Symptoms of Uremia in Advanced Kidney Disease
Uremia is a clinical syndrome characterized by a constellation of symptoms and signs that occur due to the accumulation of toxins in the blood when kidney function significantly declines, typically at GFR <15 ml/min/1.73m².
Neurological Manifestations
Cognitive and Mental Status Changes:
- Confusion and lethargy
- Dizziness
- Seizures or changes in seizure threshold
- Somnolence
- Tremors, ataxia, and dysarthria
- Asterixis (flapping tremor)
- Neurodevelopmental delay (in children)
- Coma (in severe cases) 1
Peripheral Nervous System:
- Peripheral neuropathy
- Restless leg syndrome
Gastrointestinal Manifestations
- Nausea and vomiting
- Anorexia (loss of appetite)
- Metallic taste in mouth (ammonia taste and breath)
- Hiccups
- Low protein tolerance 1, 2
Cardiovascular Manifestations
- Pericarditis (inflammation of the heart lining)
- Congestive heart failure
- Hypertension
- Accelerated atherosclerosis 1
Hematological Manifestations
- Platelet dysfunction leading to bleeding tendency
- Coagulation defects
- Anemia (though primarily due to decreased erythropoietin production) 1, 2
Endocrine and Metabolic Manifestations
- Amenorrhea
- Reduced core body temperature
- Protein-energy wasting
- Insulin resistance
- Heightened catabolism 1
Dermatological Manifestations
- Pruritus (itching)
- Yellow-brown skin discoloration
- Uremic frost (crystallized urea on skin in very advanced cases) 1, 2
Musculoskeletal Manifestations
- Renal osteodystrophy (bone disease)
- Hypotonia
- Failure to thrive (especially in children) 1
Fluid, Electrolyte, and Acid-Base Disturbances
- Volume overload unresponsive to diuretics
- Hyperkalemia
- Hyperphosphatemia
- Metabolic acidosis
- Hypocalcemia 1, 3
Inflammatory Manifestations
- Serositis (inflammation of serous membranes)
- Pleuritis (lung lining)
- Pericarditis (heart lining) 1
Important Clinical Considerations
Progression Pattern: Uremic symptoms typically progress from mild (confusion, nausea) to severe (seizures, coma) as kidney function declines 4.
Diagnostic Challenge: Uremia is a nonspecific constellation of symptoms superimposed on low GFR, making it challenging to definitively identify. Providers should search for reversible causes of similar symptoms before attributing them to uremia 1.
Indication for Dialysis: The presence of uremic symptoms, particularly neurological manifestations, pericarditis, or persistent electrolyte abnormalities unresponsive to medical management, is a clear indication for initiating renal replacement therapy 1, 2.
Symptom Overlap: Many symptoms of advanced CKD and patients already on hemodialysis can be similar, raising questions about which symptoms would improve with kidney replacement therapy 1.
Uremic Encephalopathy: This serious neurological complication requires prompt dialysis, especially in hemodynamically unstable patients or those with cerebral edema 2, 4.
Remember that uremic symptoms reflect systemic toxicity affecting multiple organ systems due to the kidney's central role in maintaining the body's internal environment. Early recognition and appropriate management are essential to prevent serious complications and improve quality of life.