Normally, your kidneys remove waste products and excess fluids from your blood. They also help maintain normal levels of acids, electrolytes and hormones such as erythropoietin. When your kidneys stop working, you have uremia.
Kidney failure from chronic kidney disease (CKD) most often causes uremia. But you can delay or prevent CKD by getting care from a specialist in treating kidney conditions (nephrologist). Uremia is rare now because of effective dialysis.
Diagnosis
Uremic frost is a complication of kidney failure that occurs when high levels of waste product called urea build up in the blood. The condition can be fatal if it’s not treated promptly. It’s usually a sign that your kidneys are failing and you need dialysis to help filter the waste out of your body.
Your doctor will do several tests to diagnose uremia. They will check your kidney function with a blood test called creatinine and measure the level of the waste product called urea in your blood. They may also order an ultrasound of your kidneys to look for scarring or blockages. They may also test for abnormalities in your electrolytes, such as potassium or calcium.
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You can develop uremia because of chronic kidney disease (CKD) or end-stage kidney disease (ESKD). CKD usually takes a long time to progress to ESKD, but it can also occur suddenly if you’re very ill.
Uremia can be difficult to diagnose because the early symptoms are vague. But the toxins from the urea build up very quickly as the kidneys fail, which can lead to more severe symptoms like fatigue and nausea.
In some cases, a healthcare provider will notice a white-to-off-white coating of crystals on the skin, known as uremic frost. The skin is coated with urea because the high levels of BUN cause your sweat to evaporate, leaving behind urea crystals on your skin.
Uremic frost is very common in patients undergoing hemodialysis, but it’s less often reported in people who don’t receive dialysis. It can be a good indicator of life-threatening kidney failure and should prompt you to start hemodialysis or other forms of renal replacement therapy immediately.
Once the urea levels in your body are controlled, you can recover from uremia. Kidney transplant surgery is the best way to cure uremia, but it can take months or years to get on a waiting list. Once you have a kidney transplant, you’ll need to take medicines called immunosuppressants for the rest of your life to prevent rejection of the new kidney.
Symptoms
Uremic frost is a striking cutaneous finding that occurs in patients with severe kidney disease. It consists of a white, friable, crystalline material that develops when blood urea nitrogen levels increase and the body’s natural ability to excrete the urea is impaired. Uremic frost is a clear indicator of advanced kidney disease and should be recognized as a life-saving signal to initiate urgent dialysis.
The first uremia symptoms may begin with mild nausea or loss of appetite, but can quickly progress to vomiting, weight loss, difficulty thinking and forgetting (cognitive dysfunction), chest pain from inflammation of the lining of the heart (pericarditis) and yellow-white crystals on the skin after sweat dries (uremic fetor).
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Uremia can also cause a variety of internal organ complications, such as fluid accumulation that leads to high blood pressure and atherosclerosis with valvular stenosis or insufficiency and congestive heart failure; anemia due to iron deficiency; glycemic fluctuations and diabetic ketoacidosis; bone disease resulting from decreased creatinine clearance; and glomerulonephritis with proteinuria. If untreated, uremia can lead to a seizure or coma, and in advanced cases of uremia, death may result from heart failure, hyperkalemia, metabolic acidosis, uremic serositis with pericarditis, central nervous system suppression and coma (uremic encephalopathy), overt peripheral neuropathy and nerve entrapment syndromes such as medial nerve neuropathy and carpal tunnel syndrome, and amyloid deposits leading to a coma and hepatic necrosis.
Full-blown uremic syndrome of advanced chronic kidney disease is rarely seen these days due to early and effective renal replacement therapy (RRT), which usually consists of hemodialysis or peritoneal dialysis. Even so, recognizing the signs and symptoms of uremia and educating patients about the importance of obtaining RRT promptly can save lives and reduce suffering from the many symptoms that are associated with this serious complication of end-stage kidney disease.
Treatment
The white, friable crystalline material called uremic frost (Figure 1) is a sign of severe kidney disease. It develops when blood levels of urea nitrogen rise. Urea is a chemical waste product that is normally excreted by the kidneys. The high levels of urea in the blood cause fluid overload, electrolyte imbalances and other symptoms associated with uremia.
Uremic Frost occurs in people who have ESRD and is a clear indication that they need to start dialysis right away. The sooner people begin dialysis, the less likely they are to have uremia and other signs of end-stage renal disease, including fatigue, delirium, nausea, vomiting and heart failure.
People who are being considered for dialysis should be educated about uremic frost, so they can recognize it and get treatment immediately if needed. This can prevent the shock of uremia and the complications that come with it, including vomiting, diarrhea, hyperkalemia, metabolic acidosis and death.
It is important to distinguish uremic frost from other skin diseases that can occur in people with ESRD, such as retention keratosis and eczema. People with uremic frost have a grayish or metallic color skin that is not shiny. They also have a urine-like smell to their breath.
Other signs and symptoms of uremia include increased protein in the urine, which causes a foamy appearance; uremic serositis with pericarditis; uremic encephalopathy; and the accumulation of urea in the joints. Uremia is one of the most common causes of death in people with CKD.
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The main treatment for uremia is dialysis, which removes the waste products and other substances that build up in the body as the kidneys fail. The dialysis method most often used is hemodialysis, which uses a machine to filter the blood through a catheter in the arm or legs. It is also possible to do peritoneal dialysis, in which the wastes are removed from the abdomen using a tube inserted into the abdominal cavity.
It is also possible to slow the progression of kidney disease by limiting the amount of sodium, phosphorus and potassium that is consumed in the diet. In addition, many studies are underway to develop new treatments that may help the kidneys regenerate or function better in ESRD patients.
Prevention
Uremic frost is a clear indicator of advanced kidney disease and demands immediate medical attention. Providing patient-centered care requires interprofessional healthcare teams to be proficient in diagnosing, evaluating and managing this condition. The team should include physicians, advanced practice clinicians, nurses, pharmacists, and technicians who work together to streamline a patient’s journey from diagnosis to treatment and beyond. This approach will help minimize errors, decrease delays, and improve patient safety, which is critical to optimizing the quality of life for patients with uremia.
Preventing uremic symptoms, including uramic frost, is primarily dependent on keeping up with dialysis treatments to ensure waste is removed from the body. It is also important to avoid foods high in sodium, phosphorus, and potassium. Those with end-stage renal disease should also receive regular blood tests to check for abnormalities.
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Kidney failure causes the release of toxins into the body, which accumulate in the bloodstream and cause many of the symptoms of uremia. The toxins can also cause problems in the heart and nervous system. For example, if the kidneys become damaged and cannot send urine to the bladder, it can cause a blockage (uremic obstruction). This leads to a build-up of fluid in the body and may be accompanied by an infection in the urinary tract called pyelonephritis. This can produce a pericardial effusion, causing pain in the chest (called pleurisy).
A shortage of oxygen-carrying red blood cells is another common symptom. This is a result of the failing kidneys not producing erythropoietin, a hormone that signals the body to make red blood cells. This can lead to fatigue and difficulty catching your breath, even in a warm room. Kidney failure can also cause abnormalities in blood electrolytes and a decrease in core body temperature. All of these can contribute to the development of uremic frost.
