END-STAGE RENAL DISEASE

Question 1

Many chronic kidney diseases, if untreated or resistant to treatment, eventually lead to

Answer 1

end-stage renal disease (ESRD)

Question 2

ESRD is characterized by

Answer 2

1-severe reductions in the GFR

2-and uremic symptoms requiring renal replacement therapy (dialysis or transplantation).

Question 3

In the United States the most common cause of ESRD requiring dialysis is

Answer 3

diabetic nephropathy

Question 4

Most complications of ESRD do not occur until GFR IS

Answer 4

<20–30% of normal (25 mL/minute)

Question 5

A few complications ………………………………………………………. are only seen when GFR <10%.

Answer 5

(altered mental state, acidosis, hyperkalemia)

Question 6

Metabolic acidosis due to …………………………………………….
The anion gap is elevated.
Treatment is ……………….

Answer 6

• retained acids not filtered from the blood by the failing kidney
• dialysis

Question 7

Hyperkalemia due to……………………………………………………
This is a common cause of death in dialysis patients. Treatment is ……………………..
…………………….. and …………………….. (e.g. kayexalate) may be used prior to dialysis.

Answer 7

• retained potassium not filtered by the failing kidney.
• a low K diet and dialysis.
• Loop diuretics and GI binding agents

Question 8

Hypermagnesemia. Magnesium accumulates because ………………………………………………………………………..
Treatment is …………………………………….

Answer 8

• the falling GFR decreases renal excretion.

- restriction of magnesium intake, e.g. avoidance of milk of magnesia.

Question 9

Hypocalcemia due to the loss of …………………………………………………………….

Answer 9

1,25-dihydroxy vitamin D production and from hyperphosphatemia (inability of the kidney to excrete phosphate)

Question 10

High phosphate levels contribute to……………………

Treatment is …………………………………………….

Answer 10

• low calcium levels by precipitating out in tissues in combination with the calcium.
• reduction of phosphate and increase of calcium.

Question 11

Hyperphosphatemia is treated with phosphate binders, such as

Answer 11

calcium carbonate or calcium acetate.

Question 12

………………. and ………………..are phosphate binders that do not contain aluminum or calcium. Use when calcium is abnormally high due to vitamin D replacement.

Answer 12

Sevelamer and lanthanum

Question 13

Hypocalcemia is treated with

Answer 13

1,25 dihydroxy-vitamin D replacement.

Question 14

………………. is a substance which simulates the effect of calcium on the parathyroid; it will tell the parathyroid to shut off ………………….. ………………… production, thus helping to decrease phosphate. Use in severe, refractory cases.

Answer 14

• Cinacalcet

- parathyroid hormone

Question 15

Renal osteodystrophy (osteitis fibrosa cystica). Bone abnormalities occur because chronic hypocalcemia leads to

Answer 15

secondary hyperparathyroidism, which removes calcium from the bones.

Question 16

In addition, bones buffer the chronic acidosis ESRD by

removing

Answer 16

calcium from bone.

Question 17

Renal osteodystrophy Patients present with

Answer 17

bone pain and fractures.

Question 18

Renal osteodystrophy is controlled with improving

Answer 18

calcium and phosphorous levels and with cinacalcet.

Question 19

Parathyroidectomy may be needed for severe …………………….. that does not respond to medications.

Answer 19

hyperparathyroidism

Question 20

Mental state changes: a variety of cognitive and mood changes occur with ……………
normally only with severe CKD (GFR <10). The only treatment is ………………

Answer 20

• uremia

- dialysis

Question 21

Anemia from the loss of production of ……………….. from the kidney.
The anemia is ……………….. and …………………
The anemia is treated with ……………….. ……………….., and ……….. replacement is often necessary when starting erythropoietin due to chronic losses from blood draws, dialysis, and malnutrition.

Answer 21

• erythropoietin
• normochromic and normocytic
• erythropoietin replacement
• iron

Question 22

Bleeding The coagulopathy in ESRD arises from ……………………………………………………………….,
which prolongs the bleeding time.

Answer 22

uremia-induced platelet dysfunction

Question 23

Treatment is …………………….., which releases subendothelial stores of von Willebrand factor and factor VIII, which increase ………………………… and …………….. A secondary cause in patients still making urine is nephrotic-syndrome associated loss of……………….. in the urine.

Answer 23

• desmopressin
• platelet aggregation and adherence
• clotting factors

Question 24

Hypertension and accelerated atherosclerosis. CKD leads to rapidly progressive coronary artery disease, which is the most common cause of death for those on
………………..
Treatment is ……………………………….

Answer 24

• dialysis

- good BP control (usually multiple medications and thorough dialysis) and statins for hyperlipidemia.

Question 25

Pericarditis: caused by

Answer 25

-unknown uremic toxins; may or may not be an associated effusion. Requires urgent hemodialysis.

Question 26

Infection. ESRD patients are at increased risk of infection because
s.

Answer 26

-neutrophils and other white cells do not work normally in a uremic environment.

Question 27

Infection is the second most common cause of death in ………………. patients.
Vascular access infections (hemodialysis) and peritonitis (peritoneal dialysis) are common.
The most common organism is …………………. due to the frequent skin punctures required in dialysi

Answer 27

• dialysis

- Staphylococcus

Question 28

Treatment of END-STAGE RENAL DISEASE

Answer 28

CKD is initially treated conservatively to minimize symptoms.
However, when conservative management fails, renal replacement therapy is required.
This can either be dialysis or renal transplantation.

Question 29

Medical management of CKD includes

Answer 29

-restriction of fluids, potassium, sodium, protein,

magnesium, and phosphate in the diet. Protein restriction is of no value and may be harmful.

Question 30

Common medications of END-STAGE RENAL DISEASE include

Answer 30

erythropoietin, 1,25 dihydroxyvitamin D, phosphate binders, multiple anti-hypertensives, and furosemide (if patient still makes urine).

Question 31

Dialysis is used in patients with……………….. (It is covered under Medicaid for all patients in the United States.) Dialysis options are ……………… and ……………. ………………

Answer 31

• GFR <20%

- hemodialysis and peritoneal dialysis.

Question 32

Acute indications for dialysis are life-threatening abnormalities that require hospitalization:

Answer 32

• Pulmonary edema refractory to diuretics
• Hyperkalemia resistant to therapy
• Metabolic acidosis
• Pericarditis
• Altered mental state

Question 33

Chronic indications for dialysis (usually initiated from the outpatient setting) include:

Answer 33

• Severe neuropathy such as myoclonus, wrist/foot drop
• Persistent nausea and vomiting
• Weight loss/malnutrition
• Bleeding diathesis
• Severe itching
• Fatigue not correctable with anemia correction

Question 34

The most common complications of dialysis are:

Answer 34

• Fluid overload
• Hypertension
• Post-dialysis orthostatic hypotension
• Dialysis access infections (peritonitis or AV access infection)
• Peritonitis. (peritoneal dialysis)

Question 35

Renal transplantation is the preferred treatment for

Answer 35

ESRD patients requiring renal replacement therapy.

Question 36

The 5-year survival rate is by far superior with transplantation when compared with dialysis:

Answer 36

• Dialysis alone: 30–40%
• Diabetics on dialysis: 20%
• Live related donor: 72% at 5 years
• Cadaveric donor: 58% at 5 years

Question 37

The average wait to obtain a kidney for transplantation is ………….. years and becoming longer because of an insufficient donor supply.

Answer 37

2–4 years

Question 38

Complications of transplantation include

Answer 38

acute and chronic rejection, and infections due to

immunosuppressive medications.

Question 39

Renal graft rejection is prevented by using

Answer 39

1-cyclosporine, 
2-tacrolimus, 
3-corticosteroids, 
4-and mycophenolate
-These are all medications which inhibit T-cell function.