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Chronic Kidney Disease

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Chronic Kidney Disease

encompasses a spectrum of different

pathophysiologic processes associated with:

abnormal kidney function

progressive decline in glomerular filtration rate

(GFR)

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National Kidney Foundation [Kidney

Dialysis Outcomes Quality Initiative

(KDOQI)] Guideline on CKDClassification

STAGE GFR (ml/min per 1.73 m2)

0 90

1 90

2 60 89

3 30 59

4 15 29

5 < 15

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Chronic Renal Failure

applies to the process of continuing significant

irreversible reduction in nephron number

typically corresponds to CKD stages 35

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End-Stage Renal Disease

stage of CKD where the accumulation of

toxins, fluid, and electrolytes normally

excreted by the kidneys results in the uremic

syndrome

This syndrome leads to death unless the toxins are

removed by renal replacement therapy, using:

dialysis or kidney transplantation

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Pathophysiology of CKD

involves two broad sets of mechanisms ofdamage:

(1) initiating mechanisms specific to the underlying

etiology immune complexes and mediators of inflammation in certain

types of glomerulonephritis

toxin exposure in certain diseases of the renal tubules andinterstitium

(2) a set of progressive mechanisms, involving hyperfiltration and hypertrophy of the remaining viable

nephrons

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In order to stage CKD, it is necessary to

estimate the GFR.

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The normal annual mean decline in GFR with age fromthe peak GFR (~120 mL/min per 1.73 m2) attainedduring the third decade of life is: ~1 mL/min per year per 1.73 m2

reaching a mean value of 70 mL/min per 1.73 m2 at age 70 The mean GFR is lower in women than in men.

For example, a woman in her 80s with a normal serumcreatinine may have a GFR of just 50 mL/min per 1.73 m2.

Thus, even a mild elevation in serum creatinineconcentration [e.g., 130 mol/L (1.5 mg/dL)], oftensignifies a substantial reduction in GFR in mostindividuals.

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Etiology & Epidemiology

The most frequent cause of CKD is diabeticnephropathy, most often secondary to type 2diabetes mellitus.

Hypertensive nephropathy is a common cause ofCKD in the elderly, in whom chronic renalischemia as a result of small and large vesselrenovascular disease may be underrecognized.

Progressive nephrosclerosis from vascular

disease is the renal correlate of the sameprocesses that lead to coronary heart disease andcerebrovascular disease.

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Clinical & Laboratory Manifestations

Uremia leads to disturbances in the function

of virtually every organ system.

Chronic dialysis can reduce the incidence and

severity of many of these disturbances

However, even optimal dialysis therapy is not

completely effective as renal replacement therapy,

because some disturbances resulting fromimpaired renal function fail to respond to dialysis.

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Clinical Abnormalities of CKD &

UremiaFLUID & ELECTROLYTE DISTURBANCES ENDOCRINE-METABOLIC DISTURBANCES

Volume expansion

Hyponatremia

Hyperkalemia

Hyperphosphatemia

Secondary hyperarathyroidism

Adynamic bone

Vit D-deficient osteomalacia

Carbohydrate reistance

HyperuricemiaHypertriglyceridemia

Inc LDL level

Dec HDL level

Protein-energy malnutirition

Impaired growth devt

Infertility & sexual dysfunctionAmenorrhea

B2-microglobulin associated amyloidosis

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NEUROMUSCULAR DISTURBANCES CARDIO-PULMONARY DISTURBANCES

Fatigue

Sleep d/o

HeadacheImpaired mentation

Lethargy

Asterixis

Muscular irritability

Peripheral neuropathy

Restless legs syndromeMyoclonus

Seizures

Coma

Muscle cramps

Dialysis disequilibrium syndrome

Myopathy

Arterial hypertension

CHF or pulmonary edema

PericarditisHypertrophic or dialted cardiomyopahy

Uremic lung

Accelerated atherosclerosis

Hypotension and arryhtmias

Vascular calcification

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DERMATOLOGIC DISTURBANCES GASTROINTESTINAL DISTURBANCES

Pallor

Hyperpigmentation

Pruritus

EcchymosesNephrogenic fibrosing dermopathy

Uremic frost

Anorexia

Nausea and vomiting

Gastroenteritis

Peptic ulcerGastrointestinal bleeding

Idiopathic ascites

Peritonitis

HEMATOLOGIC & IMMUNOLOGIC DISTURBANCES

Anemia

Lymphocytopenia

Bleeding diathesis

Increased susceptibility to infectionLeukopenia

Thrombocytopenia