Chronic kidney disease 714452 225445367 2008-07-13T19:00:10Z Mboverload 49010 [[WP:AWB/T|Typo fixing]], typos fixed: comfirm → confirm using [[Project:AutoWikiBrowser|AWB]] {{Infobox_Disease | Name = Chronic kidney disease | Image = | Caption = | DiseasesDB = 11288 | ICD9 = {{ICD9|585}} | ICD10 = {{ICD10|N|18||n|17}} | ICDO = | OMIM = | MedlinePlus = | eMedicineSubj = med | eMedicineTopic = 374 | MeshID = D007676 | }} '''Chronic kidney disease''' (CKD), also known as '''chronic renal disease''', is a progressive loss of [[kidney|renal function]] over a period of months or years through five stages. Each stage is a progression through an abnormally low and deteriorating [[glomerular]] filtration rate, which is usually determined indirectly by the [[creatinine]] level in [[blood serum]].<ref name=KDOQI>{{cite web | author=National Kidney Foundation | title=K/DOQI clinical practice guidelines for chronic kidney disease | url=http://www.kidney.org/professionals/KDOQI/guidelines_ckd | year=2002 | accessdate=2008-06-29}}</ref> Stage 1 CKD is mildly diminished renal function, with few overt symptoms. '''Stage 5 CKD''' is a severe illness and requires some form of renal replacement therapy ([[dialysis]] or [[renal transplant]]). Stage 5 CKD is also called '''end-stage renal disease (ESRD)''', '''chronic kidney failure (CKF)''' or '''chronic renal failure''' (CRF). ==Signs and symptoms== Initially it is without specific symptoms and can only be detected as an increase in serum [[creatinine]] or protein in the urine. As the [[kidney]] function decreases: * [[blood pressure]] is increased due to fluid overload and production of vasoactive hormones, increasing one's risk of developing [[hypertension]] and/or suffering from [[congestive heart failure]] * [[Urea]] accumulates, leading to [[azotemia]] and ultimately [[uremia]] (symptoms ranging from lethargy to [[pericarditis]] and [[encephalopathy]]). Urea is excreted by sweating and crystallizes on skin ("uremic frost"). * [[Potassium]] accumulates in the blood (known as [[hyperkalemia]] with a range of symptoms including [[malaise]] and potentially fatal [[cardiac arrhythmia]]s) * [[Erythropoietin]] synthesis is decreased (potentially leading to [[anemia]], which causes [[fatigue (physical)|fatigue]]) * [[Fluid balance|Fluid volume overload]] - symptoms may range from mild [[edema]] to life-threatening [[pulmonary edema]] * [[Hyperphosphatemia]] - due to reduced phosphate excretion, associated with [[hypocalcemia]] (due to [[vitamin D3]] deficiency). ** Later this progresses to [[tertiary hyperparathyroidism]], with [[hypercalcaemia]], [[renal osteodystrophy]] and vascular calcification that further impairs cardiac function. * [[Metabolic acidosis]], due to accumulation of sulfates, phosphates, uric acid etc. This may cause altered enzyme activity by excess acid acting on enzymes and also increased excitability of cardiac and neuronal membranes by the promotion of [[hyperkalemia]] due to excess acid ([[acidemia]])<ref>{{cite journal |author=Adrogué HJ, Madias NE |title=Changes in plasma potassium concentration during acute acid-base disturbances |journal=Am. J. Med. |volume=71 |issue=3 |pages=456–67 |year=1981 |month=September |pmid=7025622 |doi=10.1016/0002-9343(81)90182-0}}</ref> People with chronic kidney disease suffer from accelerated [[atherosclerosis]] and are more likely to develop [[cardiovascular disease]] than the general population. Patients afflicted with chronic kidney disease and cardiovascular disease tend to have significantly worse prognoses than those suffering only from the latter. ==Diagnosis== In many CKD patients, previous renal disease or other underlying diseases are already known. A small number presents with CKD of unknown cause. In these patients, a cause is occasionally identified retrospectively. It is important to differentiate CKD from [[acute renal failure]] (ARF) because ARF can be reversible. Abdominal [[medical ultrasonography|ultrasound]] is commonly performed, in which the size of the [[kidney]]s are measured. Kidneys with CKD are usually smaller (< 9 cm) than normal kidneys with notable exceptions such as in [[diabetic nephropathy]] and [[polycystic kidney disease]]. Another diagnostic clue that helps differentiate CKD and ARF is a gradual rise in serum creatinine (over several months or years) as opposed to a sudden increase in the serum creatinine (several days to weeks). If these levels are unavailable (because the patient has been well and has had no blood tests) it is occasionally necessary to treat a patient briefly as having ARF until it has been established that the renal impairment is irreversible. Additional tests may include [[nuclear medicine]] [[MAG3 scan]] to confirm blood flows and establish the differential function between the two kidneys. [[dimercaptosuccinic acid|DMSA]] scans are also used in renal imaging; with both MAG3 and DMSA being used [[chelation|chelated]] with the radioactive element [[Technetium-99]]. In chronic renal failure treated with standard dialysis, numerous uremic toxins accumulate. These toxins show various cytotoxic activities in the serum, have different molecular weights and some of them are bound to other proteins, primarily to albumin. Such toxic protein bound substances are receiving the attention of scientists who are interested in improving the standard chronic dialysis procedures used today. == Stages== All individuals with a [[Glomerular filtration rate]] (GFR) <60 mL/min/1.73 m2 for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage. The rationale for including these individuals is that reduction in kidney function to this level or lower represents loss of half or more of the adult level of normal kidney function, which may be associated with a number of complications.<ref name=KDOQI/> All individuals with kidney damage are classified as having chronic kidney disease, irrespective of the level of GFR. The rationale for including individuals with GFR 60 mL/min/1.73 m2 is that GFR may be sustained at normal or increased levels despite substantial kidney damage and that patients with kidney damage are at increased risk of the two major outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular disease.<ref name=KDOQI/> ===Stage 1 CKD=== Slightly diminished function; Kidney damage with normal or increased GFR (>90 mL/min/1.73 m2). Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies.<ref name=KDOQI/> ===Stage 2 CKD=== Mild reduction in GFR (60-89 mL/min/1.73 m2) with kidney damage. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies.<ref name=KDOQI/> ===Stage 3 CKD=== Moderate reduction in GFR (30-59 mL/min/1.73 m2)<ref name=KDOQI/> ===Stage 4 CKD=== Severe reduction in GFR (15-29 mL/min/1.73 m2)<ref name=KDOQI/> ===Stage 5 CKD=== Established kidney failure (GFR <15 mL/min/1.73 m2, or permanent renal replacement therapy (RRT)<ref name=KDOQI/> ==Causes== The most common causes of CKD are [[diabetic nephropathy]], [[hypertension]], and [[glomerulonephritis]]. Together, these cause approximately 75% of all adult cases. Certain geographic areas have a high incidence of HIV nephropathy. Historically, kidney disease has been classified according to the part of the renal anatomy that is involved, as:{{fact|date=June 2008}} * [[Vascular]], includes large vessel disease such as bilateral [[renal artery stenosis]] and small vessel disease such as ischemic nephropathy, [[hemolytic-uremic syndrome]] and [[vasculitis]] * Glomerular, comprising a diverse group and subclassified into ** Primary Glomerular disease such as [[focal segmental glomerulosclerosis]] and [[IgA nephritis]] ** Secondary Glomerular disease such as [[diabetic nephropathy]] and [[lupus nephritis]] * Tubulointerstitial including [[polycystic kidney disease]], drug and toxin-induced chronic tubulointerstitial nephritis and [[reflux nephropathy]] * Obstructive such as with bilateral [[kidney stone]]s and diseases of the [[prostate]] <!--* ''more to be added''--> ==Treatment== The goal of therapy is to slow down or halt the otherwise relentless progression of CKD to stage 5. Control of [[blood pressure]] and treatment of the original disease, whenever feasible, are the broad principles of management. Generally, [[angiotensin converting enzyme inhibitor]]s (ACEIs) or [[angiotensin II receptor antagonists]] (ARBs) are used, as they have been found to slow the progression of CKD to stage 5.<ref>{{cite journal |author=Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G |title=Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy |journal=Lancet |volume=352 |issue=9136 |pages=1252–6 |year=1998 |month=October |pmid=9788454 |doi=10.1016/S0140-6736(98)04433-X}}</ref><ref>{{cite journal |author=Ruggenenti P, Perna A, Gherardi G, ''et al'' |title=Renoprotective properties of ACE-inhibition in non-diabetic nephropathies with non-nephrotic proteinuria |journal=Lancet |volume=354 |issue=9176 |pages=359–64 |year=1999 |month=July |pmid=10437863 |doi=10.1016/S0140-6736(98)10363-X}}</ref> Replacement of [[erythropoietin]] and [[vitamin D3]], two hormones processed by the kidney, is usually necessary, as is [[calcium]]. [[Phosphate binders]] are used to control the serum [[phosphate]] levels, which are usually elevated in chronic kidney disease. When one reaches stage 5 CKD, [[renal replacement therapy]] is required, in the form of either [[dialysis]] or a [[Kidney transplant|transplant]]. ==Prognosis== The prognosis of patients with chronic kidney disease is guarded as [[epidemiology|epidemiological data]] has shown that all cause [[death|mortality]] (the overall death rate) increases as kidney function decreases.<ref name=perazella16538076>{{cite journal |author=Perazella MA, Khan S |title=Increased mortality in chronic kidney disease: a call to action |journal=Am. J. Med. Sci. |volume=331 |issue=3 |pages=150–3 |year=2006 |month=March |pmid=16538076 |doi=10.1097/00000441-200603000-00007}}</ref> The leading cause of death in patients with chronic kidney disease is cardiovascular disease, regardless of whether there is progression to stage 5.<ref name=perazella16538076/><ref>{{cite journal |author=Sarnak MJ, Levey AS, Schoolwerth AC, ''et al'' |title=Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention |journal=Circulation |volume=108 |issue=17 |pages=2154–69 |year=2003 |month=October |pmid=14581387 |doi=10.1161/01.CIR.0000095676.90936.80 |url=http://circ.ahajournals.org/cgi/content/full/108/17/2154}}</ref><ref>{{cite journal |author=Tonelli M, Wiebe N, Culleton B, ''et al'' |title=Chronic kidney disease and mortality risk: a systematic review |journal=J. Am. Soc. Nephrol. |volume=17 |issue=7 |pages=2034–47 |year=2006 |month=July |pmid=16738019 |doi=10.1681/ASN.2005101085 |url=http://jasn.asnjournals.org/cgi/content/full/17/7/2034}}</ref> While [[renal replacement therapy|renal replacement therapies]] can maintain patients indefinitely and prolong life, the [[quality of life]] is severely affected.<ref>{{cite journal |author=Heidenheim AP, Kooistra MP, Lindsay RM |title=Quality of life |journal=Contrib Nephrol |volume=145 |issue= |pages=99–105 |year=2004 |pmid=15496796 |doi=10.1159/000081673 |url=}}</ref><ref>{{cite journal |author=de Francisco AL, Piñera C |title=Challenges and future of renal replacement therapy |journal=Hemodial Int |volume=10 Suppl 1 |issue= |pages=S19–23 |year=2006 |month=January |pmid=16441862 |doi=10.1111/j.1542-4758.2006.01185.x |url=}}</ref> [[Renal transplantation]] increases the survival of patients with stage 5 CKD significantly when compared to other [[therapeutic]] options;<ref>{{cite journal |author=Groothoff JW |title=Long-term outcomes of children with end-stage renal disease |journal=Pediatr. Nephrol. |volume=20 |issue=7 |pages=849–53 |year=2005 |month=July |pmid=15834618 |doi=10.1007/s00467-005-1878-9}}</ref><ref>{{cite journal |author=Giri M |title=Choice of renal replacement therapy in patients with diabetic end stage renal disease |journal=Edtna Erca J |volume=30 |issue=3 |pages=138–42 |year=2004 |pmid=15715116}}</ref> however, it is associated with an increased short-term mortality (due to complications of the surgery). Transplantation aside, high intensity [[home hemodialysis]] appears to be associated with improved survival and a greater [[quality of life]], when compared to the conventional three times a week [[hemodialysis]] and [[peritoneal dialysis]].<ref>{{cite journal |author=Pierratos A, McFarlane P, Chan CT |title=Quotidian dialysis--update 2005 |journal=Curr. Opin. Nephrol. Hypertens. |volume=14 |issue=2 |pages=119–24 |year=2005 |month=March |pmid=15687837}}</ref> ==See also== *[[Acute renal failure]] *[[Dialysis]] *[[Hepatorenal syndrome]] *[[Renal failure]] *[[Artificial kidney]] ==Organizations== In the USA, the [[National Kidney Foundation]] is a national organization representing patients and professionals who treat kidney diseases. The [[Renal Support Network]] (RSN) is a nonprofit, patient-focused, patient-run organization that provides non-medical services to those affected by [[Chronic kidney disease|CKD]]. The [[American Association of Kidney Patients]] (AAKP) is a non-profit, patient-centric group focused on improving the health and well-being of CKD and [[dialysis]] patients. The [[Renal Physicians Association]] (RPA) is an association representing [[nephrology]] professionals. In the United Kingdom, the [[National Kidney Federation]] represents patients, and the [[Renal Association]] represents renal physicians and works closely with the [[National Service Framework]] for kidney disease. The [[International Society of Nephrology]] is an international body representing specialists in kidney diseases. ==References== {{Sisterlinks}} <div class="references-small"> {{reflist}} </div> ==External links== *[http://www.kidney.org/ National Kidney Foundation] *[http://www.endstagekidneydisease.com End Stage Kidney Disease] * [http://www.emedicine.com/emerg/topic501.htm Renal Failure, Chronic and Dialysis Complications] - emedicine.com * [http://www.emedicine.com/med/topic374.htm Chronic Renal Failure] - emedicine.com {{Nephrology}} [[Category:Nephrology]] [[Category:Kidney diseases]] [[Category:Organ failure]] [[bg:Бъбречна недостатъчност]] [[ca:Insuficiència renal crònica]] [[de:Chronisches Nierenversagen]] [[es:Insuficiencia renal crónica]] [[fr:Insuffisance rénale chronique]] [[id:Gagal ginjal kronis]] [[it:Insufficienza renale]] [[pam:Pangapalya ning batu]] [[ja:慢性腎不全]] [[pt:Insuficiência renal crônica]] [[ru:Хроническая почечная недостаточность]] [[simple:Kidney failure]] [[sv:Kronisk njursvikt]]