Dialysis Indications

A 58-year-old man with a 12-year history of type 2 diabetes mellitus presents to the nephrology clinic. He has been on antihypertensive therapy for 8 years. Current medications include metformin, lisinopril, and amlodipine. His blood pressure is 138/86 mmHg. Laboratory investigations show: serum creatinine 4.2 mg/dL, blood urea nitrogen 68 mg/dL, serum potassium 5.8 mEq/L, serum phosphate 6.1 mg/dL, serum calcium 7.2 mg/dL, and arterial blood gas shows pH 7.28 with HCO₃⁻ 16 mEq/L. His urine output is 800 mL/day. He denies any symptoms of uremia. What is the most appropriate next step in management?

A 42-year-old woman with lupus nephritis (WHO class IV) presents with a 3-month history of progressive edema, dyspnea on exertion, and oliguria. She has been on prednisolone 20 mg daily and mycophenolate mofetil for 6 months. Current blood pressure is 162/98 mmHg. Laboratory findings: serum creatinine 3.8 mg/dL (baseline 0.9), blood urea nitrogen 62 mg/dL, serum sodium 128 mEq/L, serum potassium 6.2 mEq/L, serum albumin 2.1 g/dL, 24-hour urine protein 8.2 g, and chest X-ray shows bilateral pulmonary edema. What is the most appropriate management at this time?

A 52-year-old man with type 2 diabetes mellitus and hypertension presents to the nephrology clinic with progressive renal dysfunction. His current investigations show: serum creatinine 8.2 mg/dL, blood urea nitrogen 92 mg/dL, potassium 6.8 mEq/L, bicarbonate 16 mEq/L, and phosphate 7.2 mg/dL. Urinalysis shows 3+ proteinuria. His blood pressure is 168/104 mmHg. He denies any symptoms of uremia. Which of the following is the most appropriate next step in management?

A 38-year-old woman with IgA nephropathy presents to the emergency department with severe dyspnea, orthopnea, and bilateral ankle edema. Examination reveals bibasilar crackles, elevated JVP, and a third heart sound. Laboratory investigations show: serum creatinine 6.8 mg/dL, potassium 7.2 mEq/L, bicarbonate 14 mEq/L, and BUN 110 mg/dL. Chest X-ray shows bilateral pulmonary edema. Urine output over the past 24 hours is 200 mL. What is the most appropriate immediate management?

A 68-year-old woman with Stage 4 CKD (eGFR 18 mL/min/1.73m²) secondary to hypertensive nephrosclerosis is seen in the nephrology clinic for routine follow-up. She reports mild fatigue and occasional dyspnea on exertion. Current labs: serum creatinine 4.1 mg/dL, BUN 68 mg/dL, potassium 5.2 mEq/L, bicarbonate 18 mEq/L, hemoglobin 8.9 g/dL, phosphate 5.8 mg/dL. Blood pressure is 152/92 mmHg on amlodipine and lisinopril. Urinalysis shows 2+ proteinuria. She is compliant with dietary sodium and protein restriction. What is the most appropriate management at this time?