Uremia Clinical Presentation
- Author: A Brent Alper, Jr, MD, MPH; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...
Uremia can occur once the creatinine clearance is below 10-20 mL/min. Clinically, it is heralded by the onset of the following signs and symptoms:
Mental status changes
Patients may report nonspecific symptoms, which become chronic and progressive over time because of the gradual onset of the disease. Making the diagnosis of uremia may be difficult in young children because of the nonspecificity of clinical symptoms.
Metabolic abnormalities such as anemia, acidemia, and electrolyte abnormalities are prominent.
Patients with diabetes may appear to be in better glycemic control but may tend to have more hypoglycemic episodes as renal function declines. This paradoxical improvement in glycemic control results from increased insulin secretion and insulin half-life, both of which occur as renal function declines.
Cardiovascular abnormalities such as hypertension, atherosclerosis, valvular stenosis and insufficiency, chronic heart failure, and angina accelerate as renal function declines. These abnormalities may contribute to clinical manifestations of uremia if not treated appropriately.
Occult GI bleeding may occur. Nausea and vomiting are common in patients with severe uremia. Uremic fetor (ammonia or urinelike odor to the breath) also may be present.
Clinical manifestations of uremic encephalopathy include fatigue, muscle weakness, malaise, headache, restless legs, asterixis, polyneuritis, mental status changes, muscle cramps, seizures, stupor, and coma. Amyloid deposits may result in medial nerve neuropathy, carpal tunnel syndrome, or other nerve entrapment syndromes.
Fluid retention, pruritus associated with calcium phosphate deposition, and nail atrophy are common in persons with uremia.
Typical physical findings in persons with uremia are those associated with fluid retention, anemia, and acidemia. Severe malnutrition can contribute to muscle wasting, while electrolyte abnormalities may cause muscle cramping, cardiac arrhythmias, and mental status changes.
The classic skin finding in persons with uremia is uremic frost, which is a fine residue thought to consist of excreted urea left on the skin after evaporation of water. The skin may have a velvety appearance and feel, particularly in patients who are pigmented. Patients who are uremic also may have a sallow coloration of the skin due to urochrome, the pigment that gives urine its color. Patients may become hyperpigmented as uremia worsens (melanosis).
Eyes and mouth.
The sclera may become slightly icteric. Calcium deposition in the sclera can cause "red eye." In patients with chronic uremia, a broad range of oral lesions may be present, such as gingival hyperplasia, enamel hypoplasia, petechiae, or gingival bleeding.
Uremic pericarditis can be associated with a pericardial rub or a pericardial effusion. Increased fluid retention may result in pulmonary edema, peripheral edema, and severe hypertension. Valvular calcification may cause aortic stenosis or accelerate underlying disease.
Fluid retention may result in pulmonary edema and corresponding crackles in the lungs. Pleural rubs occur in the setting of uremic lungs.
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