Chronic Kidney Disease

Chronic kidney disease is a general term that describes a gradual loss in kidney function. More specifically: greater than or equal to 3 months with kidney damage and/or low GFR (<60mL/min).

=Objectives=
 * Understand the importance of creatinine when discussing chronic kidney disease
 * Understand that treatment of chronic kidney disease is based off of stage.

=Symptoms=
 * 1) Usually asymptomatic unless severe failure.
 * 2) By system
 * 3) General: nausea, vomiting, anorexia, malaise
 * 4) Neurologic: altered mental status, neuropathy
 * 5) Cardiovascular: hypertension, pericarditis, accelerated atherosclerosis
 * 6) Hematologic: anemia
 * 7) Metabolic: hyperkalemia, hyperphosphatemia, hypocalcemia

=Mechanism=
 * Diabetes
 * HTN
 * Polycystic Kidney Disease
 * Glomerulonephritis
 * Congenital Disease
 * Drugs
 * Myeloma
 * Long-standing acute renal failure

=Differential Diagnosis=
 * 1) Arrange in order
 * 2) Most common
 * 3) Least common

=Diagnostic Workup=
 * 1) Serum creatinine
 * 2) Basic metabolic panel (other than serum creatinine)
 * 3) hyperkalemia
 * 4) hyponatremia
 * 5) hypocalcemia
 * 6) hyperphosphatemia
 * 7) Ultrasound
 * 8) Hydronpehrosis or atrophy
 * 9) Determine Stage of Kidney Disease
 * 10) Stage 1: >90 mL/min GFR
 * 11) Stage 2: 60-89 mL/min GFR
 * 12) Stage 3: 30-59 mL/min GFR
 * 13) Stage 4: 15-29 mL/min GFR
 * 14) Stage 5: <15 mL/min or dialysis

=Management= The overarching goal of managment is to prevent metabolic abnormalities and to prevent further damage to the kidney.

Management starts with first making sure that the patient does not have acute renal failure. Answer the question: does this patient have a stable glomerular filtration rate? There are many ways to calculate someone's GFR (read about different strategies here). At the very least, each formula uses a patient's serum creatinine. The caveat, however, is that creatinine levels lag glomerular filtration rate, so that a 2.0mg/dL creatinine doesn't give you useful clinical data. For example, a day to day trend of 0.3mg/dL to 2.0mg/dL (extremely low GFR) implies a completely different GFR than 2.0 to 2.0 (moderate GFR).

A second related question that must be answered by any medicine team is determining if the patient is at baseline renal function. Determine their baseline function by plotting their creatinine vs. time. This will give you a sense about their disease stability. A patient can have severe kidney disease but can continue conservative management if creatinine levels are stable. A person with severe, but stable, CKD does not need to remain in the hospital.

Management is based on stage:
 * Stage 1: Slow the progression of renal function decline by controlling blood pressure and diabetes.
 * Stage 2: Slow the progression of renal function decline by controlling blood pressure and diabetes.
 * Stage 3: Treat metabolic complications (renal osteodystrophy, secondary hyperparathyroidism, and anemia)
 * Stage 4: Prepare for patient for dialysis
 * Stage 5: Patient on dialysis, examine for uremia to determine if dialysis is urgently needed.

On intake assessment and on rounds you will need to monitor:


 * potassium


 * phosphate


 * calcium


 * sodium

Vitals should be examined for hypertension as this can accelerate the rate of kidney function decline.
 * magnesium

=Pimping Points= Put common pimping items here.

=Floor Fodder= Put controversial topics, or good items for discussions with attendings, residents, and other students here.

=Study Questions= The goal here is to use the objectives to increase retention of the information you have just read. Questions should be high yield. Include an explanation below the question with the answer. Leave a little space so that you can read the question without seeing the answer.