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Chronic Kidney Disease (CKD) overview

Published: July 17, 2009. Updated: October 02, 2009

Chronic kidney disease (CKD) is a slowly progressive loss of renal function over a period of months or years.

Definition

CKD is defined as a reduced glomerular filtration rate (GFR) below 60 ml/min/1.73m2 and / or kidney damage as evidenced by pathology, imaging or lab/urine findings.1

Epidemiology

CKD is a common condition with a prevalence of approximately 11% in the US.

Causes

  • IgA nephropathy (Berger's disease)
  • Glomerulonephritis (chronic or severe acute cases)
  • Nephrotic syndrome (longstanding)
  • Hypertension
  • Diabetes mellitus (all types, dependant on duration and glycemic control)
  • Amyloid
  • Multiple myeloma
  • Drug induced renal failure
  • Polycystic kidney disease2
  • Lupus erythematosus (lupus nephritis)
  • Progression of acute renal failure (ARF)

Stages of CKD

  • Stage I: GFR > 90 ml/min/1.73m2
  • Stage II: 60-89 ml/min/1.73m2
  • Stage III: 30-59 ml/min/1.73m2
  • Stage IV: 15-29 ml/min/1.73m2
  • Stage V: < 15 ml/min/1.73m2 or dialysis (kidney failure).

Signs and symptoms

Initially it is without symptoms. As the kidney functions less:

  • Blood pressure is increased (leading to hypertension)
  • Urea accumulates, leading to uremia (lethargy and encephalopathy)
  • Potassium accumulates, leading to malaise and cardiac arrhythmias
  • Erythropoietin synthesis is decreased (leading to anemia)
  • Vitamin D3 synthesis is impaired (leading to renal osteodystrophy and secondary hyperparathyroidism). Clinically the patient may develop hyperphosphatemia, acidosis, and hypocalcemia.
  • Fluid balance disturbances are generally mild.

CKD patients suffer from accelerated atherosclerosis, mostly due to hypercholesterolemia. Coagulation is often disrupted, leading to a prothrombotic state (a high likelihood of developing thrombosis). Pericarditis occurs at an increased rate in CKD patients.

Diagnosis

In many CKD patients, previous renal disease or other underlying diseases are already known. A small number presents with CKD of unknown cause. In these patients, a cause is occasionally identified retrospectively.

If a patient presents for the first time with manifestations suggestive of renal failure it is very important to decide whether the renal failure is acute or chronic. History could provide indications as to the onset of problems from the history of urinary changes in terms of quantity and quality; and history of a loss in body weight, chronic fatigue etc. The presence of anaemia suggests CKD; bilateral small kidneys suggest CKD; neuropathy, lipiduria, and osteodystrophy. The presence of loin pain may be a good sign favoring acute renal failure.

Treatment

CKD is cured is usually not cured except with renal transplant in those that are eligible. In the period usually required to find a transplant, dialysis (renal function replacement therapy) is the only way to clear waste products from the blood that are usually excreted through the urine (urea, potassium).

Blood pressure control to below 130/80 mm Hg, start with an ACE inhibitor if not contraindicated. Strict diabetic control is advised.

Replacement of erythropoietin with a goal to reach a hemoglobin level of 11-12 mg/dL. Vitamin D3 replacement, which is another hormone processed by the kidney, is usually necessary, as is replacement of calcium.

Dietary restrictions of sodium if the patient is hypertensive, potassium if hyperkalemic or oliguric. It is usually recommended to restrict protein intake to moderate amounts.

References



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