General Medicine

CLINICAL PRESENTATION

CKD patients may present with symptoms and signs resulting directly from diminished kidney function, such as edema or

hypertension. However, many have no clinical symptoms.

Depending upon the duration and severity of CKD, patients may also present with symptoms and/or signs of prolonged

kidney failure, including weakness and easy fatigability, anorexia, vomiting, pruritus, and, in very advanced stages, with

encephalopathy or seizures

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Oliguria or anuria An abnormally reduced urine output (ie, oliguria or anuria) is seldom observed with CKD alone and

always indicates at least some component of acute kidney injury (AKI).

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Laboratory findings include increased serum creatinine and blood urea nitrogen. Urine studies may show proteinuria

(or albuminuria) and/or abnormal red or white blood cells on urine microscopy. Other common laboratory abnormalities

that may be part of the clinical picture include anemia, hyperphosphatemia, hyperkalemia, metabolic acidosis,

hypocalcemia, and elevated parathyroid hormone (PTH). The degree to which these abnormalities are present depends upon

the severity of CKD.

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CAUSES diabetes mellitus and hypertension, which leads to damage to small vessels and overload of nephrons, due to

the need to reabsorb glucose.

Any cause of kidney injury, if sufficiently severe or long-standing, may lead to persistently abnormal kidney function and

therefore CKD. As an example, a patient with severe heart failure may have recurrent or prolonged acute kidney injury

(AKI) due to reduced effective arterial blood volume (ie, prerenal disease). Over time, even if cardiac function and renal

perfusion pressure improve, glomerular filtration rate (GFR) may never fully recover to normal.

INITIAL ASSESSMENT AND TRIAGE

The initial assessment for all patients who present with suspected CKD starts with triage of those who may need urgent

dialysis based upon symptoms or life-hreatening laboratory abnormalities.

Identification of patients needing urgent dialysis

Patients with CKD may have absolute or relative indications for dialysis at the time that their kidney disease is discovered.

Those who have refractory pulmonary edema, life-threatening hyperkalemia or metabolic acidosis, encephalopathy, or a

pericardial rub should be referred to the emergency department for rapid evaluation and possible initiation of dialysis.

Determine the duration and trajectory of kidney disease

Among patients who do not require dialysis, we start by evaluating the duration of the kidney disease. Establishing the

duration and trajectory of the disease accurately is fundamentally important and requires that older data be obtained for

comparison. Recognition of a rapidly progressive process versus stable disease permits early intervention to curtail an active

process and to preserve residual kidney function.

Distinction between CKD and subacute kidney injury

The clinical course of gradually progressive CKD is commonly punctuated by transient, small "spikes" in serum creatinine,

which often improve to resume a prior long-term trajectory.

SUBSEQUENT EVALUATION

Evaluation to identify cause:

- Cause-specific history,

●Long-standing diabetes and hypertension

●Renovascular disease (renal artery stenosis)

● history of prior severe or prolonged acute kidney injury (AKI)

●Histories of obesity, heart failure, liver failure, autoimmune disease, recurrent and complicated

urinary tract infections, and reduced kidney mass (eg, nephrectomy, renal agenesis) should be elicited

due to their associations with CKD.

- targeted physical examination,

- urine studies

- imaging 11

The initial tests that each patient must perform are: collection of serum creatinine for the calculation of GFR, blood count

(esami del sangue), urinalysis, quantification of proteins and albumin in the urine.

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Targeted radiologic assessment Kidney ultrasound is generally performed in all patients at the time of their initial

evaluation for CKD. Patients who are at a high risk for renovascular disease should have dedicated imaging to evaluate for

renal artery stenosis.

GENERAL MANAGEMENT OF CHRONIC KIDNEY DISEASE

The general management of the patient with CKD involves the following issues:

●Treatment of reversible causes of kidney failure

●Preventing or slowing the progression of kidney disease is focused on treating with an ACE enzyme inhibitor

and achieving the right blood pressure.

●Treatment of the complications of kidney failure

●Adjusting drug doses when appropriate for the level of estimated glomerular filtration rate (eGFR)

●Identification and adequate preparation of the patient in whom kidney replacement therapy will be require

Other therapeutic modalities are: protein restriction, smoking cessation, treatment of metabolic acidosis with bicarbonate

can slow the progression towards acute kidney disease, glycemic control.

- Several disorders may develop as a result of loss of kidney function, including disturbance in electrolyte fluid

balance, abnormalities related to systemic or hormonal dysfunction.

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Treatment of complications Volume overload

Sodium and intravascular volume balance are usually maintained via homeostatic mechanisms until the eGFR falls below

10 to 15 mL/min/1.73 m2. However, the patient with mild to moderate CKD, despite being in relative volume balance, is

less able to respond to rapid intake of sodium and is therefore prone to fluid overload (“sodium carries water”). Patients

with CKD and volume overload generally respond to the combination of dietary sodium restriction and diuretic therapy.

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Treatment of complications Hyperkalemia

The ability to maintain potassium excretion at near-normal levels is generally maintained in patients with kidney disease as

long as both aldosterone secretion and distal flow are maintained. Thus, hyperkalemia generally develops in the patient who

is oliguric or who has an additional problem such as a high-potassium diet, increased tissue breakdown, or

hypoaldosteronism 

Treatment of complications Metabolic acidosis

There is an increasing tendency to retain hydrogen ions among patients with CKD. Metabolic acidosis may be treated with

bicarbonate supplementation. 

Treatment of complications Mineral and bone disorders

Chronic kidney disease (CKD) is commonly associated with disorders of mineral and bone metabolism, manifested by

either one or a combination of the following three components:

●Abnormalities of calcium, phosphorus, parathyroid hormone (PTH), and vitamin D metabolism

●Abnormalities in bone turnover, mineralization, volume linear growth, or strength

●Extraskeletal calcification

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Treatment of complications Hyperphosphatemia.

A tendency toward phosphate retention begins early in kidney disease due to the reduction in the filtered phosphate load.

Prevention and/or treatment of mineral and bone disorders in patients with predialysis CKD are primarily based upon dietary

phosphate restriction, the administration of oral phosphate binders, and the administration of calcitriol (or vitamin D

analogs) to directly suppress the secretion of PTH

Treatment of complications

Hypertension — Hypertension is present in approximately 80 to 85 percent of patients with CKD. It can be a cause or

consequence of CKD; it should be properly treated.

Anemia — The anemia of CKD is, in most patients, normocytic and normochromic and is due primarily to reduced

production of erythropoietin by the kidney 12

TREATMENT of complications of end-stage kidney disease (ESKD)

Once the patient has reached the stage of near ESKD (eGFR < 15 mL/min/1.73 m2), signs and symptoms related to uremia

begin to occur, such as malnutrition, anorexia, nausea, vomiting, fatigue, sexual dysfunction, platelet dysfunction,

pericarditis, and neuropathy. Malnutrition is common in patients with advanced CKD because of a lower food intake

(principally due to anorexia), decreased intestinal absorption and digestion, and metabolic acidosis.

REFERRAL TO NEPHROLOGISTS

Patients with CKD should be referred to a nephrologist when the estimated glomerular filtration rate (eGFR) is <

30 mL/min/1.73 m2 in order to discuss and potentially plan for kidney replacement therapy. Patients referred late to the

nephrologist invariably present with biochemical indices of severe uremia and an imminent need for dialysis

It is important to identify patients who may eventually require kidney replacement therapy since adequate

preparation can decrease morbidity and perhaps mortality.

Once it is determined that kidney replacement therapy will eventually be medically indicated, the patient should be

counseled to consider the advantages and disadvantages of

- hemodialysis (in-center or at home),

- peritoneal dialysis (continuous or intermittent modalities), and

- kidney transplantation (living or deceased donor). After transplant pts needs immunosuppressive therapy (to

avoid/delay graft rejection) which is burdened by side effects.

The option of conservative management should also be discussed among patients who are unwilling or unable to undergo

kidney replacement therapy. Kidney transplantation is the treatment of choice for ESKD. However, not all patients

are appropriate candidates for a kidney allograft, because of absolute and/or relative contraindications to this procedure

or the subsequent required medications.

HEMODIALYSIS

Hemodialysis requires a stable access to the bloodstream to permit dialysis to be performed. The access should

generally be placed in the nondominant upper extremity because of the increased risk of infection and more severe

consequences of arterial steal syndrome with lower extremity grafts. There are three major types of vascular access for

maintenance hemodialysis: primary arteriovenous (AV) fistulas, AV grafts, and tunneled hemodialysis catheters.

1. Arteriovenous fistulas

AV fistulas are the preferred form of vascular access given their significantly higher long-term patency rates and lower rate

of complications. Since an AV fistula requires months to mature and is the access of choice

2. Arteriovenous grafts

AV grafts are constructed by interposing a graft between an artery and vein, most commonly polytetrafluoroethylene

(PTFE). Usually be used two weeks after placement. However, AV grafts have a higher long-term complication rate (eg,

infection, thrombosis) compared with primary fistulas. As for a fistula, the patient should be instructed in the care of the

AV graft

3. Tunneled hemodialysis catheters

Following placement, typically in the right internal jugular vein, tunneled hemodialysis catheters can be used immediately.

Tunneled hemodialysis catheters are primarily used as intermediate-duration vascular access during maturation of AV

fistulas.

PERITONEAL DIALYSIS

Peritoneal dialysis catheters, which are placed into the abdominal cavity, can be used immediately after placement.

Among asymptomatic patients with progressive CKD, the timing of initiation of dialysis is unclear, and there is no specific

threshold eGFR level that has been established for the initiation of dialysis. To help a