Oftentimes we can see low calcium and high phosphate with kidney disease so these can lead to issues with muscle spasms and twitching. And we mentioned this before but we can also see anemia in kidney disease, so low red blood cells or low hemoglobin, and this is an anemia of chronic kidney disease. So again this often occurs later in a kidney disease process – so chronic kidney disease – and this is because the kidney produces erythropoietin or EPO (“EPO”) and what erythropoietin does is it actually stimulates the bone marrow to produce red blood cells (so erythrocytes), and as the kidney becomes more and more damaged, it has less and less ability to produce erythropoietin so it actually produces less and less EPO or erythropoietin leading to less red blood cells being produced leading to this anemia of chronic kidney disease – so this is why we see anemia in chronic kidney disease. Now we mentioned that the kidneys are very important in excreting many toxins and in balancing electrolytes and one particular toxin is urea, so the kidneys normally filter and excrete urea. So urea is a breakdown product of protein metabolism, and when there’s kidney failure this leads to an increased urea in the blood – what we call uremia. So increased, abnormally high levels of urea in the blood and this uremia (this increased urea in the blood in our body) can lead to several different, very important signs and symptoms that we need to recognize. One of them is uremic pericarditis – so uremia can lead to pericarditis “itis” for inflammation of the pericardium, the uremia can cause inflammation of the layers of the pericardium along with some other metabolic toxins as well. So we can see patients having chest pain, often positional and maybe pleuritic as well. And uremia can also cause uremic encephalopathy – so we can see this in oftentimes more advanced kidney disease, so this encephalopathy can lead to an altered mental status oftentimes delirium in these patients and confusion as well. And related to uremic encephalopathy is asterixis, so when an individual has uremic encephalopathy, they can have this sign known as asterixis, so what is asterixis? It is actually a tremor flap at the wrist so what a clinician will do is they will get a patient to put their arms straight out in front of them, lift their wrist like so and get them to close their eyes, if the patient lets go of their hand or they lose control they’re not able to keep it in this position, it falls  here, they will quickly bring it back up into the original position this looks like a tremor flap, that’s why this is called a tremor flap and this is often due to an interruption of the postural pathway in the reticular formation.

This occurs bilaterally so we can see it in both hands and it is associated with metabolic diseases so we can see it in uremic encephalopathy but we can also see it in liver diseases as well and another symptom we can see in kidney disease patients is pruritis so pruritis is an itching sensation, so very itchy dry skin and this is again due to uremia, so uremia can cause a patient to feel very itchy on most parts of their body, and this will actually lead to excoriations, so scratch marks, on many parts of their body, so we can see this as a sign of kidney disease as well and this can also be known as uremic pruritis. So an itching sensation caused by increased urea in the blood and uremia can cause some other signs and symptoms as well including nausea and vomiting so patients who are in an advanced stage of kidney disease are oftentimes very nauseous and don’t feel very well. This is again caused by uremia, and this can lead to anorexia or weight loss so patients can become very thin again caused by uremia ultimately caused by this nausea and vomiting, so they have a very low appetite or decreased appetite. Now another important point to note is platelet dysfunction, and again this is due to uremia. So uremia can cause platelet dysfunction – so although platelets may look like they are in a normal level or in a normal range, they may be dysfunctional and this can look like thrombocytopenia or a low platelet count; so patients with platelet dysfunction secondary to uremia can experience increased gingival bleeding, so increased bleeding of their gums of their mouth, increased cutaneous bleeding, so if they cut themselves on their hand, the bleeding may be difficult to stop, epistaxis, so a nose bleed, petechiae and purpura are these little red and purple spots on the skin – so this is superficial bleeding within the skin and easy bruising so they can gently hit their arm on a surface and it can be bruised quite easily. So these are all signs of platelet dysfunction. So again platelet dysfunction, secondary to uremia – we see gingival bleeding, cutaneous bleeding, epistaxis, petechia, purpura and easy bruising, and we can also see increased risk of excessive bleeding in cases like menstruation, during surgeries, and during and after childbirth as well.

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