4 End-Stage Renal Disease, pt 1

Question 1

Biosynthetic function of the kidnes

Answer 1

85% of erythropoietin is produced in the kidneys.
Kidneys also secrete 1a-hydroxylase, which is necessary to produce the acitve form of vitamin D3.

Question 2

The most common indications for emergency dialysis

Answer 2

Fluid overload (51%)
Hyperkalemia (18%)
Severe acid-base disturances

Question 3

Most common indication for nonemergent dialysis

Answer 3

Uremia

Question 4

Remarks on neurologic complications of dialysis patients

Answer 4

Stroke occurs in approx 6% of hemodialysis patients, with half being hemorrhagic and half ischemic.
Subdural hematomas occur 10x more frequently in dialysis patients than in the general population.

Question 5

Remarks on cardiac markers in ESRD

Answer 5

Elevated levels of Troponin I and T are common even in asymptomatic hemodialysis patients.
This probably reflects left ventricular hypertrophy and microvascular disease.
To account for higher baseline levels of troponin T and I, many define myocardial infarction only by a 20% or more dynamic rise and with at least one value above the 99% percentile.

Question 6

Most common cause of heart failure in ESRD

Answer 6

Hypertension

Question 7

Cornerstones of therapy in pulmonary edema in ESRD

Answer 7

1. Supplemental oxygen if needed
2. BIPAP
3. Nitrates
4. ACEi
5. Loop diuretics
6. *Hemodialysis - ultimate treatment for fluid overload in ESRD patients

• Peritoneal dialysis does not remove volume fast enough to have a significant impact on pulmonary edema

Question 8

Remarks on loop diuretics in pulmonary edema

Answer 8

Furosemide (60 to 100 mg IV) may aide even in those with minimal urine output because loop diureitcs have short-lived vasodilatory actions

Question 9

Remarks on Cardiac tamponade in ESRD

Answer 9

Often presenting without classic findings
Instead, signs include changes in mental status, hypotension, or SOB
Bedside pericardiocentesis is used only in hemodynamically unstable patients because of its high complication rate.

Question 10

Pericardial friction rubs in uremic pericarditis are described as

Answer 10

Louder than in most other forms of pericarditis
Often palpable
and frequently persist for some time after metabolic abnormalities have been corrected

Question 11

One of the unique features of uninfected uremic pericarditis is

Answer 11

that the inflammatory cells do not penetrate into the myocardium, so typical ECG changes of acute perciarditis are absent.
When the ECG has features typical of acute pericarditis, suspect infection.

Question 12

Dialysis-related pericarditis is most common during

Answer 12

periods of increased catabolism (trauma and sepsis) or inadequate dialysis due to missed sessions or vascular access problems

Question 13

Management of uremic and dialysis-related pericarditis in patients in hemodynamically stable condition

Answer 13

Intensive dialysis, usually effective after 10-14 days.
If not, anterior pericardiectomy ids often used,
with total pericardiectomy reserved for constrictive pericarditis

Question 14

Mechanisms of uremic bleeding

Answer 14

Decreased platelet function
Abnormal platelet-vessel wall interactions
Altered vWF
Anemia
Abnormal production of nitric oxide

Question 15

Mechanism of immunologic deficiency in ESRD patients

Answer 15

Depressed leukocyte chemotaxis and phagocytosis
Abnormal T-cell activation

Question 16

Remarks on immunologic deficiency in ESRD patients

Answer 16

Dialysis does not improve the immune function and may exacerbate immunodeficiency by complement activation after exposure to the hemodialysis filter membrane

Question 17

Metastatic calcification occurs when?

Answer 17

When the calcium-phosphate product [Ca2+ (mg/dL) x PO4 (mg/dL)] is higher than 70 to 80
Short-term mortality rate is higher in ESRD patients with a calcium-phosphate product of >72