Uremia: Difference between revisions

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**Similar to uremic encephalopathy except progressive, no improvement w/ dialysis  
**Similar to uremic encephalopathy except progressive, no improvement w/ dialysis  
**EEG findings can differentiate uremic encephalopathy from dialysis dementia
**EEG findings can differentiate uremic encephalopathy from dialysis dementia
*CVA
*[[CVA]]
**Cerebrovascular disease, trauma, bleeding dyscrasias, anticoagulant, HTN
**Cerebrovascular disease, trauma, bleeding dyscrasias, anticoagulant, HTN
*Subdural hematoma
*[[Subdural hematoma]]
**10x more likely than in general population
**10x more likely than in general population
**Headache, focal neurologic deficits, seizure, coma
**Headache, focal neurologic deficits, seizure, coma
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**Circulating digitalis-like substances have been implicated
**Circulating digitalis-like substances have been implicated
**Dialysis rarely improves LV function
**Dialysis rarely improves LV function
*Pericarditis
*[[Pericarditis]]
**Uremic pericarditis (75% of cases)
**Uremic pericarditis (75% of cases)
***Most common when the other symptoms of uremia are most severe
***Most common when the other symptoms of uremia are most severe
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**Treatment
**Treatment
***Dialysis
***Dialysis
*Tamponade
*[[Tamponade]]
**Presents w/ AMS, hypotension, dyspnea
**Presents w/ AMS, hypotension, dyspnea
***Rarely present w/ classic signs of Beck's triad
***Rarely present w/ classic signs of Beck's triad
**Pericardiocentesis should only be attempted if hemodynamically unstable
**Pericardiocentesis should only be attempted if hemodynamically unstable
*Pulmonary Edema
*[[Pulmonary Edema]]
**Commonly ascribed to fluid overload; also consider MI
**Commonly ascribed to fluid overload; also consider MI
***Treat similar to non-ESRD pt
***Treat similar to non-ESRD pt
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****Induced diarrhea (sorbitol)
****Induced diarrhea (sorbitol)
****Phlebotomy - withdrawal of as little as 150 mL is safe and effective
****Phlebotomy - withdrawal of as little as 150 mL is safe and effective
*CHF
*[[CHF]]
**May be preexisting
**May be preexisting
**May be caused by uremic cardiomyopathy, fluid overload, AV-related high-output failure  
**May be caused by uremic cardiomyopathy, fluid overload, AV-related high-output failure  


===Hematologic===
===Hematologic===
*Anemia
*[[Anemia]]
**Without tx the hematocrit in ESRD pts should stabilize at 15-20%
**Without tx the hematocrit in ESRD pts should stabilize at 15-20%
**Treatment = erythropoietin
**Treatment = erythropoietin
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===GI===
===GI===
*Anorexia, N/V
*Anorexia, [[N/V]]
*Increased incidence of GI bleeding, diverticular disease, ascites
*Increased incidence of GI bleeding, diverticular disease, ascites


Revision as of 17:29, 4 September 2015

Background

  • Uremia = clinical syndrome a/w end-stage renal disease (contamination of blood w/ urine)
    • Correlation exists between uremia symptoms and low GFR (15-20% of nl)
    • BUN/Cr are inaccurate markers of clinical syndrome of uremia
  • Contributing Factors:
    • Excretory failure
      • Leads to toxin accumulation
    • Biosynthetic failure
      • Loss of Vitamin D and erythropoietin
    • Regulatory failure
      • Uremic state produces excess free radicals -> atherosclerosis, amyloidosis

Clinical Features and Management

Neurologic

  • Uremic encephalopathy
    • Diagnosis of exclusion
    • Cognitive defects, memory loss, decreased attentiveness, slurred speech
    • Asterixis, seizure, coma
    • Improves w/ dialysis
  • Dialysis dementia
    • Similar to uremic encephalopathy except progressive, no improvement w/ dialysis
    • EEG findings can differentiate uremic encephalopathy from dialysis dementia
  • CVA
    • Cerebrovascular disease, trauma, bleeding dyscrasias, anticoagulant, HTN
  • Subdural hematoma
    • 10x more likely than in general population
    • Headache, focal neurologic deficits, seizure, coma
  • Peripheral neuropathy
    • Occurs in 60-100% of dialysis pts
    • Paresthesias, impaired proprioception, weakness
    • Autonomic neuropathy (postural dizziness, gastroparesis, bowel dysfunction)

Cardiovascular

  • CK-MB and troponin are specific markers of MI even in pts undergoing regular dialysis
  • Mortality from CV disease is 10-30x higher in dialysis pts than general population
  • HTN is common
  • Uremic cardiomyopathy
    • Diagnosis of exclusion
    • Circulating digitalis-like substances have been implicated
    • Dialysis rarely improves LV function
  • Pericarditis
    • Uremic pericarditis (75% of cases)
      • Most common when the other symptoms of uremia are most severe
      • BUN is nearly always >60
      • Loud friction rub that is often palpable
      • Typical pericarditis ECG changes are absent (inflammation does not involve myocardium)
        • If ECG does have typical changes consider infection
    • Dialysis-related (25% of cases)
      • Most common during increased catabolism (trauma, sepsis) or missed dialysis sessions
      • Constitutional symptoms, such as fever, are more common than in uremic pericarditis
    • Treatment
      • Dialysis
  • Tamponade
    • Presents w/ AMS, hypotension, dyspnea
      • Rarely present w/ classic signs of Beck's triad
    • Pericardiocentesis should only be attempted if hemodynamically unstable
  • Pulmonary Edema
    • Commonly ascribed to fluid overload; also consider MI
      • Treat similar to non-ESRD pt
        • Lasix 80mg IV may be effective even if minimal Urine output (pulmonary vasodilation)
      • Preload reduction can be accomplished via:
        • Induced diarrhea (sorbitol)
        • Phlebotomy - withdrawal of as little as 150 mL is safe and effective
  • CHF
    • May be preexisting
    • May be caused by uremic cardiomyopathy, fluid overload, AV-related high-output failure

Hematologic

  • Anemia
    • Without tx the hematocrit in ESRD pts should stabilize at 15-20%
    • Treatment = erythropoietin
  • Bleeding diathesis
    • Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired plt function
    • Treatment = desmopressin, cryoprecipitate, conjugated estrogen
  • Immunodeficiency

GI

  • Anorexia, N/V
  • Increased incidence of GI bleeding, diverticular disease, ascites

Renal bone disease

  • Metastatic calcification (calciphylaxis)
    • When calcium-phosphate product (Ca x PO4) > 70-80, metastatic calcification can ensue
    • Symptoms of pseudogout, skin/finger necrosis (small vessel involvement)
    • Life-threatening calcifications can occur in the cardiac and pulmonary systems
    • Tx = use of low-calcium dialysate and phosphate-binding gels
  • Hyperparathyroidism (osteitis fibrosa cystica)
    • Calciphylaxis + vitamin D3 deficiency results in depressed Ca, stimulation of PTH
    • Leads to high bone turnover > weakened bones > increased fracture susceptibility
    • Tx = phosphate binding gels, vitamin D3 replacement
  • Vitamin D3 deficiency and aluminum intoxication (osteomalacia)
    • Leads to osteomalacia (defect in bone calcification)
    • Symptoms similar to hyperparathyroidism (muscle weakness, bone pain)
    • Tx = desferrioxamine
  • Amyloidosis
    • Common in pts >50yr who have received dialysis for >10yr
    • Complications: GI perforation, bone cysts w/ pathologic fx, arthropathies

References

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