Please enable JavaScript.
Coggle requires JavaScript to display documents.
Systemic manifestations of CKD (CVD (MCC death) (HTN (Na+ retention (…
Systemic manifestations of CKD
CVD
(MCC death)
:checkered_flag:Vessel narrowing
Atherosclerosis
Pro-inflammatory cytokines
Asymmetric dimethylarginine (ADMA)
--> NO inhibited
PTH-mediated medial calcification
HTN
Na+ retention
:check:Dialysis
Dialysis-resistant HTN
SNS, RAS, PTH, endothelial dysfunction
Vasoconstriction, VSM hypertrophy, vessel rigidity
:check: Loops, ACEi/ARBS
Others:
• HFrEF
• Edema
• LVH
Uremic pericarditis
(BUN > 60 mg/dL)
• Fever
• Precordial chest pain -- Worse w/ breathing & recumbent
• Friction rub
• EKG: May
not
have ST elevation (myocardium spared)
Complications
Tamponade
• EKG: Electrical alternans
• Pulses paradoxus
• Blunted or absent Y descent
Constrictive pericarditis
• Kussmaul sign
• Sharp X&Y descent
• Absent pulsus paradoxus
GI
Anorexia, N/V, hiccups
GI bleeding
Upper GI
Superficial mucosal erosions
Lower GI
Uremic colitis & angiodysplasia
Hematologic
Normocytic normochromic anemia
(
Always
when Scr > 3 mg/dL)
↓ EPO
(Type I interstitial fibroblasts)
↑ hepcidin
:check: EPO & Fe
• B/c HTN is s/e of EPO, give just enough to bring Hct up to ~30%
• Suspect GI bleed if tx fails
Uremic toxins
↓ RBC lifespan
Hypercoagulability
↓ platelet adhesion
NORMAL PT, PTT, platelet count
Neurologic
:checkered_flag:Distal symmetric PN
Stocking-glove paresthesia, RLS, muscle twitch, areflexia, leg cramps
Autonomics: Orthostatic hotn, GI motility probs, erectile dysfx
Uremic encephalopathy (UE)
Asterixis, irritable, ↓ concentration, agitation
Dementia, obtundation, seizures, coma
Metabolic & endocrine
Glucose
↑ Insulin resistance
Worsening
hyperglycemia
in type 1&2 diabetics
No kidney to metabolize insulin
Type I diabetics can get
hypoglycemia
• :check: ↓ exogenous insulin (35-50%)
Protein malnutrition despite normal protein intake
:checkered_flag:Hypogonadism
Women
• Inferile
• Anovulatory menses
Men
• Primary testicular failure
• ↓ libido
• Erectile dysfx
Thyroid
• Normal T4 & rT3
• Low T3
:star: :checkered_flag:Renal osteodystrophy
(ALL CKD pts) :star:
Secondary hyperparathyroidism
↓ GFR -->
↑ serum [phosphate]
↑ FGF-23
(osteocytes)
Inhibit 1a-hydroxylase
↓ Vit D production
Osteomalacia
(adults)
• Long bone pain
• ↑ ALP
Rickets (kids)
•Long bone bowing & deformities
Inhibits phosphate reabsorption in PCT
↓ plasma Ca2+
↑ PTH
High bone turnover
• ↑ ALP (↑ bone formation)
• ↑ TRAP (↑ osteoclast activity)
Osteitis fibrosa cystica
• Bone cysts
• S&P skull
• Subperiosteal bone deposition
:check: Cinacalcet in dialysis pts
• ↓ PTH secretion
:check: Oral phosphate binders (CaCO3, sevelamer carbonate)
• ↓ intestinal PO4 absorption
• ↓ hyperphosphatemia
Adynamic bone disease
• ↓ osteoid, ↓ bone turnover
↓ osteoblasts & osteoclasts
↓ serum bone ALP
(high sens)
↓ serum PTH
Causes:
•
Cinacalcet
• Bone resistance to PTH
Asymptomatic, or
• Persistent bone pain
• Multiple fracture
Tissue calcifications
:star:
Serum Ca2+ x Serum PO3- > 55 mg/dL
• Dermis nodule
• Arteries
• Lungs (RLD
• Band keratopathy
Metabolic acidosis
Anorexia, N/V, fatigue, altered mental, exercise intolerance
↑ branched-chain a-keto acid DH activity
↓ skeletal muscle mass
Osteoporosis
Bone buffers acid w/ H+/Ca2+ exchange
↓ Type I collagen synthesis
Skin
↑ blood urobilin
Sallow, yellow skin
Uremic frost
(BUN > 200 mg/dL)
Lindsay nails (↑ MSH): Half & half nails
Pruritis
(4 mech)
Infection
(2nd MCC death)
• UTI, sepsis, pneumonia
• ↓ antibody production
• CMI & cutaneous anergy
• Maybe no fever
• :check:Immunize (though responses are impaired>,<)
Pulmonary
:checkered_flag:RLD d/t calcification & fibrosis
Uremic pneumonitis -- ARDS pretty much (cytokine-mediated permeability pulmonary edema)
KEY:
• Stage 2 - Green
• Stage 3 - Blue
• Stage 4 - Magenta
• Stage 5 - Red