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Chronic Renal Disease (CRD) / End-Stage Renal Disease (ESRD)

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Topic updated on 04/20/16 9:53pm

Introduction
  • A decrease in kidney function classified by severity of GFR reduction
  • Results in inability to
    • make urine and excrete nitrogenous wastes
    • buffer blood pH
    • control blood ionic content
    • synthesize 1,25 dihydroxyvitamin D
      • due to ↓ activity of 1-α hydroxylase
    • synthesize erythropoietin
      • due to loss of EPO secretion by peritubular capillaries
Presentation
  • Symptoms/physical exam
    • Uremia causes
      • uremic frost
      • anorexia
      • nausea and vomiting
      • mental status changes
      • bleeding
        • secondary platelet dysfunction
      • epigastric pain
        • secondary to fibrinous pericarditis
    • Na+/H2O retention causes
      • CHF
      • hypertension
      • pulmonary edema
    • Fractures and bone pain caused by renal osteodystrophy 
      • combination of
        • osteitis fibrosa cystica
          • due to hypocalcemia leading to increased bone resorption
          • caused by ↓ Vit D and ↑ PTH
        • osetomalacia
          • caused by ↓ Vit D
        • osteoporosis
          • due to ↑ bone buffering of metabolic acidosis
Evaluation
  • Serology
    • azotemia
    • metabolic acidosis
      • due to accumulation of sulfates, phosphates, organic acids
    • hyperkalemia
      • due to inability to excrete K+ in urine
    • hypocalcemia
      • due to lack of Vitamin D production
    • anemia
      • due to low EPO
    • dyslipidemia
      • ↑ triglycerides
    • ↑ cystatin C
      • biomarker of kidney function
      • filtered but not secreted by the kidney
  • Urinalysis findings
    • waxy casts are characteristic of end stage renal failure
    • fixed specific gravity with loss of urine concentrating ability
      Disease
      Microscopic Urine Analysis
      End Stage Renal Failure Way casts
      ATN muddy brown granular casts
      Pyelonephritis White Blood Cell (WBC) Casts
      Glomerulonephritis Red Blood Cell Casts (pathognomonic)
      Nephrotic Syndrome Double-refractile fat bodies
      Atheroembolic disease Urinary eosinophils
      Allergic nephriti Urinary eosinophils
Imaging
  • Radiograpics
    • may shows
      • renal osteoporosis
      • metastatic calcification
        • due to hyperphosphatemia driving calcium into tissue
  • Renal ultrasound
    • shows small kidneys due to chronic disease
Treatment
  • Nonopeative
    • dietary restrictions
      • ↓ protein intake
      • ↓ salt and water intake
    • pharmacologic interventions
      • diuresis to prevent fluid overload
      • antihypertensives
        • beta-blockers, vasodilators
      • erythropoiesis stimulation with EPO
        • side effects
          • headache
          • hypertension 
          • flu-like symptoms
      • active vitamin D and calcium supplements
      • phosphate chelators (sevelamer)
    • dialysis
      • To correct electrolyte abnormalities
      • Most common cause of death among patients on dialysis: cardiovascular disease 
  • Operative
    • kidney transplant


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(M2.RL.48) A 65-year-old female with end-stage renal disease currently on dialysis is being assessed by a nephrologist who notes her hemoglobin to be 9.5 g/dL. Which of the following is a known side effect of the drug she will most likely be administered? Topic Review Topic

1. A rash that may progress to Stevens Johnson syndrome
2. Reduced clotting ability
3. Worsening hypertension
4. Diffuse pruritis
5. Fatigue

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