Acute/ Chronic Kidney Injuries

Question 1

Full meaning of CKD
The shape of the kidney
The size of the kidney
The location of the kidney

Healthy kidneys filter about a half cup of blood every minute, removing wastes and extra water to make urine.True/false?

Chronic kidney disease, also known as chronic renal disease or CKD, is a condition characterized by a gradual loss of kidney function over time. True /False?

Answer 1

Chronic kidney disease

The kidneys are two bean-shaped organs,
each about the size of a fist.

They are located just below the rib cage, one on each side of your spine.

TRUE— Healthy kidneys filter about a half cup of blood every minute, removing wastes and extra water to make urine.

TRUE— Chronic kidney disease, also known as chronic renal disease or CKD, is a condition characterized by a gradual loss of kidney function over time.

Question 2

CKD is a Longstanding disease of the kidneys leading to renal failure. True/False.

The kidneys filter / removal of waste and excess fluid from the blood. As kidneys fail, waste builds up.True/False?

Chronic kidney 🫘disease 🦠 is also called…….
….. and it involves a gradual loss of…….

Functions of the kidney 🫘
Note 📝
Definition of CKD

Answer 2

TRUE— CKD is a Longstanding disease of the kidneys leading to renal failure.

TRUE— The kidneys filter / removal of waste and excess fluid from the blood. As kidneys fail, waste builds up.
OR

Chronic kidney 🫘disease🦠, also called chronic kidney 🫘failure😨,

involves a gradual loss of kidney 🫘function.

Functions of the kidney 🫘

1. Remove waste products from the body
2. Remove drugs from the body
3. Balance the body’s fluids
4. Release hormones that regulate blood pressure
5. Produce an active form of vitamin D that promotes strong, healthy bones
   control the production of red blood cells

Note
—Your kidneys filter wastes and excess fluids from your blood, which are then removed in your urine.

—Your kidneys also remove acid that is produced by the cells of your body and maintain a healthy balance of water, salts, and minerals—such as sodium, calcium, phosphorus, and potassium—in your blood.

—Advanced chronic kidney disease can cause dangerous levels of fluid, electrolytes and wastes to build up in your body.

CKD is the gradual loss of kidney 🫘function over time

Question 3

Signs and symptoms

Answer 3

Symptoms
y None in the early stages
y Reduced attention and concentration y Anorexia, nausea, vomiting
y Gastrointestinal bleeding y Hiccups
y Breathlessness on exertion y Thirst
y Nocturia, polyuria y Muscle Cramps
y Paraesthesia
y Pruritus
y Insomnia

Signs
y Lethargy
y Bleedingtendency
y Pallor
y Hypertension
y Pericarditis
y Peripheral neuropathy
y Peripheral oedema
y Asterixis (flapping tremor)
y Increased skin pigmentation and/or excoriation

In the early stages of chronic kidney disease, you might have few signs or symptoms. You might not realize that you have kidney disease until the condition is advanced.

Treatment for chronic kidney disease focuses on slowing the progression of kidney damage, usually by controlling the cause. But, even controlling the cause might not keep kidney damage from progressing. Chronic kidney disease can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or a kidney transplant.

Symptoms
Signs and symptoms of chronic kidney disease develop over time if kidney damage progresses slowly. Loss of kidney function can cause a buildup of fluid or body waste or electrolyte problems. Depending on how severe it is, loss of kidney function can cause:

—Nausea🤢

—Vomiting 🤮

—Loss of appetite😋

—Blood 🩸 in urine (haematuria)

—Fatigue and weakness

—Muscle cramping especially at night

—Urinating more particularly at night or less urination

—difficulty sleeping 🛌 (insomnia)

—headaches🤕

—erectile dysfunction in men

—Decreased mental sharpness; trouble concentrating🥴

—Muscle cramps

—have puffiness around your eyes 👀 , especially in the morning

—Swelling of feet 🦶 or ankles 🦵and hands 🙌 ; as a result of water retention (oedema)

—Dry, itchy skin

—High blood pressure (hypertension) that’s difficult to control

—Shortness of breath, if fluid builds up in the lungs 🫁

—Chest pain, if fluid builds up around the lining of the heart🫀

—This stage of CKD is known as kidney failure, end-stage renal disease or established renal failure. It may eventually require treatment with dialysis or a kidney transplant.

Signs and symptoms of kidney disease are often nonspecific. This means they can also be caused by other illnesses. Because your kidneys are able to make up for lost function, you might not develop signs and symptoms until irreversible damage has occurred.

When to see a doctor

Make an appointment with your doctor if you have signs or symptoms of kidney disease. Early detection might help prevent kidney disease from progressing to kidney failure.

If you have a medical condition that increases your risk of kidney disease, your doctor may monitor your blood pressure and kidney function with urine and blood tests during office visits. Ask your doctor whether these tests are necessary for you.

Question 4

Causes of CKD and how they cause CKD

Answer 4

Causes

y Chronic hypertension
y Chronic glomerulonephritis
y Diabetes mellitus
y Obstructive uropathy
y Renal calculi
y Polycystic kidney disease
y Toxins (drugs, herbs, heavy metals, etc.)
y Connective tissue disease

A healthy kidney and a diseased kidney
Healthy kidney vs. diseased kidney Open pop-up dialog box
Polycystic kidney compared with normal kidney
Polycystic kidney Open pop-up dialog box
Chronic kidney disease occurs when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years.

Causes Of CKD
*Diseases and conditions that cause chronic kidney disease include:

Diabetes and high blood pressure, or hypertension, are responsible for two-thirds of chronic kidney disease cases.

1. Type 1 or type 2 diabetes: Diabetes: Diabetes occurs when your blood sugar remains too high. Over time, unmanaged blood sugar can cause damage to many organs in your body, including the kidneys and heart and blood vessels, nerves, and eyes.
2. High blood pressure: High blood pressure occurs when your blood pressure against the walls of your blood vessels increases. If uncontrolled or poorly controlled, high blood pressure can be a leading cause of heart attacks, strokes, and chronic kidney disease. Also, chronic kidney disease can cause high blood pressure.
3. Glomerulonephritis (gloe-mer-u-low-nuh-FRY-tis), an inflammation of the kidney’s filtering units (glomeruli)
   Interstitial nephritis (in-tur-STISH-ul nuh-FRY-tis), an inflammation of the kidney’s tubules and surrounding structures; Glomerulonephritis is a group of diseases that cause inflammation and damage the kidney’s filtering units. These disorders are the third most common type of kidney disease.
4. Polycystic kidney disease or other inherited kidney diseases; Polycystic kidney disease, or PKD, is a common inherited disease that causes large cysts to form in the kidneys and damage the surrounding tissue.
5. Prolonged obstruction of the urinary tract, from conditions such as enlarged prostate, kidney stones and some cancers; Obstructions caused by kidney stones or tumors can cause kidney damage. An enlarged prostate gland in men or repeated urinary infections can also cause kidney damage.
6. Vesicoureteral (ves-ih-koe-yoo-REE-tur-ul) reflux, a condition that causes urine to back up into your kidneys
   Recurrent kidney infection, also called pyelonephritis (pie-uh-low-nuh-FRY-tis)
7. Kidney and urinary tract abnormalities before birth: Malformations that occur as a baby develops in its mother’s womb. For example, a narrowing may occur that prevents normal outflow of urine and causes urine to flow back up to the kidney. This causes infections and may damage the kidneys.
8. Autoimmune diseases: When the body’s defense system, the immune system, turns against the body, it’s called an autoimmune disease. Lupus nephritis is one such autoimmune disease that results in inflammation (swelling or scarring) of the small blood vessels that filter wastes in your kidney.
9. Drugs / Toxins ( mercury, gold, hernicenamide etc)
10. Cancer

Question 5

Risk Factors

Answer 5

Risk factors
Factors that can increase your risk of chronic kidney disease include:

—Diabetes
—High blood pressure
—Heart (cardiovascular) disease
—Smoking
—Obesity
—Being Black, Native American or Asian American
—Family history of kidney disease
—Abnormal kidney structure
—Older age
—Frequent use of medications that can damage the kidneys

Question 6

CKD includes………..

Complications

Answer 6

Chronic kidney disease includes conditions that damage your kidneys and decrease their ability to keep you healthy by filtering wastes from your blood.

Complications

If kidney disease worsens, wastes can build to high levels in your blood and make you feel sick. You may develop complications like:
—high blood pressure
—anemia (low blood count)
—weak bones
—poor nutritional health
—nerve damage

—Pulmonary edema: Fluid retention, which could lead to swelling in your arms and legs, high blood pressure, or fluid in your lungs (pulmonary edema)

—Hypokalaemia: A sudden rise in potassium levels in your blood 🩸 , which could impair your heart’s function and can be life-threatening

—Heart🫀 disease 🦠 : Heart disease is the primary cause of death for all people with CKD

—Weak bones 🦴 and an increased risk of bone 🦴 fractures.

—Decreased sex drive,
—erectile dysfunction or
—reduced fertility

—Damage to your central nervous system, which can cause difficulty concentrating, personality changes or seizures

—Decreased immune response, which makes you more vulnerable to infection

—Pericarditis, an inflammation of the saclike membrane that envelops your heart (pericardium)

—Pregnancy complications that carry risks for the mother and the developing fetus

—Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival.

Question 7

Prevention

Answer 7

Prevention
To reduce your risk of developing kidney disease:

Follow instructions on over-the-counter medications. When using nonprescription pain relievers, such as aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others), follow the instructions on the package. Taking too many pain relievers for a long time could lead to kidney damage.
Maintain a healthy weight. If you’re at a healthy weight, maintain it by being physically active most days of the week. If you need to lose weight, talk with your doctor about strategies for healthy weight loss.
Don’t smoke. Cigarette smoking can damage your kidneys and make existing kidney damage worse. If you’re a smoker, talk to your doctor about strategies for quitting. Support groups, counseling and medications can all help you to stop.
Manage your medical conditions with your doctor’s help. If you have diseases or conditions that increase your risk of kidney disease, work with your doctor to control them. Ask your doctor about tests to look for signs of kidney damage.

Chronic kidney disease (CKD) cannot always be prevented, but you can take steps to reduce the chances of getting the condition.

Following the advice below can reduce your risk.

Manage underlying conditions

If you have a long-term condition that could lead to CKD, such as diabetes or high blood pressure, it’s important this is managed carefully.

Follow the advice of your GP, take any medicine you’re prescribed and keep all appointments relating to your condition.

Stop smoking

Smoking increases your risk of cardiovascular disease, including heart attacks or strokes, which is associated with a higher risk of CKD.

Stopping smoking will improve your general health and reduce your risk of these serious conditions.

The NHS Smokfree helpline can offer you advice and encouragement to help you quit smoking. Call 0300 123 1044 or visit the NHS Smokefree website.

Find out more about stopping smoking.

Healthy diet

A healhy, balanced diet can reduce your risk of kidney disease by keeping your blood pressure and cholesterol at a healthy level.

A balanced diet should include:

plenty of fruit and vegetables – aim for at least 5 portions a day
meals that include starchy foods, such as potatoes, wholegrain bread, rice or pasta
some dairy or dairy alternatives
some beans or pulses, fish, eggs, or meat as a source of protein
low levels of saturated fat, salt and sugar
You may also be given advice about dietary changes that can specifically help with kidney disease, such as limiting the amount of potassium or phosphate in your diet.

Manage alcohol intake

Drinking excessive amounts of alcohol can cause your blood pressure and cholesterol levels to rise to unhealthy levels.

Sticking to the recommended alcohol limit is the best way to reduce your risk:

men and women are advised not to regularly drink more than 14 units a week
spread your drinking over 3 days or more if you drink as much as 14 units a week
14 units is equivalent to 6 pints of average-strength beer or 10 small glasses of low-strength wine.

Find out more about alcohol units.

Exercise regularly

Regular exercise should help lower your blood pressure and reduce your risk of developing kidney disease.

At least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week is recommended, as well as strength exercises on 2 or more days a week that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms).

Find out more about health and fitness.

Be careful with painkillers

Kidney disease can be caused by taking too many non-steroidal anti-inflammatories (NSAIDs), such as aspirin and ibuprofen, or taking them for longer than recommended.

If you need to take painkillers, make sure you follow the instructions that come with the medicine.

Kidney risk calculator

There is a calculator you can use to work out your risk of developing moderate to severe kidney disease over the next 5 years. You just need to answer some simple questions.

The calculator is only valid if you do not already have a diagnosis of CKD stage 3b or worse. Ask your doctor if you’re unsure.

You may wish to use the tool during your next GP or practice nurse consultation.

Use the QKidney Web Calculator.

Question 8

Diagnosis/ Investigations

Answer 8

Investigations
y FBC, Sickling, Blood film comment
y Urinalysis
y Blood Urea, Electrolytes, Serum Creatinine y Calcium, Phosphate
y Fasting blood glucose
y Lipids
y Chest X-ray
y Ultrasound of kidneys

Chronic kidney disease (CKD) can be diagnosed with blood and urine tests.

In many cases, CKD is only found when a routine blood or urine test you have for another problem shows that your kidneys may not be working normally.

Tests for CKD

Blood test

The main test for kidney disease is a blood test. The test measures the levels of a waste product called creatinine in your blood.

Your doctor uses your blood test results, plus your age, size, gender and ethnic group to calculate how many millilitres of waste your kidneys should be able to filter in a minute.

This calculation is known as your estimated glomerular filtration rate (eGFR).

Healthy kidneys should be able to filter more than 90ml/min. You may have CKD if your rate is lower than this.

Urine test

A urine test is also done to:

check the levels of substances called albumin and creatinine in your urine – known as the albumin:creatinine ratio, or ACR
check for blood or protein in your urine
Alongside your eGFR, urine tests can help give a more accurate picture of how well your kidneys are working.

Other tests

Sometimes other tests are also used to assess the level of damage to your kidneys.

These may include:

an ultrasound scan, MRI scan or CT scan – to see what the kidneys look like and check whether there are any blockages
a kidney biopsy – a small sample of kidney tissue is removed using a needle and the cells are examined under a microscope for signs of damage

Test results and stages of CKD

Your test results can be used to determine how damaged your kidneys are, known as the stage of CKD.

This can help your doctor decide the best treatment for you and how often you should have tests to monitor your condition.

Your eGFR results is given as a stage from 1 of 5:

stage 1 (G1) – a normal eGFR above 90ml/min, but other tests have detected signs of kidney damage
stage 2 (G2) – a slightly reduced eGFR of 60 to 89ml/min, with other signs of kidney damage
stage 3a (G3a) – an eGFR of 45 to 59ml/min
stage 3b (G3b) – an eGFR of 30 to 44ml/min
stage 4 (G4) – an eGFR of 15 to 29ml/min
stage 5 (G5) – an eGFR below 15ml/min, meaning the kidneys have lost almost all of their function
Your ACR result is given as a stage from 1 to 3:

A1 – an ACR of less than 3mg/mmol
A2 – an ACR of 3 to 30mg/mmol
A3 – an ACR of more than 30mg/mmol
For both eGFR and ACR, a higher stage indicates more severe kidney disease.

Question 9

Treatment/ Management

Answer 9

There’s no cure for chronic kidney disease (CKD), but treatment can help relieve the symptoms and stop it getting worse.

Your treatment will depend on the stage of your CKD.

The main treatments are:

lifestyle changes – to help you stay as healthy as possible
medicine – to control associated problems, such as high blood pressure and high cholesterol
dialysis – treatment to replicate some of the kidney’s functions, which may be necessary in advanced (stage 5) CKD
kidney transplant – this may also be necessary in advanced (stage 5) CKD

Question 10

Lifestyle changes

Answer 10

Lifestyle changes

The following lifestyle measures are usually recommended for people with kidney disease:

stop smoking if you smoke
eat a healthy, balanced diet
restrict your salt intake to less than 6g a day – that’s around 1 teaspoon
do regular exercise – aim to do at least 150 minutes a week
manage your alcohol intake so you drink no more than the recommended limit of 14 units of alcohol a week
lose weight if you’re overweight or obese
avoid over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, except when advised to by a medical professional – these medicines can harm your kidneys if you have kidney disease
Find out more about living with CKD and what you can do to stay healthy.

Medicine

There’s no medicine specifically for CKD, but medicine can help control many of the problems that cause the condition and the complications that can happen as a result of it.

You may need to take medicine to treat or prevent the different problems caused by CKD.

Question 11

High blood pressure

Answer 11

High blood pressure

Good control of blood pressure is vital to protect the kidneys.

People with kidney disease should usually aim to get their blood pressure down to below 140/90mmHg, but you should aim to get it down to below 130/80mmHg if you also have diabetes.

There are many types of blood pressure medicines, but medicines called angiotensin converting enzyme (ACE) inhibitors are often used. Examples include ramipril, enalapril and lisinopril.

Side effects of ACE inhibitors can include:

a persistent dry cough
dizziness
tiredness or weakness
headaches
If the side effects of ACE inhibitors are particularly troublesome, you can be given a medicine called an angiotensin-II receptor blocker (ARB) instead.

Find out more about how high blood pressure is treated.

Question 12

Diabetes or high ACR

High cholesterol

Answer 12

Diabetes or high ACR

If you also have type 2 diabetes or a high albumin to creatinine ratio (ACR) you may be offered a medicine called dapagliflozin, as well as medicines for high blood pressure. Dapagliflozin helps to lower your blood sugar and can reduce damage to your kidneys.

High cholesterol
People with CKD have a higher risk of cardiovascular disease, including heart attack and stroke.

This is because some of the causes of kidney disease are the same as those for cardiovascular disease, including high blood pressure and high cholesterol.

You may be prescribed medicines called statins to reduce your risk of developing cardiovascular disease. Examples include atorvastatin and simvastatin.

Side effects of statins can include:

headaches
feeling sick
constipation or diarrhoea
muscle and joint pain
Find out more about how high cholesterol is treated.

Question 13

High Potassium Levels

Answer 13

High potassium levels

People with CKD can develop high potassium levels in their blood, called hyperkalaemia, because their kidneys do not work properly.

Hyperkalaemia can cause muscle weakness, stiffness and tiredness. If it becomes severe, it can cause an irregular heartbeat (arrhythmia) which can lead to a heart attack.

If you have CKD, it’s important to avoid taking potassium supplements and some medicines used to treat high blood pressure and heart failure because they can make your potassium levels too high. Talk to a GP about the medicines you take if you’re worried.

A medicine called sodium zirconium cyclosilicate can be used to treat hyperkalaemia in adults, but only if it’s used:

in emergency care for acute life-threatening hyperkalaemia alongside standard care
in people with hyperkalaemia that does not get better, CKD stage 3b to 5, or heart failure
People with hyperkalaemia that does not get better (called persistent CKD) who also have CKD stage 3b to 5, or heart failure, should only take sodium zirconium cyclosilicate if they:

have a serum potassium level of at least 6.0 mmol/litre and
are not also taking a certain amount of renin-angiotensin-aldosterone system (RAAS) inhibitor because of hyperkalaemia and
are not on dialysis
You should stop taking sodium zirconium cyclosilicate if RAAS inhibitors are no longer suitable for you.

Answer 14

Water retention

You may get swelling in your ankles, feet and hands if you have kidney disease.

This is because your kidneys are not as effective at removing fluid from your blood, causing it to build up in body tissues (oedema).

You may be advised to reduce your daily salt and fluid intake, including fluids in food such as soups and yoghurts, to help reduce the swelling.

In some cases you may also be given diuretics (tablets to help you pee more), such as furosemide.

Side effects of diuretics can include dehydration and reduced levels of sodium and potassium in the blood.

Anaemia

Many people with advanced-stage CKD develop anaemia, which is a lack of red blood cells.

Symptoms of anaemia include:

tiredness
lack of energy
shortness of breath
a pounding, fluttering or irregular heartbeat (palpitations)
If you have anaemia, you may be given injections of a medicine called erythropoietin. This is a hormone that helps your body produce more red blood cells.

If you have an iron deficiency as well, iron supplements may also be recommended.

Find out more about how iron deficiency anaemia is treated.

Want to know more?

National Institute for Health and Care Excellence (NICE): treating anaemia in people with chronic kidney disease

Answer 15

Bone problems

If your kidneys are severely damaged, you can get a build-up of phosphate in your body because your kidneys cannot get rid of it.

Along with calcium, phosphate is important for maintaining healthy bones. But if your phosphate level rises too much, it can upset the balance of calcium in your body and lead to thinning of the bones.

You may be advised to limit the amount food you eat which are high in phosphate, such as red meat, dairy products, eggs and fish.

If this does not lower your phosphate level enough, you may be given medicines called phosphate binders. Commonly used medicines include calcium acetate and calcium carbonate.

Some people with CKD also have low levels of vitamin D, which is necessary for healthy bones.

If you’re low in vitamin D, you may be given a supplement called colecalciferol or ergocalciferol to boost your vitamin D level.

Glomerulonephritis

Kidney disease can be caused by inflammation of the filters inside the kidneys, known as glomerulonephritis.

In some cases this happens as a result of the immune system mistakenly attacking the kidneys.

If a kidney biopsy finds this is the cause of your kidney problems, you may be prescribed medicine to reduce the activity of your immune system, such as a steroid or a medicine called cyclophosphamide.

Want to know more?

Kidney Care UK: medicines for chronic kidney disease
Improving muscle strength

If you are having a bad flare-up and are unable to exercise, you may be offered electrical stimulation to make your muscles stronger.

This is where electrodes are placed on your skin and small electrical impulses are sent to weak muscles, usually in your arms or legs.

Question 16

Dialysis

Answer 16

Dialysis

For a small proportion of people with CKD, the kidneys will eventually stop working.

This usually hapens gradually, so there should be time to plan the next stage of your treatment.

One of the options when CKD reaches this stage is dialysis. This is a method of removing waste products and excess fluid from the blood.

There are 2 main types of dialysis:

haemodialysis – this involves diverting blood into an external machine, where it’s filtered before being returned to the body
peritoneal dialysis – this involves pumping dialysis fluid into a space inside your tummy to draw out waste products from the blood as they pass through vessels lining the inside of your tummy
Haemodialysis is usually done about 3 times a week, either at hospital or at home. Peritoneal dialysis is normally done at home several times a day, or overnight.

If you don’t have a kidney transplant, treatment with dialysis will usually need to be lifelong.

Talk to your doctor about the pros and cons of each type of dialysis and which type you would prefer if your kidney function becomes severely reduced.

Want to know more?

Find out more about dialysis
Kidney Patient Guide: treating kidney failure with dialysis
Kidney Care UK: dialysis

Answer 17

Kidney transplant

An alternative to dialysis for people with severely reduced kidney function is a kidney transplant.

This is often the most effective treatment for advanced kidney disease, but it involves major surgery and taking medicines (immunosuppressants) for the rest of your life to stop your body attacking the donor organ.

You can live with one kidney, which means donor kidneys can come from living or recently deceased donors.

But there’s still a shortage of donors, and you could wait months or years for a transplant.

You may need to have dialysis while you wait for a transplant.

Survival rates for kidney transplants are very good. About 90% of transplants still function after 5 years and many work usefully after 10 years or more.

Want to know more?

Find out more about kidney transplants
Kidney Patient Guide: transplants
Kidney Care UK: kidney transplant

Answer 18

Supportive treatment

You’ll be offered supportive treatment if you decide not to have dialysis or a transplant for kidney failure, or they’re not suitable for you. This is also called palliative or conservative care.

The aim is to treat and control the symptoms of kidney failure. It includes medical, psychological and practical care for both the person with kidney failure and their family, including discussion about how you feel and planning for the end of life.

Many people choose supportive treatment because they:

are unlikely to benefit from or have a good quality of life with treatment
do not want to go through the inconvenience of treatment with dialysis
are advised against dialysis because they have other serious illnesses, and the negative aspects of treatment outweigh any likely benefits
have been on dialysis, but have decided to stop this treatment
are being treated with dialysis, but have another serious illness, such as severe heart disease or stroke, that will shorten their life
Supportive care through the kidney unit can still help you to live for some time with a good quality of life.

Doctors and nurses will make sure you receive:

medicines to protect your remaining kidney function for as long as possible
medicines to treat other symptoms of kidney failure, such as feeling out of breath, anaemia, loss of appetite or itchy skin
help to plan your home and money affairs
bereavement support for your family
Want to know more?

Cruse Bereavement Care
Kidney Patient Guide: the emotional effects of kidney failure
Kidney Research UK: information on choosing not to start dialysis
Kidney Care UK: deciding not to have dialysis (conservative treatment)

Question 19

Living with
- Chronic kidney disease

Answer 19

Many people with chronic kidney disease (CKD) are able to live long lives without being unduly affected by the condition.

Although it’s not possible to repair damage that has already happened to your kidneys, CKD will not necessarily get worse.

CKD only reaches an advanced stage in a small proportion of people.

But even if your condition is mild, it’s important to take good care of yourself to help stop it getting worse and reduce your risk of other health problems, such as cardiovascular disease.

Looking after yourself

Take your medicine

It’s very important that you take any prescribed medicine, even if you do not feel unwell. Some medicines are designed to prevent serious problems from happending in the future.

It’s also useful to read the information leaflet that comes with the medicine about possible interactions with other medicines or supplements.

Check with your care team if you plan to take any painkillers or nutritional supplements. These can sometimes affect your kidneys or interfere with your medicine.

Read more about pharmacy remedies and kidney disease.

Also speak to your care team if you have any concerns about the medicine you are taking, or if you’re experiencing any side effects.

Have a healthy diet

A healthy, balanced diet can help improve your general health and reduce your risk of developing further problems.

A balanced diet should include:

plenty of fruit and vegetables – aim for at least 5 portions a day
meals that include starchy foods, such as potatoes, wholegrain bread, rice or pasta
some dairy or dairy alternatives
some beans or pulses, fish, eggs, or meat as a source of protein
low levels of saturated fat, salt and sugar
You may also be given advice about dietary changes that can specifically help with kidney disease, such as limiting the amount of potassium or phosphate in your diet.

Exercise regularly

Regular physical activity can also help improve your general health.

Do not be scared to exercise. Exercise is good for anyone with kidney disease, however severe.

Not only will it boost your energy, help you sleep, strengthen your bones, ward off depression and keep you fit, it may also reduce your risk of problems such as heart disease.

If you have mild to moderate CKD, your ability to exercise should not be reduced. You should be able to exercise as often and as vigorously as someone the same age as you with healthy kidneys.

If your condition is more advanced or you’re already on dialysis, your ability to exercise is likely to be reduced and you may become breathless and tired more quickly.

But exercise is still beneficial. Start slowly and build up gradually. Check with your doctor before beginning a new exercise programme.

Want to know more

Kidney Care UK: diet, fluids and exercise
Stop smoking

If you smoke, stopping smoking can improve your overall health and reduce your risk of many other health problems.

Speak to a GP or NHS stop smoking service if you need help quitting. They can provide support and, if necessary, prescribe stop smoking treatments.

Limit your alcohol consumption

You may still be able to drink alcohol if you have kidney disease, but it’s advisable not to exceed the recommended limits of more than 14 alcohol units a week.

Speak to your GP or care team if you find it difficult to cut down the amount of alcohol you drink.

Find out more about cutting down on alcohol.

Get vaccinated

Kidney disease can put a significant strain on your body and make you more vulnerable to infections.

Everyone with the condition is encouraged to have the annual flu jab and the one-off pneumococcal vaccination.

You can get these vaccinations at your GP surgery or a local pharmacy that offers a vaccination service.

Regular reviews and monitoring

You’ll have regular contact with your care team to monitor your condition.

These appointments may involve:

talking about your symptoms – such as whether they’re affecting your normal activities or are getting worse
a discussion about your medicine – including whether you are experiencing any side effects
tests to monitor your kidney function and general health
It’s also a good opportunity to ask any questions you have or raise any other issues you’d like to discuss with your care team.

You may also want to help monitor your condition at home – for example, by using a home blood pressure monitor.

Contact your GP or healthcare team if your symptoms are getting worse or you develop new symptoms.

Relationships and support

Coming to terms with a condition such as CKD can put a strain on you, your family and your friends. It can be difficult to talk to people about your condition, even if they’re close to you.

Learning about CKD may help you and your family understand what to expect and to feel more in control of the illness, instead of feeling that your lives are now dominated by CKD and its treatment.

Be open about how you feel, and let your family and friends know what they can do to help. However, do not feel shy about telling them that you need some time to yourself, if that is what you need.

Get support

Your GP or healthcare team can reassure you if you have questions about your CKD, or you may find it helpful to talk to a trained counsellor, psychologist or specialist telephone helpline operator. Your GP surgery will have information on these.

Some people find it helpful to talk to other people with CKD at a local support group or through an internet chat room.

Want to know more?

Kidney Patient Guide: online forum
National Kidney Federation: helpline
Sex and pregnancy

Sex

Having CKD can affect a sexual relationship. Some couples become closer after a diagnosis of CKD, while others find their loved ones are affected by worries about how they’ll cope with the illness.

Both men and women may have issues about body image and self-esteem, and this can affect a relationship.

Problems such as erectile dysfunction and reduced sex drive are also fairly common in people with CKD.

Try to share your feelings with your partner. If you have problems with sex that do not get better with time, speak to your care team. Treatment and support is available.

Want to know more?

Kidney Care UK: sexual health and contraception
Pregnancy

If you have mild to moderate kidney disease, it’s unlikely your condition or its treatment will affect your chances of having children.

More advanced kidney disease may affect a woman’s periods and reduce a man’s sperm count, which can make it more difficult to get pregnant, although this does not mean you will not be able to have a child.

It’s important to use contraception if you do not want to get pregnant.

If you do want to try for a baby, it’s a good idea to speak to your healthcare team for advice first. There may be risks to mother and baby, and changes to your treatment or check-ups may be necessary.

Want to know more?

National Kidney Federation: kidney failure and having children
Work, finances and benefits

Can I continue working?

If you’re well enough, you can keep working for as long as you feel able.

Talk to your employer as soon as you feel your condition is affecting your ability to do your job so you can find a solution that suits both of you. For example, it may be possible for you to work part-time.

The Disability Discrimination Act 1995 requires employers to make reasonable adjustments to help a person with a disability.

This might, where possible, include changing or modifying tasks, altering work patterns, installing special equipment, allowing time off to attend appointments, or helping with travel to work.

What happens if I can no longer work?

If you have to stop work or work part-time because of CKD, you may find it hard to cope financially.

You may be entitled to one or more of the following types of financial support:

if you have a job but cannot work because of your illness, you are entitled to Statutory Sick Pay from your employer for up to 28 weeks
if you don’t have a job and cannot work because of your illness, you may be entitled to Employment and Support Allowance
if you’re aged 65 or over, you may be able to get Attendance Allowance
if you’re caring for someone with CKD, you may be entitled to Carer’s Allowance
you may be eligible for other benefits if you have children living at home or a low household income
Want to know more?

Kidney Patient Guide: finances
Money Advice Service
Kidney Care UK: benefits
Holidays and insurance

If you have mild CKD or you’ve had a transplant, going on holiday should not pose additional health problems, whether you’re staying in the UK or going abroad.

Speak to your care team before you travel, and make sure you take enough medicine with you to cover your trip and some back-up medicine in case you end up needing to stay away from home for longer than planned.

If you’re on dialysis, you can still enjoy holidays if you book your treatment before you go away.

If you want to travel to another part of the UK, discuss your plans with your renal unit as early as you can so they can arrange dialysis at a unit close to your destination.

In many parts of the country, the lack of facilities restricts the freedom of patients to travel, but Kidney Care UK’s Dialysis Freedom service runs a holiday dialysis “swap” scheme to help with dialysis availability in other areas.

If you’re going abroad, it may be easier to arrange dialysis at short notice as some overseas centres have more facilities, although holiday destinations may get booked up early.

It’s a good idea to take out holiday health insurance in addition to carrying the EHIC. Anyone with kidney disease should declare it as a pre-existing medical condition on standard insurance application forms. It may exclude you from some policies.

Want to know more?

Kidney Care UK: travel insurance

Question 20

Differential diagnosis

Answer 20

Diagnostic Considerations
Chronic kidney disease (CKD) can have a variety of different presentations depending on the stage of the disease and its cause, as well as patient factors such as age. A detailed history and physical examination is essential. In addition to routine laboratory studies, the workup should include calculation of the estimated glomerular filtration rate (GFR), measurement of albumin levels, and acquisition of radiologic studies. The differential diagnosis for CKD includes the following conditions, as well as the disorders listed in the next section:
Systemic lupus erythematosus (SLE)
Renal Artery Stenosis
Urinary Tract Obstruction
Granulomatosis with Polyangiitis (Wegener Granulomatosis)

Differential Diagnoses
Acute Kidney Injury (AKI)
Alport Syndrome
Antiglomerular Basement Membrane Disease
Chronic Glomerulonephritis
Diabetic Nephropathy
Multiple Myeloma
Nephrolithiasis
Nephrosclerosis
Rapidly Progressive Glomerulonephritis

Question 21

Stages ofCKD
Stage 1,2,3,4,5

Question 22

DISORDERS OF GENITOURINARY SYSTEM

Answer 22

DISORDERS OF GENITOURINARY SYSTEM
1. Acute Glomerulonephritis (Acute nephritis)

Question 23

1. Acute Glomerulonephritis (Acute nephritis)

Answer 23

1. Acute Glomerulonephritis (Acute nephritis)
   Glomerulonephritis is inflammation of the tiny filters of the kidneys (glomeruli).

Functions:
Glomeruli remove excess fluid, electrolytes and waste from the body through the urine

It can be:
Glomerulonephritis can come on suddenly (acute) or
gradually (chronic)

Causes of Acute GN
•Strept throat infections

•Other bacterial infections-salmonella

•Systemic Lupus Erythromatosis:—an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs

•Amyloidosis

•Polyarteritis nodosa

•Hep B, C,

• HIV

•Parasitic infections- malaria

Clinical Features- Acute GN:
•Edema- of face, hands , feet and abdomen from fluid retention

•Hematuria- urine pink, cola-colored

•High BP

•Cough due to extra fluid in the lungs

•Oliguria(urine volume <400mls a day)

•Proteinuria- foamy urine due to excess protein
• Azitemia. • Uremia

Investigations
•Urine test
-RBC and red cell casts- possible damage to glomeruli
-Increase protein- indicate nephron damage
-WBC- indicator of infection

•Blood test
- creatinine, BUN- kidney damage and impairment of glomeruli

•Imaging test- USG, CT scan, X-ray- evidence of damage

•Renal biopsy- to determine the cause of the inflammation-postponed in children until after a trial of steroids

Essentials of Diagnosis
•History of preceding streptococcal infection or rarely other infections
•Malaise, headache, anorexia, low grade fever
•Mild generalized oedema, mild hypertension
•Haematuria
•Urine- protein, red cell casts, granular and hyaline casts, epithelial cells

Treatment
•Bed rest until hematuria, hypertension, oedema and proteinuria have disappeared
•Reduce protein intake
•Reduce salt intake
•Restrict fluid
•Diuretics if severe oedema-frusemide 40-80mg daily
•Streptococcal infection should be treated with penicillin
•Hypertensive encephalopathy should be treated

Hypertensive encephalopathy management:
— Give IV labetalol immediately
— Reduce the BP to a target of 20 to 25% of the MAP( mean arterial pressure)

Nephritic Syndrome : The nephritic syndrome is a clinical syndrome that presents as hematuria, elevated blood pressure, decreased urine output, and edema. The major underlying pathology is inflammation of the glomerulus that results in nephritic syndrome.

Question 24

Nephrotic Syndrome

Answer 24

A kidney disorder that causes the body to excrete too much protein in the urine.
Nephrotic syndrome is often caused by damage to small blood vessels in the kidneys that filter waste and excess water from the blood. An underlying health condition usually plays a role.

Nephrotic syndrome is a group of symptoms that can appear if your kidneys are not working well.

Symptoms
•Proteinuria- too much protein in urine (>3gm/24 hours)

•Hypoalbuminemia- low levels of albumin in the blood (<30gm/l)

•Edema- swelling of legs, feet, ankles, genitals and sometimes hands and face

•Hyperlipidemia- high fat and cholesterol levels in the blood 🩸

• Lipiduria

Causes
•80% are due to glomerulonephritis- minimal change GN common in children and membranous GN common in adults
•Also seen with DM,
• allergies.
•Infections-Hep B/C,
• HIV,
• post-streptococcal
•Parasites-P. malariae, schisto mansoni
•Drugs- mercury, gold, heroin captopril, NSAIDs

Differentials
•Cardiac failure
•Liver disease
• Malnutrition
• Angioedema

Investigations
•Urine R/E
- microscopy- casts
- protein- proteinuria

•Serum protein- decrease in serum protein

•Serum cholesterol/lipids- increase

•Hepatitis B/C

•FBS

•USG— Ultrasound of the kidneys

Complications:
•Increase susceptibility to infection- due partly to loss of immunoglobulin in the urine.

•Hyperlipidaemia- increase cholestrol and triglycerides

•thromboembolism

Essentials of Diagnosis
•Massive oedema
•Proteinuria>3.5gm/day
•Hypoalbuminaemia <3gm/100ml
•hyperlipidaemia

Treatment
•Salt intake should be restricted
•High protein diet.
•Diuretics- for control of oedema- frusemide (40-80mg 12 hourly or 40-80mg daily); metolazone(D) 2.5-10mg oral daily for resistant oedema
•Corticosteroids- most of children and some adults undergo remission with steroids but are prone to relapse
•ACE inhibitors- lower pressure in glomeruli and amount of protein in urine and slow progression of renal impairment (lisinopril(B2) oral 5-20mg daily
•Treat infections promptly and treat hypertension
•Cholesterol lowering drugs

Question 25

Acute Renal Failure(Acute kidney injury-AKI)

Answer 25

Acute Renal Failure(Acute kidney injury-AKI)
Is a recent rapid and profound decline in renal function occurring over hours or days.

Clinical Features
•There may be no signs
•Oliguria is common(less than 400mls urine/24hrs)
•Biochemically by rising serum creatinine and urea levels
•Anuria,
• flank pain,
•Nausea and vomiting,
• loss of appetite,
• change mood
•Oedema
•hiccups

Staging of AKI
Staged by Kidney Disease: Improving Global Outcomes (KDIGO)

Stage
Serum Creatinine
Urine Output
1
1.5-1.9.times baseline or increase of >26.4 micromol
< 0.5ml/kg/hr for 6-12 hrs
2
2.0-2.9 times baseline
< 0.5ml/kg/hr for >12 hrs
3
3.0 times baseline or increase in serum creatinine to >353.6 micromol/L or initiation of dialysis
< 0.3ml/kg/hr for > 24hrs or anuria for > 12 hrs

Causes
They are usually considered in 3 groups:
1.Pre-renal
•Hypovolaemia
•Interference with renal blood flow(CCF, liver cirrhosis, NSAIDs, renal artery stenosis, ACE inhibitors)
•Sepsis
•Trauma

2.Renal
•Malignant hypertension
•Drugs/ nephrotoxins- aminoglycosides, tetracyclines, contrast materials, organic solvents, haemoglobinuria
•Acute tubular necrosis
•Arterial occlusion
•Multisystem disease
•Glomerulonephritis
•Haemolysis
•Rhabdomyolysis

1.Post-renal
•Urinary tract obstruction
Pre-renal failure may be prevented by correction of the causes.
Renal failure caused by nephrotoxins, surgery or obstetric complications(post-renal) is potentially reversible.
A diuretic phase usually begins spontaneously during the 2nd or 3rd week after the onset of renal failure

Diagnosis
Can be made from
•Full history & examination
•Urinalysis- nitrites, blood, protein, glucose, leucocytes
•Microscopy-RBC, casts, crystals, WBC
•Renal ultrasound
•Blood- urea& electrolytes, FBC
Essentials of Diagnosis
•Sudden onset of oliguria
•Anorexia, nausea, vomiting, elevated BP
•Progressive increase in BUN, creatinine, potassium
•Proteinuria and haematuria

Management
•Treat underlying cause if possible
•Attention to fluid: previous day fluid lost(urine, vomitus, diarrhoea, drains)+ 800mls for insensible loss = current day intake
•Dialysis to correct hyperkalaemia, uraemia, fluid overload
•Diet – low protein.

Question 26

Chronic Kidney Disease (CKD)

Answer 26

Chronic Kidney Disease (CKD)
It is a progressive decline of renal function for at least 3 months. The progressive impairment of the following functions of the kidneys(excretory, haemostatic, metabolic, humoral).
This refers to all 5 stages of kidney damage. The stages using Glomerular Filtration Rate (GFR):
•Stage 1- normal or high GFR (GFR>90mL/min)
•Stage 2- mild CKD (GFR = 60-69mL/min)
•Stage 3A- moderate CKD (GFR = 45-59mL/min)
•Stage 3B- moderate CKD (GFR = 30-44mL/min)
•Stage 4- severe CKD (GFR = 15-29mL/min)

Symptoms
You may have one or more of the following symptoms

Tiredness, hiccups, thirst, insomnia, bleeding tendencies
•Nocturia, polyuria, HPT, oedema, peripheral neuropathy
•Anaemia
•Loss of libido, flapping tremors(asterixis)
•Skin changes
•Pruritis
•Bone pain
•Fluid overload
•Anorexia
•Nausea& vomiting
Causes
•Glomerulonephritis
•Diabetes mellitus
•Hypertension
•Pyelonephritis
•BPH
•Renal stones
•Toxins(drugs, herbs)

Investigations
•Hb(FBC)
•Urinalysis- blood or protein
•Urea & electrolytes
•Glucose
•Ultrasound of kidney

Management(conservative)
•Restrict dietary protein and potassium
•Maintenance of correct fluid and sodium balance

•Hypertension- use ACE inhibitors-they decrease the loss of function of the kidney
•Oedema- high doses furosemide plus metolazone(D)
•Hyperlipidaemia- statins©
•Renal dialysis/transplant
• Renal anaemia by administration of human recombinant erythropoietin 0.75 micograms/kg sc every 2 weeks
•Treat any treatable cause

Question 27

Urinary Tract Infection

Answer 27

5. Urinary Tract Infection
   • Bacteriuria- is the presence of micro-organisms within the urinary tract with or without symptoms or signs of inflammation
   • UTI- is the presence of a pure growth of over 100,000 organisms/ml in a midstream urine or supra-pubic aspiration
   • Recurrent UTI- is a further infection with a new organism

Predisposing Factors
•Sexual intercourse
•Pregnancy
•Immunosuppression
•Diabetes mellitus
•Menopause
•Urinary tract obstruction
•Stones
•Catheter, foreign bodies
•malformations

Clinical Features
• Fever
•Convulsion in children
•May be vomiting
•Confusional state in the elderly
•Strong-smelling urine
•Strong, persistent urge to urinate
•Burning sensation when urinating
•Passing frequent, small amounts of urine

•Urine that appear cloudy
•Urine that has a sign of blood in it- red, pink, cola-colored
•Pelvic pain (in centre of pelvis and around pubic bone), in women
Types of UTI and their Features
•Acute pyelonephritis (kidneys)
-Upper back and flank pains
-High fever, rigors
- Nausea, vomiting
- Pelvic pressure
-Loin pain and tenderness
-Oliguria
•Cystitis (bladder)
-frequent, painful urination
-Blood in urine
-Suprapubic tenderness
•Urethritis (urethra)
-Burning with urination
-discharge

•Prostatitis
- Flu-like symptoms
-Low back pain
-Pain on prostate on rectal examination

NB If male child or recurrent unexplained infections in women investigate for:
•Obstructive uropathy
•Calculi
•Diabetes mellitus
•Structural renal or urinary tract disorder
•Neurogenic bladder

Investigations
•Examination of the urine is the most essential step (midstream urine)
-Nitrates or leucocytes in the urine
-WBCs >20/ cubic millimetre
•Growing urinary bacteria in lab (Urine culture)
•Using a scope to see inside the bladder (cystoscopy)
•Creating images of the urinary tract (USG, CT scan, MRI)

Treatment
•Drink a lot of fluids to flush out
•Ciprofloxacin 500mg bdx7 or
amoksiclav 625mg bdx7/cefuroxime(B2) in children
For prostatitis the treatment should be for 4 weeks