9 - Podiatric Manifestations of End Stage Renal Disease Flashcards
What does it mean when a patient is in end stage renal disease?
The patient will be on dialysis
What is the leading cause of end stage renal disease (ESRD)?
Diabetes
45% of cases
What is a diabetic patient’s risk of developing an ulcer?
25% of diabetic patient’s will develop ulcer during lifetime
What are the complications of renal disease?
- PAD
- Neuropathy
- Derm disorders
- Psychosocial issues
Describe the case of PAD and renal disease
- 15% of patients with ESRD have PAD
- As renal function decreases, phosphate levels increase
- Calcium and phosphorus deposit in the vascular bed leading to calcified vessels
- ESRD linked with hyperparathyroidism
- High C reactive protein (CRP) contributes to PAD
- Dialysis patients shown to have high CRP
What can you see on an x-ray of a patient with PAD and renal disease?
- Calcification of arteries in the lower extremity
- Posterior tibialis, dorsalis pedis and branches
- You lose the elasticity of blood vessels
- Can even effect small vessels and lead to more problems
Describe neuropathy and renal disease
- 50-60% of hemodialysis patients have neuropathy
- Uremia on its own can cause neuropathy
- Autonomic neuropathy in 45-60% of patient
Describe uremia as a cause of neuropathy
- Shows similar distribution as diabetic neuropathy
- Can get motor neuropathy and fat pad atrophy
Describe autonomic neuropathy
- Postural hypotension
- Shunting of cutaneous capillary beds
- Atrophy of sebaceous and sweat glands
Dry skin (cracks in skin) and less blood flow (slow healing)
Describe susceptibility to infections
Uremia a cause of immune dysfunction
- Impairs polymorphonuclear cells
- Impaired resistance to bacteria
- Impaired T cell function
Higher rate of polymicrobial infection
What are the dermatological manifestations?
Acquired perforating dermatosis Porphyria cutanea tarda Calcinosis Cutis Calciphylaxis Nephrogenic systemic fibrosis Uremic pruritus Foot ulcer
What is acquired perforating dermatosis?
- Characterized by transdermal elimination of material from dermis
- Scattered cone shaped and plugged keratotic papules, plaques and nodules
- Located in high friction areas (lower extremities most common)
- Lesions pink in fair skin, brown in darker skin
How do you treat acquired perforating dermatosis?
- Potent corticosteroids
- Topical or oral retinoids
- Vitamin A
- Keratolytics
- UVB light therapy
Describe porphyria cutanea tarda
- Disorder of heme biosynthesis
- Vesicles (small blisters) erupt in sun exposed areas
- Not as common now because iron overload in dialysis not as prevalent
How do you treat porphyria cutanea tarda?
- Manage iron overload
- Minimize sun exposure
- Minimize any photosensitizing medication
What is calcinosis cutis?
- Firm papules, plaques or nodules
- Occasionally can exude white chalky substance
- Found near joints or on fingertips
How do you treat calcinosis cutis?
Treatment is management calcium and phosphorus levels
What is calciphylaxis?
- Get calcification and obstruction of small and medium cutaneous vessels
- Hyperplasia of tunica media and tunica intima
- Septal and/or lobular subcutaneous necrosis
What is the result of this pathology?
- All this leads to distal ischemia, painful ulcers and possible amputation
- Is often fatal
Describe the incidence of calciphylaxis
Exact etiology unknown
High incidence in
- Dialysis patients
- Hyperparathyroid patients
- Combined
How do you treat calciphylaxis?
- Debridement and local wound care (fibrinolytics)
- Hypophosphatemic diet
- Calcitriol supplementation
- Pain management
- Hyperbaric oxygen (need daily treatment)
What do you need to know about pain control in patients with ESRD?
Do not want to use
- NSAIDs due to kidney function
- Corticosteroids may make calciphylaxis worse
Pretty much need to need narcotics for pain control
What is nephrogenic systemic fibrosis?
- Seen in patients with ESRD with exposure to gadolinium
- Usually see symptoms 2-4 weeks after exposure
Describe the pathology of nephrogenic systemic fibrosis
Location
- Starts in lower extremity first
- Can move up to upper extremities, and trunk
- Spares the head
Other manifestation
- Bilateral fibrotic or brawny induration of the skin
- Thickened, indurated erythematous raised skin lesions
- Can lead to permanent contractions
- “peau de orange” appearance
Differential dx
- Scleroderma, systemic sclerosis, calciphylaxis
What is the prognosis of nephrogenic systemic fibrosis?
Not good
- No proven efficacious treatment
- 20% modestly improve
- 28% don’t improve
- 28% die
Describe uremic puritus
- Severe itching of the skin
- Pathophysiology unclear
- Excessive scratching leads to breaks in skin which may lead to infection
- Nalfurafine and Naltrexone can be helpful to reduce itching
What is the possible pathophysiology?
Immunohypothesis
- Systemic inflammation
Opioid hypothesis
- Overexpression of opioid µ receptor with down regulation of ĸ opioid receptor
Describe the Kaminksi study on foot ulcers
Aim
- To determine the prevalence of risk factors for foot ulcers in patient with ESRD and/or DM
Groups
- Group 1 – ESRD without DM
- Group 2 – DM without ESRD
- Group 3 – coexisting ESRD and DM
What were the results?
The biggest risk factors
- Peripheral neuropathy
- Vascular insufficiency
This is an additional risk factor…
- Podiatry attendance
- Patients aren’t necessarily going to see their podiatrist when they have a foot problem
What else did they find?
- In this study, those with both DM and ESRD had highest incidence of ulcer (27%) and LEA (20%)
- Not significantly higher than other groups though
Describe the Ndip study on foot ulcers and dialysis
- Looked at dialysis as an independent risk factor for ulceration
- Study patients had Stage 4 or 5 renal disease with glomerular filtration rate of
How did they assess the risk in this study?
Internation Working Group on the Diabetic Foot (IWGDF) Classification
- Used to assign risk for foot problems
Risk groups
- Risk 0 – no recognizable risk factor
- Risk 1 – neuropathy with no other risk factors
- Risk 2 – PAD with or without neuropathy
- Risk 3 – current foot ulcer, history of foot ulcer or prior amputation
What did they find in this study?
- Prevalence of foot ulcers was 5 times higher in the dialysis group
- Lower extremity complications (neuropathy, PAD and amputation) was 2 times higher in dialysis group
What are the theories of why those on dialysis are on higher risk?
- During dialysis there is a reduction in skin microcirculation and tissue oxygenation
- Constant change in fluid volume in the tissues
- Less likely to inspect feet and go to podiatry visists
Describe depression in the dialysis patient population
20-30% of hemodialysis patients suffer from depression
Leads to decrease in care
- Less self monitoring
- Missed appointments
- Compliance
What nutritional deficits do we see in patients on dialysis?
- Albumin
- Zinc
What is zinc needed for?
- Needed for keratinocyte migration
- Protects against apoptosis
