Snapshot A 56-year-old man presents to his primary care physician with shortness of breath and fatigue. He denies any chest pain but states that his wife noticed his legs appear swollen. Medical history is significant for hypertension and obesity. On physical exam there is dullness to percussion, decreased tactile fremitus, and dullness to percussion in the chest wall. There is pitting edema in the lower extremities. On laboratory testing, his glomerular filtration rate (GFR) 45 mL/minute/1.73 m2. Summary Clinical definition chronic kidney disease (CKD) describes abnormalities in kidney structure or function occuring for > 3 months e.g., glomerular filtration rate (GFR) < 60 mL/minute/1.73 m2 for > 3 months when CKD requires renal transplantation or dialysis, the patient is said to have end-stage renal disease (ESRD) Epidemiology incidence 1 in 10 American adults have some form of CKD risk factors older age diabetes mellitus hypertension acute kidney injury microalbuminuria or proteinuria overweight or obesity smoking, alcohol, and drug abuse Etiology insults that result in renal damage e.g., diabetes mellitus, autoimmune disease (such as lupus), and hypertension Pathogenesis in normal conditions the kidneys have the ability to maintain glomerular filtration rate (GFR) in the setting of nephron loss login to view 2 more bullets a number of sequela occur as the GFR continues to decrease such as hyperkalemia metabolic acidosis normochromic normocytic anemia login to view 1 more bullet secondary hyperparathyroidism hyperphosphatemia hypocalcemia login to view 1 more bullet impairment of sodium and free water excretion login to view 2 more bullets Presentation Symptoms typically asymptomatic in early stages of the disease clinical presentation secondary to uremia include fatigue nausea and vomiting pruritis chest pain login to view 1 more bullet seizure Physical exam hypertension uremic frost growth retardation in children peripheral edema osteitis fibrosa cystica osteomalacia "renal rickets" Differential Acute on chronic kidney disease Studies Labs complete blood count (CBC) can see normochromic, normocytic anemia basic metabolic panel ↑ blood urea nitrogen (BUN), creatinine, and potassium ↑ phosphate ↑ parathyroid hormone ↓ calcium ↓ calcitriol cystatin C it is secreted but not reabsorbed an endogenous marker of renal function urine studies to assess for proteinuria can see waxy-casts on urinalysis in patients with ESRD and CKD Biopsy percutaneous renal biopsy is typically performed when there is renal impairment (or nephrotic range proteinuria) and the diagnosis is unclear after extensive workup Imaging Renal ultrasound indication considered the first-line imaging modality when working up a patient with CKD used to evaluate between obstructive and intrinsic parenchymal disease to assess for retroperitoneal involvement and renal cysts Treatment Conservative protein restriction indication login to view 1 more bullet Medical ACE inhibitors or ARBs indications login to view 5 more bullets vitamin D supplementation indication login to view 1 more bullet erythropoiesis-stimulating agent indication login to view 5 more bullets phosphate binders indication login to view 1 more bullet statins indication login to view 1 more bullet dialysis indication login to view 2 more bullets Operative renal transplant indication login to view 1 more bullet Complications Anemia Mineral and bone disease Hypertension Hypervolemia Depression Cardiovascular disease Prognosis typically progressive loss of renal function and may result in ESRD