1. Uremic neuropathy
신장내과 R2 장준용

2. Introduction Common among ESRD patient
Indication to Initiate Dialysis in CKD patient

3. Uremic polyneuropathy
Distal, Symmetric, Mixed sensorimotor
Demyelination & Axonal degeneration
60-100% of ESRD patient
In CKD patient
Cr : 35%
Cr : 89%
Cr 5 이상 : 100%
More common in Man
Distal 일수록 Severe / CNS 를 침범하기도 함.
증상이 없는경우도 많음

4. Uremic polyneuropathy Contributing factor
Deficiency of
Thiamine, Zinc, Biotin, Transketolase activity
Increase of
Phenols, Myoinositol, B2-microglobulin
Other middle molecular weight substance
Hyperparathyroidism
Vit B7

5. Uremic polyneuropathy Clinical manifastation
Initial : Sensory / Progress Proximally
Tingling  Burning pain
Advanced : Motor
Myoclonus, Paralysis
Physical Examination
Position & Vibration, DTR(Achilles reflex)
Paradoxical heat sensation
Muscle atrophy (Advanced)
긴 Axone 의 말단부터 -> Knee 까지 Progression 하면 Hand 에 도 영향.

6. Uremic polyneuropathy Diagnosis
Clinical presentation + Electrophysiologic study
Motor NCV is M/C parameter
Sensory NCV is more sensitive
Electrophysiologic study can be used for Monitor after treatment

7. Uremic polyneuropathy Differential diagnosisDM
SLE
Systemic vasculitis
Multiple myeloma
Amyloidosis
GVHD

8. Uremic polyneuropathy Differential diagnosis
Guillain-Barre syndrome
Areflexia, Progressive muscle weakness
Progression of Symptom to 4 Weeks
Elevated protein in CSF
Membranous nephropathy
Predominance of Motor symptom

9. Uremic polyneuropathy Treatment
CKD  Dialysis or Transplantation
HD = CAPD < Transplantation
ESRD on Dialysis
Check Dialysis prescription
Increase the amount of delivered Dialysis
Transplantation

10. Uremic polyneuropathy treatment
Medical treatment
Gabapentin
TCA : Desipramine, Imipramine
Anticonvulsant : Carbamazepine, Phenytoin, Topiramate
Pregabalin, Dulexetine
Tramadol, Low dose narcotics for break through pain
Baclofen, Mexiletine, Dextromethorphan
Gabapentin : mg daily + 300mg after each dialysis
Antidepressant Ib

11. Uremic polyneuropathy treatment
Physical exercise
Ankle-foot orthosis
Splint
Walking assistance device
Gabapentin : mg daily + 300mg after each dialysis
Antidepressant

12. Uremic polyneuropathy Prognosis
The degree of improvement directly related to Severity of symptom at initiation of dialysis
Gabapentin : mg daily + 300mg after each dialysis
Antidepressant

13. Uremic Mononeuropathy Carpal tunnel syndrome
Most common
By Dialysis related Amyloidosis
By Fistula or graft
Increased v. pressure during dialysis Extravasation of fluid Ext. compression of n.
Bleeding from access
Vascular steal phenomenon
Calcium phosphate deposit
Splint or Surgery

14. Uremic Mononeuropathy Ulnar neuropathy
Up to 50% of patient By
Positioning during HD, Uremic tumoral calcinosis
Symptom
M. weakness, Sensory loss (Hypothena area)
Conservative treatment or Surgery
팔꿈치를 기대지 말기, 굽힌 자세로 오래있지 말기, Night splint
명확한 구조적 이상이 없을시 / Electrophysiologic evidance, Clear weakness/ 2년이상된 만성적 병변은 수술의 의미가 없음

15. Uremic Mononeuropathy Femoral neuropathy
By Femoral v. catheterization
KT recipient (2%)
Thigh weakness, Pain or Sensory loss of Calf & Thigh
Observation

16. Uremic Mononeuropathy Acute ischemic monomelic neuropathy
Neuropathy affects forearm immediately following AVF or Graft surgery
Risk factor
DM neuropathy, Upper arm, PAOD
Both motor & Sensory symptom
Banding or ligation of access

17. Uremic Mononeuropathy Cranial n. neuropathy
Facial n.
Vestiulocochlear n.
Optic n.