Chronic kidney disease and

end- stage renal disease

Kidney Anatomy and its Function

The kidneys are a pair of organs located in the back of the abdomen. Each
kidney is about 4 or 5 inches long -- about the size of a fis
The kidneys' function are to filter the blood. All the blood in our bodies passes
through the kidneys several times a day. The kidneys remove wastes, control
the body's fluid balance, and regulate the balance of electrolytes
As the kidneys filter blood, they create urine, which collects in the kidneys'
pelvis -- funnel-shaped structures that drain down tubes called ureters to the
bladder
Each kidney contains around a million units called nephrons, each of which is
a microscopic filter for blood. It's possible to lose as much as 90% of kidney
function without experiencing any symptoms or problems
Chronic Kidney Disease
Definition
Chronic kidney disease is the slow loss of kidney function over time. The main
function of the kidneys is to remove wastes and excess water from the body.
Alternative Names
Kidney failure - chronic; Renal failure - chronic; Chronic renal insufficiency;
Chronic kidney failure; Chronic renal failure

Causes,
CKD

incidence, and risk factors of

Chronic kidney disease (CKD)

slowly gets worse over time. In
the early stages, there
may be no symptoms. The
loss of function usually
takes months or years to occur. It may be
so slow that symptoms do not occur until kidney function is less than onetenth of normal .
The final stage of chronic kidney disease is called end-stage renal disease
(ESRD). The kidneys no longer function and the patient needs dialysis or a
kidney transplant.
Chronic kidney disease and ESRD affect more than 2 out of every 1,000
people in the United States.
Diabetes and high blood pressure are the two most common causes and
account for most cases
Many other diseases and conditions can damage the kidneys, including:
Problems with the arteries leading to or inside the kidneys
Birth defects of the kidneys (such as polycystic kidney disease)
Some pain medications and other drugs
Certain toxic chemicals
Autoimmune disorders (such as systemic lupus erythematosus and
scleroderma)
Injury or trauma
Glomerulonephritis
Kidney stones and infection
Reflux nephropathy (in which the kidneys are damaged by the backward flow
of urine into the kidneys)
Other kidney diseases
Chronic kidney disease leads to a buildup of fluid and waste products in the
body. This condition affects most body systems and functions, including red
blood cell production, blood pressure control, and vitamin D and bone health
Other tips for protecting the kdineys and preventing heart disease and stroke

Do not smoke.
Eat meals that are low in fat and cholesterol Get regular exercise (talk to your
doctor or nurse before starting).
Take drugs to lower your cholesterol, if necessary. Keep your blood sugar
under control
Stages of chronic kidney disease

Symptoms of CKD

The early symptoms of chronic kidney disease often occur with other
illnesses, as well. These symptoms may be the only signs of kidney disease
until the condition is more advanced.
Symptoms may include:
General ill feeling and fatigue
Generalized itching (pruritus) and dry skin
Headaches
Weight loss without trying to lose weight
Appetite loss
Nausea
Other symptoms that may develop, especially when kidney function has
worsened:
Abnormally dark or light skin
Bone pain
Brain and nervous system symptoms
Drowsiness and confusion
Problems concentrating or thinking
Numbness in the hands, feet, or other areas
Muscle twitching or cramps
Breath odor
Easy bruising

bleeding, or blood in the stool

Excessive thirst
Frequent hiccups
Low level of sexual interest and impotence
Menstrual periods stop (amenorrhea)
Sleep problems, such as insomnia, restless leg syndrome, and obstructive
sleep apnea Swelling of the feet and hands (edema) Vomiting, typically in the
morning
Signs and tests of CKD
High blood pressure is almost always present during all stages of chronic
kidney disease. A neurologic examination may show signs of nerve damage.
The health care provider may hear abnormal heart or lung sounds with a
stethoscope.
A urinalysis may show protein or other changes. These changes may appear
6 months to 10 or more years before symptoms appear.

Tests that check how well the kidneys are working include:
Creatinine levels
BUN
Creatinine clearance
Chronic kidney disease changes the results of several other tests. Every
patient needs to have the following checked regularly, as often as every 2 - 3
months when kidney disease gets worse:
Potassium
Sodium
Albumin
Phosphorous

Calcium

Cholesterol

Magnesium

Complete blood count (CBC) Electrolytes

Causes of chronic kidney disease may be seen on

This

Abdominal CT scan
Abdominal MRI
Abdominal ultrasound
Renal scan
disease may also change the results of the following tests

Erythropoietin
PTH
Bone density test
Treatment

Controlling blood pressure is the key to delaying further kidney damage.

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor
blockers (ARBs) are used most often.
The goal is to keep blood pressure at or below 130/80 mmHg
Other treatments may include:
Special medicines called phosphate binders, to help prevent phosphorous
levels from becoming too high
Treatment for anemia, such as extra iron in the diet, iron pills, special shots of
a medicine called erythropoietin, and blood transfusions
Extra calcium and vitamin D (always talk to your doctor before taking)
You may need to make changes in your diet. See: Diet for chronic kidney
disease for more details.
You may need to limit fluids.
Your health care provider may recommend a low-protein diet.
You may have to restrict salt, potassium, phosphorous, and other electrolytes.
It is important to get enough calories when you are losing weight
Different treatments are available for problems with sleep or restless leg
syndrome.
Everyone with chronic kidney disease should be up-to-date on important
vaccinations
Prevention

Treating the condition that is causing the problem may help prevent or delay
chronic kidney disease.
People who have diabetes should control their blood sugar and blood
pressure levels and should not smoke
Other tips for protecting the kdineys and preventing heart disease
and stroke
Do not smoke.
Eat meals that are low in fat and cholesterol Get regular exercise (talk to your
doctor or nurse before starting).
Take drugs to lower your cholesterol, if necessary. Keep your blood sugar
under control
Pathophysiology of End-Stage Renal Disease and Dialysis

In adults, end-stage renal disease may be a consequence of diabetic

glomerulopathy (the diagnosis in 44% of transplant recipients in one large
study
other glomerulonephritides (23%),

polycystic kidney disease (6%),

chronic pyelonephritis (5%),
obstructive uropathy, Alport syndrome, or lupus nephritis.
Whatever the cause, patients manifest the uremic syndrome, with inability
to regulate the volume and composition of their body fluids. Untreated, this
results in excessive intravascular volume, acidemia, and imbalance of key
electrolytes such as potassium, phosphorus, magnesium, and calcium,
leading to secondary dysfunction in other organ systems.
For example, the cardiovascular complications associated with uremia may
include congestive heart failure (CHF), pericarditis, hypertension,
arrhythmias, and capillary fragility; pulmonary edema or pleural effusions
may affect the lungs; musculoskeletal manifestations include renal
osteodystrophy, generalized muscle weakness, and metastatic
calcifications; nervous system involvement may encompass peripheral
neuropathy and a spectrum of mental status changes ranging from
lethargy to coma.
Hematologic effects of uremia include anemia, platelet dysfunction, and a
shifted oxyhemoglobin dissociation curve;
Nausea
vomiting
intestinal ileus
GI ulceration are also found, as are certain immunologic responses
(impaired cellular immunity) and effects on the integument (pruritus
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What is Dialysis?
The kidneys are responsible for filtering waste products from the blood.
Dialysis is a procedure that is a substitute for many of the normal duties of
the kidneys.

Continuous Ambulatory Dialysis

When do patients require dialysis

Patients usually require dialysis when the waste products in their body
become so high that they start to become sick from them
The two major blood chemical levels that are measured are the "creatinine
level" and the "blood urea nitrogen" (BUN) level. As these two levels rise,
they are indicators of the decreasing ability of the kidneys to cleanse the
body of waste products .
Doctors use a urine test, the "creatinine clearance," to measure the level of
kidney function. The patient saves urine in a special container for one full
day. The waste products in the urine and in the blood are estimated by
measuring the creatinine. By comparing the blood and urine level of this
substance, the doctor has an accurate idea of how well the kidneys are
working. This result is called the creatinine clearance. Usually, when the
creatinine clearance falls to 10-12 cc/minute, the patient needs dialysis
If the patient is experiencing a major inability to rid the body of excess water,
or is complaining of problems with the heart, lungs, or stomach, or difficulties
with taste or sensation in their legs, dialysis may be indicated even though
the creatinine clearance has not fallen to the 10-12 cc/minute level.
What types of dialysis are there?

There are two main types of dialysis: "hemodialysis" and "peritoneal dialysis."
Hemodialysis uses a special type of filter to remove excess waste products
and water from the body. Peritoneal dialysis uses a fluid that is placed into
the patient's stomach cavity through a special plastic tube to remove excess
waste products and fluid from the body.
RENAL TRANSPLANTATION
Renal transplantation has transformed the outlook for many patients
with end stage renal disease. One-year patient and graft survival is
98% and 90-95%.
That renal transplantation is the treatment of choice for patients with
end stage renal disease who are fit to receivea renal transplant
Renal disease are frail and elderly and/or have a number of co-existing
medical problems such that they are not fit to undergo major
operation(implantation of the kidney).
For those patients who are fit enough to receive a renal transplant and
are succesfully transplanted, there is a profound survival benefit
compared to remaining on dialysis treatment
Transplantation is a far less expensive treatment than dialysis,
particularly after the first year, when the large majority of the costs are
limited to payment for the immunosuppressive drugs
One of the major challenges for renal transplantation is the
identification of a sufficient number of donor kidneys to fulfil demand.
Kidney donated for the national waiting list are harvested from
deceased donors. At the time of donation, donors are classified as
dead as a consequence of either brain stem as cardiac death; these
are also called heart beating and non-heart beating donors,
respectively
The numbers of deceased donors as a proportion of those on the
waiting list for a kidney transplant have fallen. Therefore, living donor
transplantation has become increasingly common. In addition to part
addressing the scarcity of donor organs, patients who receive kidney
transplant.
This is due to a number of factors, including the quality of the organs,
because living donors undergo a deatailed health screening and if
there is any indication that they have significant medical problems
they are excluded from donation.
One of the major factors responsible for excellent outcomes for kidney
transplant recipients is the use immunosuppressive drugs to control
the response the immune system of the recipient mounts against the
donor kidney. Alloimmunity refers to an immune response against
tissue derived from an individual of the same species as the recipient
of the tissue.
The major disadvantage of all immunosuppressive agents is
their relative non-specificity, in that they cause a general

depression of the immune system. This exposes the patient to

an increased risk of malignancy and infection, which is an
important cause of mordibility and mortality.

CASE STUDY
Mr. A is patient with CKD secondary to chronic interstitial nephritis. He
complains of chronic fatigue, lethargy and breathlessness on exertion,
palpitations and poor concentration. His recent haematological results
were found to be:
Reference range
Haemoglobin
5.6 g/dL
(13.5-17.5)
Red cell count
2.92x109 L-1
(4.5-6.5x109 L-1)
Haematocrit
0.208
(0.40-0.54)
Serum ferritin
88.0 cg/L
(15-300)
Question
Explain Mr. As symptoms and haematological results and outline the optimal
treatment.

Anwer: Mr. As symptoms are most likely to result from a normochromic,

normocytic anaemia caused by renal failure. Levels of erythropoetin produced by
the kidney are reduced in renal failure. Production of erythropoetin from extrarenal
sites, for example, liver, are not sufficient to maintain erythropoesis, which is also
inhibited by uraemic toxins and hyperparathyroidism. The anaemia associated with
renal failure is further compounded by a reduction in red cell survival through lowgrade haemolysis, bleeding from the gastro-intestinal tract and blood loss through
dialysis, aluminum toxicity which interferes with haem synthesis, and iron
deficiency, usually through poor dietary intake

Therapy with epoetin is the treatment of choice. However, iron and folate
deficiencies should be corrected if poetin therapy is to be successful. Iron demands
are generally raised during epoetin treatment and iron status should be regularly
monitored. If serum ferritin falls below 100 ch/L then supplementation should be
started. Often intravenous iron is required to provide an adequate supply, despite
the dangers associated with administration of iron by this route.
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