What is the approach to history taking and clinical examination for an adult patient with Chronic Kidney Disease (CKD) stage 5d on dialysis, with potential comorbidities such as hypertension, diabetes, and cardiovascular disease?

Comprehensive Approach to History Taking and Clinical Examination in CKD Stage 5D Patients

For CKD stage 5D patients on dialysis, your history and examination must systematically address disease etiology, dialysis adequacy, life-threatening complications (particularly cardiovascular disease and fluid overload), nutritional status, and medication safety, as these directly impact the leading causes of mortality in this population. 1

History Taking Framework

Disease Etiology and Chronicity Assessment

• Diabetes history: Document duration of diabetes (type 1 typically develops CKD after 10 years; type 2 may have CKD at diagnosis), glycemic control trajectory, and presence of retinopathy, neuropathy, or foot ulcers as these indicate microvascular disease severity 2, 3

• Hypertension assessment: Establish duration, historical blood pressure control patterns, and end-organ damage including prior stroke, myocardial infarction, heart failure, or left ventricular hypertrophy 2, 1

• Hereditary kidney disease: Specifically ask about family history of kidney failure, polycystic kidney disease, or hereditary nephropathies (Alport syndrome, Fabry disease) 2

• Glomerulonephritis history: Inquire about hematuria episodes, prior kidney biopsies, autoimmune diseases (lupus, vasculitis), and hepatitis B/C serology 2

Dialysis Preparation and Access Status

• Prior nephrology care: Document when nephrology care began, as patients known to nephrology before reaching stage 5 have median survival of 32 months versus 15 months for those without prior care 2

• Vascular access evaluation: For hemodialysis patients, document presence and maturity of arteriovenous fistula, arteriovenous graft, or tunneled catheter; assess for access complications including thrombosis, infection, or steal syndrome 2

• Transplant status: Determine if patient has been evaluated for or listed for kidney transplantation, blood type, panel reactive antibody status, and potential living donors 2

• Dialysis adequacy: Ask about interdialytic weight gain (target <2-3 kg between sessions), residual urine output, and symptoms of inadequate dialysis including nausea, pruritus, or altered mental status 1

Life-Threatening Complications Screening

• Cardiovascular disease assessment: Document history of myocardial infarction, heart failure (including NYHA class), arrhythmias, coronary revascularization, and peripheral vascular disease, as cardiovascular disease is the leading cause of death in CKD 5D 2, 1

• Fluid overload symptoms: Specifically ask about orthopnea, paroxysmal nocturnal dyspnea, peripheral edema progression, and recent weight gain patterns 2

• Hyperkalemia symptoms: Inquire about muscle weakness, palpitations, cardiac symptoms, and dietary potassium intake including high-risk foods (bananas, oranges, tomatoes, potatoes) 2

• Bleeding risk: Document history of gastrointestinal bleeding, subdural hematoma, easy bruising, or prolonged bleeding from access sites 1

Medication Review and Nephrotoxin Exposure

• Nephrotoxic agents: Identify current or recent use of NSAIDs, aminoglycosides, calcineurin inhibitors, lithium, and contrast agents 2, 3

• Medications requiring dose adjustment: Review antibiotics (particularly fluoroquinolones, aminoglycosides), anticoagulants (warfarin, direct oral anticoagulants), diabetes medications (insulin, sulfonylureas requiring dose reduction), and opioids 2, 4

• ACE inhibitors/ARBs: Document current use and any recent discontinuation; these should be continued unless creatinine increased >30% or hyperkalemia developed 2

• Phosphate binders: Calculate total daily elemental calcium intake from calcium-based binders plus dietary sources (should not exceed 2,000 mg/day) 3

• Cinacalcet use: Document dose, duration, and timing, as this increases hypocalcemia risk 7.38-fold compared to placebo 3

Nutritional Assessment Components

• Protein-energy wasting screening: Assess appetite changes, unintentional weight loss, muscle wasting, and dietary protein intake 1

• Sodium and fluid intake: Quantify daily salt consumption and fluid restriction adherence (typically 1-1.5 liters daily for anuric patients) 2

• Dietary calcium intake: CKD patients require approximately 30 mg/kg/day to achieve neutral calcium balance due to impaired intestinal absorption 3

• Phosphorus and potassium sources: Identify high-phosphorus foods (dairy, processed foods with additives) and high-potassium foods requiring restriction 2

Functional Status and Quality of Life

• Exercise tolerance: Document ability to perform activities of daily living, distance walked without dyspnea, and New York Heart Association functional class 5

• Social support assessment: Evaluate caregiver availability, transportation access to dialysis, housing stability, and financial resources for medications 2

• Employment and disability status: Document work capacity and disability applications, as these affect quality of life and treatment adherence 1

Clinical Examination Framework

Cardiovascular Examination

• Blood pressure measurement: Obtain pre-dialysis and post-dialysis blood pressures; target remains controversial but systolic <140 mmHg is reasonable, though observational data show U-shaped mortality curve 1, 6

• Volume status assessment: Examine jugular venous pressure, presence of S3 gallop, pulmonary crackles, peripheral edema (grade 1-4+), and ascites 2, 6

• Cardiac auscultation: Listen for murmurs (particularly aortic stenosis from calcific disease), pericardial friction rub (uremic pericarditis), and irregular rhythms 1

• Peripheral vascular examination: Palpate all pulses, assess for bruits, measure ankle-brachial index if peripheral vascular disease suspected 1

Vascular Access Examination

• Fistula/graft assessment: Palpate for thrill, auscultate for bruit, assess for aneurysm formation, and examine for signs of infection or skin breakdown 2

• Catheter examination: Inspect exit site for erythema, purulent drainage, or tenderness; document catheter type and insertion date 2

• Steal syndrome evaluation: Assess distal pulses and capillary refill in access extremity; test for hand weakness or pain with fist clenching 2

Nutritional and Metabolic Examination

• Body weight and BMI: Measure at consistent time relative to dialysis (post-dialysis "dry weight"); monitor monthly in hemodialysis and peritoneal dialysis patients 1

• Body composition assessment: Use bioelectrical impedance (preferably multi-frequency) performed minimum 30 minutes after hemodialysis to allow fluid redistribution; alternatively use DXA as gold standard despite volume status influence 1

• Anthropometric measurements: Measure mid-arm circumference, triceps skinfold thickness, and assess for temporal wasting and muscle bulk loss 1

• Nutrition-focused physical findings: Examine for signs of protein-energy wasting including muscle wasting, subcutaneous fat loss, and edema 1

Bone and Mineral Disorder Assessment

• Skeletal examination: Palpate for bone tenderness (particularly ribs, hips, spine), assess for skeletal deformities, and document height loss suggesting vertebral fractures 7, 8

• Soft tissue calcification: Examine for calciphylaxis lesions (painful violaceous skin lesions with necrosis), periarticular calcifications, and vascular calcifications 3

• Parathyroid examination: Palpate neck for parathyroid adenomas (rare but possible in tertiary hyperparathyroidism) 3

Neurological Examination

• Uremic neuropathy: Test distal sensation with monofilament, assess for restless leg syndrome, and evaluate for asterixis (metabolic encephalopathy) 1

• Cognitive assessment: Screen for uremic encephalopathy with attention testing and orientation; consider formal cognitive testing if concerns 1

• Autonomic dysfunction: Assess for orthostatic hypotension (common in dialysis patients) by measuring blood pressure supine and standing 6

Dermatological Examination

• Uremic pruritus: Document severity and distribution of scratching lesions 1

• Calciphylaxis screening: Examine for painful skin lesions with livedo reticularis pattern, particularly on abdomen, thighs, and buttocks 3

• Access site skin integrity: Assess for breakdown, infection, or ischemic changes 2

Critical Monitoring Parameters

Laboratory Assessment Frequency

• Monthly monitoring: Hemoglobin, serum albumin, calcium, phosphorus, intact PTH (if abnormal or on active treatment), and dialysis adequacy (Kt/V) 1, 3

• Every 3 months: Complete metabolic panel, lipid panel, and HbA1c (if diabetic) 2

• Biannual assessment: Vitamin D levels (25-hydroxyvitamin D), iron studies (ferritin, transferrin saturation), and comprehensive nutrition screening 1

Cardiovascular Risk Stratification

• Smoking history: Current smoking increases cardiovascular event risk with adjusted hazard ratio 1.49 compared to never smokers; former smoking shows hazard ratio 1.09 1

• Lipid management: While statins show no mortality benefit in dialysis patients (AURORA, 4D trials showed HR 0.96 and RR 0.92 respectively), they may reduce atherosclerotic events 1

• Aspirin consideration: Increases major bleeding risk (RR 1.98) without clear cardiovascular benefit in dialysis patients; use only for secondary prevention 1

Common Pitfalls to Avoid

• Do not discontinue ACE inhibitors/ARBs for minor creatinine increases (<30%) in absence of volume depletion or hyperkalemia, as these provide cardiovascular protection 2

• Do not assume all respiratory infections require antibiotics; most are viral and symptomatic treatment alone may be appropriate 4

• Do not reflexively reduce azithromycin doses in renal impairment, as elimination is not renally dependent 4

• Do not continue nephrotoxic medications during acute illness, as risk of acute-on-chronic kidney injury is substantial; temporarily discontinue ACE inhibitors, ARBs, NSAIDs, and diuretics during acute illnesses 4

• Do not use tetracyclines in CKD 5D as they exacerbate uremia; avoid aminoglycosides due to extreme nephrotoxicity 4

• Do not ignore CNS-acting antihypertensives (alpha-2 agonists, centrally acting agents), as these are protective against bone loss with preservation of cortical mass and volume 7