CSR Risk Assessment & Mitigation 2 — Questions and Answers
Question 1: A patient with CKD stage 4 has a serum phosphorus of 6.8 mg/dL and is prescribed a calcium-based phosphate binder. What is the primary risk the renal dietitian should monitor for in this scenario?
- Hypocalcemia from binder competition
- Vascular and soft tissue calcification (Correct answer)
- Aluminum toxicity from calcium acetate
- Hypomagnesemia from calcium displacement
Correct answer: Vascular and soft tissue calcification
Calcium-based phosphate binders increase the calcium load and, when combined with elevated phosphorus, promote vascular and soft tissue calcification, increasing cardiovascular mortality risk.
Question 2: Which tool is most appropriate for screening malnutrition risk in a hospitalized ESRD patient prior to a dietitian's full nutritional assessment?
- Malnutrition Universal Screening Tool (MUST) (Correct answer)
- Subjective Global Assessment (SGA)
- Mini Nutritional Assessment (MNA)
- Patient-Generated SGA (PG-SGA)
Correct answer: Malnutrition Universal Screening Tool (MUST)
MUST is validated for rapid inpatient malnutrition risk screening and helps triage which patients require a more comprehensive assessment.
Question 3: A hemodialysis patient's normalized protein catabolic rate (nPCR) drops from 1.1 to 0.7 g/kg/day over 3 months. What nutritional risk does this trend indicate?
- Excessive protein intake leading to uremia
- Protein-energy wasting and inadequate dietary intake (Correct answer)
- Improved metabolic control from dietary adherence
- Increased muscle anabolism from exercise
Correct answer: Protein-energy wasting and inadequate dietary intake
A declining nPCR below 1.0 g/kg/day in hemodialysis patients signals inadequate protein intake and is a marker of protein-energy wasting risk.
Question 4: Which serum marker, when persistently low, is the strongest independent predictor of mortality risk in dialysis patients according to current evidence?
- Pre-albumin (transthyretin)
- Serum albumin (Correct answer)
- C-reactive protein (CRP)
- Transferrin
Correct answer: Serum albumin
Serum albumin below 3.5 g/dL is consistently associated with significantly increased all-cause and cardiovascular mortality in dialysis patients, despite its role as an inflammation marker.
Question 5: A peritoneal dialysis patient gains 4 kg over 2 months without a dietary change. Which risk should the dietitian prioritize investigating?
- Excessive oral caloric intake from dietary recall errors
- Glucose absorption from peritoneal dialysate (Correct answer)
- Protein overconsumption leading to fluid retention
- Vitamin D toxicity causing hypercalcemia
Correct answer: Glucose absorption from peritoneal dialysate
PD patients absorb significant glucose from dialysate, which can lead to hypertriglyceridemia, obesity, and metabolic complications that must be assessed and mitigated.
Question 6: When assessing cardiovascular risk in a CKD patient, an elevated serum FGF-23 level is most directly associated with which adverse outcome?
- Increased risk of hyperkalemia
- Left ventricular hypertrophy and cardiovascular mortality (Correct answer)
- Accelerated iron deficiency anemia
- Worsening hyperphosphatemia from gut absorption
Correct answer: Left ventricular hypertrophy and cardiovascular mortality
Elevated FGF-23 is independently associated with left ventricular hypertrophy and increased cardiovascular mortality in CKD patients, beyond its role in phosphate regulation.
Question 7: A CKD stage 3b patient reports consuming a high-protein diet (1.5 g/kg/day) for weight loss. What is the primary nutritional risk the dietitian should communicate?
- Excessive phosphorus and potassium intake accelerating CKD progression (Correct answer)
- Protein-induced metabolic alkalosis
- Inadequate fiber intake from high protein foods
- Excessive calcium intake from dairy-based protein sources
Correct answer: Excessive phosphorus and potassium intake accelerating CKD progression
High protein diets increase phosphorus and potassium load while also generating acid that accelerates hyperfiltration, all of which can hasten CKD progression.
CSR Risk Assessment & Mitigation 2
A patient with CKD stage 4 has a serum phosphorus of 6.8 mg/dL and is prescribed a calcium-based phosphate binder.
What is the primary risk the renal dietitian should monitor for in this scenario?