Management of CKD Complications

Question 1

Example of CKD complications

Answer 1

1. Uremic Bleeding
2. Pruritus
3. Anemia
4. Malnutrition
5. Fluid and Electrolyte Abnormalities
6. CV; HTN & Hyperlipidemia
7. Metabolic Acidosis
8. ROD

Question 2

What are the cause of uremic bleeding?

Answer 2

Accumulation of uremic toxin due to:
1. Increase secretion of PTH and ANP
2. Decreased renal clearance of metabolic by-products of protein metabolism

Question 3

Definition of anemia according to KDIGO ?

Answer 3

Hb level <13 g/dL in male, <12 g/dL in female

Question 4

Why in CKD reduced epo production?

Answer 4

Due to reduction in the number of functioning nephrons

Question 5

Anemia of chronic renal disease, also known as anemia …

Answer 5

normocytic, normochromic anemia

Question 6

RBC production stimulate by ESA can increase iron demand and lead to…

Answer 6

Iron deficiency (common in CKD pt). so require iron supplementation

Question 7

Other contributing factors of anemia of CKD?

Answer 7

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

Question 8

Iron deficiency is (effect)….

Answer 8

leading cause of resistance to ESA

Question 9

Pts on HD, the aim is to…

Answer 9

maintain a predialysis or
stabilized HCO3- concentration ≥ 22 mEq/L

Question 10

Non-Pharmacologic Therapy: management of MA

Answer 10

altering HCO3− levels in the dialysate fluid

Question 11

sodium load administered with HCO3
− replacement can cause

Answer 11

risk of volume overload

Question 12

What are the causes of nutritional
disorder in CKD Pts?

Answer 12

1. inadequate nutrient intake
2. ineffective nutrient utilization

Question 13

What is uremic malnutrition?

Answer 13

a syndrome that is distinct from
malnutrition caused by inadequate nutrient intake

Question 14

Non-Pharmacologic Therapy of Pruritus ?

Answer 14

1. Adequate dialysis -> significant improvement
2. Maintaining proper nutritional intake, especially dietary phosphorus and protein intake
3. UV phototherapy

Question 15

Pharmacologic Therapy of Pruritus ?

Answer 15

1. 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
2. Cholestyramine at doses of 5 g q 12 hrs
3. Oral activated charcoal has also been used in doses of 1 to 1.5 g q 6 hrs
4. Gabapentin has also been show to be effective, used with caution to minimize
   neurotoxicity risk
5. Topical emollients for dry skin, but they are often not effective in relieving pruritus associated with CKD
6. Other therapies (used on combination): Oral SSRIs, Ondansetron, Naloxone & topical capsaicin

Question 16

Non-Pharmacologic Therapy of Uremic bleeding ?

Answer 16

1. Dialysis has become the mainstay of treatment for ESRF, the uremia
2. management of anemia and nutritional status
   3.

Question 17

Pharmacologic Therapy of Uremic bleeding ?

Answer 17

1. Cryoprecipitate
2. Desmopressin
3. Estrogens

Question 18

Cryoprecipitate contains what?

Answer 18

contains various components
important in platelet aggregation and clotting;
i.e., fibrinogen, von Willebrand’s factor, factor
XIII and fibronectin

Question 19

Disadvantage of cryoprecipitate

Answer 19

cost and the risk of infection

Question 20

Desmopressin

Answer 20

Bleeding time is promptly reduced, within
1 hour of administration, and is sustained for 4 to 8 hrs

Question 21

Estrogens

Answer 21

Slower onset of action than Desmopressin,
but more sustained

Question 22

S/E of Desmopressin?

Answer 22

1. Repeated doses can cause tachyphylaxis by depleting stores of von Willebrand’s factor
2. flushing, dizziness, and headache

Question 23

Common GI abnormalities in CKD pts?

Answer 23

1. Anorexia
2. N & V
3. Hiccups
4. Abdominal pain
5. GI bleeding
6. Diarrhea & constipation

Question 24

Diminished gastric motility can occur from ?

Answer 24

uremia, diabetes & diabetic
neuropathy (diabetic gastroparesis)

Question 25

Gastroparesis often cause

Answer 25

distension, N & V

Question 26

Gastroparesis may improve with

Answer 26

adequate HD

Question 27

Metoclopramide

Answer 27

[started @ low dose; 5 mg before meal] is
recommended to relieve these symptoms – consider the risk for extrapyramidal SE

Question 28

Drug-induced N & V

Answer 28

Digoxin

Question 29

Contributing Factors: Hypertension

Answer 29

1. Fluid retention (as a major contributor)
   2.↑ Sympathetic activity
2. ↓ Activity of vasodilators such as nitric oxide
3. ↑ Levels of endothelin-1
4. Chronic use of an ESAs
5. Hyperparathyroidism
6. Metastatic calcification (arterial structural changes)

Question 30

Monitoring parameter of HTN in CKD pts?

Answer 30

edema, BP especially in CKD stages 4 & 5 Pts, to be evaluated at every clinic visit & at home,

Question 31

Target BP of ESRF pts based on K/DOQI guidelines?

Answer 31

Predialysis BP of < 140/90 mm Hg
Postdialysis BP of < 130/80 mm Hg

Question 32

Non-Pharmacologic treatment of HTN in ESRF pts?

Answer 32

1. Na+ restriction to approximately 2g/d
2. Fluid restriction in Pts with volume overload
3. lifestyle modification (regular exercise, weight loss & smoking cessation)
4. Extended-hours HD (12-24 hrs) can also maintains normal BP, improves survival, & reduces the need for antihypertensive Rx;

Question 33

Pharmacologic treatment of HTN in ESRF pts?

Answer 33

1. All antihypertensive classes can be utilized
2. 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