What is the most likely complication associated with a patient presenting with impaired renal function, pruritis, and a history of hypertension (high blood pressure)?

Gouty Arthritis is the Most Likely Complication

In an elderly hypertensive patient presenting with severe pruritus and deteriorating renal function, gouty arthritis (Option B) represents the most likely complication among the choices provided. This is because chronic kidney disease directly impairs uric acid excretion, leading to hyperuricemia and subsequent gout development 1.

Clinical Reasoning

The Primary Condition: Chronic Kidney Disease with Uremic Pruritus

• Pruritus is a hallmark symptom of chronic kidney disease (CKD) and end-stage renal disease (ESRD), occurring in 42-65% of patients with advanced renal dysfunction 1, 2.
• The extensive scratch marks described indicate severe, chronic pruritus consistent with CKD-associated pruritus (formerly termed uremic pruritus) 3, 2.
• Xerosis (dry skin) occurs in 80% of CKD patients and correlates with pruritus intensity, explaining the visible scratch marks 4, 5.
• This patient's untreated hypertension likely contributed to progressive renal damage through hypertensive nephrosclerosis 1.

Why Gouty Arthritis is the Most Likely Complication

Renal dysfunction is the primary risk factor for hyperuricemia and gout development:

• As GFR declines, uric acid clearance decreases proportionally, leading to elevated serum uric acid levels 1.
• Hypertension itself is strongly associated with both CKD progression and hyperuricemia, creating a synergistic effect 1.
• The combination of untreated hypertension and deteriorating renal function creates the perfect metabolic environment for gouty arthritis 1.
• Gout is a well-established complication in patients with renal dysfunction, whereas the other options are either unrelated or far less common 1.

Why the Other Options Are Less Likely

Renal Cell Carcinoma (Option A):

• While mentioned in oncology literature, renal cell carcinoma does not typically present with pruritus as a primary manifestation 1.
• The clinical picture of deteriorating renal function with pruritus points to functional kidney disease, not malignancy 1, 2.

Myelodysplastic Syndrome (Option C):

• This hematologic malignancy is not a recognized complication of CKD with pruritus 1.
• The evidence does not support any pathophysiologic link between uremic pruritus and myelodysplastic syndrome 3, 2.

Critical Management Considerations

Immediate Priorities

• Evaluate the severity of renal dysfunction and determine if dialysis is needed, particularly if creatinine exceeds 500 μmol/L (5 mg/dL) 1.
• Check serum uric acid levels to confirm hyperuricemia and assess gout risk 1.
• Blood pressure control is essential to slow further renal deterioration, though the patient is currently refusing treatment 1.

Management of Uremic Pruritus

• Emollients are essential first-line therapy for the xerosis that underlies much of the pruritus 1, 5.
• Topical capsaicin 0.025% cream applied four times daily has shown significant benefit in hemodialysis patients with severe pruritus 1.
• Optimize dialysis adequacy if the patient progresses to requiring renal replacement therapy, as inadequate dialysis worsens pruritus 1.
• Difelikefalin represents the first FDA-approved medication specifically for CKD-associated pruritus 3.

Common Pitfalls

• Do not routinely investigate for endocrine causes or malignancy unless additional clinical features suggest these diagnoses 1.
• Avoid nephrotoxic medications including NSAIDs, which could accelerate renal decline 1.
• ACE inhibitors and ARBs must be used cautiously in advanced renal dysfunction (creatinine >2.5 mg/dL requires specialist supervision), though they may worsen pruritus through drug-related mechanisms 1, 6.
• Thiazide diuretics are ineffective when creatinine clearance is <30 mL/min; loop diuretics should be used instead 1.

The patient's refusal of hospital care and medication adherence represents a significant barrier that must be addressed through patient education about the serious consequences of untreated hypertension and progressive renal failure 1.