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GI and Renal Exam 1 > 9 - Podiatric Manifestations of End Stage Renal Disease > Flashcards

9 - Podiatric Manifestations of End Stage Renal Disease Flashcards

1
Q

What does it mean when a patient is in end stage renal disease?

A

The patient will be on dialysis

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2
Q

What is the leading cause of end stage renal disease (ESRD)?

A

Diabetes

45% of cases

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3
Q

What is a diabetic patient’s risk of developing an ulcer?

A

25% of diabetic patient’s will develop ulcer during lifetime

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4
Q

What are the complications of renal disease?

A
  • PAD
  • Neuropathy
  • Derm disorders
  • Psychosocial issues
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5
Q

Describe the case of PAD and renal disease

A
  • 15% of patients with ESRD have PAD
  • As renal function decreases, phosphate levels increase
  • Calcium and phosphorus deposit in the vascular bed leading to calcified vessels
  • ESRD linked with hyperparathyroidism
  • High C reactive protein (CRP) contributes to PAD
  • Dialysis patients shown to have high CRP
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6
Q

What can you see on an x-ray of a patient with PAD and renal disease?

A
  • Calcification of arteries in the lower extremity
  • Posterior tibialis, dorsalis pedis and branches
  • You lose the elasticity of blood vessels
  • Can even effect small vessels and lead to more problems
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7
Q

Describe neuropathy and renal disease

A
  • 50-60% of hemodialysis patients have neuropathy
  • Uremia on its own can cause neuropathy
  • Autonomic neuropathy in 45-60% of patient
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8
Q

Describe uremia as a cause of neuropathy

A
  • Shows similar distribution as diabetic neuropathy

- Can get motor neuropathy and fat pad atrophy

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9
Q

Describe autonomic neuropathy

A
  • Postural hypotension
  • Shunting of cutaneous capillary beds
  • Atrophy of sebaceous and sweat glands

Dry skin (cracks in skin) and less blood flow (slow healing)

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10
Q

Describe susceptibility to infections

A

Uremia a cause of immune dysfunction

  • Impairs polymorphonuclear cells
  • Impaired resistance to bacteria
  • Impaired T cell function

Higher rate of polymicrobial infection

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11
Q

What are the dermatological manifestations?

A 
Acquired perforating dermatosis
Porphyria cutanea tarda
Calcinosis Cutis
Calciphylaxis
Nephrogenic systemic fibrosis
Uremic pruritus  
Foot ulcer
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12
Q

What is acquired perforating dermatosis?

A
  • Characterized by transdermal elimination of material from dermis
  • Scattered cone shaped and plugged keratotic papules, plaques and nodules
  • Located in high friction areas (lower extremities most common)
  • Lesions pink in fair skin, brown in darker skin
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13
Q

How do you treat acquired perforating dermatosis?

A
  • Potent corticosteroids
  • Topical or oral retinoids
  • Vitamin A
  • Keratolytics
  • UVB light therapy
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14
Q

Describe porphyria cutanea tarda

A
  • Disorder of heme biosynthesis
  • Vesicles (small blisters) erupt in sun exposed areas
  • Not as common now because iron overload in dialysis not as prevalent
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15
Q

How do you treat porphyria cutanea tarda?

A
  • Manage iron overload
  • Minimize sun exposure
  • Minimize any photosensitizing medication
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16
Q

What is calcinosis cutis?

A
  • Firm papules, plaques or nodules
  • Occasionally can exude white chalky substance
  • Found near joints or on fingertips
17
Q

How do you treat calcinosis cutis?

A

Treatment is management calcium and phosphorus levels

18
Q

What is calciphylaxis?

A
  • Get calcification and obstruction of small and medium cutaneous vessels
  • Hyperplasia of tunica media and tunica intima
  • Septal and/or lobular subcutaneous necrosis
19
Q

What is the result of this pathology?

A
  • All this leads to distal ischemia, painful ulcers and possible amputation
  • Is often fatal
20
Q

Describe the incidence of calciphylaxis

A

Exact etiology unknown

High incidence in

  • Dialysis patients
  • Hyperparathyroid patients
  • Combined
21
Q

How do you treat calciphylaxis?

A
  • Debridement and local wound care (fibrinolytics)
  • Hypophosphatemic diet
  • Calcitriol supplementation
  • Pain management
  • Hyperbaric oxygen (need daily treatment)
22
Q

What do you need to know about pain control in patients with ESRD?

A

Do not want to use

  • NSAIDs due to kidney function
  • Corticosteroids may make calciphylaxis worse

Pretty much need to need narcotics for pain control

23
Q

What is nephrogenic systemic fibrosis?

A
  • Seen in patients with ESRD with exposure to gadolinium

- Usually see symptoms 2-4 weeks after exposure

24
Q

Describe the pathology of nephrogenic systemic fibrosis

A

Location

  • Starts in lower extremity first
  • Can move up to upper extremities, and trunk
  • Spares the head

Other manifestation

  • Bilateral fibrotic or brawny induration of the skin
  • Thickened, indurated erythematous raised skin lesions
  • Can lead to permanent contractions
  • “peau de orange” appearance

Differential dx
- Scleroderma, systemic sclerosis, calciphylaxis

25
Q

What is the prognosis of nephrogenic systemic fibrosis?

A

Not good

  • No proven efficacious treatment
  • 20% modestly improve
  • 28% don’t improve
  • 28% die
26
Q

Describe uremic puritus

A
  • Severe itching of the skin
  • Pathophysiology unclear
  • Excessive scratching leads to breaks in skin which may lead to infection
  • Nalfurafine and Naltrexone can be helpful to reduce itching
27
Q

What is the possible pathophysiology?

A

Immunohypothesis
- Systemic inflammation

Opioid hypothesis
- Overexpression of opioid µ receptor with down regulation of ĸ opioid receptor

28
Q

Describe the Kaminksi study on foot ulcers

A

Aim
- To determine the prevalence of risk factors for foot ulcers in patient with ESRD and/or DM

Groups

  • Group 1 – ESRD without DM
  • Group 2 – DM without ESRD
  • Group 3 – coexisting ESRD and DM
29
Q

What were the results?

A

The biggest risk factors

  • Peripheral neuropathy
  • Vascular insufficiency

This is an additional risk factor…

  • Podiatry attendance
  • Patients aren’t necessarily going to see their podiatrist when they have a foot problem
30
Q

What else did they find?

A
  • In this study, those with both DM and ESRD had highest incidence of ulcer (27%) and LEA (20%)
  • Not significantly higher than other groups though
31
Q

Describe the Ndip study on foot ulcers and dialysis

A
  • Looked at dialysis as an independent risk factor for ulceration
  • Study patients had Stage 4 or 5 renal disease with glomerular filtration rate of
32
Q

How did they assess the risk in this study?

A

Internation Working Group on the Diabetic Foot (IWGDF) Classification
- Used to assign risk for foot problems

Risk groups

  • Risk 0 – no recognizable risk factor
  • Risk 1 – neuropathy with no other risk factors
  • Risk 2 – PAD with or without neuropathy
  • Risk 3 – current foot ulcer, history of foot ulcer or prior amputation
33
Q

What did they find in this study?

A
  • Prevalence of foot ulcers was 5 times higher in the dialysis group
  • Lower extremity complications (neuropathy, PAD and amputation) was 2 times higher in dialysis group
34
Q

What are the theories of why those on dialysis are on higher risk?

A
  • During dialysis there is a reduction in skin microcirculation and tissue oxygenation
  • Constant change in fluid volume in the tissues
  • Less likely to inspect feet and go to podiatry visists
35
Q

Describe depression in the dialysis patient population

A

20-30% of hemodialysis patients suffer from depression

Leads to decrease in care

  • Less self monitoring
  • Missed appointments
  • Compliance
36
Q

What nutritional deficits do we see in patients on dialysis?

A
  • Albumin

- Zinc

37
Q

What is zinc needed for?

A
  • Needed for keratinocyte migration

- Protects against apoptosis

GI and Renal Exam 1 (16 decks)

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