Kidney Disease, Chronic

Key Features

Essentials of Diagnosis

• Decline in the glomerular filtration rate (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 ultrasonogram in advanced disease

General Considerations

• Affects 10% of Americans

• Over 70% of cases of late-stage chronic kidney disease (CKD) (stage 5 CKD and end-stage kidney disease [ESKD]) 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 ancestry

• Progressive decline in kidney function

Clinical Findings

Symptoms and Signs

• Symptoms develop slowly with the progressive decline in GFR and are nonspecific

• Can be asymptomatic until kidney disease is far advanced (GFR < 5–10 mL/min/1.73 m²)

• General symptoms of uremia (eTable 22–2):

  • Fatigue

  • Anorexia

  • Nausea

  • Vomiting

  • Metallic taste in the mouth

• Hypertension is the most common sign

• Generalized pruritus (without rash)

• Memory impairment, insomnia, restless legs, and twitching

• Decreased libido, menstrual irregularities

• Pleuritic chest pain can occur with pericarditis (rare)

• Renal osteodystrophy (osteitis fibrosa cystica), osteomalacia, and adynamic bone disease

Differential Diagnosis

• See Table 22–5...