Uremia

Pt with h/o ESRD presents with BUN >60 mg/dL. Reports confusion, fatigue, anorexia, vision loss, chest pain, N/V, erectile dysfunction, decreased libido, pruritus, LE numbness/tingling, seizures. Medications include diuretics, NSAID, ACE inhibitor, macrolide antibiotic. Fever, orthostatic hypotension, PERRLA, dry mucous membranes, pleuritic chest pain, pericardial friction rub on exam.

• Obtain CBC, CMP, PT/PTT/INR, ABG, urinalysis with microscopy

• Albumin:creatinine ratio >300 mg/g

• RBC casts on urine microscopy

• EKG shows no diffuse ST or T-wave elevations

• Treatment

  • Administer 1L bolus NS and re-evaluate volume status

  • Stop diuretics, NSAID, ACE inhibitors; transition to alternative antibiotic regimen

  • Pt actively bleeding; consider desmopressin, cryoprecipitate, estrogen, and/or dialysis to improve platelet function

  • Place hemodialysis catheter and initiate emergent hemodialysis

  • Pt will require long-term renal replacement therapy; discuss hemodialysis versus peritoneal dialysis

• Consults

  • Consult surgery about placement of AV fistula vs. peritoneal dialysis catheter pending pt preference

  • Consult nephrology

• Pt educated about s/sx of uremia

Notes

• Hypovolemia is a common cause of transient declines in kidney function

• Decreased glomerular filtration: NSAIDs prevent afferent arteriole dilation and ACE inhibitors prevent efferent arteriole constriction

• Aminoglycoside (e.g. gentamicin, tobramycin, neomycin) toxicity may precipitate uremia

• Uremia impairs platelet function and increases bleeding risk

• Uremic pericarditis presents as fever, pleuritic chest pain, friction rub. Unlike other pericarditis etiologies, there is no ST or T-wave elevation on EKG.

• AV fistulas are used for hemodialysis 2-5x per week and require at least 1 month to mature

• Uremic neuropathy is characterized by LE numbness/burning and may be a contraindication to initiating dialysis

• Severe uremia may cause transient cortical blindness