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Gastrointestinal Manifestations of Chronic Kidney Disease

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Gastrointestinal Manifestations of Chronic Kidney Disease Rev. Colomb. Nefrol. 2017;4(1): 3 - 12. http://www.revistanefrologia.org InvestigaciónOriginal Research original http://doi.org/10.22265/acnef.4.1.266 Gastrointestinal manifestations of chronic kidney disease Manifestaciones gastrointestinales de la enfermedad renal crónica Mario Santacoloma Osorio1,*, Germán Camilo Giraldo2 1 Medical specialist in Internal Medicine and Gastroenterology, University of Caldas; University of Paris VII. Associate Professor, University of Caldas, Colombia 2 General practitioner, University of Manizales; Specialist Internal Medicine, University of Caldas, MEDICAL research group, Caldas, Colombia Abstract Introduction: There is a wide variety of gastrointestinal clinical manifestations that may increase the deterioration of the quality of life in patients with chronic kidney disease (CKD), which are manageable if properly detected. Objective: The objective of this work is to perform an updated and analytical re-view of the literature on the manifestations in the digestive tract of patients with chronic deterioration of renal function. Results: The results indicate that some of the signs and symptoms on the gastrointestinal tract of patients with CKD are individual, and non-specific symptoms such as anorexia, nausea and vomiting predominate, which can be controlled with adequate renal replacement therapy; while others, rarer, such as ascites associated with dialysis, impoverish the prognosis and illustrate the need for transplantation. Key words: Gastrointestinal diseases, gastrointestinal tract, chronic renal failure, digestive signs and symptoms, symptom assessment, uremia. http://doi.org/10.22265/acnef.4.1.266 Resumen Introducción: existe una amplia variedad de manifestaciones clínicas gastrointestinales que pueden aumentar el deterioro de la calidad de vida en los pacientes con enfermedad renal crónica (ERC), que son manejables si se detectan adecuadamente. Objetivo: el objetivo de este trabajo es realizar una actualización y revisión analíti-ca de la literatura sobre las manifestaciones en el tracto digestivo de pacientes con deterioro crónico de la función renal. Resultados: los resultados indican que algunos de los signos y síntomas sobre el tracto gastrointestinal de los pacientes con ERC son individuales, y predominan los síntomas inespecíficos como la anorexia, las náuseas y el vómito, los cuales pueden controlarse con una adecuada terapia de reemplazo renal; mientras que otros, más raros, como la ascitis asociada a la diálisis, empobrece el pronóstico e ilustra la necesidad de trasplante. Palabras clave: enfermedades gastrointestinales, tracto gastrointestinal, insuficiencia renal crónica, signos y síntomas digestivos, evalua- ción de síntomas, uremia. http://doi.org/10.22265/acnef.4.1.266 Referenciar este artículo: Santacoloma Osorio M, Giraldo GC. Manifestaciones gastrointestinales de la enfermedad renal crónica. Rev. Colomb. Nefrol. 2017;4(1): 17 - 26. Correspondencia: Mario Santacoloma Osorio: [email protected] Recibido: 10-11-16 • Aceptado: 30-01-17 • Publicado en línea: 20-02-17 Santacoloma Osorio M, Giraldo GC 3 Rev. Colomb. Nefrol. 2017;4(1): 3 - 12. http://www.revistanefrologia.org Introduction necessary to improve the quality of life of these patients sick. The clinical manifestations found in this subgroup can be distributed as follows (Table he digestive pathologies are frequent in 1). patients with chronic kidney disease (CKD), Tthere is a clear underreporting of the disease, Nonspecific symptoms: resulting in the lack of knowledge of the mechanisms that lead to a wide range of symptoms, from nausea Usually present in patients with stage VREC: to Anorexia, and disturbances in the balance of anorexia, dyspepsia, nausea, vomiting and uremic 4,5 sodium and potassium, contributing to a final state fetor. They have a prevalence of around 60% . of malnutrition. However, it is estimated that about In most studies it does not differ from the general 80% of patients present some type of symptom in population. the gastrointestinal tract (GIT) during the course Nausea and vomiting: these are the result 1 of their disease . However, some of them, such as of uremic syndrome, changes in fluids and dyspepsia, may have prevalence not different from electrolytes during dialysis. They disappear with 2 that of the general population . renal replacement therapy1, 2. Of these, the origin In the symptoms of GIT in patients with of anorexia has been studied extensively, finding chronic kidney disease, there is a multifactorial within the contributing causes: stomatitis, anemia, origin. Among them is the retention of toxic and acidosis, drastic changes in the diet, forced toxic products (endogenous and exogenous), with feeding or the use of supplements, alterations alteration of the homeostasis of the extracellular in taste of food, uremia, diuretics, dehydration, environment, iatrogenic origin, the influence of gastroenteritis, hypokalemia, hyperazoemia and 4,6 the underlying disease that led to CKD, the higher hyperparathyroidism . prevalence of anxiety disorders, Depression and Ureic Fetus: ammoniacal odor produced by irritable bowel syndrome, therapy and type of renal nitrogenous metabolites in saliva. It is characteristic replacement therapy, alteration in the microbiota the metallic taste that they present7. and persistent trans mural inflammation of the intestinal mucosa. All of them cause deleterious Hypo: posterior to diaphragmatic irritation effects, not only on the function of the digestive that disappears with the substitution therapy. If tract but also on many organs and systems, which it is not corrected, it finds adequate response to can present not only a series of symptoms but also chlorpromazine and metoclopramide4. suffer complications, which in some cases may be Diarrhea: in these patients there are profound asymptomatic, but which manage to constitute A changes in the composition of the intestinal risk for possible complications1-3. microbiota and alteration of the structure and The management of CKD is aimed at preventing function of the intestinal epithelial barrier. These or attenuating the appearance of systemic clinical alterations lead to the generation and absorption manifestations resulting from diminished renal of harmful and toxic byproducts that contribute to function, and to allow the symptomatic management systemic inflammation, uremic toxicity, malnutrition of patients when dialysis and transplantation are and other morbidities. 4 Gastrointestinal manifestations of chronic kidney disease Rev. Colomb. Nefrol. 2017;4(1): 3- 12. http://www.revistanefrologia.org Table 1. Distribution in the gastrointestinal tract Oropharynx Stomatitis, gingivitis, mumps Esophagitis, gastro-esophageal reflux, biliary reflux, gastritis, duodenitis, peptic ulcer, angiodysplasias and Upper digestive tract digestive bleeding. Constipation, diverticular disease, ischemic colitis, uremic colitis, perforation of the colon, angiodysplasias Lower digestive tract and digestive bleeding. Pancreas and bile duct Pancreatitis, cholelithiasis. Peritoneum Ascites associated with dialysis, peritonitis. Nonspecific Anorexia, nausea, vomiting, uremic fetor. Inespecíficos Anorexia, nauseas, vómito, fetor urémico. Source: own elaboration It can present either acutely or chronically: the derived from protein metabolism contributes to the acute form is distinguished by infectious processes pathophysiology. These measures can alleviate the or intestinal irritation, by peritoneal sparings symptoms of the disease4, 10-12 or changes in diet; the chronic form requires complementary studies (co-procultive antibiogram), Once these symptoms are present, they are in order to detect the toxin for Clostridium difficile considered a good clinical marker of the need to - if there is suspicion - and endoscopic study. Once start with -or increase- dialysis therapy before they the infectious origin is ruled out, loperamide is an contribute significantly to malnutrition, since it is a effective measure. The treatment consists in the poor prognostic factor in morbidity and mortality 12,13 evaluation of the hydroelectrolytic balance (ORS: among patients . If symptoms do not subside after controlling the amount of potassium and phosphorus initiation of substitution therapy, it is necessary to individually). For its part, its infectious form (also consider other possible causes, such as side effects known as “traveler’s diarrhea”) causes fever and of medications (more frequent) or anxiety disorders, lasts for more than a week. Immunosuppression: depression or inter-current processes. antimicrobial therapy (ciprofloxacin). Once the If the technique is peritoneal dialysis, anorexia infectious origin has been ruled out, the use of and inappetence may be due to sensation of 8,9 loperamide is recommended . abdominal fullness, caused by dialysis fluid or by Changes in the patient on peritoneal dialysis: absorption of glucose through the peritoneum1,12. one of the main findings at this level is the increase Diseases of the oropharynx: in some in leptin levels. This hormone, secreted by the cases may exceed 90%, being more common adipocytes, modulates the sensation of satiety and hyperpigmentation of the lips. Stomatitis, gingivitis controls the ingestion and the energy expenditure. and mumps may accompany the uremic syndrome, For this reason, the hormone is associated with the but their frequency has decreased due to better occurrence of cases of anorexia and malnutrition. renal replacement therapy. These lesions may be
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