Uremia Follow-up

  • Author: A Brent Alper Jr, MD, MPH; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Mar 17, 2010
 

Further Inpatient Care

  • Inpatient care is required when patients have a uremic emergency, such as hyperkalemia, hypervolemia, acidosis, pericardial effusion with symptoms, and uremic encephalopathy; these patients require emergent dialysis.
  • Initiate dialysis gently (2-h initial session) to avoid dialysis disequilibrium syndrome, but dialysis should be long enough to remove potassium if dialysis is being initiated for this reason.
  • Therapy should be initiated with the care and oversight of a nephrologist and may need to occur in the intensive care unit if the patient is unstable or has cardiac abnormalities secondary to acidemia or hyperkalemia.
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Further Outpatient Care

  • Continue outpatient care under the direction of the consulting nephrologist. Outpatient care may include initiation of chronic renal replacement therapy such as peritoneal dialysis or hemodialysis. Patients with renal failure and uremia should also be considered for transplantation using a living, related donor; a living, nonrelated donor; or a cadaveric donor.
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Inpatient & Outpatient Medications

  • Inpatient medications include medications necessary for emergent treatment of underlying disorders associated with uremia (emergent treatment of hyperkalemia, acidosis, and hypocalcemia).
  • Outpatient medications include EPO for anemia, iron, phosphate binders, calcitriol for PTH suppression and hypocalcemia, water-soluble vitamins (eg, folate, vitamin C), and, potentially, oral bicarbonate solution or tablets for acidosis.
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Transfer

  • Consider transferring patients to centers with dialysis capabilities if a nephrologist and/or dialysis facilities are not available to assist with management and potential interventions if necessary.
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Deterrence/Prevention

  • Avoid nephrotoxic medications such as nonsteroidal anti-inflammatory drugs, renal toxic aminoglycoside antibiotics, and other potential renal toxins.
  • N -acetyl-cystine can be administered before and after radiologic imaging that requires intravenous contrast (eg, CT scan, renal angiogram, intravenous pyelogram) to avoid nephrotoxicity. However, consider an alternative method of imaging (eg, ultrasound, MRI) in this setting to avoid ARF, particularly in patients with diabetes.
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Complications

  • Severe complications of untreated uremia include seizure, coma, cardiac arrest, and death.
  • Spontaneous bleeding can occur with severe uremia and may include GI bleeding, spontaneous subdural hematomas, increased bleeding from any underlying disorder, or bleeding associated with trauma.
  • Cardiac arrest may occur from severe underlying electrolyte abnormalities such as hyperkalemia, metabolic acidosis, or hypocalcemia.
  • Severe hypoglycemic reactions may occur in diabetic patients if hyperglycemic medications are not adjusted for their decreased creatinine clearance.
  • Renal failure associated bone disease (renal osteodystrophy) may lead to an increased risk of osteoporosis or bone fracture with trauma.
  • Medication clearance is decreased in persons with renal failure and may lead to untoward adverse effects, such as a digoxin overdose, an increased sensitivity to narcotics, and a decreased excretion of normal medications.
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Prognosis

  • The prognosis for patients with uremia of CRF is poor unless the uremia is treated with renal replacement therapy such as dialysis or transplantation.
  • The prognosis for ARF and renal failure secondary to a reversible or treatable cause, such as rapidly progressive glomerulonephritis (eg, lupus nephritis, Wegener disease, Goodpasture disease, thrombotic thrombocytopenic purpura, hemolytic uremia syndrome, multiple myeloma), depends on the timing of diagnosis and the rapidity of appropriate treatment (eg, steroids, chemotherapeutic agents, plasmapheresis).
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Patient Education

  • Patients should be sent to the nephrologist early for education regarding renal disease and renal replacement therapy options and for evaluation and diagnosis of their underlying renal disease process.
  • Inform diabetic patients about potential changes in insulin or oral hypoglycemic medication needs.
  • Inform patients and their families regarding dialysis to avoid the shock of emergent dialysis and the decreased quality of life that occurs with this disease.
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Contributor Information and Disclosures
Author

A Brent Alper Jr, MD, MPH  Associate Professor of Medicine, Section of Nephrology and Hypertension, Department of Medicine, Tulane University School of Medicine

A Brent Alper Jr, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society of Hypertension, American Society of Nephrology, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Rajesh G Shenava, MD  Assistant Professor of Medicine, Section of Nephrology and Hypertension, Department of Internal Medicine, Louisiana State University Health Sciences Centre

Rajesh G Shenava, MD is a member of the following medical societies: American College of Physicians, American Society of Nephrology, National Kidney Foundation, and Renal Physicians Association

Disclosure: Nothing to disclose.

Bessie A Young, MD, MPH  Associate Professor, Division of Nephrology, Department of Medicine, University of Washington; Director of Home Hemodialysis, Northwest Kidney Center, Seattle

Bessie A Young, MD, MPH is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Society of Nephrology, International Society of Nephrology, and National Kidney Foundation

Disclosure: NxStage Grant/research funds Principal Investigator; Amgen Grant/research funds Principal Investigator

Specialty Editor Board

Donald A Feinfeld, MD, FACP, FASN  Consulting Staff, Division of Nephrology & Hypertension, Beth Israel Medical Center

Donald A Feinfeld, MD, FACP, FASN is a member of the following medical societies: American Academy of Clinical Toxicology, American Society of Hypertension, American Society of Nephrology, and National Kidney Foundation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eleanor Lederer, MD  Consulting Staff, Louisville VA Hospital; Professor of Medicine; Interim Chief of Nephrology; Director of Nephrology Training Program; Director, Metabolic Stone Clinic; Director of Outpatient Clinics, Kidney Disease Program, University of Louisville School of Medicine

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

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