Stages of Chronic Kidney Disease

GFR*
Stage Description
mL/min/1.73m2
Slight kidney damage with normal
1 More than 90
or increased filtration
2 Mild decrease in kidney function 60-89
Moderate decrease in kidney
3 30-59
function
4 Severe decrease in kidney function 15-29
Less than 15 (or
5 Kidney failure
dialysis)
*GFR is glomerular filtration rate, a measure of the kidney's function.

Diabetes Mellitus

One cause of kidney failure is diabetes mellitus, a condition characterised by

high blood glucose (sugar) levels. Over time, the high levels of sugar in the blood
damage the millions of tiny filtering units within each kidney. This eventually
leads to kidney failure.

Around 20 to 30 per cent of people with diabetes develop kidney disease

(diabetic nephropathy), although not all of these will progress to kidney failure. A
person with diabetes is susceptible to nephropathy whether they use insulin or
not. The risk is related to the length of time the person has diabetes. There is no
cure for diabetic nephropathy, and treatment is lifelong. Another name for the
condition is diabetic glomerulosclerosis. People with diabetes are also at risk of
other kidney problems including narrowing of the arteries to the kidneys, called
renal artery stenosis or renovascular disease.

Kidneys explained

The human body has two kidneys, one on either side of the spine beneath the
lower ribs. Inside each kidney are about one million tiny units called nephrons.
Each nephron consists of a small filter (glomerulus) attached to a tubule. Water
that contains waste is separated from the blood by the filters and directed into the
tubules. Much of the water is returned to the blood by the tubules, while the
wastes are concentrated into urine. The urine is collected from the tubules by a
funnel-like structure (renal pelvis). From there, the urine flows down a tube
(ureter) that joins each kidney to the bladder. Urine leaves the bladder via the
urethra, the thin tube that connects to the outside of the body. Kidneys affected
by diabetic nephropathy no longer work efficiently, and trace amounts of protein
appear in the urine (microalbuminuria). The retained water and salts cause the
characteristic fluid retention and, frequently, the blood pressure begins to rise.

The mechanism is unknown

It is clear that diabetes can lead to kidney disease, but just why high blood
sugars should damage the glomeruli is unclear. High blood pressure
(hypertension) is a known risk factor for kidney disease and people with diabetes
are prone to hypertension. The renin-angiotensin system - which helps regulate
blood pressure - is also thought to be involved in the development of diabetic
nephropathy. Other risk factors include cigarette smoking and family history.
Diabetic nephropathy progresses steadily despite medical intervention. However,
treatment can significantly slow the rate of damage.

Obstructive uropathy

It is the structural or functional hindrance of normal urine flow, sometimes leading

to renal dysfunction
Obstructive nephropathy: Obstructive nephropathy is renal dysfunction
(renal insufficiency, renal failure, or tubulointerstitial damage)
resulting from urinary tract obstruction. The mechanism involves,
among many factors, increased intratubular pressure, local
ischemia, and, often, UTI. Obstruction may result in type 1 renal
tubular acidosis due to reduced distal hydrogen secretion probably
because of a defect in the hydrogen ion transporter. In this case, Na
wasting can occur and predispose to ECF volume depletion. If
obstruction is bilateral, nephropathy may result in renal
insufficiency. Renal insufficiency may rarely occur when obstruction
is unilateral because autonomic-mediated vascular or

Hemodialysis

Hemodialysis involves circulation of blood through a filter or dialyzer on a dialysis

machine.

• The dialyzer has two fluid compartments and is configured with bundles
of hollow fiber capillary tubes.

• Blood in the first compartment is pumped along one side of a

semipermeable membrane, while dialysate (the fluid that is used to cleanse the
blood) is pumped along the other side, in a separate compartment, in the
opposite direction.

• Concentration gradients of substances between blood and dialysate lead

to desired changes in the blood composition, such as a reduction in waste
products (urea nitrogen and creatinine); a correction of acid levels; and
equilibration of various mineral levels.
• Excess water is also removed.

• The blood is then returned to the body.

Bladder Irrrigation / Cystoclysis

• Bladder irrigation is the process of flushing the bladder with normal saline
to prevent or treat clot formation. Bladder irrigation may also be used to
instill medications such as antibiotics for treating bladder infections. This is
done over a period of time, and runs continuously. A special catheter is
used for the above procedure.

• To prevent blood clot formation, allow free flow of urine and maintain IDC
patency, by continuously irrigating the bladder with Normal Saline.

Medical Management

Medicines to treat high blood pressure

From 80% to 90% of people who have chronic kidney disease have problems
with high blood pressure at some time during their disease. Medicines to
lower blood pressure (antihypertensives) are used to keep blood pressure in a
safe range and slow the progression of kidney damage that is caused by high
blood pressure. The target is to keep your blood pressure below 130/80. The
type of blood pressure medicine used is thought to be less important than how
well the medicine lowers blood pressure.

Common blood pressure medicines include:

• Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors

decrease blood pressure by opening (dilating) blood vessels. ACE
inhibitors slow damage to the kidneys caused by diabetes and other
kidney diseases.
• Angiotensin II receptor blockers. These medicines block the action of a
hormone that causes blood vessels to narrow. As a result, blood vessels
relax and open, reducing blood pressure.
• Diuretics. Diuretics help remove extra sodium and fluid from the body,
decreasing the volume of circulating blood and lowering blood pressure.
• Beta-blockers. Beta-blockers decrease blood pressure by
decreasing heart rate and cardiac output. They also relax blood vessels.
• Calcium channel blockers. Calcium channel blockers dilate blood
vessels by relaxing the muscles in the vessel walls. This makes it easier
for blood to flow through the vessels and helps lower blood pressure.
 • Vasodilators. Vasodilators relax the smooth muscle of blood vessels,
which opens (dilates) the blood vessels.
• Direct renin inhibitors block the enzyme renin from starting a process
that helps regulate blood pressure. As a result, blood vessels relax and
widen, making it easier for blood to flow through the vessels, which lowers
blood pressure.

Medicines to treat complications of chronic kidney disease

Other medicines may be used to treat complications of chronic kidney
disease, such as:

• Erythropoietin (rhEPO) therapy and iron replacement

therapy for anemia. Anemia occurs during chronic kidney disease,
because as kidney function declines, the kidneys produce too
little erythropoietin, which is needed to make new red blood cells.
• Medicines for electrolyte imbalances. Specific medicines are
sometimes needed to treat imbalances of electrolytes, such as high
potassium, high phosphate, and low calcium levels.
• Diuretics to treat fluid buildup caused by chronic kidney disease.
• ACE inhibitors and angiotensin II receptor blockers for heart failure.
Regular blood tests are required to make sure that these medicines do not
raise potassium levels (hyperkalemia) or make kidney function worse.

Medicines used during dialysis

Both erythropoietin (rhEPO) therapy and iron replacement therapy

may also be used during dialysis to treat anemia, which often develops in
advanced chronic kidney disease.

• Erythropoietin (rhEPO) stimulates the production of new red blood cells

and may decrease the need for blood transfusions. This therapy may also
be started before dialysis is needed, when anemia is severe and causing
symptoms.
• Iron therapy can help increase levels of iron in the body when rhEPO
therapy alone is not effective.
• Vitamin D helps keep bones strong and healthy.