How should uremic gastritis be treated in a patient with end‑stage renal disease on maintenance dialysis?

Management of Uremic Gastritis in End-Stage Renal Disease on Maintenance Dialysis

The primary treatment for uremic gastritis in dialysis patients is optimization of dialysis adequacy to reduce uremic toxin burden, as gastrointestinal symptoms are direct manifestations of inadequate uremic toxin clearance. 1

Optimize Dialysis Prescription

For hemodialysis patients, verify that the delivered Kt/V is ≥1.4 per session (minimum 1.2) with sessions lasting at least 3 hours. 2, 1, 3 This target should be measured monthly using formal urea kinetic modeling. 2 The frequency of treatments must be included when assessing dose adequacy. 2

• For peritoneal dialysis patients, reassess 24-hour clearances if gastrointestinal symptoms persist with no alternative explanation. 1
• Verify that decreased ultrafiltration from reduced dialysate dextrose concentration is not contributing to inadequate clearance in PD patients. 1
• Check for nonadherence by verifying supply orders, home inventory, and cycler memory systems. 1

Consider Intensive Dialysis Modalities

If symptoms persist despite adequate conventional dialysis (Kt/V ≥1.4), consider frequent hemodialysis regimens such as short daily or nocturnal dialysis. 1, 3 Home long hemodialysis (6-8 hours, 3-6 nights per week) provides better uremic toxin control and symptom relief, though it carries increased risks of vascular access complications and hypotension. 1, 3

Exclude Reversible Causes of Inadequate Dialysis

Systematically evaluate for loss of residual kidney function from volume depletion, NSAID use, or overzealous blood pressure control. 1 These factors can worsen uremia independent of dialysis prescription. 1

• Avoid nephrotoxic medications, particularly NSAIDs, which can precipitate loss of residual renal function. 1
• In PD patients, rule out peritonitis, as protein losses double during even mild peritonitis episodes and can worsen nutritional status. 1

Nutritional Assessment and Support

Monitor protein intake by calculating normalized protein nitrogen appearance (nPNA) or dietary protein intake (DPI) during clearance assessments. 1 Uremic patients spontaneously decrease protein intake as GFR falls below 50 mL/min, creating a vicious cycle of malnutrition. 1

• Account for dialysate losses in PD patients, who lose 5-15 g protein and 2-4 g amino acids daily. 1
• Screen patients with CKD G4-G5 twice annually for malnutrition using validated assessment tools. 3
• Provide medical nutrition therapy under supervision of renal dietitians for patients with signs of malnutrition. 3
• Consider oral nutritional supplements or enteral nutrition for those with severe symptoms affecting oral intake. 2, 3

Helicobacter Pylori Considerations

While H. pylori infection is more prevalent in uremic patients (63-66%) compared to controls (35%), and is strongly associated with chronic gastritis and atrophic gastritis, the evidence does not establish that eradication improves uremic gastropathy specifically. 4, 5 Treatment of H. pylori may help prevent further mucosal injury in both pre- and post-transplant patients. 6

Acid Suppression Therapy

Acid-controlling therapies can be effective prophylaxis against uremic gastropathy. 6 However, the evidence base is limited, and this should be considered adjunctive to dialysis optimization rather than primary therapy.

Definitive Treatment: Kidney Transplantation

Kidney transplantation offers superior outcomes compared to dialysis for mortality and quality of life and should be discussed with all appropriate candidates experiencing uremic complications. 1, 3, 7 Patients should be referred 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. 3, 7

When to Escalate Care

Uremic gastropathy symptoms may indicate the need for dialysis initiation in pre-dialysis patients when accompanied by uremic signs, refractory symptoms, or protein-energy wasting. 1 In patients already on dialysis, persistent symptoms despite optimized dialysis prescription warrant consideration of intensive dialysis modalities or expedited transplant evaluation. 1, 3

Critical Pitfalls to Avoid

• Do not rely solely on endoscopic findings to assess uremic gastropathy severity. 4 Histopathologic examination of antral mucosal biopsies is mandatory, as there is no correlation between endoscopic and histopathologic findings in uremic patients. 4
• Do not overlook peritonitis in PD patients presenting with gastrointestinal symptoms. 1
• Do not assume adequate dialysis based on prescription alone—verify delivered dose monthly with formal measurements. 2, 1
• Recognize that uremic arteriolopathy and autonomic nervous system dysfunction can present with GI symptoms mimicking uremic gastropathy. 6 These require different management approaches.

Multidisciplinary Approach

A multidisciplinary care team including nephrologist, dietitian, and patient support persons should develop an individualized ESRD Life-Plan with annual comprehensive reviews. 3 This team-based approach addresses the complex interplay between dialysis adequacy, nutritional status, and symptom management that characterizes uremic gastropathy.