ESRD: Body System

Question 1

Cardiovascular System

Answer 1

Hypertension - increased extracellular volume from sodium retention or possibly from plasma renin activity
Atherosclerosis - causes coronary artery disease, CVAs, and peripheral artery disease
(LVH) - interferes with the normal pumping activity of the heart, resulting in congestive heart failure, chest pain, dizziness, and arrhythmias
Coronary artery calcification, from calcium-phosphorus metabolism imbalances, can
result in heart attack
Congestive heart failure is caused by the retention of sodium and water
Pericarditis is the inflammation of the pericardium caused by uremic toxins, infections, or fluid overload
Pericardial effusion occurs when fluid fills the pericardial sac and can result in pericardial tamponade in which the cardiac muscle becomes compressed

Question 2

Immune System

Answer 2

 Immunodepression contributes to the high incidence of infection
 The combination of reduced WBC count and poor granulocytic response to infection results in decreased bacteriocidal capability
 Other contributing factors are malnutrition, frequency of cannulation, and invasive procedures
 The elevated uremic level has an effect on the body’s ability to develop a fever as a response to infection
 The ESRD patient may present with a subnormal body temperature,

Question 3

Integumentary System

Answer 3

 Uremic frost is a rare condition in which white urea crystals form on the skin giving a “frosty” appearance
 Pruritus, from calcium deposits on the skin, causes uncontrollable itching
 Discoloration ranges from pallor (associated with anemia) to hyperpigmentation of the mucous membranes, palms, and soles to an ashen cast caused by urochrome and carotinoid depositions
 Degeneration of collagen causes excessive skin wrinkling
 ‘Half and half’ nails refers to a condition in which half of the nail appears white due to edema and the other half is normal
 Ecchymosis (excessive bruising) is a result of abnormal functioning of platelets

Question 4

Respiratory System

Answer 4

Left ventricular dysfunction and excessive fluid volume may lead to pulmonary edema; Pulmonary infections, including tuberculosis, fungal, viral, and other bacterial infections;

Question 5

Reproductive System

Answer 5

Infertility is common in ESRD patients of both sexes. In women, menstruation and ovulation are frequently disrupted, and pregnancy rates are low. When
pregnancy is achieved, it may result in low birth weight and prematurity
There is a decrease in libido with reduced ability to reach orgasm. ESRD patients experience hypothalamic-pituitary-gonadal dysfunction.
 An increase in the adequacy of dialysis, correction of anemia, and administration of estradiol may result in the alleviation of some of the sexual complications in women
 Erectile dysfunction and low sperm count may be partially corrected by the administration of Epogen to reduce anemia

Question 6

Metabolic Disturbances

Answer 6

 The healthy kidney functions to eliminate the excess hydrogen ions, but in ESRD patients, the pH of the blood decreases due to the damaged kidney’s inability to
produce bicarbonate
 The patient may develop Kussmaul respirations (deep rapid breathing), increasing the amount of CO2 exhaled, resulting in some degree of compensation
 If left untreated, metabolic acidosis may progress to cause lethargy, coma, and seizures
 It may also lead to arrhythmias, ventricular tachycardia, and hypotension
 Diagnosis is made by arterial blood gas testing showing a pH of under 7.35 andbicarbonate levels of <mmol/l
 Treatment may include administration of bicarbonate (50-100 mmol) and dialysis

Question 7

Lipoprotein Metabolism

Answer 7

Type 4 hyperlipoproteinemia occurs regularly in this type of patient; low levels of carnitine, a compound that is required for the transport of fatty acids into the mitochondria, may be found to play a part in this metabolic dysfunction

Question 8

Protein Metabolism

Answer 8

Poor intake, resulting in low serum albumin, depletion of nutrients during dialysis, and abnormal metabolism are all factors that influence this process; Loss of tissue mass may be obscured by edema

Question 9

Endocrine System

Answer 9

 Insulin production
 Parathyroid hormone levels disorder
 Increased plasma norepinephrine
 Inconsistent epinephrine levels
 Increased aldosterone
 Elevated levels of glucagon (pancreatic hormone used for carbohydrate metabolism) and gastrin (stimulates the secretion of gastric acid), which occurs as a consequence of renal metabolism clearance
 Hypothyroidism
 Low response to thyroid-releasing hormone (TRH) with mostly normal response to (TSH)
 Increased growth hormone and prolactin
 Abnormal production of estrogen, progesterone, or testosterone
 Elevated luteinizing hormone (LH) in both sexes

Question 10

Psychosocial Concerns

Answer 10

 Effects of the illness
 Dietary restrictions
 Scheduling constraints
 Fear of dying
 Marital discord, sexual dysfunction, hormonal effects
 Tense interpersonal relationships with family, medical staff, administrative
personnel
 Expense of treatment
 Unemployment
 Psychological complaints, anxiety, anger, hostility and depression with feelings of lack of worth, lack of interest in daily activities, changes in weight, altered sleep
patterns, fatigue, inability to concentrate
 Psychiatric disorders such as dementia, delirium, psychosis, anxiety disorders, and drug abuse

Question 11

Anemia

Answer 11

> diminished erythropoietin (EPO), a hormone that stimulates the production of blood cells by bone marrow
inability to successfully absorb and use iron
the life span of the red blood cell decreases
platelet abnormalities lead to bleeding from the gums, nose, GI tract, uterus, and skin
dialyzer may leak, frequent blood tests are done, and blood recovery may be incomplete

Question 12

Normal Hematocrit: male

Answer 12

46-52%

Question 13

Normal Hematocrit: female

Answer 13

40-45%

Question 14

Symptoms of Anemia

Answer 14

  Weakness
  Fatigue
  Shortness of breath
  Chest pain
  Poor exercise tolerance
  Inability to think clearly

Question 15

Gastro intestinal complaints:

Answer 15

 Nausea
 Poor appetite
 Metallic taste in mouth
 Vomiting
 Fetid breath (from decomposing urea)
 GI bleeding, often occult may be caused by platelet abnormalities and aggravated by the use of Heparin
 Ammonia or hyperkalemia may cause diarrhea
 Functional constipation and possible impactions may result from medications, diet, and lack of exercise or fluid restriction

Question 16

Bone health: Physiology

Answer 16

 The hormone calcitriol (also known as vitamin D3), produced by the kidney, enables absorption of calcium from food sources into the bloodstream and promotes formation of strong bones
 When kidney function is impaired, the amount of calcitriol produced decreases, causing calcium levels to drop and phosphorus levels to increase
 The body responds by increasing (PTH), which functions to normalize the calcium level in the blood and maintain the calcium/phosphorus balance
 PTH causes the resorption of calcium from the bones back into the bloodstream. This depletion of calcium from the bones leaves them brittle and prone to fracture
 Chronic acidosis contributes to further resorption of calcium, resulting in even more
bone density loss

Question 17

What is osteomalacia?

Answer 17

results from defective mineralization (calcification) of the bone, usually due to the lack of vitamin D

Question 18

What is Osteitis fibrosa?

Answer 18

the replacement of bone with fibrous tissue due to the resorption of calcium from the bones into the bloodstream

Question 19

What is Adynamic bone disease (ABD)?

Answer 19

a condition in which there is low bone resorption

and formation

Question 20

What is Metastatic calcification?

Answer 20

the deposits of calcium in normal tissue, usually in
the interstitial tissues of the kidneys, lungs, or gastric mucosa. It results when the product of serum calcium times phosphorus equals 75 milligrams per deciliter or greater

Question 21

What is osteoporosis?

Answer 21

the reduction of bone mineral density (BMD). The bone

microarchitecture (matrix) and calcification are deficient

Question 22

What is Osteosclerosis?

Answer 22

a significant increase in bone density

Question 23

Symptoms of osteodystrophy:

Answer 23

  Back pain
  Foot pain
  Fractures
  Joint pain, sometimes caused by metastaticcalcification
  Itching
  Gangrene in tips of toes and fingers

Question 24

Treatment objective of renal osteodystrophy?

Answer 24

the maintenance of low serum phosphorus levels:
>restricting the dietary intake of protein helps in maintaining lower serum phosphate levels
>calcium carbonate (Tums) or calcium acetate (PhosLo) prevents the phosphorous from being absorbed in GI
>once the serum phosphate level is lowered to 4mg/dL and serum calcium is raised to 10mg/dL, PTH production will decrease

Question 25

Optimal level of PTH

Answer 25

between 1.5 and 3 times the upper limit of normal

Question 26

What is Calciphylaxis?

Answer 26

> rare syndrome that is frequently associated with hypercalcemia, hyperphosphatemia, and hyperparathyroidism.
involves vascular calcification and thrombosis and frequently leads to skin necrosis; when the calcium phosphorous product exceeds 70mg/100mL, insoluble calcium phosphate crystals form.

Question 27

What is dialysis amyloidosis?

Answer 27

> also known as dialysis related amyloidosis (DRA), is a frequent complication of long term dialysis.
a disabling condition in which small proteins (Beta-2-microglobulin molecules, which are the main components of amyloid fibrils) accumulate in synovial membranes and osteoarticular sites, causing destructive osteo-arthropathies, such as carpal tunnel syndrome and flexor tenosynovitis

Question 28

What is carpal tunnel syndrome?

Answer 28

> median neuropathy, compression of the median nerve at the wrist by the thickened sheath of the carpal tunnel.
The cause of this thickening, in dialysis patients, is the amyloid deposition in the sheath
leads to numbness and muscle weakness in the hand,
especially the thumb, index, and middle fingers
hallmark pain or numbness and tingling at night
treatment consists of nonsteroidal anti-inflammatory drugs (NSAIDS) and ultrasound therapy
kidney transplantation frequently leads to a prompt cessation of symptoms