9: Podiatric Manifestations in End Stage Renal Disease - Frush

Question 1

leading cause ESRD

Answer 1

diabetes (45%)

Question 2

___ of diabetic pts will develop ulcer during lifetime

Answer 2

25%

Question 3

4 complications of renal disease

Answer 3

PAD
neuropathy
derm disorders
psychosocial issues

Question 4

15% of pts with ESRD have PAD why?

Answer 4

as renal function decreases, phosphate levels increase (calcium and phosphorus deposit in the vascular bed leading to calcified vessels)

ESRD is also linked to hyperparathyroidism

High CRP contributes to PAD (dialysis pts shown to have high CRP)

Question 5

______ of hemodialysis pts have neuropathy

Answer 5

50-60%
- uremia on its own can cause neuropathy

autonomic neuropahty in 45-60%

Question 6

characteristics of autonomic neuropathy

Answer 6

• postural hypotension
• shunting of cutaneous capillary beds
• atrophy of sebaceous and sweat glands

Question 7

how is uremia a cause of immune dysfunction?

Answer 7

• impairs polymorphonuclear cells (impaired resistance to bacteria)
• impaired T cell function

Question 8

describe acquired perforating dermatosis

Answer 8

• transdermal -elimination of material from dermis
• scattered cone shaped and plugged keratotic papules, plaques and nodules
• located in high friction areas
• lesions pink in fair skin, brown in darker skin

Question 9

tx acquired perforating dermatosis

Answer 9

potent corticosteroids
topical or oral retinoids
vit A
keratolytics
UVB light therapy

Question 10

describe porphyria cutanea tarda

Answer 10

• disorder of heme biosythesis

- vesicles erupt in sun exposed areas

Question 11

tx porphyria cutanea tarda

Answer 11

• manage iron overload

- minimize sun and photosensitizing medication

Question 12

describe calcinosis cutis

Answer 12

• firm papules, plaques or nodules
• occasionally can exude white chalky substance
• near joint or on fingertips
• manage calcium and phosphorus for tx

Question 13

describe calciphylaxis

Answer 13

• get calcification and obstruction of small and medium cutaneous vessels
• hyperplasia of tunica media and tunica intima
• septal and/or lobular subcutaneous necrosis

–> distal ischemia, painful ulcers and possible amputation (often fatal)

Question 14

tx calciphylaxis

Answer 14

debridement and local wound care with fibrinolytics

hypophosphatemic diet
calcitriol supplementation
pain management

Question 15

what would you use for pain management for calciphylaxis?

Answer 15

NOT NSAIDS (kidney function)

corticosteroids may make calciphylaxis worse

Question 16

seen in pts with ESRD with exposure to gadolinium

Answer 16

nephrogenic systemic fibrosis

symptoms 2-4 wks after exposure

Question 17

describe nephrogenic systemic fibrosis

Answer 17

• starts first in LE - can move to UE and trunk but spares ehad
• bilateral fibrotic or brawny induration of skin
• thickened, indurated erythematous raised skin lesions
• peau de orange appearance
• can lead to permanent contractions

Question 18

severe itching of the skin

Answer 18

uremic pruritus

immunohypothesis and opioid hypothesis as possible pathophysiology

Question 19

tx itching of uremic pruritus

Answer 19

nalfurafine and naltrexone

Question 20

those with _____ had highest incidence of ulcer and LEA

Answer 20

both DM and ESRD

Question 21

is dialysis itself a risk factor for foot ulcers?

Answer 21

prevalence of foot ulcers was 5 times higher in dialysis group

LE complications 2 times higher in dialysis group

Question 22

why dialysis risk factor for foot ulcers?

Answer 22

• during dialysis there is reduction in skin microcirculation and tissue oxygenation
• constant change in fluid volume in the tissues
• less likely to inspect feet and go to podiatry visits

Question 23

______ of hemodialysis pts suffer from depression

Answer 23

20-30%

leads to decrease in care (less self monitoriing, missed appts, compliance)

Question 24

needed for keratinocyte migration and protects against apoptosis

Answer 24

zinc

also need albumin for wound healing

Question 25

there is a suggested reading article

Answer 25

look at it maybe