2025 New Edition ABA ITE Sample Question
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Try This ABA ITE Sample Question from the 2025 New Edition
A 59-year-old man with a history of end-stage renal disease on intermittent hemodialysis presents to the ED after a fall. He is found to have a fracture of the femoral neck and is brought to the OR for emergent repair. He last received dialysis 2 days before the injury. Which of the following metabolic derangements is MOST likely to be seen on initial chemistry analysis?
A. Hypocalcemia
B. Hypomagnesemia
C. Hypophosphatemia
Show The Answer Key
Did you get it right? The correct answer is A.
Answer Explanation
Hypocalcemia is the electrolyte abnormality most likely to be seen perioperatively on initial chemistry analysis for this patient and is common in end-stage renal disease (ESRD) due to two primary etiologies. It can be caused by increased serum phosphorus due to the increased complexing of phosphorus with calcium, resulting in a decreased serum availability of free calcium ions. Hypocalcemia is also caused by decreased renal production of 1,25-dihydroxy vitamin D, resulting in decreased enteral absorption of calcium from dietary sources.
Although ESRD has implications for every organ system in the body, one of the most relevant to anesthesiologists is its effect on the metabolic system. ESRD typically causes a wide range of clinically significant metabolic derangements. Patients tend to exist in an acidemic state, which is transiently corrected with dialysis.
| Metabolic Derangements in End-Stage Renal Disease | ||||||||||
| Factor | Na+ | K+ | Osmolality | Blood Urea Nitrogen | Creatinine | Mg2+ | Phosphorus | Ca2+ | Albumin | pH |
| Change | ↔ | ↑ | ↔/↑ | ↑↑ | ↑ | ↑ | ↑ | ↓ | ↓ | ↓ |
| Abbreviations: Ca2+, calcium ions; K+, potassium ions; Mg2+; magnesium ions; Na+, sodium ions. | ||||||||||
The hypervolemia associated with ESRD is due to a failure to excrete sodium effectively; however, the resultant increase in total body water maintains an essentially normal sodium level. Weight gain from this increased water is typically offset by a decrease in lean body mass, resulting in minimal change in total body weight in patients with ESRD. In ESRD, potassium is not effectively excreted at the level of the distal collecting tubule. Although gastrointestinal excretion is enhanced in patients with ESRD, it is not usually enough to mitigate the loss of renal excretion of potassium. In addition, metabolic acidosis and protein catabolism result in increased serum potassium, and both are common in the ESRD state. Osmolality may increase if dialysis is not received regularly. However, due to the inability to eliminate free water in urine, serum osmolality is relatively diluted, and the effect of increased serum solute is attenuated. Serum blood urea nitrogen and creatinine levels are markedly elevated in ESRD due to a loss of renal elimination.
The increase in phosphorus seen in ESRD involves more than just decreased phosphorus excretion, although this factor plays a role. As chronic kidney disease (CKD) progresses, the kidneys lose their ability to secrete calcitriol, the hormone responsible for stimulating bone growth. The calcitriol loss is balanced by an increase in parathyroid hormone, which increases bony turnover and mobilizes phosphorus from the bones. As the kidneys lose their ability to excrete phosphorus, serum phosphorus levels will increase, leading to the hyperphosphatemia seen in ESRD.
Albumin is decreased in ESRD due to decreased synthesis and increased catabolism of albumin. The pathophysiology of these changes is likely due to the systemic inflammatory state accompanying ESRD. A state of acidemia tends to occur in the later stages of CKD and in ESRD. As the kidneys lose their ability to excrete organic anions, the anion gap will expand to an average of ∼ 20 mmol/L with an appropriate decrease in serum bicarbonate levels. It is especially crucial to be mindful of this change after surgery. The inflammatory changes and tissue injury may result in increased production of organic anions, which may exceed the body’s ability to compensate. This result can precipitate further acidemia or hyperkalemia and its associated harmful cardiac effects.
Incorrect Answer Explanations
Answer B: Magnesium tends to increase in ESRD due to decreased excretion instead of being low, as in hypomagnesemia. However, magnesium levels may be normal or even low in some patients due to poor intake and absorption of nutritional magnesium.
Answer C: When coupled with decreased phosphorus excretion in ESRD, serum phosphorus levels tend to rise in patients with ESRD rather than being low, as in hypophosphatemia. The loss of calcitriol excretion and the subsequent unopposed parathyroid hormone action tend to mobilize phosphorus from the bones.
Bottom Line
Myriad metabolic derangements occurring in the setting of end-stage renal disease may be clinically significant to anesthesiologists. Potassium is typically elevated, whereas calcium tends to be decreased. Patients tend to exist in an acidemic state, which is transiently corrected with dialysis.
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