What is the next best management step for a patient with uremia due to Chronic Kidney Disease (CKD)?

Management of Uremia in Chronic Kidney Disease

For patients with uremia due to CKD, the next best management step is to initiate renal replacement therapy (dialysis) when conservative measures fail to control uremic symptoms. 1, 2

Initial Assessment and Conservative Management

• Implement an individualized approach for patients with CKD G3-G5 and uremic symptoms that includes dietary and pharmacologic interventions, considering associated comorbidities and quality of life 3
• Consult with a renal dietitian for assessment and education regarding dietary modifications 3
• Monitor electrolytes, particularly potassium, as hyperkalemia is a common complication in uremic patients 4
• Limit intake of foods rich in bioavailable potassium (e.g., processed foods) for CKD G3-G5 patients with hyperkalemia 3

Pharmacological Management

• Continue RAS inhibitors (ACEi or ARB) unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase 3
• Consider reducing the dose or discontinuing ACEi or ARB in the setting of symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms in kidney failure (eGFR <15 ml/min per 1.73 m²) 3
• Treat metabolic acidosis with sodium bicarbonate (0.5-1 mEq/kg/day) to achieve serum bicarbonate levels of 22-24 mmol/L 4
• Use loop diuretics in higher than normal doses to manage volume overload; combination with thiazides may be useful in refractory cases 4
• For anemia management in CKD patients with uremia, consider epoetin alfa when hemoglobin is <10 g/dL 5
  • Initial dose: 50-100 Units/kg three times weekly intravenously or subcutaneously 5
  • Monitor hemoglobin weekly until stable, then monthly 5

Management of Hyperkalemia

• Review medications that can worsen hyperkalemia (ACEIs, ARBs, aldosterone antagonists, NSAIDs, etc.) 4
• Implement dietary potassium restriction with GFR less than 20 ml/min 4
• For asymptomatic hyperkalemia, use oral ion exchange resins 4
• For symptomatic hyperkalemia with ECG changes, use parenteral treatments (calcium gluconate, insulin with glucose, salbutamol) 4
• Consider hemodialysis for severe hyperkalemia in patients with GFR below 10 ml/min 4

Indications for Renal Replacement Therapy

• Initiate dialysis when conservative measures fail to control uremic symptoms, which may include:
  • Neurological manifestations (encephalopathy, seizures, asterixis, myoclonus) 1
  • Gastrointestinal symptoms (nausea, vomiting, anorexia) 2
  • Refractory fluid overload 4
  • Uncontrolled hyperkalemia or metabolic acidosis 4
  • Uremic pericarditis 2

Ongoing Monitoring and Management

• Monitor weight and volume status regularly in hospitalized patients with CKD 4
• Check serum potassium two weeks after initiation of treatment with ACEIs/ARBs 4
• For patients on SGLT2 inhibitors (recommended for CKD with eGFR ≥20 ml/min per 1.73 m²), continue even if eGFR falls below 20 ml/min per 1.73 m², unless not tolerated or kidney replacement therapy is initiated 3
• Consider statin or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min per 1.73 m² not on dialysis 3

Common Pitfalls and Caveats

• Do not discontinue RAS inhibitors when eGFR falls below 30 ml/min per 1.73 m² unless specific adverse effects occur 6
• Avoid routine use of aldosterone antagonists in advanced CKD due to hyperkalemia risk 4
• The reversible decrease in eGFR upon SGLT2i initiation is not an indication to discontinue therapy 6
• Hyperkalemia with RAS inhibitors should be managed with measures to reduce potassium rather than immediately stopping the medication 6
• Avoid NSAIDs for pain management in CKD patients as they can worsen kidney function and increase hyperkalemia risk 3