 0.2. There has been no changes to his dialysate Kt/V. He has no signs of volume overload, as his laboratory values are unremarkable.
He still works full-time and lives a relatively active life.
Q2 WHAT IS THE BEST NEXT STEP?
A. Add a 1.5L, 1.5% dextrose, last fill
B. Increase cycle fill volumes to 2.4 L
C. Add a 5th evening cycle and increase total time to 11 hours.
D. Inquire about diuretic use
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Despite increasing cycler fill volumes to 2.4L, he still has some lingering symptoms. You are certain this can be treated with increasing dialysis. The patient's most recent PET showed D/P creatinine of 0.48 (low transport status).
Q3 WHICH OF THE FOLLOWING IS THE LEAST HELPFUL IN AUGMENTING CLEARANCE?
A. Add a 1.5L, 1.5% dextrose, last fill
B. Add a 5th evening cycle, and keep total cycler time to 9 hours.
C. Keep 4 cycles and increase total time to 11 hours.
D. Transition to CADP with 4 manual exchanges spaced out throughout the day
Click here for answer, explanation, and additional reading
The patient preferred to keep his time on PD essentially unchanged because of his rigorous work schedule. However, he asks if you can increase his cycles from 4 to 5 while keeping 9 hours.
Q4 ALL OF THE FOLLOWING CAN BE COMPLICATIONS OF THIS PRESCRIPTION EXCEPT:
A. Hyponatremia
B. Increased third
C. Insufficent ultrafilation
Click here for answer, explanation, and additional reading
He asks if PD can be scheduled around his full-time job.
He weighs 70 kg, looks well without any excess fluid on exam. His urine volume is 1500 ml per day with residual weekly Kt/V of 0.5.
His labs are unremarkable and peritoneal solute transplant status is unknown.
Q1 WHAT IS THE BEST INITIAL PD PRESCRIPTION?
A. Four cycles with 2 L, 1.5% dextrose, over 9 hours. No last fill.
B. Four cycles with 2 L, 1.5% dextrose, over 9 hours with 1.5 L, 1.5% dextrose, last fill.
C. Four cycles with 2 L, 1.5% dextrose, over 9 hours with 1.5 L, 1.5% dextrose, last fill plus midday exchange.
D. Four cycles with 2 L, 1.5% dextrose, over 9 hours with 1.5 L, icodextrin, last fill.
Click here for answer, explanation, and additional reading
He adapts to PD well and has no major issues. However, six months late he says to be feeling progressively more tired with morning nausea. There is no signs of infection or recent illnesses. He has noticed steady decrease in urine output and his renal weekly Kt/V is now 0.2. There has been no changes to his dialysate Kt/V. He has no signs of volume overload, as his laboratory values are unremarkable.
He still works full-time and lives a relatively active life.
Q2 WHAT IS THE BEST NEXT STEP?
A. Add a 1.5L, 1.5% dextrose, last fill
B. Increase cycle fill volumes to 2.4 L
C. Add a 5th evening cycle and increase total time to 11 hours.
D. Inquire about diuretic use
Click here for answer, explanation, and additional reading
Despite increasing cycler fill volumes to 2.4L, he still has some lingering symptoms. You are certain this can be treated with increasing dialysis. The patient's most recent PET showed D/P creatinine of 0.48 (low transport status).
Q3 WHICH OF THE FOLLOWING IS THE LEAST HELPFUL IN AUGMENTING CLEARANCE?
A. Add a 1.5L, 1.5% dextrose, last fill
B. Add a 5th evening cycle, and keep total cycler time to 9 hours.
C. Keep 4 cycles and increase total time to 11 hours.
D. Transition to CADP with 4 manual exchanges spaced out throughout the day
Click here for answer, explanation, and additional reading
The patient preferred to keep his time on PD essentially unchanged because of his rigorous work schedule. However, he asks if you can increase his cycles from 4 to 5 while keeping 9 hours.
Q4 ALL OF THE FOLLOWING CAN BE COMPLICATIONS OF THIS PRESCRIPTION EXCEPT:
A. Hyponatremia
B. Increased third
C. Insufficent ultrafilation
Click here for answer, explanation, and additional reading
VOLUME OVERLOAD
A 52 year old woman with ESKD secondary to type 2 diabetes mellitus has just started peritoneal dialysis one month ago. Her PD script is NIPD 9 hours x 4 cycles of 2 liters. She uses 1.5% dextrose concentration, and she does not use a last fill or day-time exchange. She has been having no issues or complications on PD since initiation. She produces about 1 liter of urine per day.
She feels good with no major complaints. Her blood pressure has been averaging 145-160/90-100 mmHg. She weighs 76 kg. Physical exam is notable for bilateral 1+ ankle edema and otherwise unremarkable.
Her medications include losartan 100 mg daily, amlodipine 10 mg daily, torsemide 20 mg daily, sevelamer 800 mg TID, and calcitriol 0.25 mcg daily.
Her total Kt/V is 2.22
Labs are Na 137, K 4.6, CO2 25, Ca 8.7, P 4.2, PTH 312, BUN 47, Cr 4.7, Alb 3.9, Hb 10.3, WBC 6.0, Plt 288
Q1 WHAT IS THE NEXT BEST STEP?
A. Switch to 2.5% dextrose
B. Up-titrate torsemide dose
C. Add a last fill of 2L, 2.5% dextrose
D. Increase NIPD time to 11 hours with 5 exchanges
Click for answer, explanation, and additional reading
You increase the dose of torsemide to 100 mg daily, and one month later her blood pressure is now 125-135/70-80 mmHg. Her weight has decreased to 73 kg, and her ankle edema is minimal. She says she actually feels much better since after increase the torsemide dose. She urinates about 2 liters per day.
Over the next six months she is doing well, however, you notice her blood pressure is back up 145-160/80-90. She has edema on her legs again, and is up to 77 kg. She says to be having no troubles with PD. She has had no changes in medications, and she takes all her doses regularly. All her labs are within normal and acceptable limits. She says she has noticed a drop in her urine production.
Q2 WHICH OF THE FOLLOWING MAY BE RESPONSIBLE FOR THIS FINDING?
A. Increased transport kinetics of peritoneum
B. Increased salt intake
C. Loss of residual kidney function
D. All of the above
Click for answer, explanation, and additional reading
After explaining why she may have gotten more volume overloaded, she asks what the next steps in treating her condition. She still has no problems with PD, specifically no abdominal pain or bloating.
She works a 9 pm - 5 pm job, and she says her PD schedule is great the way it is.
Q3 WHAT IS THE NEXT BEST STEP?
A. Increase each NIPD cycle volume from 2L to 2.3L
B. Add a last fill of 7.5% icodextrin of 1.5L to be kept in for the day
C. Change NIPD cycles from 1.5% to 2.5% solution
D. Add an additional NIPD 2L cycle such that it is 5 cycles over 11 hours
Click for answer, explanation, and additional reading
Q4 TRUE OR FALSE?
Hyperglycemia can contribute to volume overload.
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A 65 year old man with ESKD on PD is admitted to the hospital with shortness of breath and hypoxia which is associated with volume overload. His other medical comorbidities including heart failure with a reduced ejection fraction of 30% and peripheral vascular disease.
He does PD in the evening with 9 hours, four 2.3L cycles of 2.5% dextrose, and a last fill of 2L 7.5% icodextrin which is left in for at least 8 hours during the day. He does not produce urine.
Labs are Na 127, K 4.7, Cl 105, CO2 20, BUN 50, Cr 5.5
Q5 WHAT IS THE MOST EFFECTIVE WAY OF TREATING VOLUME OVERLOAD THROUGH PD IN THIS CASE?
A. 9 hours overnight with five 2.3L cycles of 4.25% dextrose plus last fill of 7.5% icodextrin
B. 11 hours overnight with six 2.3L cycles of 2.5% dextrose plus a last fill AND subsequent manual exchange of 2L 2.5% dextrose
C. 9 hours overnight with five 2.3L cycles of 7.5% icodextrin
Click for answer, explanation, and additional reading
She feels good with no major complaints. Her blood pressure has been averaging 145-160/90-100 mmHg. She weighs 76 kg. Physical exam is notable for bilateral 1+ ankle edema and otherwise unremarkable.
Her medications include losartan 100 mg daily, amlodipine 10 mg daily, torsemide 20 mg daily, sevelamer 800 mg TID, and calcitriol 0.25 mcg daily.
Her total Kt/V is 2.22
Labs are Na 137, K 4.6, CO2 25, Ca 8.7, P 4.2, PTH 312, BUN 47, Cr 4.7, Alb 3.9, Hb 10.3, WBC 6.0, Plt 288
Q1 WHAT IS THE NEXT BEST STEP?
A. Switch to 2.5% dextrose
B. Up-titrate torsemide dose
C. Add a last fill of 2L, 2.5% dextrose
D. Increase NIPD time to 11 hours with 5 exchanges
Click for answer, explanation, and additional reading
You increase the dose of torsemide to 100 mg daily, and one month later her blood pressure is now 125-135/70-80 mmHg. Her weight has decreased to 73 kg, and her ankle edema is minimal. She says she actually feels much better since after increase the torsemide dose. She urinates about 2 liters per day.
Over the next six months she is doing well, however, you notice her blood pressure is back up 145-160/80-90. She has edema on her legs again, and is up to 77 kg. She says to be having no troubles with PD. She has had no changes in medications, and she takes all her doses regularly. All her labs are within normal and acceptable limits. She says she has noticed a drop in her urine production.
Q2 WHICH OF THE FOLLOWING MAY BE RESPONSIBLE FOR THIS FINDING?
A. Increased transport kinetics of peritoneum
B. Increased salt intake
C. Loss of residual kidney function
D. All of the above
Click for answer, explanation, and additional reading
After explaining why she may have gotten more volume overloaded, she asks what the next steps in treating her condition. She still has no problems with PD, specifically no abdominal pain or bloating.
She works a 9 pm - 5 pm job, and she says her PD schedule is great the way it is.
Q3 WHAT IS THE NEXT BEST STEP?
A. Increase each NIPD cycle volume from 2L to 2.3L
B. Add a last fill of 7.5% icodextrin of 1.5L to be kept in for the day
C. Change NIPD cycles from 1.5% to 2.5% solution
D. Add an additional NIPD 2L cycle such that it is 5 cycles over 11 hours
Click for answer, explanation, and additional reading
Q4 TRUE OR FALSE?
Hyperglycemia can contribute to volume overload.
Click for answer, explanation, and additional reading
A 65 year old man with ESKD on PD is admitted to the hospital with shortness of breath and hypoxia which is associated with volume overload. His other medical comorbidities including heart failure with a reduced ejection fraction of 30% and peripheral vascular disease.
He does PD in the evening with 9 hours, four 2.3L cycles of 2.5% dextrose, and a last fill of 2L 7.5% icodextrin which is left in for at least 8 hours during the day. He does not produce urine.
Labs are Na 127, K 4.7, Cl 105, CO2 20, BUN 50, Cr 5.5
Q5 WHAT IS THE MOST EFFECTIVE WAY OF TREATING VOLUME OVERLOAD THROUGH PD IN THIS CASE?
A. 9 hours overnight with five 2.3L cycles of 4.25% dextrose plus last fill of 7.5% icodextrin
B. 11 hours overnight with six 2.3L cycles of 2.5% dextrose plus a last fill AND subsequent manual exchange of 2L 2.5% dextrose
C. 9 hours overnight with five 2.3L cycles of 7.5% icodextrin
Click for answer, explanation, and additional reading
PERITONITIS
A 70 year old woman with ESRD secondary to IgA has been on PD for three years. She calls the PD clinic because she has noticed increased abdominal discomfort and tenderness. Her effluent drain solution has been cloudy as well. She reports no fever, chills, diaphoresis, fatigue, dysuria, nausea, vomiting, or diarrhea. She has some constipation. She has no swelling, tenderness, or erythema around her PD catheter exit site. She has never had any prior infections related to PD, and she has had no recent abdominal surgeries. She has not recently been on antibiotics.
Her labs are unremarkable.
Her PD script is CCPD 9 hr on cycler with four cycles of 2.3L, 2.5% dextrose, followed by a last fill of 2L of icodextrin.
Q1 WHAT IS THE NEXT BEST STEP?
A. Order oral ciprofloxacin and metronidazole
B. CT of the abdomen and pelvis
C. Send to the emergency department for further evaluation
D. Obtain cell count and culture of PD effluent
Click here for answer, explanation, and additional reading
The cell count is 8000 u/l with 80% PMN. Gram stain shows gram negative rods and culture is still pending.
Q2 ALL OF THE FOLLOWING ARE APPROPRIATE FIRST-LINE THERAPIES FOR INTRAPERITONEAL ANTIBIOTICS, EXCEPT:
A. Vancomycin and ceftazidime
B. Cefazolin and metronidazole
C. Cefazolin and ceftazidime
D. Cefepime
Click here for answer, explanation, and additional reading
You choose the administer IP vancomycin and ceftazidime.
Q3 WHAT IS THE BIGGEST RISK OF DOSING ANTIBIOTICS CONTINUOUSLY VS INTERMITTENT
A. Underdosing with continuous antibiotics
B. Underdosing with intermittent antibiotics
C. Greater antibiotic compatibility with continuous dosing
D. Greater antibiotic compatibility with intermittent dosing
Click here for answer, explanation, and additional reading
The next day, peritoneal cultures show Pseudomonas aeruginosa.
Q4 WHAT ADJUSTMENTS SHOULD BE MADE FOR THE ANTIBIOTICS?
A. Continue ceftazidime and discontinue vancomycin
B. Discontinue both ceftazidime and vancomycin, and start IP cefepime
C. Discontinue both ceftazidime and vancomycin, and start IV cefepime
D. Continue ceftazidime, discontinue vancomycin, and start oral ciprofloxacin
Click here for answer, explanation, and additional reading
Q5 WHICH OF THE FOLLOWING IS NOT A POTENTIAL ADJUNCTIVE THERAPY?
A. Addition of heparin 500 u/l
B. Addition of icodextrin for volume overload
C. Rapid exchanges as peritoneal lavage
D. Addition of nystatin swish and swallow
Click here for answer, explanation, and additional reading
You make the changes to the antibiotics and by day 5 the patient still has ongoing abdominal pain. Repeat peritoneal cell count is 5000 u/l with 70% PMN. Effluent is slightly cloudy.
Q6 WHAT IS THE NEXT BEST STEP?
A. Continue therapy and resample PD fluid in 3 days
B. Switch oral ciprofloxacin to IP gentamicin
C. Switch IP ceftazidime to IV cefepime
D. Remove peritoneal dialysis catheter
Click here for answer, explanation, and additional reading
Q7 WHAT IS AN APPROPRIATE PLAN IF THE PD CATHETER IS REMOVED?
A. Observe a "line holiday" for 48 hours while on systemic antibiotics, and monitor for improvement prior to PD catheter re-insertion
B. Insert a new PD catheter immediately and resume the prior antibiotic regimen until symptoms and PD fluid improves
C. Convert to hemodialysis and switch systemic antibiotics least two weeks
Click here for answer, explanation, and additional reading
The patient sees you in clinic four weeks later. She is off antibiotics and she feels much better. She is eager to restart PD with a new catheter.
Q8 WHICH OF THE FOLLOWING IS NOT AN APPROPRIATE PROPHYLAXIS MEASURE AGAINST PERITONITIS
A. Recommend low dose oral antibiotic suppression
B. PD re-training
C. Avoid hypokalemia
D. Avoid H2-blockers
E. Avoid pets in the room where PD takes place
Click here for answer, explanation, and additional reading
Her labs are unremarkable.
Her PD script is CCPD 9 hr on cycler with four cycles of 2.3L, 2.5% dextrose, followed by a last fill of 2L of icodextrin.
Q1 WHAT IS THE NEXT BEST STEP?
A. Order oral ciprofloxacin and metronidazole
B. CT of the abdomen and pelvis
C. Send to the emergency department for further evaluation
D. Obtain cell count and culture of PD effluent
Click here for answer, explanation, and additional reading
The cell count is 8000 u/l with 80% PMN. Gram stain shows gram negative rods and culture is still pending.
Q2 ALL OF THE FOLLOWING ARE APPROPRIATE FIRST-LINE THERAPIES FOR INTRAPERITONEAL ANTIBIOTICS, EXCEPT:
A. Vancomycin and ceftazidime
B. Cefazolin and metronidazole
C. Cefazolin and ceftazidime
D. Cefepime
Click here for answer, explanation, and additional reading
You choose the administer IP vancomycin and ceftazidime.
Q3 WHAT IS THE BIGGEST RISK OF DOSING ANTIBIOTICS CONTINUOUSLY VS INTERMITTENT
A. Underdosing with continuous antibiotics
B. Underdosing with intermittent antibiotics
C. Greater antibiotic compatibility with continuous dosing
D. Greater antibiotic compatibility with intermittent dosing
Click here for answer, explanation, and additional reading
The next day, peritoneal cultures show Pseudomonas aeruginosa.
Q4 WHAT ADJUSTMENTS SHOULD BE MADE FOR THE ANTIBIOTICS?
A. Continue ceftazidime and discontinue vancomycin
B. Discontinue both ceftazidime and vancomycin, and start IP cefepime
C. Discontinue both ceftazidime and vancomycin, and start IV cefepime
D. Continue ceftazidime, discontinue vancomycin, and start oral ciprofloxacin
Click here for answer, explanation, and additional reading
Q5 WHICH OF THE FOLLOWING IS NOT A POTENTIAL ADJUNCTIVE THERAPY?
A. Addition of heparin 500 u/l
B. Addition of icodextrin for volume overload
C. Rapid exchanges as peritoneal lavage
D. Addition of nystatin swish and swallow
Click here for answer, explanation, and additional reading
You make the changes to the antibiotics and by day 5 the patient still has ongoing abdominal pain. Repeat peritoneal cell count is 5000 u/l with 70% PMN. Effluent is slightly cloudy.
Q6 WHAT IS THE NEXT BEST STEP?
A. Continue therapy and resample PD fluid in 3 days
B. Switch oral ciprofloxacin to IP gentamicin
C. Switch IP ceftazidime to IV cefepime
D. Remove peritoneal dialysis catheter
Click here for answer, explanation, and additional reading
Q7 WHAT IS AN APPROPRIATE PLAN IF THE PD CATHETER IS REMOVED?
A. Observe a "line holiday" for 48 hours while on systemic antibiotics, and monitor for improvement prior to PD catheter re-insertion
B. Insert a new PD catheter immediately and resume the prior antibiotic regimen until symptoms and PD fluid improves
C. Convert to hemodialysis and switch systemic antibiotics least two weeks
Click here for answer, explanation, and additional reading
The patient sees you in clinic four weeks later. She is off antibiotics and she feels much better. She is eager to restart PD with a new catheter.
Q8 WHICH OF THE FOLLOWING IS NOT AN APPROPRIATE PROPHYLAXIS MEASURE AGAINST PERITONITIS
A. Recommend low dose oral antibiotic suppression
B. PD re-training
C. Avoid hypokalemia
D. Avoid H2-blockers
E. Avoid pets in the room where PD takes place
Click here for answer, explanation, and additional reading
Catheter related INFECTIONS
A 70 year old man with ESKD on PD has been experiencing redness around his exit site for the past one day. He says it does not itch. He applies topical gentamycin ointment daily and cleans the exit site after a shower multiple times per week. He has no abdominal pain and no cloudy effluent. He has no allergies. On examination you see exit site has very mild erythema and no significant tenderness to palpation or drainage.
Q1 WHAT IS THE NEXT BEST STEP?
A. Prescribe two week course of oral cephalexin
B. Prescribe two week course of intraperitoneal vancomycin
C. Monitor for one to two more days prior to diagnosing exit site infection
D. Intensify local exit site care
E. A or C
Click here for answer, explanation, and additional reading
You prescribe a course of oral cephalexin for two weeks. He starts the antibiotics the same evening, however, the next day he notices worsening erythema with thick dark yellow discharge. You ask him to come back to clinic to obtain a culture of the drainage. The culture later results positive for Pseudomonas aeruginosa (sensitive of ciprofloxacin, levofloxacin, amikacin, and gentamicin).
Q2 HOW WILL YOU ADJUST THERAPY?
A. Continue current course of therapy
B. Start oral ciprofloxacin for a two week course
C. Start oral ciprofloxacin for a three week course
D. Remove catheter
Click here for answer, explanation, and additional reading
During the same exam (above) you notice the exit site drainage can be expressed when compressing along the tract of the catheter.
Q3 WHAT IS THE NEXT STEP IN MANAGEMENT?
A. Further imagining (ultrasound or CT) to confirm diagnosis of tunnel infection
B. Catheter removal
C. Continue antibiotics as prescribed
D. Both A and C
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CT of his abdomen confirms tunnel infection without any abscess or fluid collections. Despite three weeks on oral ciprofloxacin and IP ceftazidime, there is only mild improvement of symptoms.
Q4 WHICH OF THE FOLLOWING IS AN INDICATION FOR CATHETER REMOVAL
A. Failure to respond to therapy after three weeks
B. ESI or tunnel infections that lead to peritonitis
C. ESI or tunnel infections with concomitant peritonitis
D. All of the above
Click here for answer, explanation, and additional reading
Q1 WHAT IS THE NEXT BEST STEP?
A. Prescribe two week course of oral cephalexin
B. Prescribe two week course of intraperitoneal vancomycin
C. Monitor for one to two more days prior to diagnosing exit site infection
D. Intensify local exit site care
E. A or C
Click here for answer, explanation, and additional reading
You prescribe a course of oral cephalexin for two weeks. He starts the antibiotics the same evening, however, the next day he notices worsening erythema with thick dark yellow discharge. You ask him to come back to clinic to obtain a culture of the drainage. The culture later results positive for Pseudomonas aeruginosa (sensitive of ciprofloxacin, levofloxacin, amikacin, and gentamicin).
Q2 HOW WILL YOU ADJUST THERAPY?
A. Continue current course of therapy
B. Start oral ciprofloxacin for a two week course
C. Start oral ciprofloxacin for a three week course
D. Remove catheter
Click here for answer, explanation, and additional reading
During the same exam (above) you notice the exit site drainage can be expressed when compressing along the tract of the catheter.
Q3 WHAT IS THE NEXT STEP IN MANAGEMENT?
A. Further imagining (ultrasound or CT) to confirm diagnosis of tunnel infection
B. Catheter removal
C. Continue antibiotics as prescribed
D. Both A and C
Click here for answer, explanation, and additional reading
CT of his abdomen confirms tunnel infection without any abscess or fluid collections. Despite three weeks on oral ciprofloxacin and IP ceftazidime, there is only mild improvement of symptoms.
Q4 WHICH OF THE FOLLOWING IS AN INDICATION FOR CATHETER REMOVAL
A. Failure to respond to therapy after three weeks
B. ESI or tunnel infections that lead to peritonitis
C. ESI or tunnel infections with concomitant peritonitis
D. All of the above
Click here for answer, explanation, and additional reading
Non-infectious CATHETER COMPLICATIONS
A 49 year old woman who has been on PD for the past four months has been experiencing decreasing drain volumes for the past three days. This has resulted in mild volume overload including hypertension (BP now 150s/90s when they were previously 130s/70s) and peripheral edema. She says everything else with PD has been okay, but he has been constipated for the past one week. You ask she come to PD clinic to be evaluated. A manual exchange is performed showing prolonged drain time with sluggish flow. Inflow appears to have no problem.
Q1 WHICH OF THE FOLLOWING IS NOT A COMMON CAUSE FOR THIS PROBLEM?
A. Constipation
B. Diarrhea
C. Abdominal inflammation
D. Omental wrapping
Click here for answer, explanation, and additional reading
Q2 ALL OF THE FOLLOWING ARE WAYS TO TROUBLESHOOT AND MANAGE THESE PROBLEMS, EXCEPT?
A. Treat constipation
B. Obtain an abdominal xray
C. Treat hypokalemia
D. Switch from APD to CAPD
Click here for answer, explanation, and additional reading
After treating the patient's constipation, she says there is improvement in his drain volumes. However, one week later she calls you to explain she woke up because he felt his bedsheets were soaked. She sees a hole along his PD catheter distal to the transfer set adapter.
Q3 WHAT IS THE NEXT BEST STEP?
A. Replace transfer set
B. Replace PD catheter
C. Repair hole
D. Obtain PD cell count and culture and prescribe an empiric dose of antibiotics
E. A and D
Click here for answer, explanation, and additional reading
Q1 WHICH OF THE FOLLOWING IS NOT A COMMON CAUSE FOR THIS PROBLEM?
A. Constipation
B. Diarrhea
C. Abdominal inflammation
D. Omental wrapping
Click here for answer, explanation, and additional reading
Q2 ALL OF THE FOLLOWING ARE WAYS TO TROUBLESHOOT AND MANAGE THESE PROBLEMS, EXCEPT?
A. Treat constipation
B. Obtain an abdominal xray
C. Treat hypokalemia
D. Switch from APD to CAPD
Click here for answer, explanation, and additional reading
After treating the patient's constipation, she says there is improvement in his drain volumes. However, one week later she calls you to explain she woke up because he felt his bedsheets were soaked. She sees a hole along his PD catheter distal to the transfer set adapter.
Q3 WHAT IS THE NEXT BEST STEP?
A. Replace transfer set
B. Replace PD catheter
C. Repair hole
D. Obtain PD cell count and culture and prescribe an empiric dose of antibiotics
E. A and D
Click here for answer, explanation, and additional reading
Non-infectious and non-catheter Complications
A 38 year old man has been on PD for one year. He uses the cycler for 9 hours during the evening x 4 exchanges of 2.5L plus a last fill of icodextrin. He has had no problems or infections associated with PD so far. He urinates about 0.5 to 1L per day with an eGFR of 8 ml/min. On exam his blood pressure is 137/83, breathing comfortably on ambient air, no respiratory distress, clear lung sounds. His heart is regular rate and rhythm. His abdomen is large, soft, and mildly distended. He has a 3 cm circumferential umbilical hernia that is reducible. He has bilateral lower extremities have trace edema. His labs are unremarkable. His hernia has been present for the past three months, and he says it is growing, and it is often uncomfortable.
Q1 WHAT IS THE BEST COURSE OF ACTION?
A. Seek surgical evaluation for hernia removal
B. Transition to HD to reduce intra-abdominal pressure, and re-evaluate hernia
C. Decrease dwell volumes to reduce intra-abdominal pressure, and re-evaluate hernia
D. Hernia surgery is contraindicated when patients are on PD
Click here for answer, explanation, and additional reading
Q2 What is the best way to manage his peritoneal dialysis after hernia repair
A. Transition to HD
B. No change to PD prescription
C. Hold PD for 1-2 weeks and start with low volume dwells
D. Start with low volume dwells immediately after surgery
Click here for answer, explanation, and additional reading
A 68 year old woman with ESRD 2/2 diabetic kidney disease is experiencing worsening shortness of breath and orthopnea. She has been on PD for the past 2 months. Her PD prescription is 9 hours x 4 cycles consisting of a 2 L mix of 1.5% and 2.5% dextrose. She has very little residual urine output. You have subsequently augmented her prescription by adding a last fill of 2L 2.5% dextrose and making all night-time dialysate fluid 2.5% dextrose. Despite this intervention, her symptoms have not improved. She is 1.5 kg above her target weight, BP is 134/76, decreased lung sounds on the right lung field, left lung field is clear, heart is regular rate and rhythm, abdomen is soft and contender, and lower extremities have very little edema. Chest x-ray shows a large right sided pleural effusion.
Q3 WHICH IS THE FOLLOWING IS NOT APPROPRIATE IN THE DIAGNOSIS AND MANAGEMENT?
A. Thoracentesis
B. Surgical referral for pleurodesis
C. Low volume, supine PD
D. Peritoneal scintigraphy
Click here for answer, explanation, and additional reading
A 31 year old woman with ESRD 2/2 lupus nephritis has been on PD for the past 6 months. She has had no complications associated with PD and reports things are going "OK." However, within the past 3 days, she says color of her effluent is red. She has no abdominal pain or back pain. She does not have nausea, vomiting, or diarrhea. She has normal menses. She has had no recent trauma. She is resting comfortably on ambient air. Blood pressure is 123/47, and the remainder of her physical exam is unremarkable. Her PD fluid cell count shows 30 nucleated cells and 3000 RBCs. Fluid culture is pending.
Other than ESRD and lupus nephritis, she does not have a significant medical history.
Q4 ALL OF THE FOLLOWING ARE STRATEGIES FOR MANAGEMENT, EXCEPT?
A. Intraperitoneal heparin
B. Peritoneal lavage
C. Colder (room temperature) dialysate
D. Empiric treatment with IP antibiotics
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A 68 year old man ESRD 2/2 DKD has been on PD for the past 10 years. Over this time he has experienced two episodes of peritonitis, but otherwise he has had no major complications associated with PD. He has no urine output. His PD prescription is NIPD 9 hours x 5 cycles of 2.5L 2.5% dextrose plus a last fill of 2L icodextrin. Over the past four months you notice his weight has been decreasing. This has been associated with decreased appetite and nausea. He has been having mild generalized abdominal discomfort not associated with PD cycles. He does not say to have increased stress or any other life-changing events recently.
BP is 142/86, he is breathing comfortably on ambient air. His abdomen is soft and not tender. The remainder of exam is unremarkable.
His weekly Kt/V 1.8,
Na 134
K 3.9
CO2 26
BUN 37
Cr 8
Ca 8.9
P 4.3
PTH 340
Hb 9.8
WBC 7
Q5. WHICH OF THE FOLLOWING DIAGNOSES SHOULD YOU HAVE A HIGH INDEX OF SUSPICION FOR?
A. Uremia
B. Encapsulating peritoneal sclerosis
C. Depression
D. Gastroparesis
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Q1 WHAT IS THE BEST COURSE OF ACTION?
A. Seek surgical evaluation for hernia removal
B. Transition to HD to reduce intra-abdominal pressure, and re-evaluate hernia
C. Decrease dwell volumes to reduce intra-abdominal pressure, and re-evaluate hernia
D. Hernia surgery is contraindicated when patients are on PD
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Q2 What is the best way to manage his peritoneal dialysis after hernia repair
A. Transition to HD
B. No change to PD prescription
C. Hold PD for 1-2 weeks and start with low volume dwells
D. Start with low volume dwells immediately after surgery
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A 68 year old woman with ESRD 2/2 diabetic kidney disease is experiencing worsening shortness of breath and orthopnea. She has been on PD for the past 2 months. Her PD prescription is 9 hours x 4 cycles consisting of a 2 L mix of 1.5% and 2.5% dextrose. She has very little residual urine output. You have subsequently augmented her prescription by adding a last fill of 2L 2.5% dextrose and making all night-time dialysate fluid 2.5% dextrose. Despite this intervention, her symptoms have not improved. She is 1.5 kg above her target weight, BP is 134/76, decreased lung sounds on the right lung field, left lung field is clear, heart is regular rate and rhythm, abdomen is soft and contender, and lower extremities have very little edema. Chest x-ray shows a large right sided pleural effusion.
Q3 WHICH IS THE FOLLOWING IS NOT APPROPRIATE IN THE DIAGNOSIS AND MANAGEMENT?
A. Thoracentesis
B. Surgical referral for pleurodesis
C. Low volume, supine PD
D. Peritoneal scintigraphy
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A 31 year old woman with ESRD 2/2 lupus nephritis has been on PD for the past 6 months. She has had no complications associated with PD and reports things are going "OK." However, within the past 3 days, she says color of her effluent is red. She has no abdominal pain or back pain. She does not have nausea, vomiting, or diarrhea. She has normal menses. She has had no recent trauma. She is resting comfortably on ambient air. Blood pressure is 123/47, and the remainder of her physical exam is unremarkable. Her PD fluid cell count shows 30 nucleated cells and 3000 RBCs. Fluid culture is pending.
Other than ESRD and lupus nephritis, she does not have a significant medical history.
Q4 ALL OF THE FOLLOWING ARE STRATEGIES FOR MANAGEMENT, EXCEPT?
A. Intraperitoneal heparin
B. Peritoneal lavage
C. Colder (room temperature) dialysate
D. Empiric treatment with IP antibiotics
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A 68 year old man ESRD 2/2 DKD has been on PD for the past 10 years. Over this time he has experienced two episodes of peritonitis, but otherwise he has had no major complications associated with PD. He has no urine output. His PD prescription is NIPD 9 hours x 5 cycles of 2.5L 2.5% dextrose plus a last fill of 2L icodextrin. Over the past four months you notice his weight has been decreasing. This has been associated with decreased appetite and nausea. He has been having mild generalized abdominal discomfort not associated with PD cycles. He does not say to have increased stress or any other life-changing events recently.
BP is 142/86, he is breathing comfortably on ambient air. His abdomen is soft and not tender. The remainder of exam is unremarkable.
His weekly Kt/V 1.8,
Na 134
K 3.9
CO2 26
BUN 37
Cr 8
Ca 8.9
P 4.3
PTH 340
Hb 9.8
WBC 7
Q5. WHICH OF THE FOLLOWING DIAGNOSES SHOULD YOU HAVE A HIGH INDEX OF SUSPICION FOR?
A. Uremia
B. Encapsulating peritoneal sclerosis
C. Depression
D. Gastroparesis
Click here for answer, explanation, and additional reading