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Chronic Kidney Disease

Chronic Kidney Disease

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Published by: luvgrace on Sep 12, 2009
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01/16/2013

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Chronic kidney diseaseChronic kidney disease
(CKD), also known as
chronic renal disease
, is a progressive loss of  renal function over a period of months or years. The symptoms of  worsening kidney function are unspecific, and might include feelinggenerally unwell and experiencing areduced appetite.Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or  diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such ascardiovascular disease
 
, anemia or   pericarditis.Chronic kidney disease is identified by a  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 isdiscovered 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  biopsy(removing a small sample of kidney tissue) are employed to find out if there is a reversible cause for the kidney malfunction.Recent professional guidelines classify the severity of chronic kidney disease in five stages, with stage1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also called
establishedchronic kidney disease
and is synonymous with the now outdated terms
end-stage renal disease (ESRD)
,
chronic kidney failure (CKF)
or 
chronic renal failure
(CRF).There is no specific treatment unequivocally shown to slow the worsening of chronic kidney disease. If there is an underlying cause to CKD, such as vasculitis, this may be treated directly with treatments aimed to slow the damage. In more advanced stages, treatments may be required for anemia and  bone disease. Severe CKD requires one of the forms of  renal replacement therapy;this may be a form of  dialysis
 
,but ideally constitutes a kidney transplant.
Signs and symptoms
Initially it is without specific symptoms and can only be detected as an increase in serumcreatinine or protein in the urine. As the kidneyfunction decreases:
 blood pressureis increased due to fluid overload and production of vasoactive hormones, increasing one's risk of developing hypertensionand/or suffering from congestive heart failure 
Ureaaccumulates, leading to azotemia and ultimately uremia (symptoms ranging from lethargy to pericarditisand encephalopathy
 
). Urea is excreted bysweating and crystallizes on skin ("uremic frost").
Potassiumaccumulates in the blood (known ashyperkalemia with a range of symptoms includingmalaiseand potentially fatal cardiac arrhythmias
 
) 
Erythropoietinsynthesis is decreased (potentially leading to anemia
 
,which causes fatigue
 
) 
Fluid volume overload- symptoms may range from mild edema to life-threatening pulmonary edema 
Hyperphosphatemia- due to reduced phosphate excretion, associated with hypocalcemia (due to vitamin D3 deficiency). The major sign of hypocalcemia  beingtetany. 
o
Later this progresses to tertiary hyperparathyroidism
 
 
, renal osteodystrophyand vascular calcification that further impairs cardiac function.
Metabolic acidosis,due to accumulation of sulfates, phosphates, uric acid etc. This may cause altered enzyme activity by excess acid acting on enzymes andalso increased excitability of cardiac and neuronal membranes by the promotion of  hyperkalemia due to excess acid(acidemia
 
)People with chronic kidney disease suffer from accelerated atherosclerosisand are more likely to developcardiovascular diseasethan the general population. Patients afflicted with chronic kidney disease and cardiovascular disease tend to have significantly worse prognoses than those suffering only from the latter.
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.
[
]
It is important to differentiate CKD from acute renal failure (ARF) because ARF can be reversible. Abdominalultrasoundis commonly performed, in which the size of  the kidneysare measured. Kidneys with CKD are usually smaller (< 9 cm) than normal kidneys with notable exceptions such as indiabetic nephropathy and  polycystic  kidney disease.Another diagnostic clue that helps differentiate CKD and ARF is a gradual rise in serum creatinine (over several months or years) as opposed to asudden 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 isoccasionally necessary to treat a patient briefly as having ARF until it has been established that the renal impairment is irreversible.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 radioactive element Technetium-99. In chronic renal failure treated with standard dialysis, numerous uremic toxins accumulate. These toxins show various cytotoxic activities in the serum, have differentmolecular weights and some of them are bound to other proteins, primarily to albumin. Such toxic protein bound substances are receiving the attention of scientists whoare interested in improving the standard chronic dialysis procedures used today
 
Stages
AGlomerular filtration rate (GFR) <60 mL/min/1.73 m
2
for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidneydamage. 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.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 m
2
is that GFR may be sustained at normal or increased levels despite substantial kidney damage and that patients with kidney damage are at increasedrisk of the two major outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular disease.Theloss 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.
Stage 1 CKD
Slightly diminished function; Kidney damage with normal or relatively high GFR (>90 mL/min/1.73 m
2
). Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies.
Stage 2 CKD
Mild reduction in GFR (60-89 mL/min/1.73 m
2
) with kidney damage. Kidney damage is defined as pathologic abnormalities or markers of damage, includingabnormalities in blood or urine test or imaging studies.
Stage 3 CKD
Moderate reduction in GFR (30-59 mL/min/1.73 m
2
). British guidelines distinguish between stage 3A (GFR 45-59) and stage 3B (GFR 30-44) for purposes of screeningand referral.
Stage 4 CKD
Severe reduction in GFR (15-29 mL/min/1.73 m
2
)
 Preparation for renal replacement therapy
Stage 5 CKD
Established kidney failure (GFR <15 mL/min/1.73 m
2
, or permanent renal replacement therapy (RRT)
Causes
The most common causes of CKD arediabetic nephropathy
 
,andglomerulonephritis.Together, these cause approximately 75% of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy.Historically, kidney disease has been classified according to the part of the renal anatomy that is involved, as
 
,includes large vessel disease such as bilateral renal artery stenosisand small vessel disease such as ischemic nephropathy, hemolytic-uremic  syndrome and vasculitis 
Glomerular, comprising a diverse group and subclassified into
o
Primary Glomerular disease such as focal segmental glomerulosclerosisand IgA nephritis 
o
Secondary Glomerular disease such as diabetic nephropathy and lupus nephritis 
Tubulointerstitial including  polycystic kidney disease,drug and toxin-induced chronic tubulointerstitial nephritis and reflux nephropathy 
Obstructive such as with bilateral kidney stonesand diseases of the  prostate 
Treatment
The 
neutrality of this section is disputed
.Please see the discussion on thetalk page. Please do not remove this message until thedispute is resolved.
 
The goal of therapy is to slow down or halt the otherwise relentless progression of CKD to stage 5. Control of  blood pressure and treatment of the original disease, whenever feasible, are the broad principles of management. Generally,angiotensin converting enzyme inhibitors(ACEIs) or  angiotensin II receptor antagonists(ARBs)
 
are used, as they have been found to slow the progression of CKD to stage 5. Although the use of ACE inhibitors and ARBs represents the current standard of care for  patients with CKD, patients progressively lose kidney function while on these medications, as seen in the IDNT and RENAAL studies, which reported a decrease over time in estimated glomerular filtration rate (an accurate measure of CKD progression, as detailed in the K/DOQI guidelines) in patients treated by these conventional methods.Currently, several compounds are in development for CKD. These include, but are not limited to, bardoxolone methyl
 
, olmesartan medoxomil, sulodexide, and avosentanReplacement of  erythropoietin and vitamin D3,two hormones processed by the kidney, is usually necessary in patients with CKD, as iscalcium. Phosphate bindersare used to control the serum  phosphate levels, which are usually elevated in chronic kidney disease. When one reaches stage 5 CKD, renal replacement therapyis required, in the form of either  dialysisor a transplant. In some cases, dietary modifications have been proven to slow and even reverse further progression. Generally this includes limiting a persons intake of protein
Prognosis
The prognosis of patients with chronic kidney disease is guarded asepidemiological data has shown that all cause mortality(the overall death rate) increases as kidney function decreases. The leading cause of death in patients with chronic kidney disease is cardiovascular disease, regardless of whether there is progression to stage 5.While renal replacement therapies can maintain patients indefinitely and prolong life, thequality of life is severely affected.
 Renal transplantation increases the survival of patients with stage 5 CKD significantly when compared to other therapeutic options; however, it is associated with an increased short-term mortality (due to complications of the surgery). Transplantation aside, high intensity home hemodialysis appears to be associated with improved survival and a greater  quality of life
 
,when compared to the conventional three times a week  hemodialysis and peritoneal dialysis.
Why separate acute from chronic renal failure?
-
Management is different
-
Manifestations may be similar 
-
Prognosis is different: Chronic Renal Failure irreversible; Acute Renal Failure reversible
Functions of the Kidney
Measuredusing:
Excretory function
BUN, creatinine
Maintenance of Acid – BaseBalance
 pH, HCO3, pCO2
Maintenance of Fluid andElectrolyte Balance
Osmolality,water, Na, K, Cl
Maintenance of Ca-PhosphateBalance
(Mineral balance)Ca, Phosphates(Mg)
Vitamin D production
Calcium
Erythropoeitin Production
Hgb, hct for confirmation
Chronic Renal Failure (CRF)
-Pathophysiologic process which is a result of varied conditions that leads to irreversible destruction of nephrons, ultimately leading to End Stage Kidney Disease (ESRD).
-Sum of all processes that happen cause by various diseases such as DM, hpn, GN, lupus, secondary causes due to multiple myeloma, etc.- Slow deterioration of kidney function- Loss of nephrons
other nephrons try to compensateduring CRF phase, you don’t see manifestations of ESRD- Normal GFR men:100ml/min; women:85ml/min- Just keep in mind that the key word in CRF is COMPENSATION- DO NOT MAKE THE MISTAKE OF DIALYSING A PATIENT WITH CRF!

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