End Stage Renal Disease Flashcards
Uremic Syndrome
Presentation/PE
Fatigue, malaise, anorexia, nausea, vomiting, metallic taste, hiccups, DOE, irritability, muscle cramps, restless legs, weakness, pruritis, easy bruising, altered mentation
Physical exam:
Cachexia, weight loss, muscle wasting, pallor (anemia) , hypertension, ecchymosis, sensory deficits, asterixis, Kussmaul respirations, “uremic frost”, HTN, swelling
Uremic Syndrome
Work up
labs: lytes, bun, creatinine, Hgb, Ca, Phosphate, PTH, albumin, bicarbonate
UA: RBC, protein, cellular casts, oval fat bodies, ketones, myoglobin, pH
Imaging: renal ultrasound r/o hydronephrosis or obstruction
End stage renal
Treatment and complications
dialysis
Complications:
Pericarditis, delirium, pericardial effusion, uremic encephalopathy
ESRD
When to refer fro dialysis
Refer for HD when eGFR 15-29 mL/min
Hemodialysis
Filtration of patient’s blood with a dialyzer; continuous or intermittent
Corrects imbalances of electrolytes, fluids, toxins, and waste
Must leave home 3 x a week
Restricted diet
Can feel “ yuck “ after
In general, refer patients for access before GFR < 15
Arteriovenous Fistulas
Av fistula usually takes 2-6 months to form
Less risk of clots or infection and last for years
Connect the artery to the vein
Surgeon may order vessel mapping to determine size and quality of veins and flow
Affected limb care includes no venipuncture/bp
Arteriovenous graft
If pt has small or weak veins that will not develop into fistula may use a synthetic graft or tube to create connection
Usually needs 2-4 weeks to develop
+ bruit + thrill
Increased risk clotting and infection; do not often last as long as AV fistula
Limb care includes no venipuncture, BP, heavy lifting
Catheter
Flexible, hollow tube inserted into large vein
Internal jugular, subclavian, femoral
Usually a means for temporary dialysis
High infection rate
Do not allow for large volume – can affect treatment
Veins can develop stenosis or clot
Usually changed every 4 weeks
Swimming/bathing not recommended
Peritoneal dialysis
Dialysis via the peritoneum
Does not require vascular access
Less stressful on the patient- decreased side effects, can be done at home
< effective than hemodialysis
Protein loss and increased risk for peritonitis
Requires intra-abdominal catheter- risk infections and adhesions
Renal transplant and complications
1 year Survival rates 98% from living donor; 95% from deceased donor
Increased failure rates among black patient’s vs white
Almost all ESRD patients are candidates unless contraindication to transplant
If receive transplant will be on immunosuppressive tx to prevent organ rejection
Waiting list for cadaver transplants > 3 years
Post renal transplant patient will be on immunosuppression- very important to monitor for infections esp UTI, wound, CMV
Higher risk to develop cancer- esp non-melanoma skin cancer!! Frequent skin checks
What is the treatment for pericarditis and uremia?
HD; AV fistula take up to 6 -12 weeks to develop, AV graft 2-3 weeks, peritoneal a few days- ; what is risk assoc with peritoneal? ( peritonitis and low protein)
What is preferred access? IJ
ESRD
Renal ultrasound findings
Large Kidneys:
Early diabetic nephropathy, multiple myeloma, polycystic kidney disease, HIV
Small Kidneys:
HTN, ischemic nephropathy, CKD
*if have small kidneys increased risk complications and complexity for renal bx
Hydronephrosis: indicates obstruction
Reduced renal cortical thickness: CKD
String of pearls sign: fibromuscular dysplasia
ESRD
Summary Slide
ESRD
Need to manage and monitor for complications
Need to establish HD site
In uremic syndrome treatment is HD – access is acute so usually CVC
Goals and Complications CKD/ESRD
Cardiovascular disease
Dyslipidemia: goal LDL < 100
Hypertension: target BP < 130/80
Vascular Calcification
Renal osteodystrophy : increased risk fracture/falls
Anemia: normocytic normochromic ( decreased erythropoietin) ; microcytic hypochromic ( iron deficiency)
Metabolic Acidosis: due to decreased bicarbonate production, decreased hydrogen excretion
Arrythmias: due to electrolyte abn
Pericarditis ( think uremia)
Pleuritis ( think uremia)
