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Kidney Disease, Chronic

For further information, see CMDT Part 22-12: Chronic Kidney Disease

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 ultrasound in advanced disease

General Considerations

  • Affects at least 10% of Americans

  • CKD staging system (Table 22–4)

  • 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 Sub-Saharan African ancestry

  • Progressive decline in kidney function

  • Potentially reversible or exacerbating causes of kidney disease that should be addressed include

    • Urinary obstruction

    • Hypovolemia, hypotension

    • Nephrotoxins (such as NSAIDs, aminoglycosides, or proton pump inhibitors)

    • Severe or emergent hypertension

    • Heart failure exacerbation

Table 22–4.Stages of CKD: a clinical action plan.1,2
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Table 22–4. Stages of CKD: a clinical action plan.1,2
Stage3 Description GFR (mL/minute/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. CVD 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 ESKD.
5 ESKD < 15 (or dialysis) Dialysis, transplant, or palliative care.

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

2CKD is defined as either kidney damage or GFR < 60 mL/minute/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 CKD progression and CVD 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.

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;3(1)(Suppl):1–150.

Table 22–5.Causes of CKD.
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Table 22–5. Causes of CKD.
Glomerular Diseases

Primary glomerular diseases

 Focal segmental glomerulosclerosis

 Membranoproliferative glomerulonephritis

 IgA nephropathy

 Membranous nephropathy

 Alport syndrome (hereditary nephritis)

Secondary glomerular diseases

 Diabetic nephropathy

 Renal ...

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