Management of CKD Complications Flashcards
Example of CKD complications
- Uremic Bleeding
- Pruritus
- Anemia
- Malnutrition
- Fluid and Electrolyte Abnormalities
- CV; HTN & Hyperlipidemia
- Metabolic Acidosis
- ROD
What are the cause of uremic bleeding?
Accumulation of uremic toxin due to:
1. Increase secretion of PTH and ANP
2. Decreased renal clearance of metabolic by-products of protein metabolism
Definition of anemia according to KDIGO ?
Hb level <13 g/dL in male, <12 g/dL in female
Why in CKD reduced epo production?
Due to reduction in the number of functioning nephrons
Anemia of chronic renal disease, also known as anemia …
normocytic, normochromic anemia
RBC production stimulate by ESA can increase iron demand and lead to…
Iron deficiency (common in CKD pt). so require iron supplementation
Other contributing factors of anemia of CKD?
i. Reduction of red cell life span (from the normal
of 120 days to around 60 days in stage 5 CKD)
ii. Vit B12 & folate deficiency
iii. Blood loss from regular lab testing &
hemodialysis
Iron deficiency is (effect)….
leading cause of resistance to ESA
Pts on HD, the aim is to…
maintain a predialysis or
stabilized HCO3- concentration ≥ 22 mEq/L
Non-Pharmacologic Therapy: management of MA
altering HCO3− levels in the dialysate fluid
sodium load administered with HCO3
− replacement can cause
risk of volume overload
What are the causes of nutritional
disorder in CKD Pts?
- inadequate nutrient intake
- ineffective nutrient utilization
What is uremic malnutrition?
a syndrome that is distinct from
malnutrition caused by inadequate nutrient intake
Non-Pharmacologic Therapy of Pruritus ?
- Adequate dialysis -> significant improvement
- Maintaining proper nutritional intake, especially dietary phosphorus and protein intake
- UV phototherapy
Pharmacologic Therapy of Pruritus ?
- Antihistamines, such as hydroxyzine 25 to 50 mg or diphenhydramine 25 to 50 mg orally or IV, are used as first line oral agents used to treat pruritus
- Cholestyramine at doses of 5 g q 12 hrs
- Oral activated charcoal has also been used in doses of 1 to 1.5 g q 6 hrs
- Gabapentin has also been show to be effective, used with caution to minimize
neurotoxicity risk - Topical emollients for dry skin, but they are often not effective in relieving pruritus associated with CKD
- Other therapies (used on combination): Oral SSRIs, Ondansetron, Naloxone & topical capsaicin
Non-Pharmacologic Therapy of Uremic bleeding ?
- Dialysis has become the mainstay of treatment for ESRF, the uremia
- management of anemia and nutritional status
3.
Pharmacologic Therapy of Uremic bleeding ?
- Cryoprecipitate
- Desmopressin
- Estrogens
Cryoprecipitate contains what?
contains various components
important in platelet aggregation and clotting;
i.e., fibrinogen, von Willebrand’s factor, factor
XIII and fibronectin
Disadvantage of cryoprecipitate
cost and the risk of infection
Desmopressin
Bleeding time is promptly reduced, within
1 hour of administration, and is sustained for 4 to 8 hrs
Estrogens
Slower onset of action than Desmopressin,
but more sustained
S/E of Desmopressin?
- Repeated doses can cause tachyphylaxis by depleting stores of von Willebrand’s factor
- flushing, dizziness, and headache
Common GI abnormalities in CKD pts?
- Anorexia
- N & V
- Hiccups
- Abdominal pain
- GI bleeding
- Diarrhea & constipation
Diminished gastric motility can occur from ?
uremia, diabetes & diabetic
neuropathy (diabetic gastroparesis)
Gastroparesis often cause
distension, N & V
Gastroparesis may improve with
adequate HD
Metoclopramide
[started @ low dose; 5 mg before meal] is
recommended to relieve these symptoms – consider the risk for extrapyramidal SE
Drug-induced N & V
Digoxin
Contributing Factors: Hypertension
- Fluid retention (as a major contributor)
2.↑ Sympathetic activity - ↓ Activity of vasodilators such as nitric oxide
- ↑ Levels of endothelin-1
- Chronic use of an ESAs
- Hyperparathyroidism
- Metastatic calcification (arterial structural changes)
Monitoring parameter of HTN in CKD pts?
edema, BP especially in CKD stages 4 & 5 Pts, to be evaluated at every clinic visit & at home,
Target BP of ESRF pts based on K/DOQI guidelines?
Predialysis BP of < 140/90 mm Hg
Postdialysis BP of < 130/80 mm Hg
Non-Pharmacologic treatment of HTN in ESRF pts?
- Na+ restriction to approximately 2g/d
- Fluid restriction in Pts with volume overload
- lifestyle modification (regular exercise, weight loss & smoking cessation)
- Extended-hours HD (12-24 hrs) can also maintains normal BP, improves survival, & reduces the need for antihypertensive Rx;
Pharmacologic treatment of HTN in ESRF pts?
- All antihypertensive classes can be utilized
- ACEIs or ARBs are the preferred agents in ESRF Pts, due to their potential benefits, including regression of LVH, reduction in sympathetic nerve activity, improvement in endothelial function, and reduced oxidative stress
