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CHRONIC KIDNEY DISEASE

Written by Olivia Yang

Last Reviewed: April 2019

Review Due: April 2020

 

DEFINITION

A chronic and progressive impairment of renal function, characterised by:

  • A duration > 3 months

  • Impaired eGFR (<60 ml/min/1.73m2)

  • Positive markers of kidney damage (incl. albuminuria, hematuria, electrolyte abnormalities, renal histological abnormalities, structural abnormalities detected by imaging

STAGING

CKD can be staged according to GFR and level of proteinuria. measured by the urine Albumin:Creatinine Ratio (ACR).

 

AETIOLOGY

The development of chronic kidney disease is associated with a number of conditions:

  • Diabetes Mellitus

  • Hypertension

  • Renal Vascular Disease

  • Glomerular Disease (e.g. primary glomerulonephritides)

  • Congenital and Inherited Disease (e.g. congenital obstructive uropathy)

  • Vascular Disease (e.g. hypertensive nephrosclerosis)

  • Tubulointerstitial Disease (includes adverse drug reactions – NSAIDs among others)

  • Obstructive Uropathies (e.g. benign prostatatic hyperplasia)

SIGNS AND SYMPTOMS

The early stages of CKD are typically asymptomatic due to the kidney’s functional renal reserve capacity. As kidney function deteriorates, patients present with symptoms, including those outlined below. Other complications include, weight loss, infertility, increased risk of infections and systemic acidosis.

 

PATHOPHYSIOLOGY

CKD results from progressive scarring of the kidney parenchyma (glomeruli, tubules, interstitium, and vessels) attributable to any cause of kidney disease. This leads to the diminishing of renal reserve, renal insufficiency and ultimately to end-stage renal failure.

 

Advanced renal failure results in: failure to maintain fluid and electrolyte homeostasis; inability to concentrate or dilute urine and urine osmolality is fixed too close to that of plasma osmolality (275 to 295 mOsm/kg); inability of kidneys to excrete excess potassium, phosphate, and acid.

 

Investigations

U&Es: Uraemia, Raised Creatinine, Hyperkalaemia, Hypernatraemia, Hyperphosphataemia, Hypocalcinaemia

 

Urinalysis: Haematuria, Proteinuria

FBC: Anaemia

USS/CT: To assess for structural abnormalities e.g. shrunken kidneys, or to exclude urinary tract obstruction

MR/CT Angiography: To investigate for renal vascular disease

 

Renal Biopsy: To exclude primary or secondary glomerulopathies and tubulointerstitial disease

 

TREATMENT

non-pharmacological

  • Encourage self-management

  • Lifestyle advice (exercise, maintenance of healthy weight, smoking cessation, avoidance of NSAIDs)

  • Diet advice (healthy diet, potassium, phosphate, calorie and salt intake appropriate to the severity of CKD)

  • Information regarding future treatment choices including dialysis, transplantation and conservative/palliative treatment

pharmacological

  • Identify and manage reversible causes of CKD

  • Control underlying conditions and optimise management of comorbidities.

  • Tight blood pressure control

    • In non- diabetics, aim for blood pressure < 140/90 mmHg

    • Urinary ACR <30 mg/mmol, treat the person in line with current guidance on hypertension (ACEi)

    • Urinary ACR of urinary ACR of ≥30 mg/mmol offer a renin-angiotensin system antagonist 

    • In diabetics, aim for blood pressure <130/80 mmHg

  • Atorvastatin for primary and secondary prevention of cardiovascular disease

 
 

EPIDEMIOLOGY

CKD is more common in ethnic minorities in association with co-morbid conditions such as hypertension in black people and diabetes in South Asians 8. In the UK, it is estimated that the age-standardized prevalence of stages 3-5 CKD lies at 8.5%, a larger proportion of whom are female. There is also a clear correlation between increasing age and CKD prevalence.

REFERENCES

  1. https://www.msdmanuals.com/en-gb/professional/genitourinary-disorders/chronic-kidney-disease/chronic-kidney-disease

  2. https://renal.org/information-resources/the-uk-eckd-guide/ckd-stages/

  3. https://pathways.nice.org.uk/pathways/chronic-kidney-disease#path=view%3A/pathways/chronic-kidney-disease/management-of-chronic-kidney-disease.xml&content=view-node%3Anodes-blood-pressure-control-and-antihypertensive-treatment

  4. https://cks.nice.org.uk/chronic-kidney-disease-not-diabetic#!scenario

  5. Oxford handbook of nephrology and hypertension. 2nd ed. Oxford: Oxford University Press; 2014.

  6. KDIGO 2017. Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease — Mineral and Bone Disorder (CKD-MBD). KIDNEYS. 2017;6(3):149-154.

  7. Ballinger A. Pocket essentials of clinical medicine. 5th ed. London: Elsevier; 2012.

  8. Kumar V, Abbas A, Aster J, Perkins J. Robbins basic pathology. 9th ed. 2013.