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24-11: Chronic Kidney Disease

Tonja C. Dirkx; Tyler B. Woodell

ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Decline in GFR over months to years.

  • Persistent proteinuria or abnormal renal morphology may be present.

  • Hypertension is commonly present.

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

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

GENERAL CONSIDERATIONS

CKD affects at least 10% of Americans. Many are unaware that they have CKD as it is asymptomatic until it becomes advanced. The National Kidney Foundation’s staging system helps clinicians formulate practice plans according to stage or severity of CKD (Table 24–5). Over 70% of cases of late-stage CKD (stage 5 CKD and 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 24–6). Genetic polymorphisms of the APOL-1 gene are associated with an increased risk of developing CKD in persons of sub-Saharan African ancestry.

Table 24–5.Stages of CKD: a clinical action plan.1,2
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Table 24–5. Stages of CKD: 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. 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/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 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 24–6.Causes of CKD.
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Table 24–6. 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 amyloidosis

 Postinfectious glomerulonephritis

 HIV-associated nephropathy

 Collagen-vascular diseases (eg, SLE)

 HCV-associated membranoproliferative glomerulonephritis
Tubulointerstitial Nephritis

 Drug hypersensitivity

 Heavy metals

 Analgesic nephropathy

 Reflux/chronic pyelonephritis

 Sickle cell nephropathy

 Idiopathic
Cystic Diseases

 Polycystic kidney disease

 Medullary cystic disease
Obstructive Nephropathies

 Prostatic disease

 Nephrolithiasis

 Retroperitoneal fibrosis/tumor

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