Uremia

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Uremia
Classification and external resources
Urea.png
ICD-10 N19, R39.2
ICD-9 585-586, 788.9
DiseasesDB 26060
eMedicine med/2341
MeSH D014511

Uremia or uraemia (see spelling differences) is the illness accompanying kidney failure (also called renal failure), in particular the nitrogenous waste products associated with the failure of this organ.[1]

In kidney failure, urea and other waste products, which are normally excreted into the urine, are retained in the blood. Early symptoms include anorexia and lethargy, and late symptoms can include decreased mental acuity and coma. Other symptoms include fatigue, nausea, vomiting, cold, bone pain, itch, shortness of breath, and seizures. It is usually diagnosed in kidney dialysis patients when the glomerular filtration rate, a measure of kidney function, is below 50% of normal.[2] Uremia can also result in uremic pericarditis. There are many dysfunctions caused by uremia affecting many systems of the body, such as blood (lower levels of erythropoietin), sex (lower levels of testosterone/estrogen), and bones (osteoporosis and metastatic calcifications). Uremia can also cause decreased peripheral conversion of T4 to T3, producing a functionally hypothyroid state.

Azotemia is another word that refers to high levels of urea, but is used primarily when the abnormality can be measured chemically but is not yet so severe as to produce symptoms.

Signs and symptoms[edit]

Uremic frost present on the forehead and scalp of a young man who presented with complaints of anorexia and fatigue with blood urea nitrogen and serum creatinine levels of approximately 100 and 50 mg/dL respectively.
Neural and muscular
Endocrine and metabolic
Other

Because uremia is mostly a consequence of kidney failure, its signs and symptoms often occur concomitantly with other signs and symptoms of kidney failure, such as hypertension due to volume overload, hypocalcemic tetany, and anemia due to erythropoietin deficiency.[3] These, however, are not signs or symptoms specific to uremia.[3] Still, it is not certain that the symptoms currently associated with uremia are actually caused by excess urea, as one study showed that uremic symptoms were relieved by initiation of dialysis, even when urea was added to the dialysate to maintain the blood urea nitrogen level at approximately 90 mg per deciliter (that is, approximately 32 mmol per liter).[3]

Causes[edit]

Besides renal failure, the level of urea in the blood can also be increased by:

  • increased production of urea in the liver, due to:
    • high protein diet
    • increased protein breakdown (surgery, infection, trauma, cancer)
    • gastrointestinal bleeding
    • drugs (e.g. tetracyclines and corticosteroids)
  • decreased elimination of urea, due to:
  • dehydration
  • chronic infection of the kidney such as chronic pyelonephritis

Diagnosis[edit]

A detailed and accurate history and physical will help determine if uremia is acute or chronic. In the cases of acute uremia, causes may be identified and eliminated, leading to higher chance for recovery of normal renal function, if treated correctly.

Blood tests[edit]

Primary tests performed for the diagnosis of uremia are basic metabolic panel with serum calcium and phosphorus to evaluate the GFR, blood urea nitrogen and creatinine as well as serum potassium, phosphate, calcium and sodium levels. Principal abnormality is very low (<30) GFR. Uremia, unlike azotemia will demonstrate elevated both urea and creatinine, likely elevated potassium, high phosphate and normal or slightly high sodium, as well as likely depressed calcium levels. As a basic work up a physician will also evaluate for anemia and thyroid and parathyroid functions. Chronic anemia may be an ominous sign of established renal failure. The thyroid and parathyroid panels will help work up any symptoms of fatigue, as well as determine calcium abnormalities as they relate to uremia vs longstanding or unrelated illness of calcium metabolism.

Urine tests[edit]

A 24 hour urine collection for determination of creatinine clearance may be an alternative although not very accurate test due to collection procedure. Other laboratory that should be considered are urinalysis with microscopic examination for the presence of protein, casts, blood and pH.

Radioisotope tests[edit]

The "gold-standard" for determining GFR is iothalamate clearance. However, it may be cost-prohibitive and time-consuming. Clinical laboratories generally calculate the GFR with Modification of Diet in Renal Disease (MDRD) formula or the Cockcroft-Gault formula.

Other[edit]

In addition, coagulation studies may indicate prolonged bleeding time with otherwise normal values (see below).

Laboratory findings in various platelet and coagulation disorders (V - T)
Condition Prothrombin time Partial thromboplastin time Bleeding time Platelet count
Vitamin K deficiency or warfarin Prolonged Normal or mildly prolonged Unaffected Unaffected
Disseminated intravascular coagulation Prolonged Prolonged Prolonged Decreased
Von Willebrand disease Unaffected Prolonged or unaffected Prolonged Unaffected
Hemophilia Unaffected Prolonged Unaffected Unaffected
Aspirin Unaffected Unaffected Prolonged Unaffected
Thrombocytopenia Unaffected Unaffected Prolonged Decreased
Liver failure, early Prolonged Unaffected Unaffected Unaffected
Liver failure, end-stage Prolonged Prolonged Prolonged Decreased
Uremia Unaffected Unaffected Prolonged Unaffected
Congenital afibrinogenemia Prolonged Prolonged Prolonged Unaffected
Factor V deficiency Prolonged Prolonged Unaffected Unaffected
Factor X deficiency as seen in amyloid purpura Prolonged Prolonged Unaffected Unaffected
Glanzmann's thrombasthenia Unaffected Unaffected Prolonged Unaffected
Bernard-Soulier syndrome Unaffected Unaffected Prolonged Decreased or unaffected
Factor XII deficiency Unaffected Prolonged Unaffected Unaffected
C1INH deficiency Unaffected Shortened Unaffected Unaffected

References[edit]

  1. ^ "uremia" at Dorland's Medical Dictionary
  2. ^ Meyer TW and Hostetter, TH (2007). "Uremia". N Engl J Med 357 (13): 1316–25. doi:10.1056/NEJMra071313. PMID 17898101. 
  3. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac Meyer, T. W.; Hostetter, T. H. (2007). "Uremia". New England Journal of Medicine 357 (13): 1316–1325. doi:10.1056/NEJMra071313. PMID 17898101.  edit [1]