Chronic Renal Failure - College of Pharmacy-Handout2012

Patient case 1 pmh uneventful fh father htn x 20

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Patient Case #1 PMH: uneventful FH: Father – HTN x 20 years, Mother – Lupus x 20 years, 1 older brother and sister alive and well SH: - smoking, - drugs, + alcohol (2-3 drinks on weekends, + caffeine (2-3 cups a day) Meds: Multivitamin daily, Motrin as needed for pain (training for a marathon past few months)
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Clinical Manifestations of Chronic Renal Failure
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Fluid and electrolytes Volume expansion or increased extracellular fluid Edema and ascites BP, pulmonary congestion and weight gain Hyponatremia Hemodilution from volume overload Hyperkalemia Hyperphosphatemia Hypermagnesemia
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Acid-base balance Kidneys regulate pH by eliminating hydrogen ions and regenerating bicarbonate With GFR phosphates, sulfates and organic acids accumulate and ammonia production Net result is metabolic acidosis Stabilizes due to buffering capacity of bone Hyperventilating to blow off CO 2 – lethargy and somnolence
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Renal osteodystrophy Alterations of calcium, phosphate and vitamin D occur early in disease state 2200 GFR decreases phosphate excretion and serum phosphate levels 2200 serum phosphate levels cause serum calcium levels Together cause in parathyroid hormone (PTH) release
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Renal osteodystrophy 2200 PTH causes increase in calcium Renal reabsorption GI absorption Bone resorption CRF reduces conversion of vitamin D to the active form – further diminishing calcium absorption Normalization of calcium and phosphate causes negative feed back and PTH levels to normal
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Parathyroid Action
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Renal osteodystrophy Osteitis fibrosa High bone turnover disease Bone resorption and formation Excessive bone matrix with low mineralization Porous bones prone to fractures Osteitis fibrosa cystica – later stages
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Renal osteodystrophy Osteomalacia Low turn over with diminished mineralization Vitamin D, acidosis Aluminum salts and dialysate toxicity Adynamic osteodystrophy Low turn over Calcium and vitamin D treatments Bone tenderness and weakness
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Cardiovascular Hypertension Salt and water retention peripheral vascular resistance renal vasodilator prostaglandins renin-angiotensin system
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Cardiovascular Heart Disease Left ventricular hypertrophy and ischemic heart disease Volume overload, shunting of blood through AV fistula, anemia and HTN Congestive heart failure and pulmonary edema Contributing factors include: HTN, anemia, DM, dyslipidemia and coagulopathies
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Cardiovascular Pericarditis 20% of chronic dialysis patients Metabolic toxins and uremia Depress myocardial contractility Chest pain upon respiratory accentuation Pericardial rub
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Gastrointestinal Uremia causes nausea, vomiting and anorexia Uremic fetor – malodorus breath and impaired taste sensation due to breakdown of urea to ammonia in saliva Uremic gastroenteritis – mucosal ulcerations throughout the GI tract PUD – 25% incidence in uremic patients PTH increases gastric acid secretion
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