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The symptoms of chronic kidney disease often develop slowly and are nonspecific (Table 22 7) Individuals can remain asymptomatic until renal failure is far advanced (GFR < 10 15
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Table 22 5 Stages of chronic kidney disease: A clinical action plan1,2
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Description Kidney damage with normal or GFR Kidney damage with mildly Moderately Severely Kidney failure
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GFR (mL/min/ 173 m2) 90 60 89 30 59 15 29 < 15 (or dialysis)
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Action3 Diagnosis and treatment Treatment of comorbid conditions Slowing of progression Cardiovascular disease risk reduction Estimating progression Evaluating and treating complications Preparation for kidney replacement therapy Replacement (if uremia is present)
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From National Kidney Foundation, KDOQI, chronic kidney disease guidelines 2 Chronic kidney disease is defined as either kidney damage or GFR < 60 mL/min/173 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 3 Includes actions from preceding stages GFR, glomerular filtration rate
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mL/min) Manifestations include fatigue, weakness, and malaise Gastrointestinal complaints, such as anorexia, nausea, vomiting, a metallic taste in the mouth, and hiccups, are common Neurologic problems include irritability, difficulty in concentrating, insomnia, subtle memory defects, restless legs, and twitching Pruritus is common and difficult to treat
Table 22 6 Major causes of chronic renal failure
Glomerulopathies Primary glomerular diseases Focal and segmental glomerulosclerosis Membranoproliferative glomerulonephritis IgA nephropathy Membranous nephropathy Secondary glomerular diseases Diabetic nephropathy Amyloidosis Postinfectious glomerulonephritis HIV-associated nephropathy Collagen-vascular diseases Sickle cell nephropathy HIV-associated membranoproliferative glomerulonephritis Tubulointerstitial nephritis Drug hypersensitivity Heavy metals Analgesic nephropathy Reflux/chronic pyelonephritis Idiopathic Hereditary diseases Polycystic kidney disease Medullary cystic disease Alport s syndrome Obstructive nephropathies Prostatic disease Nephrolithiasis Retroperitoneal fibrosis/tumor Congenital Vascular diseases Hypertensive nephrosclerosis Renal artery stenosis
As uremia progresses, decreased libido, menstrual irregularities, chest pain from pericarditis, and paresthesias can develop Symptoms of drug toxicity especially for drugs eliminated by the kidney increase as renal clearance worsens On physical examination, the patient appears chronically ill Hypertension is common The skin may be yellow, with signs of easy bruisability Rarely seen in the dialysis era is uremic frost, a cutaneous reflection of ESRD Uremic fetor is the characteristic fishy odor of the breath Cardiopulmonary
Table 22 7 Symptoms and signs of uremia
Organ System General Skin Symptoms Fatigue, weakness Pruritus, easy bruisability Metallic taste in mouth, epistaxis Shortness of breath Dyspnea on exertion, retrosternal pain on inspiration (pericarditis) Anorexia, nausea, vomiting, hiccups Nocturia, impotence Restless legs, numbness and cramps in legs Generalized irritability and inability to concentrate, decreased libido Stupor, asterixis, myoclonus, peripheral neuropathy Isosthenuria Signs Sallow-appearing, chronically ill Pallor, ecchymoses, excoriations, edema, xerosis Urinous breath Pale conjunctiva Rales, pleural effusion Hypertension, cardiomegaly, friction rub
ENT Eye Pulmonary Cardiovascular
Gastrointestinal Genitourinary Neuromuscular
Neurologic
Kidney Disease
10 09
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Table 22 8 Reversible causes of renal failure
Reversible Factors Infection Obstruction Extracellular fluid volume depletion Diagnostic Clues Urine culture and sensitivity tests Bladder catheterization, then renal ultrasound Orthostatic blood pressure and pulse: blood pressure and pulse upon sitting up from a supine position Serum electrolytes, calcium, phosphate, uric acid Drug history Blood pressure, chest radiograph Physical examination, chest radiograph 1/Scr
Hypokalemia, hypercalcemia, and hyperuricemia (usually > 15 mg/dL) Nephrotoxic agents Hypertension Congestive heart failure
01 1 2 3 4 5 6 7 Time (years) 8 9 10
signs may include rales, cardiomegaly, edema, and a pericardial friction rub Mental status can vary from decreased concentration to confusion, stupor, and coma Myoclonus and asterixis are additional signs of uremic effects on the central nervous system The term uremia is used for this clinical syndrome, but the exact cause remains unknown BUN and serum creatinine are considered markers for unknown toxins, with parathyroid hormone (PTH) possibly one such toxin In any patient with renal failure, it is important to identify and correct all possibly reversible causes Urinary tract infections, obstruction, extracellular fluid volume depletion, nephrotoxins, hypertension, and congestive heart failure should be excluded (Table 22 8) Any of the above can worsen underlying chronic renal failure
Value of serum creatinine level = 10 mg/dL Value of serum creatinine level = 20 mg/dL 3 Value of serum creatinine level = 50 mg/dL
Figure 22 1 Decline in renal function plotted against time to end-stage renal disease (ESRD) The solid line indicates the linear decline in renal function over time The dotted line indicates the approximate time to ESRD
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