Chronic kidney disease in detail

Chronic kidney disease is a common health problem that is faced by the population of the entire world. It is a condition characterized by reduced kidney functioning eventually leading to kidney failure and reduced glomerular filtration rate or GFR. It has a prevalence of 11 to 15% of the world population. This condition has a high risk of occurrence in patients with underlying risk factors such as obesity, diabetes, hypertension, thyroid dysfunction, bad lifestyle, and secondary health issues. All these issues with their remedies and dealt with in detail later in this article. It is one of the many causes of death due to improper treatment availability, negligence, not abiding by the doctor’s advice, no donor kidney availability, and so on. 

There are various stages of this condition which is treated in various ways depending on the severity and requirement as explained later. There is a specific set of interventions that are supposed to be taken as a treatment to get the patient back to his daily and normal life as before.

The prevalence is increasing in developing parts of the world due to poverty and illiteracy. The incidences are increasing in developed countries due to poor lifestyles and risk factors pertaining to this condition.

Due to the etiological factors as mentioned later the kidneys tend to get damaged. This causes nephrons to die. This in turn causes a reduction in the number of nephrons to carry out the same amount of work. This causes load on the remaining nephron and thus the kidney. This leads to kidney disease. When this condition persists for a longer duration of time it is termed as chronic kidney disease. There comes a point where the kidney can no longer sustain this ever increasing pressure, it leads to failure. So chronic kidney disease eventually leads to failure of the kidneys.

Causes of chronic kidney disease.

• Congenital abnormalities: these are the conditions where the fetus grows abnormally due to various reasons leading to kidney issues by birth. This can be inherited or developmental malformation.
• Abnormal kidney structure: fused kidneys, ectopic kidneys, nonfunctional kidneys, mal aligned kidneys, abnormal size and shape, weak and inactive kidney.
• Familial history: if the first degree relative has developed CKD then it is very likely for you to have a chance of developing this condition in the future.
• Injurious cause: direct injury to the back or side of the abdomen by punching can cause damage to the kidney, high impact injury like fall from a height, burns of the third and fourth degree, stab injury, etc.
• Acute kidney disease: sudden kidney disease due to any cause which never happened before, but when left untreated or reappears from time to time it leads to chronic kidney disease.
• Age: people above the age of 60 have a greater chance of developing this issue.
• Cardiovascular cause: uncontrolled and long standing hypertension. Angina pectoris, thromboembolism.
• The high sugar content of blood or diabetes mellitus.
• Nephrotic syndrome.
• Nephritic syndrome.
• Glomerulonephritis.
• Renal carcinoma.
• Renal infections: viral infections by Epstein- Barr virus, hepatitis virus. Bacterial causes like streptococcal infections. Nematode infections etc.
• Tuberculosis of the kidney by mycobacterium tuberculosis. It can be the primary infection or an infection that has traveled by blood or lymph from the lungs or other foci to the kidney.
• Failure of a kidney transplant.
• Prostatic hypertrophy.
• Kidney stones.
• Renal ischemia due to burns etc.
• Kidney tissue necrosis.
• Other causes: malaria, syphilis, acquired immune deficiency syndrome, kala-azar, amyloidosis, systemic lupus erythematosus, polyarteritis, peripheral vascular diseases.
• Autoimmune disorders.
• Idiopathic origin.
• Renal hypertrophy.
• Liver and pancreatic abnormalities.
• Abnormally high dose of drug usage which can be medical or abusive in nature including acetaminophen drugs, NSAIDs, cocaine, etc.
• Urinary retention from a very long span as a habit since childhood can cause CKD in geriatric life.
• Pregnancy complications.
• Improperly treated conditions which in later stages lead to such complications.

Stages of chronic kidney disease:

Based on the damage to the kidneys and its efficiency of working and carrying out its functions there are five stages of chronic kidney disease.

• Stage 1: the damage to the kidney is very little. It may not be symptomatic to the patient. The patient carries out his daily routine normally with no difficulty. The glomerular filtration rate is either normal or is slightly increased. It is between 80 to 90 ml per minute. There can be proteinuria and polyuria. The patient can get to know about CKD in an earlier stage by getting a routine check up along with renal function tests done with the nephrologist.
• Stage 2: the damage to the kidney is fair or moderate in nature. The glomerular filtration rate is reduced than normal. It ranges between 60-80 ml/minute. The patient may notice oliguria. There can be an observational finding of slightly darker urine. Mild symptoms are present such as weakness, painful urination, and abdominal pain. When stage one is left untreated it further proceeds to stage 2. At this stage, the damage to the kidney is very much reversible.
• Stage 3: stage 3a is the condition where the glomerular filtration rate is 40to 60ml/minute. 3b is the condition where the glomerular filtration rate is between 30 to 40ml/minute. This stage develops when stage 2 is left untreated. There is severe damage to the kidney. Haematuria, proteinuria, and various other symptoms are present at this stage. Intervention is essential to keep kidneys well to function.
• Stage 4: the condition where the glomerular filtration rate is between 18 to 29ml/minute. Kidneys are seriously damaged and their functioning has deteriorated to a greater extent. The patient’s quality of life is reduced and the entire well-being is adversely affected. This stage may need surgery or dialysis as the main treatment option.
• Stage 5: glomerular filtration rate is less than 18ml/minute. Very serious condition. This can lead to death too if left untreated.

Symptoms and signs of CKD.

Symptoms let the patient know that something is wrong with him or her. So, in CKD there are various signs and symptoms that the patient, family of the patient, and doctors observe for clinically forming the differential diagnosis.

• In the early stage of CKD: malaise, headache, loss of appetite, loss of consciousness, proteinuria, polyuria, muscle cramps, edema, frequent urinary tract infections. Most of the time this stage remains asymptomatic. 
• In middle stages of CKD: unrelatable fatigue, dark urine color, less urine output or oliguria, pain in the abdomen and lower back where kidneys are situated, referred pain to different body parts, high blood pressure, mental instability, blood in the urine or haematuria, inability to sleep or insomnia, renal hypertension.
• In later stages of CKD: nausea, vomiting, malaise, frothy urine, dark urine, painful abdomen and back, muscle weakness, and tremors. Anemia like symptoms, lightheadedness, cardiovascular complications like unstable angina, arrhythmias. Depression, confusion and electrolyte imbalance, diabetes, dehydration and lack of strength, numbness in the extremities, bad wound healing properties, building up of secondary complications. Recent and frequent infections, the low immune response by the body, breathlessness, metabolic acidosis.
• In complicated stages of CKD: fluid retention in lungs, pulmonary infections are frequent, cardiovascular dysfunctions like abnormal pulse, cardiac arrest. Bad breath and a typical smell of urea are present around the patient. Low bone density leads to frequent fractures and osteoporosis. Extreme lethargy, vertigo, excruciating pain all over the body, multiorgan failure, death.
• Clinical signs: abnormal reflexes, low grades in manual muscle testing, balance issues, speech disturbances, history and assessment, grading pain, albuminuria, abnormal calcium, potassium, sodium, and phosphate levels. Renal function tests are done to get an exact diagnosis as mentioned later. 

What are the investigations done to diagnose chronic kidney disease?

Clinical examination is done as mentioned above.

• Renal function tests: these are a group of examinations done to check for the efficiency of the kidney function. Some interventions tell about the extent of damage to the kidney and the extent of its working ability. It contains concentration tests, dilution tests, clearance tests like creatinine clearance, urea clearance, para amino hippuric acid clearance tests.
• Albumin levels measurement: normally urine does not contain albumin. It is a substance that is filtered by the tubules of normal kidneys. The presence of albumin hence denotes abnormal filtration by the renal glands. So, the presence of albumin denotes kidney disease.
• Creatinine levels measurement: kidneys flush out the creatinine from the blood. The inability of clearing this substance denotes renal dysfunction. So, high levels of blood creatinine denote kidney problems.
• Glomerular filtration rate or GFR: low glomerular filtration rate signifies bad kidney functioning. The stages are as mentioned earlier.
• Urine test: output, red cells, bacteria and infection, smear, and microscopic examination.
• Kidney biopsy: done in cases of suspected malignancies, necrosis, tuberculosis of kidneys, and so on. 
• Ultrasound: to check for ureter obstruction, renal hypertension, bladder damage, or complication.
• Blood tests: hemoglobin, albumin, urea, potassium, triglycerides, beta microglobulin, blood nitrogen, etc are the points of concern.
• Lipid profile: cholesterol, triglycerides, fats, and other substances are measured.
• Blood pressure.
• Blood glucose levels are monitored for diabetes.

Medical and dietary management of chronic kidney disease.

• In reversible damage, treat the cause and manage the risk factors by lifestyle modification, dietary modifications as mentioned later.
• In partially reversible cases use of angiotensin converting enzyme inhibitors, spironolactone, diuretics, calcium channel blockers are used to reduce hypertension.
• To control blood sugar levels use of meglitinides, biguanides, metformin is done. This controls diabetes and thus is a major treatment strategy for chronic kidney disease.
• Reduce protein intake to less than 40gm per day. Essential amino acids should be present in those 40gm themselves.
• Reduce salt intake to less than 2gm per day. This controls hypertension and load on the kidneys.
• DASH diet should be considered. The dietary approach to reduce hypertension consists of less salt, more fiber, and a mineral diet. Less oil, spices, and fats.
• Haemodialysis: artificial purification of blood by the means of the machine rather than kidney. In stages 3,4 and 5 of CKD, this option is used in frequent intervals. Blood is passed through the machine and then pure blood is administered back to the body.
• Appropriate electrolyte administration to the patient to maintain proper brain and muscle function.
• Treating pulmonary edema, cardiovascular abnormalities with cardio-selective beta blockers, nitroglycerin, salbutamol, terbutaline, etc. to reduce arrhythmia and breathlessness respectively.
• Calcium carbonate, sodium citrate are administered to control tubular acidity in case of renal tubular acidosis and metabolic acidosis.
• Radiation therapy, chemotherapy, and drug therapy are done to treat the cancerous condition of the kidneys.
• Lifelong hemodialysis, drugs for hypertension and blood sugar control, dietary changes and periodic wellness testing is the best way of living with this condition.

Surgical management of chronic kidney disease.

Dialysis is costly and hard to manage lifelong in younger patients with a life expectancy of more than 10 years. So, removal of the affected kidney or transplanting the kidney is a better option nowadays.

• Surgical removal of the kidney is called nephrectomy. There are various types of nephrectomy such as simple, partial, total, and radical nephrectomy based on the anatomical extent of removal of the kidney and surrounding structures.
• The patient is in lateral decubitus position and either open, laparoscopic or robotic assisted nephrectomies is done.
• Pre operative evaluations are done such as BP, GFR, creatinine levels, urine culture, etc.
• Renal transplant: fitting of the donor’s heart in the void created by removal of damaged kidney. The procedure is the same just that the donor kidney arteries are anastomosed with the patient’s body. 
• The laparoscopic method of nephrectomy is used widely as it is least invasive and painful, quickly heals, and makes the patient independent in no time.

10 Complications of surgical management of CKD:

1. Urinary fistula
2. Deep vein thrombosis
3. Hemorrhage
4. Infection
5. Bowel perforation
6. Hernia.
7. Haemothorax
8. Pneumothorax
9. Hematoma
10. Graft failure and allergic reaction.

Management of secondary complications of CKD.

Abnormal potassium levels: in case of hyperkalemia reduce the intake of dry fruits, leafy vegetables, meat, etc. in hypokalaemia eat controlled potassium supplements so as to not let it lead to hyperkalemia.

Metabolic acidosis: have calcium carbonate administered under the doctor’s supervision.

Edema: elevation of the leg or hand whichever is affected with the help of pillow or suspension. Keep moving the ankle and wrist up and down with finger and toe movements.

Lung pathologies: airway clearance techniques like coughing, huffing, active cycle of breathing technique, autogenic drainage, positioning, etc.

Splinting to avoid tears or surgical site complications: cover and fix the surgical area before coughing.

Infections: prophylactic antibodies to avoid infections due to surgery or any other cause.

Keeping the doctor up to date about the condition of the patient is the best way to manage secondary complications of CKD.

Pain management: transcutaneous nerve muscle stimulation, interferential therapy, relaxation techniques, pain relieving medications, social activity.

Inferiority complex or feeling of diseased: psychological counseling, family support, physical therapy, participation in group activities, vocational therapy are the remedies.

Lifestyle modification and prevention of CKD 

• Eat healthily: avoid salt, sugar, spices, fish, chicken, pork, crabs, mutton, ham, cheese, milk, dry fruits. Eat cooked vegetables. Drink the calculated amount of water. Reduce gluten in your diet.
• Have a strict low potassium diet.
• Eat at frequent intervals: don’t eat a lot at a single time. Eat less over more times.
• Sleep adequately: proper sleep is essential for the body as the blood pressure falls down physiologically which gives rest to kidneys to a considerable extent.
• Daily physical exercise: get an exercise regime planned for you by your physiotherapist for the best care of your condition and prevention of any complications.
• Medication and yoga can calm your body.
• Reduce stress and anxiety which will control your fluctuating blood pressure.
• Control diabetes by dietary and stress modifications.
• Stop alcohol, smoking, and abusive drug usage.
• Stop taking medications that are not prescribed. Stop consuming analgesics unnecessarily in case of headaches, body aches. This is a leading cause of kidney damage in the long run.
• Voiding of urine without controlling it for a longer duration.
• Maintain hygienic life and clean sanitation practices.
• Community based rehabilitation for improving quality of life.
• Using assistive devices for walking, reaching, climbing, etc.
• A home cooked meal is a must. Do not eat junk food with preservatives and carbonated drinks to invite this dangerous condition of CKD.

Risk factors and management of risk factors in CKD.

• Obesity: reduce obesity by eating healthy, physical activity.
• Sedentary lifestyle.
• Hypertension: manage it by diet, stress reduction, and medication.
• Diabetes: manageable with anti diabetic medicine, health awareness.
• Increasing age.
• Bad lifestyle.
• Alcohol consumption: manageable with rehabilitation, self control, and other methods.
• Malignancies: hard to manage but early detection can be very helpful.
• Family history.
• Previous kidney complication.
• Anemia.
• Lung pathologies.
• American natives have been seen to have CKD more commonly.
• Urinary tract infection.
• Heart and lung surgeries.
• Multiorgan failure.
• Acquired immune deficiency syndrome.
• Bed ridden patient.
• Excessive use of anti-hypertensive agents.
• Malnutrition.
• Severe jaundice.
• Bowel and bladder abnormalities.

What is the consequence of chronic kidney disease?

• Chronic kidney disease is a serious condition occurring usually due to untreated or undertreated acute kidney disease. This condition is not curable. It can be controlled and managed throughout life and the patient can lead a normal life with interventions and treatment.
• The consequence with treatment: the condition is under control, and the patient leads a good life.
• Consequence without treatment or without adequate treatment: condition deteriorates, other bodily complications start arising like an organ system failure. The patient has a high chance of going into unavoidable circumstances.
• Medical consequence: chronic kidney disease leads to renal failure. This is the condition where the kidney stops functioning completely.

Chronic kidney disease in India and its awareness.

CKD is a condition which has become more common in the past 10 years in India. Ever increasing population, illiteracy and negligence are the major factors contributing to this condition. Consanguinity in marriages, poor health awareness, and sanitation are other causes.

Poverty and high medical expenses have made it impossible for citizens under the poverty line to take treatment. 

People with diabetes and hypertension are increasing day by day which is increasing the risk of CKD in the nation in the upcoming years.

Lack of awareness during pregnancy has led to a lot of congenital kidney issues further increasing the burden on the nation.

Lack of donors, political factors, fewer government organizations have further worsened the condition in the country.

Rural underdevelopment, rituals, and practices, lack of exposure have to be addressed soon.

Measures were taken up by the organizations in India to control CKD.

• Government and non government organizations are coming together to contain and limit the occurrence of CKD.
• Screening and treating the risk factors like diabetes and hypertension are being done from taluka to the national level.
• Data collection and analysis for this condition are being done by various public health service providers for understanding the statistics better.
• Education, understanding, and the importance of early interventions are now given to the local population of the country.
• Free medications, generic tablets, and government treatment have led to a lot of improvement.
• Primary health care centers have been active in creating awareness in a lot of Indian cities.
• Team members include community medicine staff, physicians, nephrologists, physiotherapists, nurses, social workers, political leaders, and technicians.

Summary

CKD is a prevalent condition in India and in the whole world. The incidence is increasing due to increasing cases of hypertension, diabetes, obesity. Symptoms include malaise, haematuria, proteinuria. Carry out renal function tests to diagnose. Treatment includes medical management, surgical intervention. It has five stages based on the degree of damage and glomerular filtration rate. Alcohol and smoking are the major risk factors. Causative agents are infection, underlying pathologies, and congenital anomalies. Lifestyle modification along with dietary modification is essential for better results. Various awareness programs are now being started to help reduce the incidence of CKD. CKD leads to renal failure and can be a cause of multiorgan failure and death. Interventions are required with doctors and nephrologists to contain the disease in the patient.