Chronic kidney disease is characterized by an irreversible deterioration of renal function

that gradually progresses to end-stage renal disease (ESRD)

Or

• As evidence of structural or functional kidney abnormalities (abnormal urinalysis,

imaging studies, or histology) that persist for at least 3 months with or without a

decreased glomerular filtration rate (GFR) as defined by a GFR of less than 60 ml/min

per 1.73 m2

Causes of Chronic Kidney Disease

• Diabetes Mellitus

• Uncontrolled hypertension

• Glomerulonephritis

• Polycystic Kidney Disease

• Chronic urinary tract infections (recurrent Pyelonephritis)

• Nephrolithiasis (obstruction)

• Vasculitis (e.g. Systemic lupus erythematosus)

• Drug toxicity

• Hypoplastic or dysplastic kidneys

• Reflux nephropathy

• Focal segmental glomerulosclerosis

• Polycystic kidney disease (both autosomal-recessive and autosomal-dominant varieties)

Pathophysiology

Despite the diverse etiologies, once chronic kidney disease develops, the subsequent response of the failing kidney is similar.

Epidemiology

• Race

In the United States, ESRD rates in blacks are 2.7 times higher than in whites.

• Sex

The incidence and rate of progression to ESRD are equal in both sexes, although

obstructive uropathies are more common in males.

• Age

The frequency of chronic kidney disease increases with age and is much more

common in adults than children.

Clinical Features of Chronic Kidney Diseases

History

• Chronic kidney disease is asymptomatic in its earliest although urinalysis findings or

blood pressure maybe abnormal.

• As chronic kidney disease progresses to more advanced stages signs and symptoms

greatly increase.

Polydipsia and nocturia (secondary to a reduced capacity to concentrate the urine)

maybe one of the earliest symptoms that indicate a diagnosis of chronic kidney

disease.

The signs and symptoms in advanced chronic kidney disease may including the

following

Volume overload (edema)

Hyperkalemia

Metabolic acidosis

Hypertension

Anemia

Bone disease (termed osteodystrophy)

Anorexia, nausea, vomiting

• The absolute serum levels of BUN or creatinine do not directly correlate with the

development of these symptoms.

• However, estimated glomerular filtration rate (eGFR) seems to be associated with a

stronger correlation.

Physical

The findings vary depending on the severity of kidney failure and can range from an absence

of any physical findings to the presence of one or more of the following

• Anemia

• Short stature

• Hypertension

• Osteodystrophy

• Cardiac abnormalities such as left ventricular hypertrophy (LVH) and pericarditis

• Peripheral neuropathy

• CNS abnormalities such ranging from loss of concentration and lethargy to seizures and

coma

Differential Diagnosis, Investigations, and Treatment of Chronic Kidney

Disease

Differential Diagnosis

• Acute renal failure

• Rapidly progressive glomerulonephritis

Investigations

• Perform dipstick screening method for detection of proteins, blood, and pus in the urine

• The dipstick is a quick method of screening and detecting proteinuria, hematuria, and

pyuria and provides an estimate of the specific gravity (urine-concentrating capacity).

• More laboratory investigations can be done at higher centers, and therefore refer the

patient to hospital.

Investigations and Treatment of Chronic Kidney Disease

Treatment

Laboratory Studies

• Urine examination is perhaps the most important test and should be considered a part of

the physical examination.

• It can be performed at the bedside or in the clinic using a fresh urine sample

• An initial evaluation consists of a multitest detection strip (dipstick) test followed by

urine microscopy

• The dipstick is a quick method of screening and detecting proteinuria, hematuria, and

pyuria and provides an estimate of the specific gravity (urine-concentrating capacity)

• Urine microscopy is performed on a centrifuge-spun urine specimen to look for RBCs,

WBCs, and casts.

• BUN and serum creatinine assessments are the most important tests

• Anemia is an important clinical finding in chronic kidney disease and a CBC count is an

important investigation both in the initial evaluation and the subsequent follow-up in

these children.

Imaging Studies

• Imaging studies help in confirming the diagnosis of chronic kidney disease and may also

provide clues to its etiology.

• The following studies are helpful

Ultrasonography

Voiding cystourethrography

CT scanning

Skeletal survey

Procedures

• Kidney biopsy-rarely needed

Treatment

• Patients with chronic kidney disease should be evaluated to determine the following

Diagnosis (type of kidney disease)

Comorbid conditions (such as hyperlipidemia)

Severity which is based on level of kidney function

Complications related to level of kidney function

Risk for loss of kidney function

Risk for cardiovascular disease

Treatment of Chronic Kidney Disease

• Specific therapy based on diagnosis ( e.g. diabetes, hypertension)

• As above it is essential to treat hypertension. Goal BP is <130/80

• Evaluation and management of reversible causes of renal dysfunction

• Prevention and treatment of complications of decreased kidney function (e.g. anemia,

bone disease, cardiovascular manifestations, hypertension, growth failure)

• Evaluation and management of comorbid conditions

• Slowing the loss of kidney function

• Preparation for kidney failure therapy

• Replacement of kidney function with dialysis and transplantation if signs and symptoms

of uremia are present

Surgical Care

Surgical intervention is often recommended in patients with obstructive uropathy to relieve

acute kidney failure due to initial or recurrent obstruction.

Diet and Electrolytes Required

• Energy

• Protein

• Phosphorus and calcium

• Potassium

• Sodium and fluid

Follow-up

Further Outpatient Care

• All patients require regular follow-up on an outpatient basis in a dedicated chronic kidney

disease clinic until initiation of long-term renal replacement therapy.

• This involves a multidisciplinary team approach that involves the nephrologist, primary

care physician, renal dietitian, nurse and social worker.

• So refer once you make a diagnosis of chronic kidney disease for expert care.

Prognosis

• Once chronic kidney disease occurs, progression to end-stage renal disease (ESRD)

appears certain.

• However, the rate of progression depends on the underlying diagnosis on the successful

implementation of secondary preventive measures and on the individual patient.

Patient Education

• Children with chronic kidney disease and their families should receive education about

the importance of compliance with secondary preventative measures, natural disease

progression, prescribed medications (highlighting their potential benefits and adverse

effects), diet and types of long-term renal replacement modalities.

• Provide pre-referral treatment.

• One of the most important treatments to prevent worsening kidney disease is to identify

and control blood pressure: goal blood pressure would be <130/80.

• Refer the patient to the higher centre for further investigation and management. 

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