Disease Description (Causes and Symptoms)
Definition: Uremia is a clinical syndrome that occurs when kidney function is severely impaired, causing waste products and electrolytes to accumulate in the body. Pathophysiology: As the glomerular filtration rate (GFR) decreases, uremic substances (such as urea and creatinine), electrolyte imbalances, and acid–base imbalances accumulate, while fluid overload and inflammatory and toxic effects cause multisystem symptoms. Causes: It occurs when kidney damage progresses due to trauma, medications (including nephrotoxic drugs), shock, toxins, acute or chronic glomerulonephritis, hypertension, pyelonephritis, and other conditions.
Major Symptoms (Clinical Findings)
- General: Fatigue, malaise, loss of appetite, nausea and vomiting (reported when kidney function has decreased by approximately 90%)
- Nervous system: Headache, impaired memory and concentration, dizziness, muscle weakness, decreased consciousness or coma, seizures
- Respiratory/cardiovascular: Shortness of breath (during exercise), edema, possible heart failure and arrhythmia
- Bleeding tendency: Bleeding gums, nosebleeds, heavy menstrual bleeding, etc.
- Skin: Severe pruritus, hyperpigmentation
- Skeletal/endocrine: Osteomalacia and fractures, amenorrhea and decreased sexual function
- Electrolyte/metabolic abnormalities: Hyperkalemia, metabolic acidosis, etc.
- Characteristic: Symptoms may be mild even when kidney function has decreased by approximately 75%, so diagnosis is often delayed.
Diagnostic Support Tests (Summary)
- Blood tests: Blood creatinine, BUN (blood urea nitrogen), electrolytes, acid–base status, and anemia-related tests
- Urinalysis: Proteinuria, hematuria, etc.
- Imaging tests: Renal ultrasound (to assess size and structure), nuclear medicine tests
- If necessary, kidney biopsy (to determine the pathological cause)
Treatment Methods
Goal: Treat the underlying disease, correct uremic symptoms and complications, delay the progression of chronic kidney failure, or provide renal replacement therapy.
Conservative Treatment (Initial and Ongoing Management)
- Treatment of the underlying disease (correction of infection, inflammation, hypertension, etc.)
- Medication adjustment: Discontinue or adjust the dosage of nephrotoxic drugs (e.g., some NSAIDs and some antibiotics), and actively manage risk factors such as blood pressure and diabetes (use caution regarding changes in kidney function with ACEi/ARBs, etc.)
- Correction of electrolyte and acid–base imbalances: Emergency treatment of hyperkalemia, bicarbonate, etc., for metabolic acidosis
- Treatment of anemia: Iron supplementation and use of erythropoietin-stimulating agents (ESAs), depending on the indication
- Mineral and bone metabolism management: Phosphate binders, active vitamin D preparations, etc.
- Nutrition and lifestyle management: Adjust intake of protein, sodium, potassium, and phosphorus (depending on the stage of kidney function), manage fluid intake, and monitor weight and blood pressure at home
- Management of infection and bleeding risks: Monitor immune- and bleeding-related complications
Replacement Therapy (Renal Replacement Therapy; RRT)
- Hemodialysis (HD): Performed for symptoms of uremia (coma, myocardial complications, treatment-resistant fluid overload, life-threatening hyperkalemia, etc.) or when uremic substances, electrolytes, or acidosis require urgent correction based on test results
- Peritoneal dialysis (PD): Considered for patients who are hemodynamically unstable or require management at home
- Kidney transplantation: Considered, when indicated, to improve long-term prognosis and quality of life
Emergency Indications (Examples of Criteria for Recommending Dialysis)
- Excessive fluid overload that does not respond to treatment (such as pulmonary edema)
- Hyperkalemia accompanied by electrocardiographic abnormalities
- Uncontrolled metabolic acidosis
- Uremic encephalopathy (coma or seizures) or uremic pleuritis or pericarditis
Precautions and Risk of Complications
- Medication dosage adjustment and avoidance of nephrotoxic drugs are necessary
- Infection (especially dialysis-related) and cardiovascular disease are major causes of death
- Persistent bone and metabolic abnormalities, anemia, bleeding tendency, or electrolyte abnormalities can cause serious complications
Checklist Before an Outpatient Visit (Including Preparation Items and Example Questions)
What to Bring
- A list of all medications currently being taken (including prescription drugs, over-the-counter medications, herbal medicines, and supplements)
- Recent test results (blood tests: creatinine, BUN, electrolytes, Hgb, etc.; urinalysis) and the dates of the tests
- Records of blood pressure and weight changes (to check for swelling due to fluid retention)
- A symptom diary (including the onset and aggravating factors of nausea and vomiting, pruritus, changes in consciousness, and changes in sleep or appetite)
- If currently receiving dialysis or with a history of dialysis: dialysis schedule and information about dialysis access (arteriovenous fistula or catheter)
- Allergies and history of surgeries and hospitalizations
Key Information to Tell the Doctor First at the Outpatient Visit
- Recent symptoms (when they began, how often they occur, and aggravating factors)
- Medication and supplement history (especially NSAIDs, anticoagulants, ACEi/ARBs, and antibiotics)
- Changes in blood pressure, weight, and food intake
Examples of General Questions to Ask the Doctor
- What are the side effects of this medication, and what symptoms should prompt me to contact you immediately?
- What is my current kidney function (eGFR and creatinine level), and what is the prognosis?
- What are the criteria for needing dialysis (hemodialysis or peritoneal dialysis) or a kidney transplant?
- What should I be careful about regarding my diet (protein, sodium, potassium, and phosphorus) or fluid intake?
- Do any of the medications I am taking need to be adjusted or discontinued?
Examples of Disease-Specific Questions
- What are my recent eGFR (or creatinine) levels, and given my current condition, when might I need to start dialysis?
- Is it safe to continue taking specific medications I am currently taking (e.g., NSAIDs, ACE inhibitors/ARBs, anticoagulants, antidiabetic medications, etc.)? If necessary, what alternative medications are available?