Chronic kidney disease Alternative Names Kidney failure - chronic Renal failure - chronic Chronic renal insufficiency Chronic kidney failure Chronic kidney disease

KIDNEY FAILURE AND KIDNEY DISEASE KIDNEY FAILURE  Kidney failure occurs when the kidneys partly or completely lose their ability to carry out normal functions.  This is dangerous because water, waste, and toxic substances build up that normally are removed from the body by the kidneys.  It also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty acids, and bone disease in the body by impairing hormone production by the kidneys.

CHRONIC KIDNEY DISEASE Chronic kidney disease is when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually over time, usually months to years. Chronic kidney disease is divided into five stages of increasing severity. For the total or near–total loss of kidney function, the patients need dialysis or transplantation to stay alive.

STAGES OF CHRONIC KIDNEY DISEASE  Stage 1 with normal or high GFR (GFR > 90 ml/min)  Stage 2 Mild CKD (GFR = ml/min)  Stage 3 Moderate CKD (GFR = ml/min)  Stage 4 Severe CKD (GFR = ml/min)  Stage 5 End Stage CKD (GFR <15 ml/min)

Stages of Chronic Kidney Disease Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. Clinically, this is often measured to determine renal function. Compare to filtration fraction.

NORMAL RANGES The normal ranges of GFR, adjusted for body surface area, are: Males: 70 ± 14 mL/min/m2 Females: 60 ± 10 mL/min/m2 (125ml/mt) GFR can increase due to hypoproteinemia because of the reduction in plasma oncotic pressure. GFR can also increase due to constriction of the efferent arteriole but decreases due to constriction of the afferent arteriole.

Stage 1 CKD Slightly diminished function; Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2). 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 m2) with kidney damage. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies

Stage 3 CKD Moderate reduction in GFR (30-59 mL/min/1.73 m2) Stage 4 CKD Severe reduction in GFR (15-29 mL/min/1.73 m2) Stage 5 CKD Established kidney failure (GFR <15 mL/min/1.73 m2, or permanent renal replacement therapy (RRT)

Causes Diabetic nephropathy Hypertension Glomerulonephritis Renal artery stenosis Hemolytic-uremic syndrome Vasculitis Focal segmental glomerulosclerosis

Diabetic nephropathy. Chronically elevated blood sugars damage blood vessels and filtering units in the kidneys, the condition is known as diabetic nephropathy.

Pyelonephritis

Causes IgG nephritis Lupus nephritis Polycystic kidney disease Reflux nephropathy Kidney stones and Prostate HIV infection

Pathophysiology of uremia  Diminished excretion of electrolytes and water,  Reduced excretion of organic solutes,  Decreased hormone production

CKD developing atherosclerosis

Clinical manifestations of kidney failure Electrolytes Edema, Hyponatremia, Hyperkalemia, Metabolic acidosis, Hyperuricemia, Hyperphosphatemia, Hypocalcemia

Gastrointestinal  Anorexia,  nausea,  vomiting,  malnutrition

Cardiovascular  Accelerated atherosclerosis,  systemic hypertension,  pericarditis

Calcification of the left coronary artery in a patient with chronic kidney disease receiving dialysis as seen on a computerized tomography (CT) scan. The extensive deposition of mineral (arrowed) results in a radio-opaque vessel with a density similar to that of bone

Hematologic  Anemia,  immune dysfunction,  platelet dysfunction

Musculoskeletal  Renal osteodystrophy,  muscle weakness,  growth retardation in children,  amyloid arthropathy caused by beta2- microglobulin deposition

Looser zone (arrow) in the distal fibula of a child with renal osteodystrophy

Neurologic  Encephalopathy,  seizures,  peripheral neuropathy

Endocrine  Hyperlipidemia,  glucose intolerance caused by insulin resistance,  amenorrhea  infertility in women,  impotence

Skin  Pruritus

Decreased hormone production The kidneys normally produce several hormones, including erythropoietin and calcitriol (1,25- dihydroxycholecalciferol), the active form of vitamin D. The decreased production of these two hormones plays an important role in the development of anemia and bone disease, respectively.

Exams and Tests  Urinalysis  Creatinine levels progressively increase.  BUN is progressively increased.  Creatinine clearance progressively decreases.

 Potassium test  Arterial blood gas  blood chemistry  Abdominal CT scan  Abdominal MRI

Systemic complications and their treatment Uremic syndrome consists of an array of complex symptoms and signs that occur when advanced kidney failure prompts the malfunction of virtually every organ system. However, the onset of uremia is slow and insidious, beginning with rather nonspecific symptoms such as malaise, weakness, insomnia, and a general feeling of being unwell. Patients may lose their appetite and complain of morning nausea and vomiting. Eventually, signs and symptoms of multisystem failure are evident.

MANAGEMENT  Potassium balance:  Sodium balance:  Water balance:  Metabolic acidosis:  Gastrointestinal complications  Cardiovascular complications  Hematologic complications  Bone disease  Hyperphosphatemia  PTH suppression  Neurologic complications

HEMODIALYSIS

HOME DIALYSIS

A gene that protects from kidney disease Scientists from the European Molecular Biology Laboratory (EMBL) and the University of Michigan have discovered a gene that protects us against a serious kidney disease. In the current online issue of Nature Genetics they report that mutations in the gene cause nephronopthisis (NPHP) in humans and mice. NPHP is a disease marked by kidney degeneration during childhood that leads to kidney failure requiring organ transplantation. The insights might help develop effective, noninvasive therapies

Enzyme For Treatment Of Diabetic Kidney Disease Northwestern University Feinberg School of Medicine scientists have observed that an enzyme called ACE2 may hold the potential to treat diabetic kidney disease, the most common form of kidney disease.