What is the long-term management of uremic gastritis in an adult patient with chronic kidney disease (CKD) or end-stage renal disease (ESRD)?

Long-term Management of Uremic Gastritis in CKD/ESRD

The cornerstone of long-term uremic gastritis management is optimizing dialysis adequacy to reduce uremic toxin accumulation, as conventional hemodialysis alone is insufficient to completely remove uremic toxins that cause gastrointestinal mucosal injury. 1, 2

Optimize Renal Replacement Therapy

Dialysis Adequacy

• Verify adequate dialysis dose with target Kt/V ≥1.2 for three-times-weekly hemodialysis to ensure sufficient uremic toxin clearance 3
• Consider intensive hemodialysis regimens (longer or more frequent sessions) as they may improve uremic symptom control including gastrointestinal manifestations 4, 3
• For patients with persistent symptoms despite conventional dialysis, evaluate for in-center short frequent hemodialysis or home long hemodialysis (6-8 hours, 3-6 nights per week) 5

Vascular Access Optimization

• Ensure proper vascular access function (AVF or AVG preferred over central venous catheters) to maintain adequate blood flow rates and dialysis clearance 5, 3
• Inadequate access can compromise dialysis efficiency and worsen uremic toxin accumulation 3

Pursue Kidney Transplantation

• Kidney transplantation should be considered the preferred definitive treatment as it offers superior outcomes for mortality and quality of life compared to chronic dialysis 5
• Refer patients for transplant evaluation when creatinine clearance reaches 25 mL/min or serum creatinine is 4 mg/dL 3
• Living donor preemptive renal transplantation should be considered when GFR is <20 ml/min/1.73 m² with evidence of progressive and irreversible CKD 5

Reduce Intestinal Uremic Toxin Generation

Dietary and Microbiome Interventions

• Address intestinal dysbiosis, which generates protein-bound uremic toxins (indoxyl sulfate, p-cresyl sulfate) through colonic protein fermentation 6
• Consider dietary interventions comprising prebiotics, probiotics, and synbiotics to manage uremic toxin production, though current data remain conflicting and require further study before definitive recommendations 1, 6
• Intestinal sorbents may be considered as an adjunctive therapy to reduce toxin absorption 1, 2

Symptom Management

Monitor and Assess Symptoms

• Screen for uremic symptoms (reduced appetite, nausea, vomiting, fatigue) at each consultation using a standardized validated assessment tool 4, 7
• Screen patients with CKD G4-G5 twice annually for malnutrition using validated assessment tools, as uremic gastritis can contribute to poor nutritional status 4

Nutritional Support

• Enable access to medical nutrition therapy under supervision of renal dietitians when signs of malnutrition are present 4
• For patients with severe symptoms affecting oral intake, consider oral nutritional supplements or enteral nutrition adapted to metabolic changes in ESRD 4

Preserve Residual Renal Function

• Maintain residual kidney function to minimize uremic toxin accumulation, avoiding overly strict blood pressure control and recognizing hemodynamic changes during dialysis that may compromise residual function 1
• Residual renal function contributes significantly to overall toxin clearance even in dialysis patients 1

Common Pitfalls to Avoid

• Do not rely solely on conventional hemodialysis parameters without assessing actual symptom burden, as standard dialysis removes mainly small unbound solutes while leaving protein-bound uremic toxins largely untouched 2, 7
• Avoid attributing all gastrointestinal symptoms to uremic gastritis without excluding other common conditions (peptic ulcer disease, GERD, medication effects, electrolyte imbalances) that are prevalent in ESRD patients 7
• Do not delay transplant evaluation, as this represents the only definitive cure for uremic complications 5

Multidisciplinary Care Coordination

• Develop an individualized ESRD Life-Plan with coordinated team including nephrologist, dietitian, and patient support persons, with annual comprehensive reviews 5
• Enable access to patient-centered multidisciplinary care including dietary counseling, medication management, and education about treatment options 4