Chronic kidney disease (CKD)

Chronic kidney disease (CKD)

CKD is also known as chronic renal failure. In this condition, kidneys are not able to remove waste products and extra fluids from the blood. Because fluid and waste products get accumulated in the body,  it affects other systems that cause harm to the body.

Common causes of CKD are

  • Diabetes mellitus
  • High blood pressure
  • Glomerulonephritis
  • Chronic tubulointerstitial disease
  • Obstruction in the path of urine flow
  • Heavy metal consumption
  • Analgesic abuse
  • Recurrent urinary tract infections involving kidneys
  • Polycystic kidney disease
  • Congenital abnormalities of the kidney and urinary tract
  • Hereditary diseases involving kidneys

Apart from the above CKD can be caused by other aetiological factors also.
When kidney function drops below a certain level, commonly less than 10% of normal, a patient requires dialysis or kidney transplant to sustain life.

Functions of kidneys in our body

  • To clear metabolic waste products from the body
  • To remove excess fluid from our body
  • To maintain strength of bones by maintaining calcium and phosphorus balance in the body
  • To maintain acid and base balance of the body
  • To help body to maintain Hemoglobin by producing a substance called erythropoietin
  • To maintain balance of Sodium, Potassium and other salts in the body
  • To convert Vit D to its active form

Both metabolic waste and fluid are excreted out of the body in the form of urine.
Blood is filtered through kidneys. This filtering occurs in the functional unit of the kidney called “Nephron”. Nephron has different parts namely glomerulus, tubules. There are around 1 million nephrons in each kidney. In CKD, there is a reduction in the number of nephrons and function causing symptoms of kidney disease.

Risk factors for CKD

  • Diabetes mellitus
  • Hypertension
  • A family history of CKD
  • African-american and other ethnic minorities
  • Obesity
  • Smoking
  • Older age
  • Presence of protein in urine
  • Presence of autoimmune disease like lupus etc

CKD is divided into 5 stages depending on approximately calculated kidney function by formula called Glomerular filtration rate(GFR). As GFR declines; patients goes from CKD 1 to 5. In India most patients are detected in CKD stage 3 to 5 because of no regular check or lower awareness amongst population.

Signs and symptoms of CKD

In early stages of CKD there may not be any signs or symptoms. Most of them are without any complaints and are detected during routine evaluation or investigations for some other reason.

Some common signs and symptoms include

  • Loss of appetite
  • Nausea and vomiting
  • Easy fatigability
  • Swelling over body and decreased urine output depending on cause
  • Breathlessness on exertion
  • Decrease in Hemoglobin level
  • Decreased sleep
  • In late stages altered mentation, fits, breathlessness at rest
  • Rise in blood pressure
  • Increase in Blood urea and creatinine level
  • Increase in potassium in blood
  • Increase in acid level in blood
  • Low Calcium and increase in Phosphorus level in blood

Diagnostic tests-

  • Kidney function test/Renal function test
    • Blood urea, Serum Creatinine
    • Serum electrolytes ( Sodium, Potassium, Chloride)
    • Arterial blood gas or serum bicarbonate level
    • Serum proteins
  • Hemogram
  • Urine analysis
  • Lipid profile
  • Blood sugar level
  • Blood tests for viruses like HIV, Hepatitis B and C
  • Antinuclear antibodies, ANCA, anti GBM antibodies
  • 24 hour urine collection for protein estimation or urine protein creatinine ratio
  • Imaging studies
    • Xray abdomen, chest
    • Sonography of abdomen , Kidney Doppler study
    • CT scan
    • MRI scan
    • Angiography of kidney blood vessels
    • Radionuclear isotope scans
    • Kidney Biopsy

From above list of investigations and few other which are not included here, those which are needed are done by the doctor.

Treatment of Chronic kidney disease

First step to determine the cause and if it is reversible; treat it immediately. Few examples of such causes are- Medications which cause kidney damage like painkillers, some antibiotics etc. Blockage in urine flow path due to stones, narrowing called strictures, enlargement of prostate gland etc. Prevention of recurrent urinary infections. Removal of blockage in blood vessels of kidney called renal arterial angioplasty.
Prompt treatment of reversible causes can result in halting or slowing of progression of CKD.
Research has shown that management of CKD is best done with the assistance of Nephrologist, a doctor who specializes in kidney diseases treatment. Early referral can prevent or decrease chance of developing complications associated with CKD.
Hypertension- Present in most of CKD patients. Multiple drugs may be required to control and achieve target blood pressure.
Strict control of blood sugar levels in patients having diabetes mellitus.
Drug called diuretic may be needed to remove excess water from body.
Correction of anemia- Iron supplements either by giving tablets or by injections, Use of erythropoietin injections at regular interval. Preventing blood loss from body due to causes like piles, gastric ulcers , excess menstrual bleeding etc.
Follow dietary restrictions as advised to you by your doctor or dietician.
Control of potassium level by avoiding foods rich in potassium or avoiding drugs which increase potassium level.
Avoid inadvertent use of painkillers or kidney toxic drugs.
Correction of Calcium level with calcium and vitamin D supplements.
Correction of Phosphate level with phosphate binders
Correction of acid level with bicarbonate supplements
Correction of cholesterol levels whenever needed.
Use of antacids and antiemetic drugs when appropriate.
Sexual dysfunction may be present in more than 50% patients of kidney diseases. Men may have problems with penile erection or decrease in sexual drive. Women can have disturbances in menstrual cycle ,infertility or decreased desire for having sex. Also Discuss with your doctors about your problems.
Pregnancy can pose risk to both mother and baby. Should be planned only after discussion with your doctor.

Preparing for dialysis

Over a period of time kidney function may deteriorate and patient may need dialysis or kidney transplantation.

There are two types of dialysis- Hemodialysis or peritoneal dialysis. Some patients want not to undergo dialysis may not have long life.

Kidney transplantation is also option even before dialysis if well planned. All need to be discussed and planned long before patient needing dialysis.

An important component of CKD treatment is planning vascular access well in advance in the form of AV fistula.

Although kidney transplantation is treatment of many cases, few patients may not be suitable for the same and many may have to wait for organ availability when they are registered for cadaver program. In these situations patients will need long term dialysis ( Maintenance dialysis).

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