CKD- Signs and Symptoms

Question 1

Define uremia.

Answer 1

Clinical syndrome of multiple organ dysfunction caused by retention of ‘uremic toxins’ and/or lack of renal hormones due to kidney failure (late finding although biochemical changes due to uremia occur earlier)

Question 2

Define axotemia.

Answer 2

accumulation of blood nitrogenous waste products due to decreased renal excretion (elevated BUN)

NOTE: BUN is not a uremic toxin but does act as a surrogate marker of toxicity

Question 3

1. Describe the clinical and laboratory abnormalities in electrolyte/volume status based one the pathophysiology of CKD.

Answer 3

hyperkalemia: decreased filtration but also some increased secretion (multifactorial-potassium supplements, diuretics, ACEI/ARB and Bblockers or uncontrolled diabetes)

metabolic acidosis: decreases in ability of patient to get rid of ammonium, which causes leaching of bicarb out of bones (tx with NaHCO3 to keep bicarb <20; unmeasured uremic ions add to a anion gap acidosis

ECF sodium and hypervolemia: reduced responsiveness/ less flexibility in filtering of sodium and water in CKD

hyperphosphatemia and hypcalcemia

Question 4

1. Describe the clinical and laboratory abnormalities in the cardiovascular system based one the pathophysiology of CKD.

Answer 4

caused mostly by inflammation and Ca and P deposition (metastatic calcification)

hypertension: both pressor and volume related although function closer to ESKD is volume-dependent HTN (HTN worse with proteinuria)

increased coronary artery disease
diastolic dysfunction
uremic pericarditis

Question 5

1. Describe the clinical and laboratory abnormalities in endocrine system based one the pathophysiology of CKD.

Answer 5

secondary hyperparthyroidism: low Vit causes low body calcium so parathyroids try to compensate by leaching Ca from bone (2ndary parathyroidism) leading to osteodystrophy; decreased calcium intake also means decreased phosphate excretion

sexual dysfunction
decreased insulin required in diabetics
hyperlipidemia (type IVB)

Question 6

1. Describe the clinical and laboratory abnormalities in the hematologic/ immune system based one the pathophysiology of CKD.

Answer 6

anemia: decreased erythropoietin production, bone marrow resistance and decreased RBC lifespan; tx. adequate iron, treat renal osteodystrophy, good nutrition, treat infections and recombinate ESAs ie. erythropoietin

uremic platelet dysfunction: defect in GPIIb/IIIa protein due to uremic toxins, anemia and increased NO tx. DDAVP, cryoprecipitate, conjugated estrogens and dialysis

WBC dysfunction

Question 7

1. Describe the clinical and laboratory abnormalities in the GI system based one the pathophysiology of CKD.

Answer 7

NV
anorexia
increased incidence of pancreatitis

Question 8

1. Describe the clinical and laboratory neurologic abnormalities based one the pathophysiology of CKD.

Answer 8

encephalopathy (end stage): thought to be related to uremic toxins and increased PTH, dependent on severity and speed of progression (lethargy, confusion, disorientation, seizures and asterixis- hand flapping)

peripheral neuropathy (earlier): secondary to retention of uremic toxins resulting mixed sensory and motor neuropathy (burning foot, restless legs) tx. with more aggressive dialysis and medications

Question 9

1. Describe the clinical and laboratory abnormalities in the skin based one the pathophysiology of CKD.

Answer 9

pruritis: due to Ca and P deposition as well as uremia
poryphria cutanea tarda
nephrogenic systemic fibrosis (associated with contrast)
calciphylaxis or calcific uremic arteriolopathy (CUA), syndrome of vascular calcification, thrombosis and skin necrosis

Question 10

2. Describe the therapies for signs and symptoms of CKD based on its pathology- acidosis.

Answer 10

oral sodium bicarbonate

Question 11

2. Describe the therapies for signs and symptoms of CKD based on its pathology.- secondary hyperparthyrpidism.

Answer 11

oral 1,25 dihydroxyvitamin D, phosphate binders, low phosphorus

Question 12

2. Describe the therapies for signs and symptoms of CKD based on its pathology- anemia

Answer 12

treated with subcutaneous EPO and oral iron

Question 13

2. Describe the therapies for signs and symptoms of CKD based on its pathology- fluid overload.

Answer 13

diuretics, sodium restriction

Question 14

2. Describe the therapies for signs and symptoms of CKD based on its pathology- hypertension.

Answer 14

antihypertensives, sodium restriction.

Question 15

2. Describe the therapies for signs and symptoms of CKD based on its pathology- hyperkalemia.

Answer 15

removal of appropriate medications, potassium restriction

Question 16

2. Describe the therapies for signs and symptoms of CKD based on its pathology- infectious risk.

Answer 16

vaccinations against Hep B, Strep pneumo, influenza

Question 17

2. Describe the therapies for signs and symptoms of CKD based on its pathology- hyperlipidemia.

Answer 17

anti lipid meds (treat as if they have CAD, as if they have already had an MI)

Question 18

2. Describe the therapies for signs and symptoms of CKD based on its pathology- bleeding risk

Answer 18

DDAVP for surgical procedures

Question 19

3. List the indications for starting chronic dialysis therapy.

Answer 19

symptomatic uremia: fatigue, anorexia, nausea, vomiting, encephalopathy, pericarditis

fluid overload (not responsive to diuretics)

hyperkalemia (not controlled with diet, loop diuretics)

GFR <15 cc.min if diabetic