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Chronic kidney failure affects 15-20 million Americans. In many patients, this condition eventually progresses to end-stage kidney disease, requiring dialysis and/or kidney transplant. Currently, there are 400,000 Americans undergoing kidney dialysis or having kidney transplant operations. The number of new patients annually with this end-stage of kidney disease is approximately 200 people per million Americans. The leading causes of chronic kidney failure are diabetes mellitus, hypertension (high blood pressure), various forms of nephritis (kidney inflammation or infection) and polycystic kidney disease.
Who is at risk to develop chronic kidney failure?
People from any social class or ethnic group in America can suffer kidney failure. However, minority patients, such as African Americans or Hispanics, experience the burden of end-stage kidney disease more strongly. The reasons for this are unclear and it may be due to the decreased availability of early detection and medical care before they become seriously ill. Other inherited and individual factors are currently under investigation. Often, the risk factors of chronic kidney disease are not obvious, and a person's symptoms are nonspecific and appear gradually. If the disease advances slowly, the patient may not feel very sick. But fatigue, weakness and anemia (not due to iron deficiency) may be noticed early. The discoveries of high blood pressure and/or of protein in the urine on routine examinations are signs that kidney disease may be present. In addition, high blood pressure not due to kidney disease can, if not properly treated, lead to kidney problems. Not all patients with diabetes or hypertension progress to kidney failure, but these two conditions are definitely risk factors for that progression. Other risk factors include smoking, taking certain drugs, and exposure to chemicals. Among the drug risks is the heavy use of over-the-counter analgesic preparations including non-steroidal anti-inflammatory drugs (aspirin, Advil, Aleve, etc.). Injected or oral illegal drug use may be an underestimated and potent risk factor for development of chronic kidney disease. Polycystic kidney disease is an inherited condition in which kidney failure usually does not occur until mid-late life. It is relatively common, affecting about 1 in every 1,500 people.
Infections such as various forms of hepatitis as well as HIV are often accompanied by kidney disease, some of which is progressive. There are also many other causes of chronic inflammation or infection of the kidney filters (glomerulonephritis). More unusual causes of chronic kidney disease include autoimmune disease such as lupus, erythematosus and inflammatory conditions of small blood vessels known collectively as vasculitis.
What are the functions of the kidney and how is the diagnosis of kidney function failure confirmed?
The healthy kidney normally filters the blood and rids the body of the waste products from protein metabolism by body cells. When the kidney fails, these waste products accumulate gradually in the blood and can cause symptoms of varying degree. Advanced kidney failure leads to a condition known as uremic poisoning. With uremic poisoning, the patient experiences loss of appetite, weight loss, fluid retention, nausea and vomiting. Inability to function properly due to depression, anxiety and lack of proper mental capacity often occurs at these late stages of uremia. Standard testing of the blood or urine may indicate abnormalities suggestive of kidney disease. The most prominent of these is protein or blood in the urine on a routine urinalysis. These findings are virtually always abnormal and your doctor may follow up any such discovery with diagnostic tests to find the cause. Routine blood testing for the waste products mentioned above such as blood urea nitrogen or serum creatinine often indicate the presence of kidney problems. While normal test results do not exclude kidney dysfunction, abnormal tests always demand an explanation. As noted, high blood pressure can either be a cause or an effect of kidney disease. People with kidney disease have an accelerated risk of generalized vascular disease. In fact, abnormal kidney function is a leading risk factor for atherosclerotic cardiovascular disease such as heart attack and stroke. While the reasons for this are not completely understood, they may be due to the additive or synergistic effects of abnormal blood fats and retention of certain artherosclerotic (artery clogging) molecular building blocks such as homocysteine and certain types of "bad " cholesterol.
How can my doctor and I control chronic kidney failure?
With diagnosis of kidney failure there are specific interventions that may delay or stabilize the course of the disease. Such treatments include tight control of blood sugar in diabetic patients, rigorous control of blood pressure in patients with hypertension, and attempts to reduce the amount of protein in the urine by certain classes of drugs, which also are effective in lowering blood pressure. These drugs, called ACE-inhibitors or angiotensin antagonists, may specifically alter the course and progression of many kidney diseases. Since kidney disease is often free of symptoms prior to diagnosis, once someone is diagnosed with the illness, it's wise to consider referral to a specialist involved in these disorders: a nephrologist. In collaboration with primary care physicians, nephrologists can often alter the course of kidney disease and, by establishing a specific individual diagnosis, perhaps offer treatments which will result in improvement or return to normal. Precise diagnosis often requires x-ray or other imaging studies of the kidney and frequently a kidney biopsy. Patients with kidney failure need to be checked for obstruction anywhere in their urinary tract. In men, enlarged prostates are the most common cause of obstructions, but blockage of the urinary tract at any point can lead to some kidney dysfunction, which can be reversed if the obstruction is relieved. The kidneys excrete and help eliminate from the body many medications that patients take for other conditions. If there is kidney dysfunction and dosages of these medications are not adjusted, adverse drug reactions can occur. In addition, there are other drugs that have toxic effects on the kidneys. Among these are certain antibiotics, drugs used to treat psychiatric disorders such as lithium, anti-inflammatory agents, non-steroidal anti-inflammatory drugs and a host of other medications that are used in clinical medicine. It is always a good idea to read the package labeling and to ask your doctor and pharmacist about the effects of these types of drugs on the kidney, particularly if you know you have kidney dysfunction. As people age, their kidney function tends to decline. Thus, adverse drug reactions are more common in the elderly and in patients taking multiple kinds of medications.
What is the treatment for end-stage kidney disease?
If kidney function reaches end-stage, there is effective treatment using various forms of kidney dialysis and/or kidney transplantation. Prior to initiating these therapies, however, patients should be seen by a team of professionals including dieticians, social workers and nephrologists who will coordinate that care. Most types of kidney failure reaching end-stage are covered under the federal government's Medicare program even for people under age 65. This exception to the Medicare laws was passed in the 1972 and qualifies most patients for end-stage kidney disease treatment coverage. Complications of kidney failure such as anemia, bone loss and cardiovascular disease that occur after dialysis or transplantation is started can largely be avoided if the patient is seen by experts in the need for end-stage management.
Questions for Patients with Chronic Kidney Disease to Ask Their Physicians
When required, do you or your staff refer patients to nephrologists? (Nephrologists are board-certified physicians who care for patients with chronic kidney disease. A consultation with nephrologists to provide a treatment plan and intervention in the case of prevention of renal disease will make rehabilitation to an improved quality of life much more likely.)
Is my blood pressure being controlled adequately to preserve kidney function as much as possible, and are the medications being prescribed protective of kidney function or simply blood pressure lowering? (Many forms of kidney disease are helped by specific medications that can be recommended.)
Are there inherited causes for my disease, and should my family members be screened? (Some kidney diseases such as polycystic kidney disease may affect 50 percent of children and, while the age of testing for these diseases is currently recommended only in adults, it is important to know whether these conditions are familial in character so that your family can make plans for screening when needed.)
Do the findings in my case require further work-up, such as blood tests or urine tests? What is the exact percentage of the kidney function that I have remaining? (The answers to the questions can be relatively simply obtained and will help establish the prognosis of any individual's disease.)
Are my immunizations and general health screening up-to-date, since I understand that these will impact on my general health, which in turn will affect my kidney disease? Does your office make referrals to kidney transplant or dialysis facilities should my disease progress?
Where can I get more information about my kidney disease? (Sources include the American Society of Nephrology, National Kidney Foundation, American Society of Transplantation and the Polycystic Kidney Research Foundation.)
Do you provide dietary counseling for the proper diet that I should follow to prevent the symptoms and progression of my kidney disease?
You should ask these questions to assure yourself that the doctor takes a meticulous, thorough approach to diagnosis and treatment, and that he or she is accessible and flexible.
William M. Bennett, M.D., FACP Medical Director, Solid Organ and Cellular Transplantation Legacy Good Samaritan Hospital
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