Chronic kidney disease

Chronic kidney biopsy (removing a small sample of kidney

disease (CKD), tissue) are employed to find out if there is a
also known as reversible cause for the kidney malfunction.
[1]
chronic renal Recent professional guidelines classify the
disease, is a severity of chronic kidney disease in five
progressive loss of stages, with stage 1 being the mildest and
renal function over usually causing few symptoms and stage 5
a period of months being a severe illness with poor life
or years. The expectancy if untreated. Stage 5 CKD is also
symptoms of called established chronic kidney disease
worsening kidney and is synonymous with the now outdated
function are unspecific, and might include terms end-stage renal disease (ESRD),
feeling generally unwell and experiencing a chronic kidney failure (CKF) or chronic
reduced appetite. Often, chronic kidney renal failure (CRF).[1]
disease is diagnosed as a result of screening There is no specific treatment unequivocally
of people known to be at risk of kidney shown to slow the worsening of chronic
problems, such as those with high blood kidney disease. If there is an underlying
pressure or diabetes and those with a blood cause to CKD, such as vasculitis, this may
relative with chronic kidney disease. be treated directly with treatments aimed to
Chronic kidney disease may also be slow the damage. In more advanced stages,
identified when it leads to one of its treatments may be required for anemia and
recognized complications, such as bone disease. Severe CKD requires one of
cardiovascular disease, anemia or the forms of renal replacement therapy; this
pericarditis.[1] may be a form of dialysis, but ideally
Chronic kidney disease is identified by a constitutes a kidney transplant.[1]
blood test for creatinine. Higher levels of
creatinine indicate a falling glomerular
filtration rate (rate at which the kidneys
filter blood) and as a result a decreased
capability of the kidneys to excrete waste
products. Creatinine levels may be normal in
the early stages of CKD, and the condition is
discovered if urinalysis (testing of a urine
sample) shows that the kidney is allowing
the loss of protein or red blood cells into the
urine. To fully investigate the underlying
cause of kidney damage, various forms of
medical imaging, blood tests and often renal
Signs and symptoms hyperparathyroidism,
with hypercalcaemia,
Initially it is without specific symptoms and renal osteodystrophy and
can only be detected as an increase in serum vascular calcification that
creatinine or protein in the urine. As the further impairs cardiac
kidney function decreases: function.
• blood pressure is increased due • Metabolic acidosis, due to
to fluid overload and production accumulation of sulfates,
of vasoactive hormones, phosphates, uric acid etc. This
increasing one's risk of may cause altered enzyme
developing hypertension and/or activity by excess acid acting on
suffering from congestive heart enzymes and also increased
failure excitability of cardiac and
• Urea accumulates, leading to neuronal membranes by the
azotemia and ultimately uremia promotion of hyperkalemia due
(symptoms ranging from to excess acid (acidemia)[2]
lethargy to pericarditis and People with chronic kidney disease suffer
encephalopathy). Urea is from accelerated atherosclerosis and are
excreted by sweating and more likely to develop cardiovascular
crystallizes on skin ("uremic disease than the general population. Patients
frost"). afflicted with chronic kidney disease and
• Potassium accumulates in the cardiovascular disease tend to have
blood (known as hyperkalemia significantly worse prognoses than those
with a range of symptoms suffering only from the latter.
including malaise and
potentially fatal cardiac Diagnosis
arrhythmias)
In many CKD patients, previous renal
• Erythropoietin synthesis is disease or other underlying diseases are
decreased (potentially leading already known. A small number presents
to anemia, which causes with CKD of unknown cause. In these
fatigue) patients, a cause is occasionally identified
• Fluid volume overload - retrospectively.[citation needed]
symptoms may range from mild It is important to differentiate CKD from
edema to life-threatening
acute renal failure (ARF) because ARF can
pulmonary edema
be reversible. Abdominal ultrasound is
• Hyperphosphatemia - due to commonly performed, in which the size of
reduced phosphate excretion, the kidneys are measured. Kidneys with
associated with hypocalcemia CKD are usually smaller (< 9 cm) than
(due to vitamin D3 deficiency). normal kidneys with notable exceptions
The major sign of hypocalcemia such as in diabetic nephropathy and
being tetany. polycystic kidney disease. Another
○ Later this progresses to diagnostic clue that helps differentiate CKD
tertiary and ARF is a gradual rise in serum
creatinine (over several months or years) as
opposed to a sudden increase in the serum
creatinine (several days to weeks). If these
levels are unavailable (because the patient
has been well and has had no blood tests) it
is occasionally necessary to treat a patient
briefly as having ARF until it has been
established that the renal impairment is
irreversible.[citation needed]
Additional tests may include nuclear
medicine MAG3 scan to confirm blood
flows and establish the differential function
between the two kidneys. DMSA scans are
also used in renal imaging; with both MAG3
and DMSA being used chelated with the
Stages
All individuals with a Glomerular filtration
rate (GFR) <60 mL/min/1.73 m2 for 3
months are classified as having chronic
kidney disease, irrespective of the presence
or absence of kidney damage. The rationale
for including these individuals is that
reduction in kidney function to this level or
lower represents loss of half or more of the
adult level of normal kidney function, which
may be associated with a number of
complications.[1]
All individuals with kidney damage are
classified as having chronic kidney disease,
irrespective of the level of GFR. The
rationale for including individuals with GFR
60 mL/min/1.73 m2 is that GFR may be
sustained at normal or increased levels
despite substantial kidney damage and that
patients with kidney damage are at increased
risk of the two major outcomes of chronic
kidney disease: loss of kidney function and
development of cardiovascular disease.[1]
The loss of protein in the urine is regarded
as an independent marker for worsening of
renal function and cardiovascular disease.
Hence, British guidelines append the letter
"P" to the stage of chronic kidney disease if
there is significant protein loss.[3]
radioactive element Technetium-99.[citation
needed]
In chronic renal failure treated with standard
dialysis, numerous uremic toxins
accumulate. These toxins show various
cytotoxic activities in the serum, have
different molecular weights and some of
them are bound to other proteins, primarily
to albumin. Such toxic protein bound
substances are receiving the attention of
scientists who are interested in improving
the standard chronic dialysis procedures
used today.[citation needed]
Stage 1 CKD
Slightly diminished function; Kidney
damage with normal or relatively high GFR
(>90 mL/min/1.73 m2). Kidney damage is
defined as pathologic abnormalities or
markers of damage, including abnormalities
in blood or urine test or imaging studies.[1]
Stage 2 CKD
Mild reduction in GFR (60-89 mL/min/1.73
m2) with kidney damage. Kidney damage is
defined as pathologic abnormalities or
markers of damage, including abnormalities
in blood or urine test or imaging studies.[1]
Stage 3 CKD
Moderate reduction in GFR (30-59
mL/min/1.73 m2).[1] British guidelines
distinguish between stage 3A (GFR 45-59)
and stage 3B (GFR 30-44) for purposes of
screening and referral.[3]
Stage 4 CKD
Severe reduction in GFR (15-29
mL/min/1.73 m2)[1] Preparation for renal
replacement therapy
Stage 5 CKD
Established kidney failure (GFR <15
mL/min/1.73 m2, or permanent renal
replacement therapy (RRT)[1]
Causes angiotensin II receptor antagonists (ARBs)
are used, as they have been found to slow
The most common causes of CKD are the progression of CKD to stage 5.[4][5]
diabetic nephropathy, hypertension, and
glomerulonephritis. Together, these cause Replacement of erythropoietin and vitamin
approximately 75% of all adult cases. D3, two hormones processed by the kidney,
Certain geographic areas have a high is usually necessary, as is calcium.
incidence of HIV nephropathy.[citation needed] Phosphate binders are used to control the
serum phosphate levels, which are usually
Historically, kidney disease has been elevated in chronic kidney disease.
classified according to the part of the renal
anatomy that is involved, as:[citation needed] When one reaches stage 5 CKD, renal
replacement therapy is required, in the form
• Vascular, includes large vessel of either dialysis or a transplant.
disease such as bilateral renal
artery stenosis and small vessel In some cases, dietary modifications have
disease such as ischemic been proven to slow and even reverse
nephropathy, hemolytic-uremic further progression. Generally this includes
syndrome and vasculitis limiting a persons intake of protein.[citation
needed]
• Glomerular, comprising a
diverse group and subclassified
Prognosis
into
○ Primary Glomerular The prognosis of patients with chronic
disease such as focal kidney disease is guarded as
segmental epidemiological data has shown that all
glomerulosclerosis and cause mortality (the overall death rate)
IgA nephritis increases as kidney function decreases.[6]
The leading cause of death in patients with
○ Secondary Glomerular
chronic kidney disease is cardiovascular
disease such as diabetic
disease, regardless of whether there is
nephropathy and lupus
nephritis
progression to stage 5.[6][7][8]
• Tubulointerstitial including While renal replacement therapies can
polycystic kidney disease, drug maintain patients indefinitely and prolong
and toxin-induced chronic life, the quality of life is severely affected.[9]
[10]
tubulointerstitial nephritis and Renal transplantation increases the
reflux nephropathy survival of patients with stage 5 CKD
significantly when compared to other
• Obstructive such as with
therapeutic options;[11][12] however, it is
bilateral kidney stones and
associated with an increased short-term
diseases of the prostate
mortality (due to complications of the
Treatment surgery). Transplantation aside, high
intensity home hemodialysis appears to be
The goal of therapy is to slow down or halt associated with improved survival and a
the otherwise relentless progression of CKD greater quality of life, when compared to the
to stage 5. Control of blood pressure and conventional three times a week
treatment of the original disease, whenever hemodialysis and peritoneal dialysis.[13]
feasible, are the broad principles of
management. Generally, angiotensin
converting enzyme inhibitors (ACEIs) or
Organizations
In the USA, the National Kidney Foundation In the United Kingdom, the National Kidney
is a national organization representing Federation represents patients, and the Renal
patients and professionals who treat kidney Association represents renal physicians and
diseases. The Renal Support Network (RSN) works closely with the National Service
is a nonprofit, patient-focused, patient-run Framework for kidney disease.
organization that provides non-medical The International Society of Nephrology is
services to those affected by CKD. The an international body representing
American Association of Kidney Patients specialists in kidney diseases.
(AAKP) is a non-profit, patient-centric
group focused on improving the health and
well-being of CKD and dialysis patients.
The Renal Physicians Association (RPA) is
an association representing nephrology
professionals.