What is the most likely complication in an elderly patient with a history of hypertension, non-compliant with medications, presenting with severe pruritus, impaired renal function, and elevated creatinine levels?

Gouty Arthritis is the Most Likely Complication

The most likely complication in this patient with severe chronic kidney disease (creatinine 980 μmol/L, approximately 11 mg/dL) is gouty arthritis (Answer B). This patient has end-stage renal disease (ESRD) with severely impaired uric acid excretion, creating a high risk for hyperuricemia and subsequent gout development.

Clinical Context and Pathophysiology

This elderly patient presents with:

• Severe renal impairment with creatinine of 980 μmol/L (normal ~60-110 μmol/L), indicating ESRD 1
• Uremic pruritus as evidenced by extensive scratch marks, which affects 42-90% of patients with ESRD 1, 2, 3
• Long-standing hypertension with medication non-compliance, a major cause of chronic kidney disease progression 1

Why Gouty Arthritis is Most Likely

Impaired uric acid excretion is inevitable in ESRD. The kidneys are responsible for approximately 70% of uric acid elimination, and when renal function deteriorates to this degree, hyperuricemia develops universally 1. Patients with chronic kidney disease have:

• Reduced glomerular filtration of uric acid
• Decreased tubular secretion capacity
• Accumulation of organic acids that compete for uric acid excretion 1

The prevalence of gout increases dramatically as kidney function declines, particularly in patients with hypertension who are often on diuretics (though this patient is non-compliant) 1.

Why Other Options Are Less Likely

Renal Cell Carcinoma (Option A)

• Not a complication of chronic kidney disease itself 1
• Renal cell carcinoma is a primary malignancy, not a consequence of renal failure
• Would not explain the pruritus or be considered a "complication" of his CKD

Myelodysplastic Syndrome (Option C)

• No established causal relationship with chronic kidney disease 1
• While anemia is common in CKD due to erythropoietin deficiency, this manifests as normocytic anemia, not myelodysplastic syndrome 1
• The question states "other parameters are within normal limits," making hematologic malignancy unlikely

Hepatic Cirrhosis (Option D)

• Not a complication of chronic kidney disease 1
• Hepatorenal syndrome represents kidney failure as a complication of cirrhosis, not the reverse
• No clinical features suggesting liver disease are mentioned

Understanding the Pruritus

The extensive pruritus with scratch marks represents uremic pruritus (chronic kidney disease-associated pruritus), affecting 50-90% of dialysis patients and those with advanced CKD 1, 4, 2, 3. This symptom:

• Usually begins approximately 6 months after dialysis initiation or with advanced CKD 4
• Ranges from localized and mild to generalized and severe 4, 5
• Is associated with elevated blood urea nitrogen, creatinine, serum phosphorus, calcium-phosphorus product, and parathyroid hormone 5
• Significantly impacts quality of life and is associated with increased mortality 2

The pathophysiology involves multiple factors including secondary hyperparathyroidism, divalent-ion abnormalities, xerodermia (dry skin), and neuropathic changes 1, 4, 5.

Clinical Implications

This patient requires urgent nephrology referral for dialysis initiation, given the severely elevated creatinine indicating ESRD 1. With creatinine of 980 μmol/L (approximately 11 mg/dL), the estimated GFR is likely <10 mL/min/1.73m², meeting criteria for stage 5 CKD requiring renal replacement therapy 1, 6.

Gouty arthritis management in ESRD is challenging because:

• Allopurinol requires dose adjustment and carries increased toxicity risk 1
• NSAIDs are contraindicated due to further nephrotoxicity 1
• Colchicine requires dose reduction 1
• Dialysis itself can help reduce uric acid levels but may not fully prevent gout attacks 1

The uremic pruritus may improve with adequate dialysis (effective in 40% of patients), though 35% have poor treatment response even with optimal management 5. Additional treatments include phosphate binders, emollients, UV phototherapy, and in refractory cases, medications like gabapentin or difelikefalin 1, 4.