Chronic Kidney Disease

Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton, Bruno Serra, Vidya Acharya and Kim Jackson  

Introduction[edit | edit source]

Kidney anatomy.jpg

Chronic kidney disease (CKD) is a progressive loss of glomerular function caused by a long-standing renal parenchymal disease. It is present when the glomerular filtration rate (GFR) is less than 60 ml/min/1.73 m2 for three consecutive months or greater than or equal to this value in patients with a kidney damage that is present for three or more months.[1]

CKD is a non-communicable disease usually caused by diabetes and hypertension[2]. It often involves a progressive loss of kidney function necessitating renal replacement therapy (dialysis or transplantation). When a patient needs renal replacement therapy, the condition is called end-stage renal disease (ESRD)[3].

It is estimated that 10% of the population worldwide is affected by chronic kidney disease (CKD), and millions die each year because they do not have access to affordable treatment[4]

Function[edit | edit source]

The kidneys are essential organs that perform several homeostatic functions[5]. The primary function of the kidneys is to filter blood and remove excess water, minerals, and waste products of protein metabolism, producing urine in the process. The kidneys also play a crucial role in controlling body fluid volume, osmolality and pH, by maintaining fluid/electrolyte balance, metabolic blood acid-base balance, and producing/modifying hormones for blood pressure, calcium/potassium homeostasis. It also plays a part in red blood cell production.

The kidneys receive a high proportion of blood, about 20% of cardiac output, enabling the filtration of large volumes of blood. Blood flow is regulated across the filtration capillaries (glomeruli) due to the unique arrangement of blood vessels. The kidneys remove waste products from the blood and produce urine.

Each kidney contains about one million functional units called nephrons, which are made up of a very small filter called a glomerulus attached to a tubule. As blood passes through the nephron, fluid and waste products are filtered out, and much of the fluid is then returned to the blood, while the waste products are concentrated in any extra fluid as urine.

Epidemiology[edit | edit source]

CKD is a prevalent disease, affecting between 10-15% of the adult population globally[1]

  • 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[6].
  • 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.
  • In 2017, the global prevalence of CKD was 9·1%, roughly 700 million cases.
  • Since 1990, the prevalence of CKD has increased by 29·3%.
  • A substantial increase was noted in age-standardised incidence of end-stage kidney disease (ESKD) treated by renal replacement therapy, with dialysis and kidney transplantation increasing by 43·1% and 34·4%, respectively.
  • Of the 2 million people who receive treatment for kidney failure, the majority are treated in only five countries – the United States, Japan, Germany, Brazil, and Italy. These five countries represent only 12% of the world population. Only 20% are treated in about 100 developing countries that make up over 50% of the world population[4]
  • The global age-standardised mortality rate for CKD is not declining, unlike those for other important non-communicable diseases.[2]

Etiology[edit | edit source]

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

  • Diabetes mellitus type 2 (30% to 50%)
  • Diabetes mellitus type 1 (3.9%)
  • Hypertension (27.2%)
  • Followed by - 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[6].

Risk Factors for Progression of CKD

  • Non-Modifiable CKD Risk Factors - Older age, male gender, a non-Caucasian ethnicity
  • Modifiable CKD Risk Factors - Include systemic hypertension, proteinuria, obesity, smoking, metabolic factors such as insulin resistance, dyslipidemia, and hyperuricemia[6].

Classification[edit | edit source]

Dialysis.jpg

Chronic kidney disease can be classified in a variety of ways. A common classification divides CKD into five stages based on the GFR (ml/min/1.73 m2)

  • stage 1: >90: kidney damage with normal or elevated GFR
  • stage 2: 60-89: kidney damage with mild reduction in GFR
  • stage 3: 30-59: moderate reduction in GFR
  • stage 4: 15-29: severe reduction in GFR
  • stage 5: <15 (or dialysis): end-stage kidney disease (ESKD)[1]

Clinical Presentation[edit | edit source]

Clinical presentation depends a lot on aetiology.

  • Children with chronic kidney disease can have growth disorder, oedema and cola coloured urine (due to RBC casts).
  • Adults can have non-specific symptoms like nausea, vomiting, weight loss, and easy fatigability.
  • Hypertension is common in adults with chronic kidney disease[1].
  • Muscle loss is seen in CKD. A cross-sectional study suggests a prevalence of sarcopenia in community-dwelling older adults with higher rates of sarcopenia and severe sarcopenia seen in more advanced stages of CKD[7].
  • SCOPE study examining the impact of CKD and lower urinary tract symptoms on falls in the community-dwelling older persons aged 75 years suggests that CKD may not be associated with a history of falls or injurious falls, but lower urinary tract symptoms was significantly associated with risk of falling[8].

Investigations[edit | edit source]

Renal function tests are used to assess overall renal function by direct measurement or estimation of the glomerular filtration rate (GFR). These tests are important in the management of patients with kidney disease or pathologies affecting renal function. They have utility in identifying the presence of renal disease, monitoring the response of kidneys to treatment, and determining the progression of renal disease. The following are some of the tests that are used to diagnose chronic kidney disease (CKD):

Management[edit | edit source]

General Management consists in adjusting drug doses for the level of estimated glomerular filtration rate (GFR) and reparation of renal replacement therapy by placing an arteriovenous fistula or graft.

  • Treat the Reversible Causes of Renal Failure;
  • Retarding the Progression of CKD - The factors which result in progression of CKD should be addressed such as hypertension, proteinuria, metabolic acidosis, and hyperlipidemia;
  • Preparation and Initiation of Renal Replacement Therapy - 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[6].

Chronic kidney disease can be treated. With early diagnosis and treatment, it's possible to slow or stop the progression of kidney disease.[4]

Fatigue[edit | edit source]

Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease, and depression. It can also impair quality of life (QoL) and the ability to participate in daily activities.

There are several potential interventions, including drugs or other non-pharmacological, that have effect on fatigue in people on dialysis. A systematic review of ninety-four studies involving 8191 randomised participants has shown that exercise, aromatherapy, massage, and acupressure improve fatigue compared to placebo or standard care[10]. On the other hand, drugs or other non-pharmacological interventions have uncertain effects on fatigue in people on dialysis.

Interprofessional team[edit | edit source]

Exercise Bike.gif

The management of kidney failure is usually done with an interprofessional team of healthcare professionals dedicated to preserving renal function. Kidney failure has enormous morbidity and mortality, costing the healthcare system billions of dollars each year. Only through open communication between the team members can the morbidity and mortality of renal failure be lowered.

  • Today most hospitals have a kidney failure nurse whose job is to educate patients on the causes, detection, and prevention of kidney failure.
  • The pharmacist also needs to regularly audit the patient.
  • The physiotherapist is involved in exercise (See Renal Rehabilitation)
  • These patients should have close follow up to ensure that the renal function is not deteriorating.
  • The patient needs to be given advice on healthy eating, discontinuing tobacco and abstaining from alcohol.
  • Kidney disease if not well managed can lead to complete renal failure, which requires dialysis[6].

Final Remark[edit | edit source]

  • The net health burden of kidney disease is substantial, growing and driven by complex interactions, between communicable and noncommunicable diseases, that are shaped by environmental and socioeconomic disparities.
  • Although kidney disease, whether acute, chronic or end-stage, can be extremely costly, it is also potentially preventable and adverse outcomes can often be delayed or prevented by inexpensive interventions[11].

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 Radiopedia CKD Available from:https://radiopaedia.org/articles/chronic-kidney-disease (last accessed 20.10.20)
  2. 2.0 2.1 Cockwell P, Fisher LA. The global burden of chronic kidney disease. The Lancet. 2020 Feb 29;395(10225):662-4.Available from:https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32977-0/fulltext (last accessed 20.10.2020)
  3. Radiopedia Kidney Failure Available from:https://www.ncbi.nlm.nih.gov/books/NBK519012/ (last accessed 20.10.2020)
  4. 4.0 4.1 4.2 NKF Global facts CKD Available from:https://www.kidney.org/kidneydisease/global-facts-about-kidney-disease (last accessed 20.10.2020)
  5. Murray IV, Paolini MA. Histology, Kidney and Glomerulus. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554544/
  6. 6.0 6.1 6.2 6.3 6.4 Vaidya SR, Aeddula NR. Chronic Renal Failure. InStatPearls [Internet] 2019 Dec 7. StatPearls Publishing.Available from:https://www.ncbi.nlm.nih.gov/books/NBK535404/ (last accessed 20.10.2020)
  7. Moreno-Gonzalez R, Corbella X, Mattace-Raso F, Tap L, Sieber C, Freiberger E, Kostka T, Guligowska A, Melzer I, Melzer Y, Carlsson AC. Prevalence of sarcopenia in community-dwelling older adults using the updated EWGSOP2 definition according to kidney function and albuminuria. BMC geriatrics. 2020 Oct;20(1):1-2.
  8. Britting S, Artzi-Medvedik R, Fabbietti P, Tap L, Mattace-Raso F, Corsonello A, Lattanzio F, Ärnlöv J, Carlsson AC, Roller-Wirnsberger R, Wirnsberger G. Kidney function and other factors and their association with falls. BMC geriatrics. 2020 Oct;20(1):1-0.
  9. Radiopedia Kidneys Available from:https://radiopaedia.org/articles/kidneys (last accessed 20.10.2020)
  10. Natale, P., Ju, A., Strippoli, G. F. M., Craig, J. C., Saglimbene, V. M., Unruh, M. L., Stallone, G., & Jauregui, A. (2023). Interventions for fatigue in people with kidney failure requiring dialysis. Cochrane Database of Systematic Reviews, 2023(8). https://doi.org/10.1002/14651858.CD013074.pub2
  11. WHO Policy and Practice Available from:https://www.who.int/bulletin/volumes/96/6/17-206441/en/ (last accessed 21.10.2020)