Chronic Renal Failure


Article Author:
Satyanarayana Vaidya


Article Editor:
Narothama Aeddula


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/6/2019 4:06:14 PM

Introduction

Chronic kidney disease (CKD) is defined as the presence of kidney damage or an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 mt2, persisting for 3 months or more, irrespective of the cause.[1] It is a state of progressive loss of kidney function ultimately resulting in the need for renal replacement therapy (dialysis or transplantation). Kidney damage refers to pathologic abnormalities either suggested by imaging studies or renal biopsy, abnormalities in urinary sediment, or increased urinary albumin excretion rates. The 2012 KDIGO CKD classification recommends details about the cause of the CKD and classifies into 6 categories based on glomerular filtration rate (G1 to G5 with G3 split into 3a and 3b). It also includes the staging based on three levels of albuminuria (A1, A2, and A3), with each stage of CKD being sub-categorized according to the urinary albumin-creatinine ratio in (mg/gm) or (mg/mmol) in an early morning “spot” urine sample.[2]

The 6 categories include:

  • G1: GFR 90 ml/min per 1.73 m2 and above
  • G2: GFR 60 to 89 ml/min per 1.73 m2
  • G3a: GFR 45 to 59 ml/min per 1.73 m2
  • G3b: GFR 30 to 44 ml/min per 1.73 m2
  • G4: GFR 15 to 29 ml/min per 1.73 m2
  • G5: GFR less than 15 ml/min per 1.73 m2 or treatment by dialysis

The three levels of albuminuria include albumin-creatinine ratio (ACR)

  • A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol)
  • A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol)
  • A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol).

The improved classification of CKD has been beneficial in identifying prognostic indications related to decreased kidney function and increased albuminuria. However, a downside of the use of classification systems is the possible overdiagnosis of CKD, especially in elderly.

Etiology

The causes of CKD vary globally, and the most common primary diseases causing CKD and ultimately end-stage renal disease (ESRD) are as follows[3]:

  • Diabetes mellitus type 2 (30% to 50%)
  • Diabetes mellitus type 1 (3.9%)
  • Hypertension (27.2%)
  • Primary glomerulonephritis (8.2%)
  • Chronic Tubulointerstitial nephritis (3.6%)
  • Hereditary or cystic diseases (3.1%)
  • Secondary glomerulonephritis or vasculitis (2.1%)
  • Plasma cell dyscrasias or neoplasm (2.1)
  • Sickle Cell Nephropathy (SCN) which accounts for less than 1% of ESRD patients in the United States[4]

CKD may result from disease processes in any of the three categories: prerenal (decreased renal perfusion pressure), intrinsic renal (pathology of the vessels, glomeruli, or tubules-interstitium), or postrenal (obstructive).

Prerenal Disease

Chronic prerenal disease occurs in patients with chronic heart failure or cirrhosis with persistently decreased renal perfusion, which increases the propensity for multiple episodes of an intrinsic kidney injury, such as acute tubular necrosis (ATN). This leads to progressive loss of renal function over time.

Intrinsic Renal Vascular Disease

The most common chronic renal vascular disease is nephrosclerosis, which causes chronic damage to blood vessels, glomeruli, and tubulointerstitium.

The other renal vascular diseases are renal artery stenosis from atherosclerosis or fibro-muscular dysplasia which over months or years, cause ischemic nephropathy, characterized by glomerulosclerosis and tubulointerstitial fibrosis.[5]

Intrinsic Glomerular Disease (Nephritic or Nephrotic)

A nephritic pattern is suggested by abnormal urine microscopy with red blood cell (RBC) casts and dysmorphic red cells, occasionally white blood cells (WBCs), and a variable degree of proteinuria.[6] The most common causes are post-streptococcal GN, infective endocarditis, shunt nephritis, IgA nephropathy, lupus nephritis, Goodpasture syndrome, and vasculitis. [7]

A nephrotic pattern is associated with proteinuria, usually in the nephrotic range (greater than 3.5 gm per 24 hours), and an inactive urine microscopic analysis with few cells or casts. It is commonly caused by minimal change disease, focal segmental glomerulosclerosis, membranous GN, membranoproliferative GN (Type 1 and 2 and associated with cryoglobulinemia), diabetic nephropathy, and amyloidosis.

Some patients may be assigned to one of these two categories.

Intrinsic Tubular and Interstitial Disease

The most common chronic tubulointerstitial disease is polycystic kidney disease (PKD). Other etiologies include nephrocalcinosis (most often due to hypercalcemia and hypercalciuria), sarcoidosis, Sjogren syndrome, reflux nephropathy in children and young adults, [8]

There is increased recognition of the relatively high prevalence of CKD of unknown cause among agricultural workers from Central America and parts of Southeast Asia called Mesoamerican nephropathy,[9]

Postrenal (Obstructive Nephropathy)

Chronic obstruction may be due to prostatic disease, nephrolithiasis or abdominal/pelvic tumor with mass effect on ureter(s) are the common causes. Retroperitoneal fibrosis is a rare cause of chronic ureteral obstruction.

Epidemiology

The true incidence and prevalence of CKD are difficult to determine because of the asymptomatic nature of early to moderate CKD. The prevalence of CKD is around 10% to 14% in the general population. Similarly, albuminuria (microalbuminuria or A2) and GFR less than 60 ml/min/1.73 mt2 have a prevalence of 7% and 3% to 5%, respectively.[10]

Worldwide, CKD accounted for 2,968,600 (1%) of disability-adjusted life-years and 2,546,700 (1% to 3%) of life-years lost in 2012.[3]

Kidney Disease Outcomes Quality Initiative (KDOQI) mandates that for labeling of chronicity and CKD, patients should be tested on three occasions over a 3-month period with 2 of the 3 results being consistently positive.[11]

Natural History and Progression of CKD

CKD diagnosed in the general population (community CKD) has a significantly different natural history and the course of progression compared to the CKD in patients referred to the nephrology practices (referred CKD).

Community CKD is seen mainly in the older population. These individuals have had a lifelong exposure to cardiovascular risk factors, hypertension, and diabetes which can also affect the kidneys. The average rate of decline in GFR in this population is around 0.75 to 1 ml/min/year after the age of 40 to 50 years. [12] In a large study of community based CKD by Kshirsagar et al., only 1% and 20% of patients with CKD stages G3 and G4 required renal replacement therapy (RRT), however, 24% and 45% respectively died predominantly from cardiovascular disease (CVD), suggesting that cardiac events rather than progressing to ESRD is the predominant outcome in community-based CKD.[13]

In contrast to community CKD, patients with referred CKD present at an early age because of hereditary (autosomal dominant polycystic kidney disease ADPKD) or acquired nephropathy (glomerulonephritis, diabetic nephropathy, or tubulointerstitial disease) causing progressive renal damage and loss of function. The rate of progression in referred CKD varies according to the underlying disease process and between individual patients. Diabetic nephropathy has shown to have a rapid rate of decline in GFR averaging around 10 ml/min/year. In nondiabetic nephropathies, the rate of progression is usually faster in patients with chronic proteinuric GN than those with a low level of proteinuria. Patients with ADPKD and renal impairment, CKD stage G3b and beyond, may have a faster rate of progression compared to other nephropathies. In patients with hypertensive nephrosclerosis, good blood pressure control and minimal proteinuria are associated with very slow progression.

Risk Factors for Progression of CKD

Non-Modifiable CKD Risk Factors

Older age, male gender, a non-Caucasian ethnicity which includes African Americans, Afro-Caribbean individuals, Hispanics, and Asians (South Asians and Pacific Asians) all adversely affect CKD progression.

Genetic factors which affect CKD progression have been found in different Kidney diseases. In a population-based cohort study by Luttropp et al., single nucleotide polymorphisms in the genes TCF7L2 and MTHFS were associated with diabetic nephropathy and CKD progression. In the same study, polymorphisms of genes coding for mediators of renal scarring and renin-angiotensin-aldosterone system (RAAS) were found to influence CKD progression.[14]

Modifiable CKD Risk Factors

These include systemic hypertension, proteinuria, and metabolic factors.[15]

Systemic hypertension is one of the main causes of ESRD worldwide and the second leading cause in the United States after diabetes. The transmission of systemic hypertension into glomerular capillary beds and the resulting glomerular hypertension is believed to contribute to the progression of glomerulosclerosis.[16] Night-time and 24-hour blood pressure measurement (ABPM) appear to correlate best with the progression of CKD. Systolic rather than diastolic BP seems to be predictive of CKD progression and has also been associated with complications in CKD.

Multiple studies in patients with diabetic and nondiabetic kidney diseases have shown that marked proteinuria (albuminuria A3) is associated with a faster rate of CKD progression. Also, a reduction in marked proteinuria by RAS blockade or by diet is associated with a better renal outcome. However, in large intervention studies like Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH)[17] and Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial (ONTARGET),[18] significant declines in GFR were noted despite a marked reduction in albuminuria. Therefore, moderate level albuminuria (A2) is not a reliable surrogate marker for CKD progression and reduction in albuminuria can be associated with both improving and worsening of CKD progression.

Multiple studies have linked the RAAS system in the pathogenesis of hypertension, proteinuria, and renal fibrosis throughout CKD. Subsequently, interventions targeting RAAS have proved effective in slowing the progression of CKD. This has led to widespread use of RAAS blockers in proteinuric and diabetic kidney disease.

Obesity and smoking have been related to the development and progression of CKD. Also, metabolic factors such as insulin resistance, dyslipidemia, and hyperuricemia have been implicated in the development and progression of CKD.[19][20]

Recommendations for CKD Screening

Screening, mostly targeting high-risk individuals is being implemented worldwide. The KDOQI guidelines recommend screening high-risk populations which include individuals with Hypertension, Diabetes mellitus, and those older than 65 years. This should include urinalysis, a urine albumin-creatinine ratio (ACR), measurement of serum creatinine and estimation of GFR preferably by chronic kidney disease epidemiology collaboration (CKD-EPI) equation. It is the most cost-effective approach, and there is no evidence to justify screening asymptomatic individuals in the general population for CKD.

Pathophysiology

Unlike acute kidney injury (AKI), where the healing process is complete with full functional kidney recovery, chronic and sustained insults from chronic and progressive nephropathies evolve to progressive kidney fibrosis and destruction of the normal architecture of the kidney. This affects all the 3 compartments of the kidney, namely glomeruli, the tubules, the interstitium, and the vessels. It manifests histologically as glomerulosclerosis, tubulointerstitial fibrosis, and vascular sclerosis.

The sequence of events which lead to scarring and fibrosis are complex, overlapping, and are multistage phenomena.

  • Infiltration of damaged kidneys with extrinsic inflammatory cells
  • Activation, proliferation, and loss of intrinsic renal cells (though apoptosis, necrosis, mesangiolysis, and podocytopenia)
  • Activation and proliferation of extracellular matrix (ECM) producing cells including myofibroblasts and fibroblasts
  • Deposition of ECM replacing the normal architecture

Mechanisms of Accelerated Progression of CKD

  • Systemic and intraglomerular hypertension
  • Glomerular hypertrophy
  • Intrarenal precipitation of calcium phosphate
  • Altered prostanoid metabolism

All these mechanisms lead to a histological entity called focal segmental glomerulosclerosis.[21]

Clinical risk factors for accelerated progression of CKD are proteinuria, hypertension, black race, and hyperglycemia. Also, environmental exposures such as lead, smoking, metabolic syndrome, possibly some analgesic agents, and obesity have also been linked to accelerated progression of CKD.[22]

History and Physical

Early CKD stages are asymptomatic, and symptoms manifest in stages 4 or 5. It is commonly detected by routine blood or urine testing. Some common symptoms and signs at these stages of CKD are:

  • Nausea
  • Vomiting
  • Loss of appetite
  • Fatigue and weakness
  • Sleep disturbance
  • Oliguria
  • Decreased mental sharpness
  • Muscle twitches and cramps
  • Swelling of feet and ankles
  • Persistent pruritus
  • Chest pain due to uremic pericarditis
  • Shortness of breath due to pulmonary edema from fluid overload
  • Hypertension that's difficult to control
  • Physical examination is often not helpful, but patients may have
  • Skin pigmentation
  • Scratch marks from pruritus
  • Pericardial friction rub due to uremic pericarditis
  • Uremic frost, where high levels of BUN result in urea in sweat
  • Hypertensive fundal changes suggesting chronicity

Evaluation

Establishing Chronicity

When an eGFR of less than 60 ml/min/1.73m is detected in a patient, attention needs to be paid to the previous blood and urine test results and clinical history to determine whether this is a result of AKI or CKD that has been present but asymptomatic. The following factors would be helpful.

  1. History of long-standing chronic hypertension, proteinuria, microhematuria, and symptoms of the prostatic disease
  2. Skin pigmentation, scratch marks, left ventricular hypertrophy, and hypertensive fundal changes
  3. Blood test results of other conditions like multiple myeloma, systemic vasculitis would be helpful.
  4. Low serum calcium and high phosphorus levels have little discriminatory value, but normal Parathyroid hormone levels suggest AKI rather than CKD
  5. Patients who have very high blood urea nitrogen (BUN) values greater than 140 mg/dl, serum creatinine greater than 13.5 mg/dl, who appear relatively well and still passing normal volumes of urine are much more likely to have CKD than acute kidney disease.

Assessment of Glomerular Filtration Rate

For patients in whom the distinction between AKI and CKD is unclear, kidney function tests should be repeated in 2 weeks of the initial finding of low eGFR below 60 ml/min/1.73 m.

If previous tests confirm that the low eGFR is chronic or the repeat blood test results over 3 months are consistent, CKD is confirmed.

If eGFR based on serum creatinine is known to be less accurate, then other markers like cystatin-c or an isotope-clearance measurement can be undertaken.

Assessment of Proteinuria

KDIGO recommends that proteinuria should be assessed by obtaining an early morning urine sample and quantifying albumin-creatinine ratio (ACR). The degree of albuminuria is graded from A1 to A3, replacing previous terms such as microalbuminuria.

Some patients may excrete proteins other than albumin and urine protein-creatinine ratio (PCR) may be more useful for certain conditions.[23]

Imaging of Kidneys

If an ultrasound examination of kidneys shows small kidneys with reduced cortical thickness, increased echogenicity, scarring, or multiple cysts, this suggests a chronic process. It may also be helpful to diagnose chronic hydronephrosis from obstructive uropathy, cystic enlargement of the kidney in ADPKD.

Renal ultrasound Doppler can be used in suspected renal artery stenosis to evaluate the renal vascular flow

Computerized tomography: A low dose of non-contrast CT is used to diagnose renal stone disease. It is also used to diagnose suspected ureteric obstruction which cannot be seen by ultrasonography.

Renal angiography has its role in the diagnosis of polyarteritis nodosa where multiple aneurysms and irregular areas of constriction are seen.

Voiding cystourethrography is mainly used when chronic vesicourethral reflux is suspected as the cause of CKD.[8] It is used to confirm the diagnosis and estimate the severity of reflux.

Renal scans can give sufficient information about the anatomy and function of kidneys. They are used predominantly in children as they are associated with lesser radiation exposure compared to CT scan. Radionuclide renal scans are used to measure the difference in function between the kidneys.

Establishing an Accurate Diagnosis

An accurate cause of CKD needs to be established such as when there is an underlying treatable condition that requires appropriate management, for example, lupus nephritis, ANCA vasculitis, among others. In addition, certain diseases carry a higher frequency of recurrence in the kidney after transplantation and accurate diagnosis will influence later management. A kidney biopsy is used to diagnose the etiology of CKD, and it also gives information about the extent of fibrosis in the kidney.

Treatment / Management

General Management

  • Adjusting drug doses for the level of estimated glomerular filtration rate (GFR)
  • Preparation of renal replacement therapy by placing an arteriovenous fistula or graft

Treat the Reversible Causes of Renal Failure

The potentially reversible causes of acute kidney injury like infection, drugs which reduce the GFR, hypotension such as from shock, instances which cause hypovolemia such as vomiting, diarrhea should be identified and intervened.

Patients with CKD should be evaluated carefully for the use of intravenous contrast studies, and any alternatives for the contrast studies should be utilized first. Other nephrotoxic agents such as aminoglycoside antibiotics and NSAIDs should be avoided.

Retarding the Progression of CKD

The factors which result in progression of CKD should be addressed such as hypertension, proteinuria, metabolic acidosis, and hyperlipidemia. Hypertension should be managed in CKD by establishing blood pressure goals. Similarly, proteinuria goal should be met.

Multiple studies have shown that smoking is associated with risk of developing nephrosclerosis and smoking cessation retards the progression of CKD.[24]

Protein restriction has also been shown to slow the CKD progression. However, the type and amount of protein intake are yet to be determined.

Bicarbonate supplementation for treatment of chronic metabolic acidosis has been shown to delay the CKD progression as well. [25] Also, intensive glucose control in diabetics has been shown to delay the development of albuminuria and also the progression of albuminuria to overt proteinuria.[26]

Preparation and Initiation of Renal Replacement Therapy

Once the CKD progression is noted, the patient should be offered various options of renal replacement therapy.

  • Hemodialysis (home or in-center)
  • Peritoneal dialysis (continuous or intermittent)[27]
  • Kidney transplantation (living or deceased donor): It is the treatment of choice for ESRD given better long-term outcomes.
  • Patients who do not want renal replacement therapy should be provided information about conservative and palliative care management.
  • The hemodialysis is performed after stable vascular access is placed in a nondominant arm. In this arm, intravenous cannulas are avoided to preserve the veins. The preferred vascular access is AV fistula. The other hemodialysis access options are AV graft and tunneled hemodialysis catheters. The patency rates of AV fistula is good, and infections are very infrequent. Higher flows can be achieved through AV fistula, and there is less chance of recirculation.
  • Peritoneal dialysis is performed after placing a peritoneal catheter.[27]

Indications for Renal Replacement Therapy

  • Pericarditis or pleuritis (urgent indication)
  • Progressive uremic encephalopathy or neuropathy, with signs such as confusion, asterixis, myoclonus, and seizures (urgent indication)
  • A clinically significant bleeding diathesis is attributable to uremia (urgent indication)
  • Hypertension is poorly responsive to antihypertensive medications
  • Fluid overload is refractory to diuretics
  • Metabolic disorders that are refractory to medical therapy such as hyperkalemia, hyponatremia, metabolic acidosis, hypercalcemia, hypocalcemia, and hyperphosphatemia
  • Persistent nausea and vomiting
  • Evidence of malnutrition

Renal transplantation is the best treatment option of ESRD due to its survival benefit compared to long-term dialysis therapy. The patients with CKD become eligible to be listed for Deceased donor renal transplant program when the eGFR is less than 20 ml/min/1.73m2

Conservative management of ESRD is also an option for all patients who decide not to pursue renal replacement therapy. Conservative care includes the management of symptoms, advance-care planning, and provision of appropriate palliative care. This strategy is often underutilized and needs to be considered for very frail patients with poor functional status with numerous comorbidities. For facilitating this discussion a 6-month mortality score calculator is being used which includes variables such as age, serum albumin, the presence of dementia, peripheral vascular disease, and (yes/no) answer to a question by a treating nephrologist "would I be surprised if this patient died in the next year?"

When to Refer to a Nephrologist

Patients with CKD should be referred to a nephrologist when the estimated GFR is less than 30 ml/min/1.73 mt2. This is the time to discuss the options of renal replacement therapy.

Staging

The 6 categories include:

  • G1: GFR 90 ml/min per 1.73 m2 and above
  • G2: GFR 60 to 89 ml/min per 1.73 m2
  • G3a: GFR 45 to 59 ml/min per 1.73 m2
  • G3b: GFR 30 to 44 ml/min per 1.73 m2
  • G4: GFR 15 to 29 ml/min per 1.73 m2
  • G5: GFR less than 15 ml/min per 1.73 m2 or treatment by dialysis

The 3 levels of albuminuria include albumin-creatinine ratio (ACR):

  • A1: ACR less than 30 mg/gm (less than 3.4 mg/mmol)
  • A2: ACR 30 to 299 mg/gm (3.4 to 34 mg/mmol)
  • A3: ACR greater than 300 mg/gm (greater than 34 mg/mmol)

Prognosis

Significant racial and ethnic differences exist in the incidence and prevalence rates of ESRD. The highest incidence is found in African Americans; followed by American Indians and Alaska Natives; followed by Asian Americans, native Hawaiians, and other Pacific Islanders; followed by Caucasians. Hispanics have higher incidence rates of ESRD than non-Hispanics.

Early stage CKD and ESRD are associated with increased morbidity and health care utilization rates. A review of the USRDS 2009 annual data report suggests that the number of hospitalizations in ESRD patients is 1.9% per patient-year. In a study by Khan SS et al., the prevalence of cardiovascular disease, cerebrovascular disease, and peripheral vascular disease in earlier stages of CKD were comparable to those in US dialysis population. It was also found that patients with CKD had 3-fold higher rates of hospitalization and hospital days spent per patient-year compared to general US population.[28] CKD patients are at a higher risk of hospitalization and cardiovascular diseases and the risk increases with a decline in GFR.

Patients with CKD and particularly end-stage renal disease (ESRD) are at increased risk of mortality, particularly from cardiovascular disease. Review of USRDS 2009 data suggests that 5-year survival probability in a patient on dialysis is only around 34%.

Complications

Treatment of Complications of Chronic Kidney Disease

Patients with CKD have diminished the ability to maintain a fluid balance after a rapid sodium load and becomes more apparent in stages IV and V of CKD. These patients respond to sodium restriction and a loop diuretic. The 2012 KDIGO guidelines recommend all CKD patients should be sodium restricted to less than 2 gm per day.

Hyperkalemia in CKD can occur specifically in oliguric patients and in whom where aldosterone secretion is diminished. Dietary intake of potassium, tissue breakdown and hypoaldosteronism could result in hyperkalemia. Drugs such as ACE inhibitors and nonselective beta blockers could also result in hyperkalemia.

Metabolic acidosis is a common complication of advanced CKD due to the increased tendency of kidneys in CKD to retain H. Chronic metabolic acidosis in CKD would result in osteopenia, increased protein catabolism, and secondary hyperparathyroidism. These patients should be treated with bicarbonate supplementation to target serum bicarbonate of equal to 23.

CKD is a significant risk factor for CVD and risk increases with increased severity of the CKD.Considerable evidence indicates a significant association between Epicardial adipose tissue(EAT) thickness and the incidence of CVD events in CKD patients.In CKD patients, EAT assessment could be a reliable parameter for cardiovascular risk assessment.[29].

Bone and Mineral Disorders

Hyperphosphatemia is a frequent complication of CKD due to a decreased filtered load of phosphorous. This leads to increased secretion of a Parathyroid hormone (PTH) and causes secondary hyperparathyroidism. Hyperparathyroidism results in normalization of phosphorous and calcium but at the expense of bone. This results in renal osteodystrophy. Therefore, phosphorus binders along with dietary restriction of phosphorus are used to treat secondary hyperparathyroidism.

Hypertension is a manifestation of volume expansion in CKD. Patients in CKD do not always have edema to suggest volume expansion. Therefore, all patients with CKD should have a loop diuretic added to control the blood pressure which needs to be titrated before considering an increase in antihypertensive therapy.

Anemia in CKD is usually normocytic normochromic. It is primarily due to reduced erythropoietin production from reduced functioning renal mass and also due to reduced red cell survival. Hemoglobin should be checked at least yearly in CKD 3, every 6 months in CKD IV and V, and every 3 months in dialysis patients. Erythropoietin stimulating agents (ESA) in CKD patients should be considered when Hb is less than 10 and provided iron saturation is at least 25% and ferritin greater than 200 ng/mL. In dialysis patients, the goal Hb concentration is 10 to 11.5 gm/dl.

Treatment of Complications of ESRD

Malnutrition in ESRD is due to anorexia and poor protein intake. The diet in ESRD should provide at least 30 to 35 Kcal/kg per day. Low plasma albumin concentration is suggestive of malnutrition.

Uremic bleeding is a complication resulting from impaired platelet function. It results in prolonged bleeding time. Asymptomatic patients are not treated. However, correction of uremic platelet dysfunction is needed during active bleeding, need for a surgical procedure. Some interventions used are desmopressin (dDAVP), cryoprecipitate, estrogen, and initiation of dialysis.

Uremia can present as uremic pericarditis and is an indication for initiation of dialysis. Uremic pericarditis is treated with dialysis and responds well.

Complications of Renal Transplantation

Complications related to cardiovascular, renal, neurologic, and gastrointestinal systems.[30][31][30]

Common complications include hypertension, dyslipidemia, coronary artery disease from new-onset diabetes mellitus and renal failure, left ventricular hypertrophy, arrhythmias,[31] and heart failure. Neurologic complications include stroke and posterior reversible encephalopathy syndrome, central nervous system (CNS) infections, neuromuscular disease, seizure disorders, and neoplastic disease. GI complications include infection, malignancy (posttransplant lymphoproliferative disorder), mucosal injury, mucosal ulceration, perforation, biliary tract disease, pancreatitis, and diverticular disease.

Consultations

  • Nephrology should be consulted for all patients with CKD where GFR is less than 30 ml/min/1.73 m.
  • Urology consultation is needed for obstructive uropathy.
  • Relieve obstruction with retrograde ureteral catheters or percutaneous nephrostomy.
  • Interventional radiology consults for placement of permanent tunneled hemodialysis catheter.
  • Vascular surgery is suggested for placing arterio-venous fistula(AVF) or grafts (AVG) along with peritoneal dialysis catheters.

Deterrence and Patient Education

All high-risk groups of patients such as Diabetic patients, hypertensives, should not only be screened for CKD but also be counseled about the symptoms and signs of CKD. Patients with CKD should be taught about the following interventions at home

Eighty percent to 85% of patients with CKD have hypertension, and they should be instructed to measure blood pressure daily and to keep a log of blood pressure, daily weights. They should be prescribed a diuretic as a part of an antihypertensive regimen.

Teaching patients with advanced CKD of home administration of subcutaneous erythropoietin stimulating agents.

There should be a discussion held with patients by nutritionists or physicians about low protein diet which may slow the progression of CKD and potassium containing foods.

All patients with advanced CKD should be instructed about the need to control phosphorus levels. They should be instructed to take phosphate binders with each meal.

CKD patients who are pregnant should be educated that pregnancy may worsen the CKD and how reduced kidney function can adversely effect pregnancy.

Pearls and Other Issues

  1. Chronic kidney disease (CKD) is defined as kidney damage or an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m persisting for three months or more irrespective of the cause.
  2. CKD is usually asymptomatic till stages IV and V.
  3. The KDOQI guidelines recommend screening high-risk populations which include individuals with hypertension, diabetes mellitus, and those older than 65 years with a urinalysis, a urine albumin-creatinine ratio (ACR), measurement of serum creatinine and estimation of GFR preferably by chronic kidney disease epidemiology collaboration (CKD-EPI) equation.
  4. Calcium and phosphorus are not useful to distinguish AKI from CKD. However, normal PTH suggests AKI rather than CKD.
  5. Systemic hypertension, proteinuria, hyperlipidemia, and metabolic acidosis cause progression of CKD and need to be treated aggressively.
  6. Bicarbonate supplementation to reach a serum bicarbonate target equal to 23 delays the progression of CKD.
  7. All CKD patients need to be evaluated for anemia, hypertension, metabolic acidosis, and bone and mineral disorders.

Enhancing Healthcare Team Outcomes

CKD has a multitude of manifestations and is optimally managed by an interprofessional team of health care professionals who practice at a single location such as CKD clinic. These clinics focus on guideline driven kidney care, evaluate and treat complications, suggest patient lifestyle modifications, and provide adequate patient education regarding the various modalities of dialysis. Fishbane et al. compared a standard care model with a healthy transitions program where a nurse care manager works with a protocol-driven informatics system which provides daily reports with incomplete steps of the process for each patient.[32] It showed a reduction in hospitalizations, increased use of AV fistulas, a decrease in emergent dialysis, and less use of catheters. Such models decrease the overall cost of health care with saving of billions of dollars. The multidisciplinary CKD clinics have access to a nutritionist who assesses the nutritional status of a patient and also formulates a meal plan. Similarly, a pharmacist performs a medication check and screens for nephrotoxic medications and adjusts the non-nephrotoxic medications to the patient’s renal function. A vascular access nurse also evaluates appropriate patients. Finally, renal transplantation information is provided to eligible patients.


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Chronic Renal Failure - Questions

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An elderly female presents with normochromic anemia. She has complaints of fatigue and swelling, with a history of hypertension, diabetes mellitus type 2, and osteoarthritis. She is on hydrochlorothiazide, metoprolol, glyburide, and ibuprofen. Her physical exam reveals a BP of 155/90, weight of 43 kg, 1+ peripheral edema, no hepatosplenomegaly. The lab results: Na 136 meq/L, K 5.0 meq/L, HCO3 18 meq/L, Cl 108 meq/L, creatinine 1.6 mg/dL, glucose 183 mg/dL, and normal liver function panel. What is the most likely diagnosis?



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A patient presents with Stage III chronic kidney disease due to hypertension. He takes an ACE inhibitor, a thiazide diuretic, and acetaminophen as needed and has a BP of 145/80. Of the following, which is MOST important in preventing the progression of kidney damage for this patient?



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Which of the following should be addressed in a patient with chronic renal failure?



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Which of the following drugs is the least likely to be affected by a reduced renal glomerular filtration rate?



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What is the most common cause of chronic renal failure in a 55-year-old?



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What is the second most common cause of chronic renal failure in a 55-year-old male?



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What type of anemia is frequently seen in patients with chronic renal failure?



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A 66-year-old man with chronic renal failure suffers painful dysesthesias from peripheral neuropathy. Which of the following is the best long-term treatment for neuropathy in this patient?



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A 49-year-old was admitted with end-stage renal disease and is about to be started on hemodialysis. Which of the following laboratory features is least likely to be seen in this individual?



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Which of the following would be expected in a patient with diabetes mellitus and chronic kidney disease?



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A glomerular filtration rate (GFR) of 45 mL/min in a patient is classified as which of the following stages of kidney disease?



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Which of the following patients should be referred to a nephrologist?



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Which of the following is suggested by a history of chronic renal failure with a 0.5 kg weight gain over 24 hours, bibasilar crackles, and elevated blood pressure?



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What is the most common cause of frequent nausea with chronic renal failure?



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In chronic renal failure, psyllium hydrophilic mucilloid should be used instead of magnesium hydroxide for the treatment of constipation for which of the following reasons?



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When educating a patient with chronic renal failure, which of the following techniques would be most appropriate given the neurological complications of uremia in such patients?



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What diet should a patient with stage V chronic kidney disease be given?



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In a patient with chronic renal failure, which feature is unlikely?



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A patient is undergoing workup for an elective cholecystectomy. She is in chronic renal failure, has bilateral peripheral edema, and has symptoms consistent with congestive heart failure. Preoperative labs include a hematocrit of 22%, a potassium level of 6.2 mEq/L, a creatinine of 7.3 mg/dL, a BNP of 850, and the chest x-ray shows bilateral pulmonary edema. She is not responding to high dose furosemide. What is the most appropriate intervention at this time?



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Which medical disorder is associated with hypocalcemia?



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A compliant patient presents for follow up of stage 5 chronic kidney disease. He is without new complaints and exam shows intact mentation, normal cardiac exam, and normal neurologic exam. There is minimal peripheral edema. Laboratories show creatinine of 6.5 mg/dL, potassium 5.0 meq/L, and HCO3 21 meq/L. Which of the following is most appropriate?



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What is the most frequent neurologic complication in patients with chronic renal failure?



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A patient has chronic kidney disease and is to be on a low-protein diet. Which of the following meals would be most appropriate?



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A 75-year-old male does not drink any fluids for 15 hours. A urine sample has a specific gravity of 1.010. What is the most likely diagnosis?



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A chronically ill 30-year-old man presents with sallow skin, Kussmaul respirations, confusion, and twitching. What is the most likely diagnosis?



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A 65-year-old male with a history of diabetes mellitus and hypertension presents with urinary frequency and urgency for 4 months. His urinalysis shows 3+ glucosuria, 2+ hematuria, and 3+ proteinuria. Which of the following represents chronic kidney damage?



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A 52-year-old woman comes to her provider because she noticed bilateral leg swelling. She is an avid runner and has been using naproxen daily for persistent right heel pain. She developed foot swelling 3 days ago. She has well-controlled type 1 diabetes mellitus and hypertension. Her only other medication is benazepril and insulin. Examination shows 1+ edema bilaterally up to her mid-calf. Which of the following is the most likely cause of her edema?



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Chronic Renal Failure - References

References

Inker LA,Astor BC,Fox CH,Isakova T,Lash JP,Peralta CA,Kurella Tamura M,Feldman HI, KDOQI US commentary on the 2012 KDIGO clinical practice guideline for the evaluation and management of CKD. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2014 May     [PubMed]
Textor SC, Ischemic nephropathy: where are we now? Journal of the American Society of Nephrology : JASN. 2004 Aug     [PubMed]
Kitamoto Y,Tomita M,Akamine M,Inoue T,Itoh J,Takamori H,Sato T, Differentiation of hematuria using a uniquely shaped red cell. Nephron. 1993     [PubMed]
Khanna R, Clinical presentation     [PubMed]
Coresh J,Astor BC,Greene T,Eknoyan G,Levey AS, Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2003 Jan     [PubMed]
K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2002 Feb     [PubMed]
Muntner P, Longitudinal measurements of renal function. Seminars in nephrology. 2009 Nov     [PubMed]
Kshirsagar AV,Bang H,Bomback AS,Vupputuri S,Shoham DA,Kern LM,Klemmer PJ,Mazumdar M,August PA, A simple algorithm to predict incident kidney disease. Archives of internal medicine. 2008 Dec 8     [PubMed]
Levey AS,Coresh J, Chronic kidney disease. Lancet (London, England). 2012 Jan 14     [PubMed]
Hostetter TH,Olson JL,Rennke HG,Venkatachalam MA,Brenner BM, Hyperfiltration in remnant nephrons: a potentially adverse response to renal ablation. Journal of the American Society of Nephrology : JASN. 2001 Jun     [PubMed]
Jamerson K,Weber MA,Bakris GL,Dahl�f B,Pitt B,Shi V,Hester A,Gupte J,Gatlin M,Velazquez EJ, Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. The New England journal of medicine. 2008 Dec 4     [PubMed]
Vidt DG, Telmisartan, ramipril, or both in patients at high risk for vascular events. Current hypertension reports. 2008 Oct     [PubMed]
Moorhead JF,Chan MK,El-Nahas M,Varghese Z, Lipid nephrotoxicity in chronic progressive glomerular and tubulo-interstitial disease. Lancet (London, England). 1982 Dec 11     [PubMed]
Johnson RJ,Nakagawa T,Jalal D,S�nchez-Lozada LG,Kang DH,Ritz E, Uric acid and chronic kidney disease: which is chasing which? Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2013 Sep     [PubMed]
Anderson S,Rennke HG,Brenner BM, Antihypertensive therapy must control glomerular hypertension to limit glomerular injury. Journal of hypertension. Supplement : official journal of the International Society of Hypertension. 1986 Dec     [PubMed]
Yu HT, Progression of chronic renal failure. Archives of internal medicine. 2003 Jun 23     [PubMed]
Methven S,Traynor JP,Hair MD,St J O'Reilly D,Deighan CJ,MacGregor MS, Stratifying risk in chronic kidney disease: an observational study of UK guidelines for measuring total proteinuria and albuminuria. QJM : monthly journal of the Association of Physicians. 2011 Aug     [PubMed]
Hallan SI,Orth SR, Smoking is a risk factor in the progression to kidney failure. Kidney international. 2011 Sep     [PubMed]
de Brito-Ashurst I,Varagunam M,Raftery MJ,Yaqoob MM, Bicarbonate supplementation slows progression of CKD and improves nutritional status. Journal of the American Society of Nephrology : JASN. 2009 Sep     [PubMed]
Nathan DM,Genuth S,Lachin J,Cleary P,Crofford O,Davis M,Rand L,Siebert C, The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The New England journal of medicine. 1993 Sep 30     [PubMed]
Fishbane S,Agoritsas S,Bellucci A,Halinski C,Shah HH,Sakhiya V,Balsam L, Augmented Nurse Care Management in CKD Stages 4 to 5: A�Randomized Trial. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2017 Oct     [PubMed]
Khan SS,Kazmi WH,Abichandani R,Tighiouart H,Pereira BJ,Kausz AT, Health care utilization among patients with chronic kidney disease. Kidney international. 2002 Jul     [PubMed]
Chapter 1: Definition and classification of CKD. Kidney international supplements. 2013 Jan     [PubMed]
Webster AC,Nagler EV,Morton RL,Masson P, Chronic Kidney Disease. Lancet (London, England). 2017 Mar 25     [PubMed]
Aeddula NR,Baradhi KM, Sickle Cell Nephropathy . 2018 Jan     [PubMed]
Aeddula NR,Baradhi KM, Reflux Nephropathy . 2018 Jan     [PubMed]
Madero M,García-Arroyo FE,Sánchez-Lozada LG, Pathophysiologic insight into MesoAmerican nephropathy. Current opinion in nephrology and hypertension. 2017 Jul     [PubMed]
Luttropp K,Lindholm B,Carrero JJ,Glorieux G,Schepers E,Vanholder R,Schalling M,Stenvinkel P,Nordfors L, Genetics/Genomics in chronic kidney disease--towards personalized medicine? Seminars in dialysis. 2009 Jul-Aug     [PubMed]
Sachdeva B,Aeddula NR, Peritoneal Dialysis . 2018 Jan     [PubMed]
Sen A,Callisen H,Libricz S,Patel B, Complications of Solid Organ Transplantation: Cardiovascular, Neurologic, Renal, and Gastrointestinal. Critical care clinics. 2019 Jan     [PubMed]
Thongprayoon C,Chokesuwattanaskul R,Bathini T,Khoury NJ,Sharma K,Ungprasert P,Prasitlumkum N,Aeddula NR,Watthanasuntorn K,Salim SA,Kaewput W,Koller FL,Cheungpasitporn W, Epidemiology and Prognostic Importance of Atrial Fibrillation in Kidney Transplant Recipients: A Meta-Analysis. Journal of clinical medicine. 2018 Oct 19     [PubMed]
Aeddula NR,Cheungpasitporn W,Thongprayoon C,Pathireddy S, Epicardial Adipose Tissue and Renal Disease. Journal of clinical medicine. 2019 Mar 2;     [PubMed]
Ghimire S,Lee K,Jose MD,Castelino RL,Zaidi STR, Adherence assessment practices in haemodialysis settings: A qualitative exploration of nurses and pharmacists' perspectives. Journal of clinical nursing. 2019 Jun;     [PubMed]

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