Chronic Kidney Disease Overview

Normal Kidneys and Their Function

The kidneys are a pair of bean-shaped organs that lie on either side of the spine in the lower middle of the
back. Each kidney weighs about ¼ pound and contains approximately one million filtering units called
nephrons. Each nephron is made of a glomerulus and a tubule. The glomerulus is a miniature filtering or
sieving device while the tubule is a tiny tube like structure attached to the glomerulus.

The kidneys are connected to the urinary bladder by tubes called ureters. Urine is stored in the urinary
bladder until the bladder is emptied by urinating. The bladder is connected to the outside of the body by
another tube like structure called the urethra.

The main function of the kidneys is to remove waste products and excess water from the blood. The
kidneys process about 200 liters of blood every day and produce about two liters of urine. The waste
products are generated from normal metabolic processes including the breakdown of active tissues,
ingested foods, and other substances. The kidneys allow consumption of a variety of foods, drugs,
vitamins and supplements, additives, and excess fluids without worry that toxic by-products will build up to
harmful levels. The kidney also plays a major role in regulating levels of various minerals such
as calcium, sodium, and potassium in the blood.
 As the first step in filtration, blood is delivered into the glomeruli by microscopic leaky blood
vessels called capillaries. Here, blood is filtered of waste products and fluid while red blood cells,
proteins, and large molecules are retained in the capillaries. In addition to wastes, some useful
substances are also filtered out. The filtrate collects in a sac called Bowman's capsule.

 The tubules are the next step in the filtration process. The tubules are lined with highly functional
cells which process the filtrate, reabsorbing water and chemicals useful to the body while secreting
some additional waste products into the tubule.

The kidneys also produce certain hormones that have important functions in the body, including the
following:

 Active form of vitamin D (calcitriol or 1,25 dihydroxy-vitamin D), which regulates absorption of
calcium and phosphorus from foods, promoting formation of strong bone. 

 Erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells.

 Renin, which regulates blood volume and blood pressure.

Chronic kidney disease

Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of kidney
function over time. This happens gradually, usually months to years. Chronic kidney disease is divided
into five stages of increasing severity (see Table 1 below). The term "renal" refers to the kidney, so
another name for kidney failure is "renal failure." Mild kidney disease is often called renal insufficiency.

With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body,
that are normally excreted by the kidney. Loss of kidney function also causes other problems such as
anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty
acids, and bone disease.

Stage 5 chronic kidney disease is also referred to as kidney failure, end-stage kidney disease, or end-
stage renal disease, wherein there is total or near-total loss of kidney function. There is dangerous
accumulation of water, waste, and toxic substances, and most individuals in this stage of kidney disease
need dialysis or transplantation to stay alive.

Unlike chronic kidney disease, acute kidney failure develops rapidly, over days or weeks.

 Acute kidney failure usually develops in response to a disorder that directly affects the kidney, its
blood supply, or urine flow from it. 

 Acute kidney failure is often reversible, with complete recovery of kidney function. 

 Some patients are left with residual damage and can have a progressive decline in kidney
function in the future.

 Others may develop irreversible kidney failure after an acute injury and remain dialysis-
dependent.
 Table 1. Stages of Chronic Kidney Disease

GFR*
Stage Description
mL/min/1.73m2
Slight kidney damage with normal or
1 More than 90
increased filtration
2 Mild decrease in kidney function 60-89
3 Moderate decrease in kidney function 30-59
4 Severe decrease in kidney function 15-29
Less than 15 (or
5 Kidney failure
dialysis)
*GFR is glomerular filtration rate, a measure of the kidney's function.

Chronic Kidney Disease Causes

Although chronic kidney disease sometimes results from primary diseases of the kidneys themselves, the
major causes are diabetes and high blood pressure.

 Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the
leading cause of kidney disease in the United States. 

 High blood pressure (hypertension), if not controlled, can damage the kidneys over time. 

 Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys, which
can cause kidney failure. Postinfectious conditions and lupus are among the many causes of
glomerulonephritis. 

 Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein
both kidneys have multiplecysts.

 Use of analgesics such as acetaminophen(Tylenol) and ibuprofen (Motrin, Advil) regularly over

long durations of time can cause analgesic nephropathy, another cause of kidney disease. Certain
other medications can also damage the kidneys. 

 Clogging and hardening of the arteries(atherosclerosis) leading to the kidneys causes a

condition called ischemic nephropathy, which is another cause of progressive kidney damage. 

 Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings), or

cancers may also cause kidney disease. 

 Other causes of chronic kidney disease include HIV infection, sickle cell disease, heroin abuse,
amyloidosis, kidney stones, chronic kidney infections, and certain cancers.

If you have any of the following conditions, you are at higher-than-normal risk of developing chronic
kidney disease. Your kidney functions may need to be monitored regularly.

 Diabetes mellitus type 1 or 2 

 High blood pressure 

 High cholesterol 

 Heart disease 

 Liver disease 

 Amyloidosis 

 Sickle cell disease 

 Systemic Lupus erythematosus 

 Vascular diseases such as arteritis, vasculitis, or fibromuscular dysplasia 

 Vesicoureteral reflux (a urinary tract problem in which urine travels the wrong way back toward
the kidney) 

 Require regular use of anti-inflammatory medications 

 A family history of kidney disease

How Common is Chronic Kidney Disease?

 Chronic kidney disease is a growing health problem in the United States. A report by the Centers
for Disease Control (CDC) determined that 16.8% of all adults above the age of 20 years have chronic
kidney disease. Thus, one in six individuals has kidney disease. By disease stage, the prevalence is
as follows:

o stage 1, 3.1%; 

o stage 2, 4.1%;

o stage 3, 7.6%;

o stage 4; and 

o stage 5, 0.5%. 

 There are over 500,000 persons on dialysis or who have received kidney transplants. 

 The prevalence of chronic kidney disease has increased by 16% from the previous decade. The
increasing incidence of diabetes mellitus, hypertension (high blood pressure), obesity, and an aging
population have contributed to this increase in kidney disease.

 Chronic kidney disease is more prevalent among individuals above 60 years of age (39.4%).

 Kidney disease is more common among Hispanic, African American, Asian or Pacific Islander,
and Native American people.
 Chronic Kidney Disease Symptoms
The kidneys are remarkable in their ability to compensate for problems in their function. That is why
chronic kidney disease may progress without symptoms for a long time until only very minimal kidney
function is left.

Because the kidneys perform so many functions for the body, kidney disease can affect the body in a
large number of different ways. Symptoms vary greatly. Several different body systems may be affected.
Notably, most patients have no decrease in urine output even with very advanced chronic kidney disease.

Effects and symptoms of chronic kidney disease include;

 need to urinate frequently, especially at night (nocturia);

 swelling of the legs and puffiness around the eyes (fluid retention);

 high blood pressure;

 fatigue and weakness (from anemia or accumulation of waste products in the body);

 loss of appetite, nausea and vomiting;

 itching, easy bruising, and pale skin (from anemia);

 shortness of breath from fluid accumulation in the lungs;

 headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered

mental status (encephalopathy from the accumulation of waste products or uremic poisons),
and restless legs syndrome;

 chest pain due to pericarditis (inflammation around the heart);

 bleeding (due to poor blood clotting);

 bone pain and fractures; and

 decreased sexual interest and erectile dysfunction.

When to Seek Medical Care

Several signs and symptoms may suggest complications of chronic kidney disease. Call your health care
practitioner if you notice any of the following symptoms:

 Change in energy level or strength

 Increased water retention (puffiness or swelling) in the legs, around the eyes, or in other parts of
the body

 Shortness of breath or change from normal breathing 

 Nausea or vomiting 
 Lightheadedness 

 Severe bone or joint pain 

 Easy bruising

 Itching

If you have diabetes, high blood pressure, or kidney problems, see your health care practitioner right
away if you know or suspect that you are pregnant.

See your health care practitioner as recommended for monitoring and treatment of chronic conditions
such as diabetes, high blood pressure, and high cholesterol.

The following signs and symptoms represent the possibility of a severe complication of chronic kidney
disease and warrant a visit to the nearest hospital emergency department.

 Change in level of consciousness - extreme sleepiness or difficult to awaken

 Fainting 

 Chest pain 

 Difficulty breathing 

 Severe nausea and vomiting 

 Severe bleeding (from any source) 

 Severe weakness

Chronic Kidney Disease Diagnosis

Chronic kidney disease usually causes no symptoms in its early stages. Only lab tests can detect any
developing problems. Anyone at increased risk for chronic kidney disease should be routinely tested for
development of this disease.

 Urine, blood, and imaging tests (X-rays) are used to detect kidney disease, as well as to follow
its progress. 

 All of these tests have limitations. They are often used together to develop a picture of the nature
and extent of the kidney disease. 

 In general, this testing can be performed on an outpatient basis.

Urine Tests

Urinalysis: Analysis of the urine affords enormous insight into the function of the kidneys. The first step
in urinalysis is doing a dipstick test. The dipstick has reagents that check the urine for the presence of
various normal and abnormal constituents including protein. Then, the urine is examined under a
microscope to look for red and white blood cells, and the presence of casts and crystals (solids).

Only minimal quantities of albumin (protein) are present in urine normally. A positive result on a dipstick
test for protein is abnormal. More sensitive than a dipstick test for protein is a laboratory estimation of the
urine albumin (protein) and creatinine in the urine. The ratio of albumin (protein) and creatinine in the
urine provides a good estimate of albumin (protein) excretion per day.

Twenty-four hour urine tests: This test requires you to collect all of your urine for 24 consecutive hours.
The urine may be analyzed for protein and waste products (urea nitrogen, and creatinine). The presence
of protein in the urine indicates kidney damage. The amount of creatinine and urea excreted in the urine
can be used to calculate the level of kidney function and the glomerular filtration rate (GFR).

Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function.
As kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min in men and 85-115
mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of
waste products in the 24-hour urine or by using special markers administered intravenously. An
estimation of the GFR (eGFR) can be calculated from the patient's routine blood tests. Patients are
divided into five stages of chronic kidney disease based on their GFR (see Table 1 above).

Blood Tests

Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine are the most
commonly used blood tests to screen for, and monitor renal disease. Creatinine is a product of normal
muscle breakdown. Urea is the waste product of breakdown of protein. The level of these substances
rises in the blood as kidney function worsens.

Estimated GFR (eGFR): The laboratory or your physician may calculate an estimated GFR using the
information from your blood work. It is important to be aware of your estimated GFR and stage of chronic
kidney disease. Your physician uses your stage of kidney disease to recommend additional testing and
suggestions on management.

Electrolyte levels and acid-base balance: Kidney dysfunction causes imbalances in electrolytes,

especially potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a particular concern.
The acid-base balance of the blood is usually disrupted as well.

Decreased production of the active form of vitamin D can cause low levels of calcium in the blood.
Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise. Testicular or
ovarian hormone levels may also be abnormal.

Blood cell counts: Because kidney disease disrupts blood cell production and shortens the survival of
red cells, the red blood cell count and hemoglobin may be low (anemia). Some patients may also have
iron deficiency due to blood loss in their gastrointestinal system. Other nutritional deficiencies may also
impair the production of red cells.

Other tests

Ultrasound: Ultrasound is often used in the diagnosis of kidney disease. An ultrasound is a noninvasive

type of imaging test. In general, kidneys are shrunken in size in chronic kidney disease, although they
may be normal or even large in size in cases caused by adult polycystic kidney disease, diabetic
nephropathy, and amyloidosis. Ultrasound may also be used to diagnose the presence of urinary
obstruction, kidney stones and also to assess the blood flow into the kidneys.

Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in which the cause of the
kidney disease is unclear. Usually, a biopsy can be collected with local anesthesia by introducing a
needle through the skin into the kidney. This is usually done as an outpatient procedure, though some
institutions may require an overnight hospital stay.

Chronic kidney disease

Kidney failure - chronic; Renal failure - chronic; Chronic renal insufficiency; Chronic kidney failure;
Chronic renal failure

Last reviewed: August 12, 2009.

Chronic kidney disease is the slow loss of kidney function over time. The main function of the kidneys is to remove
wastes and excess water from the body.

Causes, incidence, and risk factors

Chronic kidney disease (CKD) slowly gets worse over time. In the early stages, there may be no symptoms. The loss
of function usually takes months or years to occur. It may be so slow that symptoms do not occur until kidney
function is less than one-tenth of normal.

The final stage of chronic kidney disease is called end-stage renal disease (ESRD). The kidneys no longer function
and the patient needs dialysis or a kidney transplant.

Chronic kidney disease and ESRD affect more than 2 out of every 1,000 people in the United States.

Diabetes and high blood pressure are the two most common causes and account for most cases.

Many other diseases and conditions can damage the kidneys, including:

 Problems with the arteries leading to or inside the kidneys

 Birth defects of the kidneys (such as polycystic kidney disease)

 Some pain medications and other drugs

 Certain toxic chemicals

 Autoimmune disorders (such as systemic lupus erythematosus and scleroderma)

 Injury or trauma
 Glomerulonephritis
 Kidney stones and infection
 Reflux nephropathy (in which the kidneys are damaged by the backward flow of urine into the kidneys)

 Other kidney diseases

Chronic kidney disease leads to a buildup of fluid and waste products in the body. This condition affects most body
systems and functions, including red blood cell production, blood pressure control, and vitamin D and bone health.
Symptoms
The early symptoms of chronic kidney disease often occur with other illnesses, as well. These symptoms may be the
only signs of kidney disease until the condition is more advanced.

Symptoms may include:

 General ill feeling and fatigue

 Generalized itching (pruritus) and dry skin
 Headaches
 Weight loss without trying to lose weight

 Appetite loss
 Nausea

Other symptoms that may develop, especially when kidney function has worsened:

 Abnormally dark or light skin

 Bone pain

 Brain and nervous system symptoms

 Drowsiness and confusion

 Problems concentrating or thinking

 Numbness in the hands, feet, or other areas
 Muscle twitching or cramps
 Breath odor
 Easy bruising, bleeding, or blood in the stool
 Excessive thirst

 Frequent hiccups

 Low level of sexual interest and impotence

 Menstrual periods stop (amenorrhea)
 Sleep problems, such as insomnia, restless leg syndrome, and obstructive sleep apnea
 Swelling of the feet and hands (edema)

 Vomiting, typically in the morning

Signs and tests

High blood pressure is almost always present during all stages of chronic kidney disease. A neurologic examination
may show signs of nerve damage. The health care provider may hear abnormal heart or lung sounds with a
stethoscope.

A urinalysis may show protein or other changes. These changes may appear 6 months to 10 or more years before
symptoms appear.

Tests that check how well the kidneys are working include:

 Creatinine levels
 BUN
 Creatinine clearance
Chronic kidney disease changes the results of several other tests. Every patient needs to have the following checked
regularly, as often as every 2 - 3 months when kidney disease gets worse:

 Potassium
 Sodium
 Albumin
 Phosphorous
 Calcium
 Cholesterol
 Magnesium
 Complete blood count (CBC)
 Electrolytes

Causes of chronic kidney disease may be seen on:

 Abdominal CT scan
 Abdominal MRI
 Abdominal ultrasound
 Renal scan

This disease may also change the results of the following tests:

 Erythropoietin
 PTH
 Bone density test
Treatment
Controlling blood pressure is the key to delaying further kidney damage.

 Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are used
most often.

 The goal is to keep blood pressure at or below 130/80 mmHg

Other tips for protecting the kdineys and preventing heart disease and stroke:

 Do not smoke.

 Eat meals that are low in fat and cholesterol

 Get regular exercise (talk to your doctor or nurse before starting).

 Take drugs to lower your cholesterol, if necessary.

 Keep your blood sugar under control.

Always talk to your kidney doctor before taking any over-the-counter medicine, vitamin, or herbal supplement.
Make sure all of the doctors you visit know you have chronic kidney disease.

Other treatments may include:

 Special medicines called phosphate binders, to help prevent phosphorous levels from becoming too high

 Treatment for anemia, such as extra iron in the diet, iron pills, special shots of a medicine called
erythropoietin, and blood transfusions

 Extra calcium and vitamin D (always talk to your doctor before taking)
You may need to make changes in your diet. See: Diet for chronic kidney disease for more details.

 You may need to limit fluids.

 Your health care provider may recommend a low-protein diet.

 You may have to restrict salt, potassium, phosphorous, and other electrolytes.

 It is important to get enough calories when you are losing weight.

Different treatments are available for problems with sleep or restless leg syndrome.

Everyone with chronic kidney disease should be up-to-date on important vaccinations, including:

 Pneumococcal polysaccharide vaccine (PPV)

 Influenza vaccine
 H1N1 (swine flu) vaccine
 Hepatitis B vaccine
 Hepatitis A vaccine

When loss of kidney function becomes more severe, you will need to prepare for dialysis or a kidney transplant.

 When you start dialysis depends on different factors, including your lab test results, severity of
symptoms, and readiness.

 You should begin to prepare for dialysis before it is absolutely necessary. The preparation includes
learning about dialysis and the types of dialysis therapies, and placement of a dialysis access.

 Even those who are candidates for a kidney transplant will need dialysis while waiting for a kidney to
become available.

Support Groups
See: Kidney disease - support group
Expectations (prognosis)
Many people are not diagnosed with chronic kidney disease until they have lost much of their kidney function.

There is no cure for chronic kidney disease. Untreated, it usually progresses to end-stage renal disease. Lifelong
treatment may control the symptoms of chronic kidney disease.
Complications
 Anemia

 Bleeding from the stomach or intestines

 Bone, joint, and muscle pain

 Changes in blood sugar

 Damage to nerves of the legs and arms (peripheral neuropathy)
 Dementia
 Fluid buildup around the lungs (pleural effusion)

 Heart and blood vessel complications

 Congestive heart failure
 Coronary artery disease

 High blood pressure

 Pericarditis
  Stroke

 High phosphorous levels

 High potassium levels
 Hyperparathyroidism

 Increased risk of infections

 Liver damage or failure

 Malnutrition
 Miscarriages and infertility
 Seizures

 Weakening of the bones and increased risk of fractures

Prevention
Treating the condition that is causing the problem may help prevent or delay chronic kidney disease. People who
have diabetes should control their blood sugar and blood pressure levels and should not smoke.