BUNEMIA: A SEVERE CASE OF UREMIA COMPLICATED BY CHRONIC KIDNEY DISEASE

Abstract

Uremia is characterized by elevated nitrogen compounds in the blood and often arises from renal impairment. It can lead to severe complications like metabolic encephalopathy and platelet dysfunction. Supportive care with intravenous uids can improve renal clearance. Severe sequela may necessitate dialysis. We describe a 56-year-old male with stage ve chronic kidney disease who presented with reduced uid intake, pan-colitis, and diarrhea. CT of the abdomen and pelvis without contrast reported non-specic pan-colitis with wall thickening. Blood urea nitrogen on presentation was 260 mg/dL and serum creatinine 17.09 mg/dL. Despite initial improvement in renal function with intravenous uids and bicarbonate therapy. The patient subsequently developed stroke and hypertensive urgency. Dialysis was started for possible uremic encephalitis complicating right occipito-parietal ischemic stroke. After a challenging clinical course, discussions with the family led to the withdrawal of care, and the patient ultimately passed away. This case underscores the efcacy of hemodialysis in managing severe uremia, even when complicating factors such as chronic kidney disease are present. It also highlights the importance of considering intravenous uids as an initial approach when dialysis is not immediately available. There is conicting evidence of reduced mortality at 30 days with early initiation of hemodialysis. The impact of chronic uremia on mental status remains an area of uncertainty, warranting further investigation for prognostic and management considerations in similar cases.

Full text

BUNEMIA: A SEVERE CASE OF UREMIA COMPLICATED BY CHRONIC KIDNEY
DISEASE
Original Research Paper
Yusuf Kagzi*
MBBS M.G.M Medical College, Indore India *Corresponding Author
Uremia is characterized by elevated nitrogen compounds in the blood and often arises from renal
impairment. It can lead to severe complications like metabolic encephalopathy and platelet dysfunction.
Supportive care with intravenous uids can improve renal clearance. Severe sequela may necessitate dialysis. We describe a
56-year-old male with stage ve chronic kidney disease who presented with reduced uid intake, pan-colitis, and diarrhea. CT
of the abdomen and pelvis without contrast reported non-specic pan-colitis with wall thickening. Blood urea nitrogen on
presentation was 260 mg/dL and serum creatinine 17.09 mg/dL. Despite initial improvement in renal function with intravenous
uids and bicarbonate therapy. The patient subsequently developed stroke and hypertensive urgency. Dialysis was started for
possible uremic encephalitis complicating right occipito-parietal ischemic stroke. After a challenging clinical course,
discussions with the family led to the withdrawal of care, and the patient ultimately passed away. This case underscores the
efcacy of hemodialysis in managing severe uremia, even when complicating factors such as chronic kidney disease are
present. It also highlights the importance of considering intravenous uids as an initial approach when dialysis is not
immediately available. There is conicting evidence of reduced mortality at 30 days with early initiation of hemodialysis. The
impact of chronic uremia on mental status remains an area of uncertainty, warranting further investigation for prognostic and
management considerations in similar cases.
ABSTRACT
KEYWORDS :
Umer Rizwan
M.D,WVU Camden Clark Medical Center, USA
Internal Medicine
INTRODUCTION:
Uremia, or rising BUN (blood urea nitrogen), is generally
associated with worsening renal function in the setting of end-
stage kidney disease due to primary or secondary causes.
BUN is predominantly eliminated via glomerular ltration,
and the plasma level typically varies inversely with GFR. The
production of urea varies with protein intake, liver function,
and catabolic rate.
Uremic symptoms appear when creatinine clearance drops
below 10 ml/min. It causes decreased platelet number and
adhesion and increases their turnover, resulting in increased
susceptibility to bleeding. Moreover, it decreases hydrogen
ions and organic acid secretion buildup, which leads to
increased anion-gap metabolic acidosis and hyperkalemia. It
can also cause perica rditis, worsen ing car diac valve
abnormalities, and reproductive hormonal dysfunction,
leading to infertility in both males and females.
Case:
A 56 year old non-hispanic non-smoker male with a past
medical history of multiple CVA (cerebro-vascular accidents),
insulin dependent type 2 diabetes mellitus, stage 5 chronic
kidney disease, and hypertension presented with diarrhea for
1-2 weeks but denied melena or hematochezia.
Vitals and blood tests and during hospitalization are denoted
in Table 1 and 2 respectively. Urinalysis revealed pyuria,
hematuria, and 2+ bacteria. A stool test revealed positive
occult blood. CT of the abdomen and pelvis reported non-
specic pan-colitis with wall thickening and fat stranding
involving the appendix.
On interviewing, I was alert, and my mental status was
baseline. Physical examination was signicant for right sided
weakness and ronchi on lung auscultation.
He was started on vancomycin, cefepime, and agyl for
sepsis, and zos yn f or s uspected infect ious pancolitis .
Nephrology recommended 2 liters of bolus uids and 150 ml/h
bicarbonate drip with no urgent indication for dialysis. On day
2, the patient was diagnosed with oliguric stage-3 acute
kidney injury, and nephrology increased bicarbonate infusion
to 200 ml/hr and 1 liter of ringer lactate. Blood investigations
and vital signs was as per Table 1 and 2.
On day 4, the patient reported worsening altered mental
status and renal function, which nephrology attributed to
uremic symptoms, switched uids to 100 ml/hr normal saline,
and recommended dialysis.
On day 6, the patient was hypertensive (199/78), remains
confused and agitated, and plans a second session of
dialysis.
On day 12, after multiple sessions of dialysis, the patient was
normotensive but still had altered mentation. Over time, the
patient's condition worsened, and the family decided to opt for
comfort care. The patient was declared on day 17.
Table: 1
Table: 2
VOLUME - 12, ISSUE - 12, DECEMBER - 2023 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra
Aliya Kagzi
Ms3, Chirayu Medical College, Bhopal, India
Vitals
On
admission
Day 2
Day 4
Day 6
Day
12
Day
17
Temperature
in Celcius
36.3
36.8
37.3
37.4
37.2
38.6
Blood
Pressure mm
/Hg
90/43
118/54
176/77
199/7
8
175/91
130/6
4
Lab
Investigations
On
admission
Day
2
Day 4
Day
6
Day
12
Day
15
BUN (mg/dL)
260
229
187
70
15
23
Creatinine
(mg/dL)
17.09
14.68
13.18
4.98
2.88
4.62
eGFR(estimat
ed glomerular
ltration rate)
(ml/min/BSA)
3
4
4
9
25
14
Anion Gap
(mmol/L)
28
22
22
16
11
11
WBC (103/µl)
40.7
37.2
25.2
8.9
8.2
5.5
Hemoglobin
(g/dl)
8.5
7.4
7.9
7.7
7.4
6.6
32 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS

DISCUSSION:
In general, increased BUN suggests impaired renal function.
However, BUN levels are increased in congestive heart failure,
1
burns, severe liver disease, and malnutrition .
In the past, studies have shown mixed data, of which Liu et al.
reported improved survival of patients who started dialysis at
BUN levels <75mg/dL, however, a study in the Netherlands
reported no mortality benet in early dialysis with high BUN.
Elevated BUN levels are strongly associated with adverse
outcomes in acute heart failure patients and are considered a
1
prognostic factor.
Symptoms associated with uremia include vomiting, fatigue,
anorexia, weight loss, muscle cramps, pruritus, and changes
in mental status. Hypertension, atherosclerosis, valvular
stenosis and insufciency, chronic heart failure, and angina
may also develop as a result of a buildup of uremic toxins.
Additionally, occult gastrointestinal bleeding is also reported
2,3
in some cases due to platelet dysfunction.
In the past, only two studies reported BUN of more than 200,
1
Persuad et al. reported one 23 year old male with BUN of 244
2
mg/dl and Raj et al. reported BUN of 213 mg/dL, both were
Afr ica n-a mer ica n in et hni cit y. Both t he patien ts were
discharged after dialysis and the child was recommended for
1-3
renal transplant.
Our patient presented with the highest reported BUN in the
literature. Except for symptoms of diarrhea and neurological
decits, he was stable and had no other complaints. It is
unusual for a BUN level of 260 mg/dL to demonstrate no
emergent or worsening signs and symptoms. Over the time
during hospital course, he demonstrated neurological
symptoms, however, there was signicant improvement in
uremia.
Regarding the treatment, a high BUN level does not change
the management strategy. Dialysis is always the rst line of
treatment and should be gentle regardless of BUN levels to
avoid disequilibrium syndrome. Other options include renal
transplantation and peritoneal dialysis in approp riate
patients. It is important to avoid protein restriction and
mal nutriti on a long wi th i ron, calcium, and vitamin D
supplements. Nephrotoxic medications should be avoided,
an d do si ng sh ou ld be t it ra te d fo r r en al ly excreted
3,4,5
medications.
Uremia is associated with high morbidity and mortality,
hence, treatment should be started early in the disease course
and should not be inuenced by symptom onset of extreme
4
high levels at the time of presentation.
CONCLUSION:
This case demonstrates the effectiveness of hemodialysis in
managing severe uremia. For patients without dialysis access,
intravenous uids might be a viable initial approach. The
impact of chronic uremia on mentation remains unclear but
may serve as a negative prognostic factor
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nitrogen
VOLUME - 12, ISSUE - 12, DECEMBER - 2023 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra
Platelets (103/µl)
451
468
274
280
332
409
Lactic acid (mmol/L)
0.7
0.7
-
0.9
-
-
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