What are the symptoms of kidney failure in individuals with underlying medical conditions such as diabetes or hypertension?

Symptoms of Kidney Failure in Patients with Diabetes or Hypertension

Kidney failure symptoms in patients with diabetes or hypertension are often subtle in early stages but become severe and multi-systemic as kidney function deteriorates, with many patients remaining asymptomatic until GFR falls below 10-15 mL/min/1.73 m², making regular screening with eGFR and UACR essential rather than relying on symptoms alone. 1

Early-Stage CKD: Often Asymptomatic

• Most patients with CKD stages 1-3 (eGFR >30 mL/min/1.73 m²) have no symptoms, which is why screening is critical in high-risk populations including those with diabetes, hypertension, age >60 years, and family history of kidney disease. 2

• The earliest detectable sign is albuminuria (UACR ≥30 mg/g), not a symptom but a laboratory finding that precedes functional decline, particularly in diabetic kidney disease where 20-40% develop microalbuminuria within 10-15 years of uncontrolled diabetes. 2

• Fluid retention manifesting as periorbital edema (puffy eyelids) may be the first noticeable symptom, especially prominent in the morning upon waking, due to loose periorbital tissues and protein loss reducing oncotic pressure. 3

Advanced CKD and Uremic Symptoms (GFR <15 mL/min/1.73 m²)

When kidney failure progresses to advanced stages, a constellation of uremic symptoms emerges affecting multiple organ systems:

Neurological Manifestations

• Altered mental status progressing from somnolence to encephalopathy and potentially coma in severe cases 1
• Asterixis (flapping tremor) - a characteristic motor sign of uremia 1
• Seizures or changes in seizure threshold 1

Cardiovascular Signs

• Pericarditis (chest pain, friction rub) - considered an overt uremic symptom requiring urgent dialysis initiation 1
• Pleuritis (chest pain with breathing) 1
• Congestive heart failure and fluid overload unresponsive to diuretics 1
• Cardiac dysrhythmias secondary to hyperkalemia and other electrolyte disturbances 1

Gastrointestinal Symptoms

• Nausea and vomiting - among the most common uremic symptoms 1
• Anorexia with resultant protein-energy wasting 1
• Hiccups (singultus) - a characteristic uremic sign 1
• Ammonia taste and breath 1

Dermatologic Findings

• Uremic pruritus (severe itching) 1
• Uremic frost - crystalline urea deposits on skin surface in severe cases 1
• Pallor related to anemia 1

Hematologic Manifestations

• Bleeding tendency from platelet dysfunction despite normal platelet counts 1
• Easy bruising 1

Fluid and Electrolyte Disturbances

• Edema and fluid overload affecting legs, lungs, and periorbital areas 1, 3
• Hypertension - both a cause and consequence of kidney disease 3
• Muscle cramps and tetany from electrolyte disturbances (hyperkalemia, hypocalcemia, hyperphosphatemia) 1, 4

Metabolic and Endocrine Changes

• Amenorrhea in women of reproductive age 1
• Reduced core body temperature 1
• Growth delays in children 1

Critical Diagnostic Approach

Do not wait for symptoms to develop before diagnosing kidney disease - this is the most important pitfall to avoid. 2, 1

Immediate Laboratory Assessment Required:

• Spot urine albumin-to-creatinine ratio (UACR) - abnormal if ≥30 mg/g 2, 3
• Serum creatinine with calculated eGFR - CKD defined as eGFR <60 mL/min/1.73 m² for ≥3 months 2, 3
• Complete metabolic panel including potassium, bicarbonate, calcium, and phosphate when eGFR <60 2

Screening Frequency in High-Risk Patients:

• Annual screening for patients with diabetes (starting at diagnosis for type 2, after 5 years for type 1) and hypertension 2
• More frequent monitoring (2-4 times yearly) if albuminuria is present or eGFR is declining 2

Special Considerations for Diabetes and Hypertension

• Diabetic kidney disease typically presents with normal-sized kidneys on imaging despite progressive damage, so normal ultrasound does not exclude CKD. 2

• Uncontrolled hypertension dramatically accelerates progression, with GFR decreasing at rates >10 mL/min/year in those with poorly controlled hypertension and macroalbuminuria. 2

• Up to 30% of patients with presumed diabetic kidney disease have other causes on biopsy, particularly if atypical features are present (short diabetes duration, absence of retinopathy, active urinary sediment, rapid GFR decline). 2

When to Refer to Nephrology

Immediate nephrology referral is indicated for: 2, 3

• eGFR <30 mL/min/1.73 m²
• Continuously increasing urinary albumin levels despite optimal management
• Continuously decreasing eGFR
• Persistent proteinuria >1,000 mg/24 hours
• Active urinary sediment (hematuria, cellular casts)
• Rapidly progressive kidney function decline (>5 mL/min/year)
• Uncertainty about etiology or atypical features
• Difficulty managing CKD complications (anemia, bone disease, resistant hypertension)

Common Pitfalls to Avoid

• Do not rely on BUN or creatinine levels alone - uremic symptoms are defined by clinical signs, not laboratory values, and typically appear when GFR <10-15 mL/min/1.73 m² though individual variation exists. 1

• Recognize that uremic symptoms are nonspecific and can have alternative causes, particularly in elderly patients on polypharmacy (medications causing nausea, confusion, or fluid retention). 1

• Do not skip albuminuria testing - eGFR and UACR provide independent prognostic information for cardiovascular events, CKD progression, and mortality. 2