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Living with kidney failure Your extensive guide

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Kidney disease

2.1

Testing for kidney disease
Chronic Kidney Disease is silent because it is possible to lose 90% of kidney function before even feeling sick. Doctors use three simple tests to assess your kidney function and help plan treatment. Blood pressure test Blood pressure can be measured in a variety of ways but the standard method is using an arm cuff and a stethoscope. It is recorded as two numbers e.g. 130/70. The first number is the systolic reading. This is the pressure in the arteries as the heart pumps out blood during a beat. The second number is the diastolic reading, which is the pressure of the blood in the arteries when the heart relaxes before the next beat. Since blood pressure varies from person to person and during the day, there are no fixed rules about what blood pressure reading is normal. These figures can be a useful guide: – Normal blood pressure: less than 120/80 – High Normal: 120-139/80-89 – High: more than 140/90 Urine tests Proteinuria is the term used to describe excessive amounts of protein in the urine. Normally, protein is not removed from the blood when the kidneys filter waste from the blood. However, when the kidneys are damaged protein leaks through the damaged filters and appears in the urine. It can be detected in the urine using a simple dipstick. The appearance of protein in the urine may be the first sign of an otherwise silent kidney condition. Protein leaks into the urine in very small or ‘micro’ amounts. The two commonest proteins that appear in the urine when this happens are albumin, an important blood protein, and globulin, which is largely made up of antibody proteins. Your microalbumin level can be measured by a special urine test either on a single urine sample or timed urine collection. A microalbumin test should be done at least once a year if you have diabetes.

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Kidney disease

Blood test A blood test can measure how well your kidneys filter the waste products and toxins from your blood, so it is the best indicator of kidney function. By combining the result of your blood creatinine level with your age and your gender, your kidney function is measured using a special formula to provide an ‘estimated Glomerular Filtration Rate’ or eGFR.
FAST F ACTS – Your e GFR is is repo and is s te n hown as rted in mililitre ili i r s mL/min per min – A nor nute /1.73m 2 7 mal GFR is greate Howeve ter than r, all res 90 mL/m ults lts = > 60 m /mi /1.7 in L/min/1 3m 2. /min/1.7 a2bove 60 are sh .73m own as – Some eGFR laborato ries do n ie because ot show re l an exac If your e sults above 60 t value may be GFR is u less tha will alw l n 60, the nreliable. ays be s actual v hown. alue lu

eGFR readings are grouped into five levels or stages of kidney function. The stages are only a guide as function can vary. The closer the value is to zero, the less kidney function you have.

eGFR 2 mL/min/1.73m – 90 60 – 89 30 – 59 15 – 29 15 – 29

Stage am No kidney damage or Stage 1 Stage 2 Stage 3 Stage 4 Stage 5

p ion Description dam Kidney damage with tion idne u ction normal kidney func nct function Mild loss in kidney tio y function s Moderate loss in kidne n y function Severe loss in kidne Kidney failure

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Kidney disease

2.2

Chronic Kidney Disease (CKD)
FAST FACTS

ears d lts over 25 ye u Australian adu such – One in seven KD e marker of CK at i n have at least on dney function. e ia or reduced ki pro e u as proteinur at increased Australians are – One in three uding those with ng CKD incl risk of developi pressure. and high blood i diabetes gns of more stralians has sig – One in 50 Au damage. v severe kidney r of people e he total numbe a – Each year th r per cent. n r ncreasing by 6 o dial on dialysis is in r er o e disease of olde re is not just a f e n – Kidney failu r cent of new p r approx 33 pe n o people. In 2005 he age of 55. d were under th t patients

If your kidneys function at a reduced level for a period of greater than three months, you have Chronic Kidney Disease or CKD. In some cases, kidney function can progressively decline with time. There are many factors that affect the progressive decline of CKD and these are not completely understood. If CKD is diagnosed at an early stage, medication, changes to diet, lifestyle and careful attention to blood pressure can increase the life of your kidneys and keep you feeling your best for as long as possible. It is important to work with your health care team and follow their advice to slow down its progress. However even with the best treatment, CKD sometimes leads to kidney failure, which requires dialysis or a kidney transplant to maintain life.

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Kidney disease

2.3

Kidney Failure
Kidney failure can be short term or permanent. It means your kidneys are only working at 10-15% or less. Some people stop passing urine completely while others still pass some weak, watery urine. Either way your kidneys are unable to properly filter waste, remove extra fluid and maintain the blood’s chemical balance. Acute kidney failure Kidney failure can happen quickly, caused for example by a sudden loss of large amounts of blood or the result of an accident. This is called ‘acute kidney failure’. Although life threatening, it is often short lived and kidney recovery is usually complete. Occasionally there can be some lasting kidney damage. Acute kidney failure is more common in males than females. Sometimes there are treatable causes for acute kidney failure but often it is simply a case of waiting for the kidneys to recover. Blood pressure and blood chemistry are monitored while waiting for function to return and some people may require dialysis for a short period. End stage kidney failure End stage kidney failure is permanent, and it means that kidney function is reduced to 10 percent or less of normal function. At this stage, it is time to consider starting dialysis or a kidney transplant to keep you alive.

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Kidney disease

2.4

Stages of chronic kidney disease
CKD can progress through a number of stages before reaching kidney failure. Early stages There may be no symptoms and blood tests can be normal. However there is more risk of dehydration and a higher sensitivity to medications. It is very important to talk to your doctor before starting any new medications including over the counter and natural or herbal medications. The risk of cardiovascular disease also starts to increase. Proper treatment including maintaining a healthy blood pressure and making healthy lifestyle choices can delay or prevent progress to the next stage. It is important to be aware that these guidelines sometimes need to be modified depending on your kidney function. Check with your kidney doctor or dietitian. Middle stages Discovery of CKD during this stage is more common as the level of waste in the blood rises. You may begin to feel unwell and notice changes in the number of times you urinate. As kidney function slows down, blood pressure rises. Early signs of bone disease and anaemia may appear. Proper treatment can slow the progress of kidney disease and reduce the likelihood of further complications. Later stages Changes may occur in the amount of urine passed and high blood pressure is almost always present. The amount of protein in the urine increases, as do the levels of creatinine and potassium in the blood. You are more likely to feel unwell, and you may also experience other complications of kidney disease, such as anaemia.

TS FAST FAC

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ts.

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Kidney disease

2.5

Signs and symptoms
Chronic kidney disease is often found by chance as many of its symptoms are wrongly linked to other causes. The symptoms may gradually worsen over time so you may not notice how severe they have become until the disease is well advanced. Symptoms can include: – Increased blood pressure – Changes in the amount and number of times urine is passed – Discomfort or burning when passing urine – Blood in the urine – Frothy or foaming urine – Puffiness, e.g. around the eyes and ankles – Pain in the kidney area – Tiredness – Loss of appetite – Difficulty sleeping – Headaches – Trouble thinking clearly – Itching – Shortness of breath – Nausea and vomiting – Bad breath and a metallic taste in the mouth – Pins and needles, e.g. in the fingers and toes – Muscle cramps Kidney disease often has no symptoms at all. It is common for people to lose up 90 per cent of their kidney function before developing any symptoms. I went to see my doctor about some constant headaches that I had. He took my blood for testing as well as urine. That night I was admitted into Royal Adelaide and started dialysis two days later. Christopher I knew for a long time before my doctor told me that my kidney was failing. I felt so unwell that I was looking forward to dialysis because I knew once I had started I would get better and feel better. Lisa

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Kidney disease

2.6

Kidney diseases
There are many different types of kidney disease, which can lead to kidney failure, including: Diabetic nephropathy Diabetes is a major cause of chronic kidney disease. Diabetes is caused by problems with the production and/or action of insulin. The pancreas does not make enough insulin (Type 1) or the body cannot use the insulin effectively (Type 2). Insulin is a hormone that controls the amount of sugar in your blood. About one third of people with diabetes will end up with some kidney damage. This is called diabetic nephropathy. It is a serious outcome of diabetes as chronic kidney disease worsens diabetic complications such as nerve and eye damage. Diabetic nephropathy damages blood vessels including those in your kidney filters and if severe, can lead to kidney failure. Diabetes also affects your kidneys in other ways. As an example, it changes the level of sugar in the blood or urine and can lead to bacterial growth in the bladder increasing the risk of kidney infections. Nerve damage can also affect your bladder making it more difficult to pass urine. Urine build up in the bladder can create a back flow into your kidneys resulting in scarring. If you have diabetes, your chance of kidney damage greatly increases if you smoke and/or have high blood pressure, high cholesterol or proteinuria. It is also affected by: – Duration of diabetes. Although kidney damage may be present when diabetes is first diagnosed, the longer diabetes is present, the greater the chance of developing kidney damage. – Family history and genetic factors. Some studies suggest that if there is a family history of high blood pressure or cardiovascular disease, your risk of diabetic nephropathy increases. Currently the genes for diabetic nephropathy have not been identified, but if your parent(s) have this condition then you are more likely to have it.

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Kidney disease

– Hyperglycaemia Hyperglycaemia or high blood sugar is a strong risk factor for developing diabetic nephropathy. It damages the small blood vessels in the kidneys, particularly to the capillaries in the kidney filters. Control of blood sugar levels may slow down the development of diabetic nephropathy. If you have diabetic nephropathy, regular monitoring of your blood sugar levels is very important. You may need adjustments to your diabetic medication as insulin is excreted via the kidneys. Good control of blood sugar levels and blood pressure can reduce or in some cases prevent further kidney damage.

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Kidney disease

Nephritis Nephritis is a general term used to describe a group of diseases that cause swelling or inflammation of the glomeruli or kidney filters in the nephrons. Nephritis is often used as an abbreviation for glomerulonephritis or ‘GN’. It is a common cause of chronic kidney disease in Australia and is more common in males. For reasons that are not always understood, the body’s immune system attacks the glomeruli causing swelling and scarring. This reduces the kidney’s ability to filter waste from the blood. There are many different types of nephritis. It can vary from a mild, non-damaging condition to a serious problem causing kidney failure. The acute form develops suddenly, sometimes after a throat or skin infection. These infections often need treatment, such as antibiotics, to prevent them from causing kidney damage. Chronic nephritis develops silently over several years and can lead to kidney failure Sometimes an acute attack can cause chronic nephritis years later. Factors such as your age and the characteristics of your urine are used to help diagnose different types of nephritis, such as: – Nephritic syndrome. Damage and inflammation of the filters/glomeruli can cause loss of blood and protein into the urine, accumulation of wastes in the blood and high blood pressure. If untreated, some diseases causing the nephritic syndrome can cause kidney failure. – Nephrotic syndrome. Damage to the filters/glomeruli causes them to leak large amounts of protein into the urine. It is harder to diagnose this syndrome because the symptoms and signs can also be caused by other conditions. Swelling due to retention of fluid and high cholesterol can also be a sign of nephrotic syndrome. Nephrotic syndrome can make the blood sticky, leading to blood clots. These can occur in the veins of the leg and cause swelling. Blood clots can go into the lungs, and cause chest pain, breathlessness or coughing up blood.

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Kidney disease

As each form of nephritis acts differently, the best course of treatment can only be determined after the type of nephritis is identified – proper identification often requires a kidney biopsy. Some types need observation and no treatment as they rarely lead to long-term kidney damage. Some people will need blood pressure treatment. Severe forms may need rapid treatment and if treated early enough, may respond well to medication. Occasionally nephritis leads to kidney failure. IgA nephropathy IgA nephropathy is the most common, serious form of nephritis. IgA refers to the antibody IgA (Immunoglobulin A), which helps to fight infection and is made in your throat, air passages, intestine and bone marrow. Nephropathy simply means kidney disease. In IgA nephropathy, two protein molecules join up and make longer chains. These chains travel in the blood and are deposited in the material between the kidney filters, called the mesangium. The build up of IgA protein triggers inflammation as well as damaging the filters, allowing protein and blood to leak into the urine. IgA nephropathy is found more often in males than females and is usually diagnosed before the age of thirty. In most cases the disease is not thought to be hereditary but in some families there may be a genetic link. There is a less common form of IgA called Henoch-Schonlein purpura. This form also affects other parts of the body as well as the kidneys, such as skin, joints and bowel.

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Kidney disease

High blood pressure Blood pressure is the pressure of the blood against the walls of the arteries as the heart pumps the blood around your body. High blood pressure damages the small vessels that take blood to the kidney filters and can also damage the filters themselves. If left unchecked, it tends to thicken the blood vessel walls causing blood vessels to narrow. High blood pressure can also lead to kidney disease, heart attack, strokes and loss of vision. It is possible to get into a vicious cycle – high blood pressure causes kidney damage leading to higher blood pressure and more kidney damage. High blood pressure has almost disappeared as a cause of kidney failure in young people but it is a common cause in older people. Usually high blood pressure does not give any warning signs and is often detected accidentally. Some people with high blood pressure experience: – Headaches – Dizziness – Nosebleeds – Vision changes

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Kidney disease

Polycystic Kidney Disease (PKD) PKD is the most common, inherited cystic kidney disease. It is caused by genetic defects, which lead to the growth of thousands of cysts in the kidneys. Both kidneys are affected but one kidney may develop the cysts earlier than the other. As the cysts grow larger, the kidneys become blocked, swell and can eventually fail. Cysts can be painful and become infected and bleed. You may still pass urine in normal amounts but the waste products remain in your body. Kidney failure caused by PKD usually develops slowly; only around 50% of people with this condition have developed kidney failure by the age of sixty. There are two types of inherited PKD: – Autosomal Dominant PKD. This is the most common, inherited form. If one parent has this type of PKD, there is a 50 per cent chance of passing the faulty gene in each pregnancy to their child. If a person does not inherit the gene, they have no chance of passing it on to their children because it never ‘skips’ a generation. Special blood tests can help to find the abnormal chromosomes linked to PKD and genetic counselling is available for affected couples. Occasionally, a person develops this condition when there is no family history. The affected person’s children also have a 50–50 chance of inheriting it. – Autosomal Recessive PKD. This is a rare, inherited form of PKD. Both parents have to carry this gene fault for a child to inherit this disease. If both parents are affected, they have a 25% chance of passing it on to their child. Symptoms begin in the early months of life or even before birth.

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Kidney disease

Medullary Cystic Kidney Disease (MCKD) This is another inherited kidney disease, which is transmitted in an autosomal dominant pattern. It often causes kidney failure between 20 and 50 years of age. In a few cases there is no family history, which may indicate a new genetic mutation. The childhood disease, juvenile nephronophthisis, is very similar but usually occurs in young children and is due to autosomal recessive inheritance. It can also be linked to nonkidney complications often affecting the eyes while MCKD is limited to the kidneys. In both diseases cysts develop in the inner part of the kidney (medulla), the kidneys shrink as the cortex (outer section) thins and kidney failure develops. The kidneys can’t concentrate urine properly, leading to an over production of urine, loss of sodium and dehydration. Other health problems usually follow, including anaemia, kidney bone disease, gout and high blood pressure. Medullary Sponge Kidney Medullary Sponge Kidney is a condition where cysts develop in the kidney’s urine collecting ducts and tubules. The exact cause of Medullary Sponge Kidney is not known. One or both kidneys may be affected. Complications include blood in the urine (haematuria), calcium deposits in the kidneys, kidney stones or infections. Kidney failure is rare but can develop as a result of repeated infections or kidney stones. Analgesic Nephropathy In the past some pain relieving drugs were shown to cause kidney damage. This condition became known as analgesic nephropathy. The best-recognised drugs to have this effect were the old APC headache powders - a combination of aspirin, phenacetin and codeine. Kidney Health Australia successfully campaigned the Australian Government to have these preparations removed from the marketplace. As a result, the rate of analgesic nephropathy has fallen steadily. However, there are some drugs which can have this effect on some people. You should consult your doctor if you are concerned that the medications you are taking may be causing kidney damage.

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Kidney disease

Vascular conditions Many older people can have a type of vascular disease where blood vessels become completely or partly blocked. The word vascular relates to your blood vessels such as arteries, veins and capillaries. Fatty deposits, cholesterol, calcium and other substances build up in the inner lining of the arteries. This affects the kidney’s filters and reduces the blood supply to the kidney, resulting in high blood pressure and reduced kidney function. This problem can cause heart attacks and strokes as well as kidney failure. Reflux Nephropathy Nephropathy describes any type of non-inflammatory kidney condition. Reflux nephropathy is a form of chronic kidney disease, linked to problems in the kidneys and urinary tract that block the flow of urine, and is often present at birth. Causes can include: – Problems with the ureters location when entering the bladder. – Repeated urine infections. – A blockage in the bladder outlet causing backpressure to build up in the kidneys. – Problems with the ureter valves. When the bladder is being emptied these valves stop the urine moving from the ureters into the kidney. One or both of these valves may not work properly. Reflux Nephropathy is often found in young children with frequent urine infections. Reflux usually fixes itself, although sometimes an operation is needed. Some doctors give daily antibiotics to try to prevent infections and scarring. Usually the damage is only minor but long-term problems like high blood pressure can occur much later in life. However, the damage caused by infection can sometimes be permanent.

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Kidney disease

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Source: A NZDATA 2006 Rep ort

FAST F ACT

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S KEY POINT

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