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End-stage renal disease (ESRD) or kidney failure has been defined as having kidney function less than 15 mL/min/1.73 m2. Kidney failure may be caused by progression of a chronic nephropathy or by acute kidney injury (AKI). Kidney failure is associated with the inability to excrete waste products, control serum electrolytes, handle the daily dietary and metabolic acid load, and maintain fluid balance. In addition, kidney failure causes inadequate production of erythropoietin, deranged calcium and phosphorous metabolism, high blood pressure, and accelerated progression of cardiovascular disease. Uremia is the term used to describe the symptoms or symptom complex attributable to advanced kidney failure or ESRD. Most chronic nephropathies demonstrate inexorable progression to kidney failure. In general, there is a straight line relationship between the decrement in kidney function over time when the kidney function is plotted longitudinally. The rates of decline in kidney function vary by underlying nephropathy, by severity of hypertension and proteinuria, by modifying factors, and between individuals. Historically, the rate of decline could be estimated as 7 to 10 mL/min/year in those with untreated chronic nephropathies such as diabetic nephropathy. However, chronic nephropathies have similar effects on electrolyte homeostasis, causes of progressive decline in function, and manifestations of kidney failure so that classification by severity permits a better understanding of underlying routes to progression, symptoms, and hopefully, treatments of chronic kidney disease (CKD). In parts of the world with access to dialysis and kidney transplantation, renal replacement therapy (RRT) has been thought to be necessary when the glomerular filtration rate (GFR) decreases to less than 15 mL/min. “Kidney damage” has been defined as structural or functional abnormalities of the kidney, initially without decreased GFR, which over time can lead to decreased GFR. Markers of kidney damage include abnormalities in the composition of the blood or urine, or abnormalities in imaging tests. Proteinuria as a marker of kidney damage has been studied most thoroughly. CKD is the term used to describe patients with a chronic decrease in GFR. There are different levels of CKD, and these levels have underpinned an international classification system (Table 87-1). It has been proposed that advanced CKD (GFR estimated <15mL/min/1.73m2) be classified as CKD Stage 5 with a suffix to classify the treatment modality. For example, a person treated by hemodialysis would be characterized as CKD Stage 5-D.

Table 87-1 Classification of Chronic Kidney Disease

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