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22-11: Chronic Kidney Disease

Tonja C. Dirkx; Tyler B. Woodell

ESSENTIALS OF DIAGNOSIS

  • Decline in the GFR over months to years.

  • Persistent proteinuria or abnormal renal morphology may be present.

  • Hypertension in most cases.

  • Symptoms and signs of uremia when nearing end-stage disease.

  • Bilateral small or echogenic kidneys on ultrasound in advanced disease.

CKD affects at least 10% of Americans. Many may be unaware of the condition because they remain asymptomatic until the disease is near end stage. The National Kidney Foundation’s staging system helps clinicians formulate practice plans (Table 22–4). Over 70% of cases of late-stage CKD (stage 5 CKD and ESRD) in the United States are due to diabetes mellitus or hypertension/vascular disease. Glomerulonephritis, cystic diseases, chronic tubulointerstitial diseases, and other urologic diseases account for the remainder (Table 22–5). Genetic polymorphisms of the APOL-1 gene have been shown to be associated with an increased risk of the development of CKD in persons of African descent.

Table 22–4.Stages of chronic kidney disease: a clinical action plan.1,2
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Table 22–4. Stages of chronic kidney disease: a clinical action plan.1,2
Stage3 Description GFR (mL/min/1.73 m2) Action
1 Kidney damage with normal or ↑↑ GFR ≥ 90 Diagnosis and treatment of underlying etiology if possible. Treatment of comorbid conditions. Estimate progression, work to slow progression. Cardiovascular disease risk reduction. 
2 Kidney damage with mildly ↓ GFR 60–89
3a Mildly-moderately ↓ GFR 45–59 As above, and evaluating and treating complications.
3b Moderately-severely ↓ GFR 30–44  
4 Severely ↓ GFR 15–29 Preparation for end-stage renal disease.
5 End-stage renal disease < 15 (or dialysis) Dialysis, transplant, or palliative care.

1Based on National Kidney Foundation, KDOQI, and KDIGO Chronic Kidney Disease Guidelines.

2Chronic kidney disease is defined as either kidney damage or GFR < 60 mL/min/1.73 m2 for 3 or more months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.

3At all stages, persistent albuminuria confers added risk for chronic kidney disease progression and cardiovascular disease in the following gradations: < 30 mg/day = lowest added risk, 30–300 mg/day = mildly increased risk, > 300–1000 mg/day moderately increased risk, > 1000 mg/day = severely increased risk.

GFR, glomerular filtration rate.

Modified and reproduced, with permission, from Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. 2013 Jan;3(1) (Suppl):1–150.

Copyright © 2013 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

Table 22–5.Causes of chronic kidney disease.
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Table 22–5. Causes of chronic kidney disease.
Glomerular Diseases

Primary glomerular diseases

 Focal segmental glomerulosclerosis

 Membranoproliferative glomerulonephritis

 IgA nephropathy

 Membranous nephropathy

 Alport syndrome (hereditary nephritis)

Secondary glomerular diseases

 Diabetic nephropathy

 Renal amyloidosis

 Postinfectious glomerulonephritis

 HIV-associated nephropathy

 Collagen-vascular diseases (eg, SLE)

 HCV-associated membranoproliferative glomerulonephritis
Tubulointerstitial Nephritis...

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