ABSTRACT
Skin • Uraemia: pruritus (scratch marks), brown nails, hyperpigmented 'frost' or sallow, injected sclera • Underlying cause: vasculitis, scleroderma, amyloid, partial lipodystrophy, angiokeratoma • Complications: pallor (anaemia), subcutaneous or scleral calcification ( I Ca2*), tophi (gout)
Cardiac • Fluid overload: pulmonary and peripheral oedema, JVP t (or i if salt-wasting) • Pericarditis; tamponade (Kussmaul's sign - paradoxical JVP T on inspiration), chest pain • Ischaemic heart disease, dilated cardiomyopathy: multifactorial, inc. hypertriglyceridaemia,
hyperhomocystinaemia, low HDL, insulin resistance, vascular calcification ABP
• T: fluid overload (less commonly; 4: salt-wasting with tubular disease) Respiratory
• Pulmonary oedema (SOB), pleurisy (chest pain), pleural effusion, pulmonary fibrosis Respiratory pattern
• Hiccups, uraemic fetor, Kussmaul's breathing (deep) due to metabolic acidosis Immunocompromise, e.g. pneumonia Neurological
• Encephalopathy: early - myoclonus, asterixis (hand flap), late - dementia, dysarthria, seizures • Peripheral neuropathy, restless legs syndrome • Myopathy: due to uraemia and osteomalacia
GIT • Gastric ulcers due to gastrin t
• Haemorrhage, due to angiodysplasia and coagulopathy, impaired platelet function
Thrombocytopenia
• Purpura, GIT haemorrhage (also due to impaired platelet function and coagulopathy) Urine
• Frequency or nocturia may occur with tubular disease • Haematuria: IgA nephropathy, vasculitis or reflecting coagulopathy • Loin pain, or renal mass - suggests renal cystic disease
Bones • Osteomalacia (Vit D deficiency), osteoporosis
Endocrine • Amenorrhoea, impotence, growth retardation (in children)
Systemic • Anaemia (depression, fatigue) • Anorexia, weight loss, cachexia; hypothermia
C H R O N I C R E N A L FA
K correct • Particular concern during acute exacerbations • Consider treating acidosis, but NaHC03 problematic due to high Na* content
Intake - salt / fluid • Fluid-overload: 1 salt and fluid intake, until normal CVP or JVP obtained • Fluid-depleted: e.g. post-ATN, post-obstruction, chronic TIN -1 salt and fluid intake, until UO > 21 / day
Diuretics • High-dose furosemide ± metolazone • ACE inhibitors: renoprotective in diabetes; contraindicated in renal artery stenosis
Dialysis • Haemodialysis:
Method: 4 hrs / session; 3 sessions / week; 250 ml / min blood dialysed via forearm AV fistula Advantage: can vary dialysate composition; flow rate or pressure (.*. diffusion gradient) Disadvantage: low creatinine clearance: 6 ml/min; loss of amino acids, vitamins; no Vit D; EPO *: Arterial injury: haemorrhage, thrombosis, ischaemia ('steal'), ABP: postural hypotension
Amyloid: /^ -microglobulin: carpal tunnel syndrome Aluminium toxicity: brain (dementia); bone marrow (anaemia); bone (osteomalacia)
• Chronic ambulatory peritoneal dialysis (CAPD): Method: introduce 21 dialysate into peritoneum and replace 3-4 x /day Advantage: slightly better creatinine clearance: 7 ml/min, but still loses amino acids and vitamins *: Infection of catheter, peritonitis; blockage, leakage
Intake fluid - mechanical back pain, genital oedema, hernia, haemorrhoids, hydrothorax Insulin resistance due to glucose loading from dialysate, obesity
Nutrition • Low protein (0.5 g/kg/day - i es uraemic toxins and acidosis); high carbohydrate; low fat • Haematinics (Fe, folate, Vit B12) and Vit C (as lost on dialysis)
NSAIDs - avoid; also avoid aminoglycosides EPO (human recombinant erythropoeitin, slow-IV or subcut)
&: ABP T; thrombocytosis; flu-like syndrome - may also require occasional blood transfusion with diuretic cover
Y : hYperlipidaemia - simvastatin hYperglycaemia - avoid metformin, chlorpropamide; caution with insulins (due to risk of 'hypos') hYperP04aemia - Rx first to avoid ectopic calcification: P04 restriction; oral P04 binders: MgC03 or CaC03 hYpoCalcaemia - la-hydroxylated cholecalciferol; calcitriol; CaC03, high-dose: 1 es PTH and i es P04
Symptomatic • Hiccups or pruritus: chlorpromazine • Peptic ulcers: omeprazole
Surgical - renal transplant % : • Rejection (immunologic, ureteric anastomosis failure); immunosuppression (infections, neoplasia)
• Vascular: polycythaemia, atherosclerosis, hypertension Secondary renal failure: treat underlying cause - diabetes, hypertension, SLE, etc.
