- Clinical science
Chronic kidney disease (CKD) is defined as an abnormality of the kidney structure or function for ≥ 3 months. The most common causes of CKD in the United States are diabetes mellitus, hypertension, and glomerulonephritis. Since the kidneys have exceptional compensatory mechanisms, most patients remain asymptomatic and are unaware of their condition until their kidney function is significantly impaired. Patients typically present with symptoms of fluid overload (e.g., peripheral edema) and uremia. Laboratory evaluation shows hyperkalemia, hyperphosphatemia, and hypocalcemia, as well as metabolic acidosis. Management focuses mainly on treating the underlying disease and preventing possible complications, e.g., treating hypertension, avoiding nephrotoxic substances, and maintaining adequate hydration. If chronic kidney disease progresses to end-stage renal disease (ESRD), renal replacement therapy (dialysis) or a kidney transplant is necessary.
- Chronic kidney disease is defined as an abnormality of the kidney structure or function for ≥ 3 months.
- Associated with an irreversible reduction of the excretory (glomerular, tubular) and the endocrine functions of the kidney
|Diagnostic criteria (≥ 3 months)|
|Abnormalities of the kidney structure|| |
Abnormalities of the urine sediment
Moderate – severe albuminuria
History of kidney transplantation
Abnormalities detected on imaging
|Abnormalities of the kidney function||GFR < 60 mL/min/1.73 m2|
- About 10% of adults in the US suffer from chronic kidney disease.
- African Americans are at increased risk of developing chronic kidney disease.
Epidemiological data refers to the US, unless otherwise specified.
- Patients are often asymptomatic until later stages.
- Peripheral edema
- Pulmonary edema (usually )
Clinical features of uremia
Fatigue, weakness, loss of appetite, headaches
- Uremic fetor
- Pigmented spots
- Uremic pericarditis
- Encephalopathy; : seizures, somnolence, coma
- Peripheral neuropathy: paresthesias
- Gastrointestinal symptoms: nausea, vomiting
- ↑ Risk of infection: leukocyte dysfunction
- ↑ Bleeding tendency secondary to platelet dysfunction
- Fatigue, weakness, loss of appetite, headaches
- Chronic kidney disease-mineral and bone disorder (CKD-MBD): abnormalities of mineral or bone metabolism in the setting of chronic renal disease
Classification based on glomerular filtration rate
|Stage||Glomerular filtration rate (GFR) (mL/min/1.73 m2)||Description|
|1||> 90||Normal or high|
|2||60 to 89||Mildly decreased|
|3||30 to 59||Moderately decreased|
|4||15 to 29||Severely decreased|
|5||< 15||Kidney failure|
Classification based on albuminuria
|Stage||Urinary albumin excretion (mg/day)||Description|
|A2||30 to 300||Mildly increased (microalbuminuria)|
|A3||> 300||Severely increased (macroalbuminuria)|
- ↑ Creatinine and BUN
- Electrolytes: hyperkalemia, hyperphosphatemia, hypocalcemia
- ↓/↑ Sodium
- Monitor blood pH for metabolic acidosis
- ↓ Calcitriol levels
- ↑ Parathyroid hormone (PTH)
- Coagulation testing: ↔︎ PT, PTT, platelet count, ↑ bleeding time caused by uremic coagulopathy
- Anemia of chronic kidney disease: ↓ hemoglobin, ↔︎ MCV
- Urinalysis: : possibly abnormal urine sediment (see , )
- Ultrasound: shrunken kidneys and fibrotic parenchyma
- Renal biopsy: sometimes indicated to determine the underlying cause
In chronic renal disease, close surveillance of serum potassium values as well as calcium and phosphate values is essential!References:
- Nephrotoxic substances avoidance
Strict blood pressure control
- Well-controlled blood pressure is essential to prevent disease progression.
- See treatment of .
- Values should generally be < 140/90 mm Hg; in patients with a urine protein excretion of ≥ 1 g/day, values should be < 130/80 mm Hg.
- Use ACE inhibitors/angiotensin receptor blockers (beware of hyperkalemia) → nephroprotective
Special patient groups
End-stage renal disease
- Dialysis until a renal transplant is available
- Anemia of chronic kidney disease
- Metabolic diseases
- Actively bleeding or about to undergo a surgical procedure
- End-stage renal disease