How to manage uremic symptoms in a patient with end-stage renal disease (ESRD) or acute kidney injury (AKI)?

Management of Uremic Symptoms in ESRD and AKI

Systematically assess uremic symptoms at every consultation using a standardized validated tool, then implement evidence-informed management strategies prioritizing symptom relief and quality of life over laboratory values alone. 1

Symptom Assessment Framework

Use validated assessment tools at each clinical encounter to identify and quantify uremic symptoms including reduced appetite, nausea, fatigue, lethargy, pruritus, sleep disturbances, and dyspnea. 1 The Edmonton Symptom Assessment System: revised—Renal (ESAS-r:R) or Dialysis Symptom Index are recommended validated instruments. 2

• Ask open-ended questions at every visit: "How are you feeling?", "What is bothering you most?", "Has anything changed?" 2
• Screen patients with CKD G4-G5, those aged >65, or those with involuntary weight loss, frailty, or poor appetite twice annually for malnutrition using validated assessment tools. 1
• Focus on symptoms most bothersome to the individual patient rather than treating based solely on laboratory abnormalities. 2

Specific Symptom Management

Uremic Pruritus

Initiate gabapentin as first-line systemic therapy for uremic pruritus, as it has the strongest evidence base among available treatments. 3

• Start with topical emollients for all patients with pruritus as baseline therapy. 4
• Consider phototherapy (UVB) as an alternative first-line option alongside gabapentin. 4
• For refractory cases, consider μ-opioid receptor antagonists (naltrexone) or κ-opioid receptor agonists (nalfurafine). 4, 5
• Recognize that uremic pruritus affects >40% of hemodialysis patients and significantly impairs quality of life and increases depressive symptoms. 6, 4

Nausea and Reduced Appetite

Screen for malnutrition twice annually in high-risk patients (CKD G4-G5, age >65, poor growth in pediatrics, involuntary weight loss, frailty). 1

• Provide medical nutrition therapy under supervision of renal dietitians when malnutrition is identified. 1
• Control phosphate intake through dietary modifications and phosphate binders (calcium acetate 2 capsules with each meal initially, titrated to 3-4 capsules per meal). 7
• Monitor serum calcium twice weekly during initial phosphate binder dosage adjustment to prevent hypercalcemia. 7
• Maintain serum calcium-phosphorus product below 55 mg²/dL². 7

Metabolic Abnormalities

Correct chronic metabolic acidosis to serum bicarbonate ≥22 mmol/L, monitoring levels at least every 3 months when GFR <30 mL/min per 1.73 m². 8

• Assess calcium, phosphorus, and intact PTH levels at least every 3 months when GFR <30 mL/min per 1.73 m². 8
• Use dialysate calcium of 1.50 mmol/L or higher to maintain neutral or positive calcium balance while avoiding predialysis hypercalcemia. 8
• Consider high-flux hemodialysis with Kt/V around 1.6 for better control of uremic complications. 8

Dialysis Considerations

Initiate dialysis based on uremic symptoms and quality of life rather than arbitrary laboratory thresholds or GFR values alone. 2

• Recognize that conservative management without dialysis is appropriate for patients with severely limited life expectancy, low quality of life, refractory pain, or progressive deterioration from untreatable disease. 2
• Consider time-limited trials of dialysis for patients with uncertain prognosis. 2
• Ensure adequate dialysis fluid exchanges in peritoneal dialysis patients to maintain effective clearance of uremic toxins and prevent fluid overload. 9

Team-Based Care Approach

Enable access to multidisciplinary care teams consisting of dietary counseling, medication management, education about kidney replacement therapy modalities, transplant options, and psychological/social support. 1

• Collaborate with pharmacists to ensure appropriate drug stewardship and management of complex medication regimens. 1
• Consider telehealth technologies including web-based applications, virtual visiting, and wearable devices for education and care delivery. 1
• Provide education programs involving care partners to promote informed, activated patients. 1

Special Considerations for AKI in Cirrhosis

Withdraw all diuretics and adjust lactulose dosage to reduce diarrhea severity when AKI develops in cirrhotic patients. 1

• Administer albumin fluid challenge at 1 g/kg body weight (maximum 100 g/day) to distinguish hypovolemic AKI from hepatorenal syndrome-AKI (HRS-AKI). 1
• Expect serum creatinine reduction to within 0.3 mg/dL of baseline in hypovolemic AKI after volume replacement. 1
• Rule out infection through chest radiography, urine and blood cultures, and diagnostic paracentesis, as spontaneous bacterial peritonitis is the most common cause of HRS-AKI. 1
• Avoid nephrotoxic medications including ACE inhibitors, angiotensin II receptor blockers, NSAIDs, and nonselective beta-blockers. 1

Common Pitfalls

Avoid focusing solely on laboratory values when determining need for dialysis initiation; consider the whole patient including symptoms, functional status, and quality of life. 2

• Do not use calcium supplements or calcium-based antacids concurrently with calcium acetate phosphate binders due to hypercalcemia risk. 7
• Recognize that hypercalcemia may aggravate digitalis toxicity in patients receiving cardiac glycosides. 7
• Be aware that evidence supporting specific medical therapies in ESRD is generally of low quality, with most recommendations being conditional rather than strong. 2
• Preserve peripheral veins in patients with stage III-V CKD for potential future hemodialysis access. 10

Follow-Up and Monitoring

Refer adults to specialist kidney care services when uremic symptoms develop, particularly with progressive CKD. 1

• Provide coping strategies when symptoms cannot be completely relieved. 2
• Ensure adequate sleep hygiene and physical activity as tolerated. 2
• Monitor for development of depression using standardized instruments validated in CKD populations. 1