<unk>  encephalopathy
Diagnosis of exclusion
Cognitive defects, memory loss, decreased attentiveness, slurred speech
Asterixis, seizure, coma
Improves with dialysis
Dialysis dementia
Similar to<unk>  encephalopathy except progressive, no improvement with dialysis
EEG findings can differentiate<unk>  encephalopathy from dialysis dementia
CVA
Cerebrovascular disease, trauma, bleeding dyscrasias, anticoagulant, hypertension
Subdural hematoma
10 times more likely than in general population
Platelet dysfunction
Headache, focal neurologic deficits, seizure, coma
Peripheral neuropathy
Occurs in 60-100% of dialysis patients
Paresthesias, impaired proprioception, weakness
Autonomic neuropathy (postural dizziness, gastroparesis, bowel dysfunction)
Diagnosis of exclusion
Cognitive defects, memory loss, decreased attentiveness, slurred speech
Asterixis, seizure, coma
Improves with dialysis
Similar to<unk>  encephalopathy except progressive, no improvement with dialysis
EEG findings can differentiate<unk>  encephalopathy from dialysis dementia
Cerebrovascular disease, trauma, bleeding dyscrasias, anticoagulant, hypertension
10 times more likely than in general population
Platelet dysfunction
Headache, focal neurologic deficits, seizure, coma
Occurs in 60-100% of dialysis patients
Paresthesias, impaired proprioception, weakness
Autonomic neuropathy (postural dizziness, gastroparesis, bowel dysfunction)
CK-MB and troponin are specific markers of MI even in patients undergoing regular dialysis
Mortality from cardiovascular disease is 10-30 times higher in dialysis patients than general population
hypertension is common<unk>  cardiomyopathy
Diagnosis of exclusion
Circulating digitalis-like substances have been implicated
Dialysis rarely improves LV function
Pericarditis<unk>  pericarditis (75% of cases)
Most common when the other symptoms of<unk>  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<unk>  pericarditis
Treatment
Dialysis
Tamponade
Presents with altered mental status, hypotension, dyspnea
Rarely present with 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 patient
Furosemide 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<unk>  cardiomyopathy, fluid overload, AV-related high-output failure
Diagnosis of exclusion
Circulating digitalis-like substances have been implicated
Dialysis rarely improves LV function<unk>  pericarditis (75% of cases)
Most common when the other symptoms of<unk>  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<unk>  pericarditis
Treatment
Dialysis
Most common when the other symptoms of<unk>  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
If ECG does have typical changes consider infection
Most common during increased catabolism (trauma, sepsis) or missed dialysis sessions
Constitutional symptoms, such as fever, are more common  than in<unk>  pericarditis
Dialysis
Presents with altered mental status, hypotension, dyspnea
Rarely present with classic signs of Beck's triad
Pericardiocentesis should only be attempted if hemodynamically unstable
Rarely present with classic signs of Beck's triad
Commonly ascribed to fluid overload; also consider MI
Treat similar to non-ESRD patient
Furosemide 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
Treat similar to non-ESRD patient
Furosemide 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
Furosemide 80mg IV may be effective even if minimal urine output (pulmonary vasodilation)
Induced diarrhea (sorbitol)
Phlebotomy - withdrawal of as little as 150 mL is safe and effective
May be preexisting
May be caused by<unk>  cardiomyopathy, fluid overload, AV-related high-output failure
Anemia
Without treatment, the hematocrit in ESRD patients should stabilize at 15-20%
Treatment = erythropoietin
Immunodeficiency
Bleeding diathesis <unk>  bleeding syndrome)
Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired platelet function
Treatment = desmopressin, cryoprecipitate, conjugated estrogen, EPO, dialysis
Without treatment, the hematocrit in ESRD patients should stabilize at 15-20%
Treatment = erythropoietin
Increased risk for of bleeding (GI, ICH, liver hematoma) due to impaired platelet function
Treatment = desmopressin, cryoprecipitate, conjugated estrogen, EPO, dialysis
Anorexia, nausea/vomiting
Increased incidence of GI bleeding, diverticular disease, ascites<unk>  frost
Generated from crystallized nitrogenous waste from sweat
Typically in BUN > 200mg/dL
Treatment is lowering BUN
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
Treatment = 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
Treatment = 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)
Treatment = desferrioxamine
Amyloidosis
Common in patients >50yo who have received dialysis for >10yr
Complications: GI perforation, bone cysts with pathologic fracture, arthropathies
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
Treatment = use of low-calcium dialysate and phosphate-binding gels
Calciphylaxis + vitamin D3 deficiency results in depressed Ca, stimulation of PTH
Leads to high bone turnover → weakened bones → increased fracture susceptibility
Treatment = phosphate binding gels, vitamin D3 replacement
Leads to osteomalacia (defect in bone calcification)
Symptoms similar to hyperparathyroidism (muscle weakness, bone pain)
Treatment = desferrioxamine
Common in patients >50yo who have received dialysis for >10yr
Complications: GI perforation, bone cysts with pathologic fracture, arthropathies
Early chronic kidney disease associated with hyperchloremic normal anion gap metabolic acidosis
Late stage disease causes anion gap
Failure to excrete acid anions, phosphate and sulfate
Bone demineralization - bone buffers H+, releasing calcium from bone, leads to osteopenia
Treatment: PO sodium bicarbonate 1 mEq/kg/day
Failure to excrete acid anions, phosphate and sulfate
Bone demineralization - bone buffers H+, releasing calcium from bone, leads to osteopenia
Uremia
Ketoacidosis
Hypercalciuria
Hypernatremia
Renal tubular acidosis
Hyperammonemia
Ketonemia
Lactic acidosis