Management of Uremia in Chronic Kidney Disease

Initial Assessment and Conservative Management

• The Kidney International guidelines recommend implementing an individualized approach for patients with CKD G3-G5 and uremic symptoms that includes dietary and pharmacologic interventions, considering associated comorbidities and quality of life 1, 2
• Consultation with a renal dietitian is recommended for assessment and education regarding dietary modifications 1
• Limiting intake of foods rich in bioavailable potassium is recommended for CKD G3-G5 patients with hyperkalemia 1, 2

Pharmacological Management

• The Kidney International guidelines recommend continuing RAS inhibitors (ACEi or ARB) unless serum creatinine rises by more than 30% within 4 weeks of initiation or dose increase 3
• Consider reducing the dose or discontinuing ACEi or ARB in the setting of symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms in kidney failure (eGFR <15 ml/min per 1.73 m²) 3

Ongoing Monitoring and Management

• The Kidney International guidelines recommend considering statin or statin/ezetimibe combination for adults ≥50 years with eGFR <60 ml/min per 1.73 m² not on dialysis 1, 4
• For patients on SGLT2 inhibitors, continue even if eGFR falls below 20 ml/min per 1.73 m², unless not tolerated or kidney replacement therapy is initiated 3

Common Pitfalls and Caveats

• Avoiding routine use of NSAIDs for pain management in CKD patients is recommended as they can worsen kidney function and increase hyperkalemia risk 1