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What is Uremia?

What is Uremia?

Uremia (also called uremic syndrome) is a condition in which the urine enters the bloodstream, instead of being eliminated from the body. This occurs as a serious complication of the kidneys’ inability to excrete waste products from the body, such in the case of acute or chronic kidney disease, other forms of renal damage, or food poisoning. [1]

As the waste products accumulate in the blood, it reaches toxic levels, which results to deterioration of the body organs, and in severe cases, results to death [1]. This condition is also associated with electrolyte, fluid, and hormone imbalances, as well as metabolic disorders [2].

 

Uremia Pathophysiology

The kidneys play various important body functions such as fluid and electrolyte regulation, acid-base homeostasis, waste products elimination, and hormone production and excretion [2]. Normally, the body is able to eliminate waste products in the urine. However, in the presence of kidney failure, the waste products are retained in the blood [3]. The primary waste products that accumulate in the blood, contributing to uremia, are:

  • Creatinine: Uremia occurs when creatinine clearance is less than 10 mL/min. Some patients manifest symptoms even if with high creatinine clearance.
  • Blood Urea Nitrogen (BUN)
  • Mineral solutes (potassium, calcium, sodium) [1, 2]

When all of these waste products accumulate in the blood, at excessive levels, uremic poisoning may occur. [1]

 Uremia-Normal kidney function

Picture 1: Normal Kidney Function

Source: saravanahospital.com

Uremia Causes

Uremia is primarily caused by kidney conditions which impair its function to filter and eliminate the body’s waste products. Here are the specific conditions which may cause uremia:

Renal Causes of Uremia

1. Medications

  • Intravenous contrast material
  • High doses of NSAIDs (Non-steroidal Anti-inflammatory Drugs)

2. Kidney Conditions

  • Renal artery occlusion or embolism: A condition in which there is  an occlusion of the blood flow, going towards the kidney
  • Injury to the kidney
  • Kidney damage caused by diabetes or hypertension
  • Kidney diseases (kidney failure, kidney stones, kidney anomalies)
  • Surgery

3. Other Urinary tract disorders

  • Urinary tract stones
  • Bladder cancer
  • Prostate enlargement

Other Uremia Causes

1. Cardiovascular problems

  • Hypovolemic shock (Excessive bleeding)
  • Congestive Heart Failure: Ineffective pumping ability of the heart
  • Hypertension

2. Gastro-metabolic disorders

  • Excessive vomiting, diarrhea
  • Severe Dehydration: This causes fluids and electrolytes loss. This may be life threatening when not treated promptly.

3. Other system disorders/conditions

  • Burns
  • Lupus [1, 3, 4, 5]

 

Uremia Symptoms

Neuromuscular System Effects

1. Decreased Level of Consciousness

  • Drowsiness/sleepiness
  • Disorientation
  • Confusion
  • In severe cases, coma may occur.

2. Thought processing

  • Impaired thinking ability
  • Impaired memory
  • Less concentration for tasks

3. Motor problems

  • Muscle cramps
  • Seizures
  • Tremors
  • Restless leg

4. Other neuromuscular effects:

  • Personality changes (apathy, psychosis)
  • Fatigue, irritability
  • Slurred speech

Cardiovascular System Effects

1. Heart disease related symptoms

  • Angina
  • Palpitations
  • Hypertension
  • Arrythmia: Irregular heart beats
  • Pericarditis: A condition in which there are inflammation and fluid accumulation of the pericardium (sac that protects the heart).

Uremia-Pericariditis

Picture 2: Illustration on how urea causes pericarditis

Source: drsvenkatesan.wordpress.com

2. Artery Disease

  • Hardening of the arteries

3. Hemopoietic effects

  • Severe anemia
  • Platelet dysfunction: Causes high bleeding tendencies
  • Spontaneous bleeding or continuous bleeding caused by a minor injury

Respiratory System Effects

  • Difficulty of breathing/Shortness of breath
  • Chronic cough
  • Respiratory disorders: Pleural Effusion (Fluid accumulation in the lungs), Pneumonia, Uremic bronchitis, Pleurisy

Digestive/Gastrointestinal System Effects

1. Malnutrition and weight loss

  • Appetite loss
  • Nausea and vomiting
  • Protein deficiency

2. Gastrointestinal Disorders

  • Diarrhea
  • Abdominal Discomfort
  • Ulcers
  • Internal bleeding

4. Other conditions

  • Glossitis
  • Urine taste in breath
  • Oral ulcer/Mouth sores

Endocrine/Metabolic System Effects

1. Reproductive system related

  • Amenorrhea
  • Sexual Dysfunction

2. Metabolism

  • Insulin Resistance
  • Lowered body temperature
  • Decreased metabolism
  • Increased catabolism of muscle protein

3. Bone disease caused by:

  • Vitamin D deficiency
  • Hyperparathyroidism
  • Hyperphosphatemia

Dermatologic System Effects

1. Uremic frost

  • This is due to the urea secretion, coming from the sweat glands.
  • This causes skin irritation and itching.

Uremia-Uremic Frost

Picture 3: Uremic Frost

Source: cmaj.ca

2. Edema

  • Swelling of the extremities such as the legs

Uremia-Edema

Picture 4: Edema caused by kidney failure

Source: doctortipster.com

Bone Effects

  • Fragile bones
  • Cysts or non-cancerous bone tumors

Immune System Effects

  • Decreased production of white blood cells.
  • Immunosuppression (Weakened immune system) [1, 3,  4, 5]

 

Uremia Diagnosis

Laboratory Work-ups

1. Urine Test

Findings of the urine test may include:

  • Specific Gravity: 1.010 and 1.012
  • Presence of red blood cells, white blood cells, protein, and casts in the urine
  • Nocturia: Frequent urination at night time

2. Blood Test

This will include findings such as:

  • Hemoglobin levels of 80g/L and below; In end stage, it is reduced up to 20-30g/L
  • Low platelet levels, increased white blood cells
  • Reduced levels of plasma protein
  • Increased levels of creatinine and urea nitrogen
  • Decreased pH at the end stage [1]

3. Glomerular Filtration Rate (GFR)

Patients with abnormal levels of creatinine clearance should be assessed for GFR. This is used to diagnose the staging of Kidney damage. The stages are:

  • Stage 1: Kidney damage; Normal GFR (90 mL/min and above)
  • Stage 2: Kidney damage; mild GFR reduction  (60-89 mL/min)
  • Stage 3: Kidney damage; moderate GFR reduction (30-59 mL/min)
  • Stage 4: Kidney damage; severe GFR reduction (15-29 mL/min)
  • Stage 5: End-stage renal disease (below 15mL/min or dialysis patients)

Imaging Studies

1. Ultrasonography

  • Done to evaluate presence of obstruction at the ureters or bladder.
  • Also, it is performed to assess the size and shape of the kidneys.

2. CT Scan

  • Ordered when there are significant changes in the mental status of the patient.
  • It is indicated to assess the abdomen for any masses, stone, or other conditions.

3. Magnetic Resonance Imaging (MRI)

  • This is performed to examine the condition of the kidneys and if there are possible renal conditions which may contribute to the presence of uremia. [2]

 

Uremia Treatment

Acute Treatment

The prompt treatment given for cases of urea is given to stabilize the patient’s condition. This treatment is given within the first 24 hours following the diagnosis. It includes:

1. Medications

  • These are given to stabilize the cardiac output and blood pressure.
  • Example: Dopamine

2. IV therapy

  • Intravenous fluid
  • Blood transfusion

Ongoing Treatment

When the vital signs of the patient have been stabilized, treatment is continued for long-term. Long-term treatment involves:

1. Dialysis

  • For the patients who have chronic and severe renal impairment, this is advised for removal of waste products from the body.

Uremia-Hemodialysis

Picture 5: Hemodialysis

Source: summitmedicalgroup.com

Uremia-Peritoneal Dialysis

Picture 6: Peritoneal Dialysis

Source: uofmhealth.org

2. Dietary Modification

  • Low protein diet: This to reduce the workload of the kidneys. This is due to the fact that protein intake results to production of nitrogenous metabolic by-products and toxins.
  • More carbohydrate foods are needed for the reduction of protein metabolism.
  • Also, reduced phosphorus in the diet is advised. This is to decrease calcium deposition in the kidneys. Phosphorus-rich foods such as pumpkin seeds, watermelon seeds, mushroom, and yeast should be eaten in moderation. [1]

3. Medications

Some medications that are recommended for management of uremia include:

  • EPO: For supplementation of iron; To manage anemia
  • Calcitriol: To address problems in Parathyroid hormone suppression and low levels of calcium
  • Phosphate binders
  • Oral bicarbonate tablets or solution for treatment of acidosis
  • Water soluble vitamins such as vitamin C and folate [2]

4. Kidney transplant

  • This is advised by the doctor if the renal damage and failure is irreversible.
  • This is done when a kidney donor becomes available. [1]

Uremia Prognosis

Uremia is a complication of end-stage renal failure. Since it is a severe and irreversible condition, prognosis may be poor if it is not treated properly. There are two factors which can affect prognosis of uremia. The underlying kidney disease is the first factor. Meanwhile, the risk factors and complications are the second factor that may influence the prognosis. If hypertension occurs, prognosis becomes worst. In order to prevent these complications, the patient’s condition should be kept controlled and stable. [4]

 

References:

1. http://renaldiet.us/uremic-poisoning.html

2. http://emedicine.medscape.com/article/245296-overview

3. http://en.wikipedia.org/wiki/Uremia

4. http://www.kidney-cares.org/uremia/

5. http://www.healthlinkbc.ca/kb/content/special/aa134576.html

6. http://www.localhealth.com/article/uremia/treatments

 



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