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Chronic Kidney Disease

Chronic Kidney Disease
Longstanding disease of the kidneys leading to renal failure. Kidney disease is a term used by doctors to include any abnormality of the kidneys, even if there is only very slight damage. ‘Chronic’ means a condition that does not get completely better and lasts over a long time. Chronic does not mean ‘severe’.


Key points

  • The kidneys filter waste and excess fluid from the blood. As kidneys fail, waste builds up. Symptoms develop slowly and aren't specific to the disease. Some people have no symptoms at all and are diagnosed by a lab test.

  • Chronic Kidney Disease is very common, but less than 1 in 10 people with CKD ever require dialysis (artificial kidney treatment) or a kidney transplant.

  • Someone with CKD is at increased risk of heart attack or stroke, especially if they smoke or are overweight.

  • People with CKD should have regular checks of their kidney function and blood pressure, and have treatment if their blood pressure is elevated.

 

How common is CKD?
Recent research suggests that around 1 in 10 of the population may have CKD, but it is less common in young adults, being present in 1 in 50 people. In those aged over 75 years, CKD is present in 1 out of 2 people. However, many of the elderly people with CKD may not have ‘diseased’ kidneys, but have normal ageing of their kidneys. Although severe kidney failure will not occur with normal ageing of the kidneys, there is an increased chance of high blood pressure and heart disease or stroke, so medical checks will be helpful.
 

How does someone know if they have CKD?
In most cases CKD is detected because tests are abnormal. These may be urine tests for blood or protein leak, or a blood test to measure kidney function or scan of the kidneys.
 

Signs and symptoms of chronic kidney disease develop over time if kidney damage progresses slowly. Loss of kidney function can cause a buildup of fluid or body waste or electrolyte problems. Depending on how severe it is, loss of kidney function can cause:
•    Nausea
•    Vomiting
•    Loss of appetite
•    Fatigue and weakness
•    Sleep problems
•    Urinating more or less
•    Decreased mental sharpness
•    Muscle cramps
•    Swelling of feet and ankles
•    Dry, itchy skin
•    High blood pressure (hypertension) that's difficult to control
•    Shortness of breath, if fluid builds up in the lungs
•    Chest pain, if fluid builds up around the lining of the heart
 

Signs and symptoms of kidney disease are often nonspecific. This means they can also be caused by other illnesses. Because your kidneys are able to make up for lost function, you might not develop signs and symptoms until irreversible damage has occurred.
 

What causes CKD?
Chronic kidney disease occurs when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years.


Diseases and conditions that cause chronic kidney disease include:

  • Type 1 or type 2 diabetes

  • High blood pressure

  • Glomerulonephritis, an inflammation of the kidney's filtering units (glomeruli)

  • Interstitial nephritis, an inflammation of the kidney's tubules and surrounding structures

  • Polycystic kidney disease or other inherited kidney diseases

  • Prolonged obstruction of the urinary tract, from conditions such as enlarged prostate, kidney stones and some cancers

  • Vesicoureteral reflux, a condition that causes urine to back up into your kidneys

  • Recurrent kidney infection, also called pyelonephritis


Risk factors

Factors that can increase your risk of chronic kidney disease include:

  • Diabetes

  • High blood pressure

  • Heart (cardiovascular) disease

  • Smoking

  • Obesity

  • Being Black, Native American or Asian American

  • Family history of kidney disease

  • Abnormal kidney structure

  • Older age

  • Frequent use of medications that can damage the kidneys


Complications

Chronic kidney disease can affect almost every part of your body. Potential complications include:

  • Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid in your lungs (pulmonary edema)

  • A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart's function and can be life-threatening

  • Anemia

  • Heart disease

  • Weak bones and an increased risk of bone fractures

  • Decreased sex drive, erectile dysfunction or reduced fertility

  • Damage to your central nervous system, which can cause difficulty concentrating, personality changes or seizures

  • Decreased immune response, which makes you more vulnerable to infection

  • Pericarditis, an inflammation of the saclike membrane that envelops your heart (pericardium)

  • Pregnancy complications that carry risks for the mother and the developing fetus

  • Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival


Measuring kidney function - EGFR

A test called the eGFR (estimated glomerular filtration rate) is used to measure kidney function. The eGFR is calculated by the laboratory from the level of a chemical called creatinine in the blood.


A normal eGFR is about 100 ml/min in young adults, so the eGFR is sometimes referred to as the percentage of normal kidney function.


Some young adults with normal kidneys will have an eGFR as low as 75 ml/min, and this falls by about 1 ml/min per year as people get older, so many healthy people aged 75 will have an eGFR of 50-60 ml/min.


Most laboratories now report eGFR alongside their measurements of blood creatinine levels and this is the most reliable way to obtain an eGFR result. It is possible to use on-line calculator by putting in age, sex, blood level of creatinine and racial origin. However, different laboratories use different methods to measure serum creatinine, and each of these methods gives slightly different answers. The eGFR that the laboratory reports takes account of these differences, but the on-line calculators do not; so the results that they give are not quite as accurate.


What are the stages of CKD?

CKD is divided into 5 stages: -

  • CKD stage 1 is eGFR greater than 90 mls/min, which is normal but there are some signs of kidney damage on other tests (eg. Blood or protein leak in urine, multiple cysts in the kidneys, single kidney).

  • CKD stage 2 is eGFR 60-90 This is mildly decreased with some sign of kidney damage on other tests

  • CKD stage 3a is eGFR 45-59 ml/min, a mild to moderate reduction in kidney function

  • CKD stage 3b is eGFR 30-44 ml/min, a moderate to severe reduction in kidney function

  • CKD stage 4 is eGFR 15-29 ml/min, a severe reduction in kidney function. You may need additional medications to support loss of certain functions of the kidneys.

  • CKD stage 5 is e GFR less than 15 ml/min, established kidney failure. Very likely to experience symptoms of kidney failure, when dialysis or a kidney transplant may be needed.

Proteinuria

Leakage of protein into the urine increases the risk of any kidney disease. Everyone with CKD should therefore have a urine test to measure the amount of protein in the urine, and if this level is high, they will receive more careful treatment and possibly more extensive investigations. This is also divided into categories depending on whether it is mildly increased, moderately increased or severely increased.


Factors that worsen leak of protein in urine include poorly controlled blood pressure, weight gain and poorly controlled diabetes.

 

What is the treatment for CKD?

There are some things that everyone with CKD should try to do. These are: -

  • Lose weight (if overweight), and take regular exercise

  • Stop smoking

  • Reduce the amount of salt in the diet in order to help control the blood pressure.

  • Eat a healthy balanced diet

  • Drink about 2 litres of fluid a day (2 litres is about 10 cups or 6 mugs), unless your eGFR is less than 15ml/min. There is no benefit in drinking larger amounts of fluid, except in people who get lots of urine infections, or in a few other special cases

  • Consider buying an automatic blood pressure monitor to check the blood pressure at home, at least twice a week.

  • Stay up-to-date with National vaccinations, including ‘flu jab (influenza vaccination), and have the pneumonia (pneumococcal) vaccine once (talk to your GP about this). If you are on medications that weaken the immune system, then speak to your kidney doctor as you shouldn’t take certain vaccinations.

  • Avoid taking medications which can harm the kidney and increase blood pressure, such as anti-inflammatory medications (eg. Ibuprofen, diclofenac), herbal medications, recreational drugs.


The blood pressure should be treated carefully. If it is above 140/85, tablets are usually needed, and the aim is to get the blood pressure down to 140/90 or lower if you have proteinuria or have diabetes. The cholesterol level should be checked, and some people will be advised to take a daily aspirin tablet. A blood test to check eGFR should be performed at least once a year, depending on your CKD stage. If the urine tests show a lot of protein in the urine, or the kidney function is declining over time, the case will be discussed with a kidney specialist, or a referral may be made to a kidney specialist.


Treatment for CKD stage 3A & 3B


Treatment as in CKD stages 1 and 2, but with more careful monitoring for declining kidney function.


Treatment for CKD stages 4 & 5


Treatment as for CKD stages 1-3. Additionally, any medications should be reviewed, as the dose may need to be altered and some drugs may need to be avoided as they could damage the kidneys further. This should include prescribed drugs and any drugs bought at the chemist and complementary therapies. In CKD stages 4 and 5 it is usually necessary to get advice from a kidney specialist, as you may need additional medications to replace loss of certain functions of the kidneys. And you may have to start planning for kidney transplant, dialysis or supportive care.


CKD & Diabetes

CKD does not cause diabetes, but CKD can be a complication of diabetes. If someone with CKD also has diabetes, extra care to control the blood pressure, blood sugar levels and cholesterol levels is required. More intensive monitoring will be performed, including extra urine tests to look for protein in the urine, as poorly controlled diabetes can make kidneys fail faster.


What if the kidney function keeps on getting worse & worse?

In people with declining kidney function, a treatment plan should be made with a kidney specialist team well before CKD stage 5 is reached.


Leading a normal life with CKD

Most people with CKD should be able to lead normal lives. CKD does not normally run in families and routine family screening is not necessary if one person is affected. However, some specific types of kidney disease do run in families, and people should check with their health care team to see if testing of family members is needed.


CKD & Pregnancy

It is important to plan pregnancy and contact your GP/kidney doctor promptly if you become pregnant unplanned. This is because in some patients, pregnancy can be an added strain on their kidneys and they require closer monitoring. Certain medications can be toxic to the unborn baby or passed in breastmilk so have them clarified. A very small number of patients with CKD can be at a slightly increased risk of other pregnancy-associated complications, including impaired growth of baby and pre-term delivery. You may be asked to start aspirin, may need frequent pre-natal scans and may be referred to a specialist center for clinics that have both a kidney doctor and an obstetrician. A lot of people with CKD do have successful pregnancies but just needs planning, education and close monitoring.


Prevention

To reduce your risk of developing kidney disease:

  • Follow instructions on over-the-counter medications. When using nonprescription pain relievers, such as aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others), follow the instructions on the package. Taking too many pain relievers for a long time could lead to kidney damage.

  • Maintain a healthy weight. If you're at a healthy weight, maintain it by being physically active most days of the week. If you need to lose weight, talk with your doctor about strategies for healthy weight loss.

  • Don't smoke. Cigarette smoking can damage your kidneys and make existing kidney damage worse. If you're a smoker, talk to your doctor about strategies for quitting. Support groups, counseling and medications can all help you to stop.

  • Manage your medical conditions with your doctor's help. If you have diseases or conditions that increase your risk of kidney disease, work with your doctor to control them. Ask your doctor about tests to look for signs of kidney damage.


A note from Pan Medical Kampala

Make an appointment with your doctor if you have signs or symptoms of kidney disease. Early detection might help prevent kidney disease from progressing to kidney failure.

If you have a medical condition that increases your risk of kidney disease, your doctor may monitor your blood pressure and kidney function with urine and blood tests during office visits. Ask your doctor whether these tests are necessary for you.

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