Nephrology Hypertension

Medical Management of the Dialysis Patient: Hyperphosphatemia

Does this patient have hyperphosphatemia? Signs and symptoms Typically detected by routine laboratory tests Symptoms may include pruritus, bone or joint pain Signs may include radiographic evidence of vascular calcification, eye deposition leading to red eye or conjunctivitis, and calciphylaxis Values may vary depending on time of day (circadian variation), prandial status, relationship to timing…

Medical Management of the Dialysis Patient: Nutritional Assessment and Support

Is this patient malnourished? Malnutrition is an important issue in dialysis patients because it can lead to suboptimal health and, in certain circumstances, even frank illness. Moreover, dialysis patients are particularly predisposed to malnutrition because of a combination of underlying disease states, frequent advanced age, lower socioeconomic status and education levels, and the effects of…

Medical Management of the Dialysis Patient: Blood Pressure and Fluid Volume Management

Does this dialysis patient have hypertension? The National Kidney Foundation’s Kidney Disease Outcome Quality Improvement program (KDOQI) published a guideline calling for a pre-dialysis systolic blood pressure (SBP) <140 mmHg. The evidence supporting this guideline was graded as weak since it was largely extrapolated from the general population in which a continuous reduction in cardiovascular…

Medical Management of the Dialysis Patient: Infectious Complications

Does this patient have infectious complications? What is the scope of the problem? Infection is the second leading cause of mortality in patients with end-stage renal disease (ESRD), next only to cardiovascular disease (Figure 1). Septicemia accounts for most of the infectious deaths Figure 1. Mortality caused by sepsis in ESRD patients compared to the…

Peritoneal Dialysis: Patient Selection

Identifying Patients There are three types of PD patients: those that start their dialysis therapy with PD; those who turn to PD after complications from HD; and those who turn to PD after a failed transplant. It is important to remember that modality education should be offered to each group and patients should be reminded…

Dialysis: Planning for Renal Replacement Therapy

Does this patient have chronic kidney disease requiring preparation for renal replacement therapy? As chronic kidney disease (CKD) progresses, an essential component of care becomes educating and preparing patients for end stage renal disease (ESRD) and possible treatment options. This chapter focuses on issues surrounding treatment for advanced renal failure and steps toward preparation for…

Kidney Transplantation: Transplant Immunology and Use of Immunosuppression

Does this patient have too much or too little immunosuppression? Choosing the proper immunosuppression for a patient involves balancing the risk of immunologic graft injury against the risks of infection and malignancy. This requires an understanding of basic immunology, the mechanism of action and side effects of immunosuppressive medications, and a thorough immunologic risk assessment.…

Acute Kidney Injury: Contrast Nephrotoxicity

Does this patient have contrast-associated acute kidney injury? Description of the problem Contrast-associated acute kidney injury (CA-AKICA-AKI) is characterized by an abrupt decline in kidney function following the intravascular administration of iodinated contrast media. CA-AKI manifests as an increase in the serum creatinine concentration (SCr) within 2-5 days following the administration of contrast. In severe…

Acute Kidney Injury: Cardiorenal Syndromes (acute decompensated heart failure and worsening renal function)

Does this patient have acute decompensated heart failure and worsening renal function? The co-existence of cardiac and renal impairment has been called “Cardiorenal Syndrome (CRS).” Initial attempts at defining CRS described it as a state in which therapy to relieve heart failure symptoms was limited by worsening renal function. However, the bidirectional interplay between these…

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