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Kidney failure

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Kidney failure
Other namesRenal failure, end-stage renal disease (ESRD), stage 5 chronic kidney disease[1]
Ahemodialysismachine which is used to replace the function of the kidneys
SpecialtyNephrology
SymptomsLeg swelling,feeling tired, loss of appetite, confusion[2]
ComplicationsAcute:Uremia,high blood potassium,volume overload[3]
Chronic:Heart disease,high blood pressure,anemia[4][5]
TypesAcute kidney failure,chronic kidney failure[6]
CausesAcute:
[6]
Chronic:
[6]
Diagnostic methodAcute:

Chronic:
TreatmentAcute:Depends on the cause[7]
Chronic:Hemodialysis,peritoneal dialysis,kidney transplant[2]
FrequencyAcute:3 per 1,000 per year[8]
Chronic:1 per 1,000 (US)[1]

Kidney failure,also known asend-stage renal disease(ESRD), is a medical condition in which thekidneyscan no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels.[2]Kidney failure is classified as eitheracute kidney failure,which develops rapidly and may resolve; andchronic kidney failure,which develops slowly and can often be irreversible.[6]Symptoms may includeleg swelling,feeling tired,vomiting,loss of appetite, andconfusion.[2]Complications of acute and chronic failure includeuremia,hyperkalemia,andvolume overload.[3]Complications of chronic failure also includeheart disease,high blood pressure,andanaemia.[4][5]

Causes of acute kidney failure includelow blood pressure,blockage of theurinary tract,certain medications,muscle breakdown,andhemolytic uremic syndrome.[6]Causes of chronic kidney failure includediabetes,high blood pressure,nephrotic syndrome,andpolycystic kidney disease.[6]Diagnosis of acute failure is often based on a combination of factors such asdecreased urine productionor increasedserum creatinine.[3]Diagnosis of chronic failure is based on aglomerular filtration rate(GFR) of less than 15 or the need forrenal replacement therapy.[1]It is also equivalent to stage 5chronic kidney disease.[1]

Treatment of acute failure depends on the underlying cause.[7]Treatment of chronic failure may includehemodialysis,peritoneal dialysis,or akidney transplant.[2]Hemodialysis uses a machine to filter the blood outside the body.[2]In peritoneal dialysis specific fluid is placed into theabdominal cavityand then drained, with this process being repeated multiple times per day.[2]Kidney transplantation involves surgically placing a kidney from someone else and then takingimmunosuppressantmedication to preventrejection.[2]Other recommended measures from chronic disease include staying active and specific dietary changes.[2]Depression is also common among patients with kidney failure, and is associated with poor outcomes including higher risk of kidney function decline, hospitalization, and death. A recentPCORI-funded study of patients with kidney failure receiving outpatient hemodialysis found similar effectiveness between nonpharmacological and pharmacological treatments for depression.[9]

In the United States, acute failure affects about 3 per 1,000 people a year.[8]Chronic failure affects about 1 in 1,000 people with 3 per 10,000 people newly developing the condition each year.[1][10]Acute failure is often reversible while chronic failure often is not.[6]With appropriate treatment many with chronic disease can continue working.[2]

Classification[edit]

See also:Hepatorenal syndrome

Kidney failure can be divided into two categories:acute kidney failureorchronic kidney failure.The type of renal failure is differentiated by the trend in the serumcreatinine;other factors that may help differentiate acute kidney failure from chronic kidney failure includeanemiaand the kidney size onsonographyas chronic kidney disease generally leads to anemia and small kidney size.[citation needed]

Acute kidney failure[edit]

Main article:Acute kidney injury

Acute kidney injury(AKI), previously called acute renal failure (ARF),[11][12]is a rapidly progressive loss ofrenal function,[13]generally characterized byoliguria(decreasedurineproduction, quantified as less than 400mLper day in adults,[14]less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); andfluid and electrolyte imbalance.AKI can result from a variety of causes, generally classified asprerenal,intrinsic,andpostrenal.Many people diagnosed withparaquat intoxicationexperience AKI, sometimes requiringhemodialysis.[citation needed]The underlying cause must be identified and treated to arrest the progress, anddialysismay be necessary to bridge the time gap required for treating these fundamental causes.[citation needed]

Chronic kidney failure[edit]

Main article:Chronic kidney disease
Illustration of a kidney from a person with chronic renal failure

Chronic kidney disease(CKD) can also develop slowly and, initially, show few symptoms.[15]CKD can be the long term consequence of irreversible acute disease or part of a disease progression.[citation needed]CKD is divided into 5 different stages (1–5) according to the estimated glomerular filtration rate (eGFR). In CKD1 eGFR is normal and in CKD5 eGFR has decreased to less than 15 ml/min.[16]

Acute-on-chronic kidney failure[edit]

Acute kidney injuries can be present on top of chronic kidney disease, a condition called acute-on-chronic kidney failure (AoCRF). The acute part of AoCRF may be reversible, and the goal of treatment, as with AKI, is to return the person to baseline kidney function, typically measured by serumcreatinine.Like AKI, AoCRF can be difficult to distinguish from chronic kidney disease if the person has not been monitored by aphysicianand no baseline (i.e., past) blood work is available for comparison.[citation needed]

Signs and symptoms[edit]

Symptoms can vary from person to person. Someone in early stage kidney disease may not feel sick or notice symptoms as they occur. When the kidneys fail to filter properly, waste accumulates in the blood and the body, a condition calledazotemia.Very low levels of azotemia may produce few, if any, symptoms. If the disease progresses, symptoms become noticeable (if the failure is of sufficient degree to cause symptoms). Kidney failure accompanied by noticeable symptoms is termeduraemia.[17]

Symptoms of kidney failure include the following:[17][18][19][20]

  • High levels ofureain the blood, which can result in:
    • Vomitingordiarrhea(or both) that may lead todehydration
    • Nausea
    • Weight loss
    • Nocturnal urination (nocturia)
    • More frequent urination, or in greater amounts than usual, with pale urine
    • Less frequent urination, or in smaller amounts than usual, with dark coloured urine
    • Blood in the urine
    • Pressure, or difficulty urinating
    • Unusual amounts of urination, usually in large quantities
  • A buildup ofphosphatesin the blood that diseased kidneys cannot filter out may cause:
  • A buildup ofpotassiumin the blood that diseased kidneys cannot filter out (calledhyperkalemia) may cause:
    • Abnormal heart rhythms
    • Muscle paralysis[21]
  • Failure of kidneys to remove excess fluid may cause:
    • Swelling of the hands, legs, ankles, feet, or face
    • Shortness of breath due to extra fluid on the lungs (may also be caused by anemia)
  • Polycystic kidney disease,which causes large, fluid-filled cysts on the kidneys and sometimes the liver, can cause:
    • Pain in the back or side
  • Healthy kidneys produce the hormoneerythropoietinthat stimulates thebone marrowtomake oxygen-carrying red blood cells.As the kidneys fail, they produce less erythropoietin, resulting in decreased production of red blood cells to replace the natural breakdown of old red blood cells. As a result, the blood carries lesshemoglobin,a condition known asanemia.This can result in:
    • Feeling tired or weak
    • Memory problems
    • Difficulty concentrating
    • Dizziness
    • Low blood pressure
  • Normally proteins are too large to pass through the kidneys. However they are able to pass through when the glomeruli are damaged. This does not cause symptoms until extensive kidney damage has occurred,[22]after which symptoms include:
    • Foamy or bubbly urine
    • Swelling in the hands, feet, abdomen, and face
  • Other symptoms include:
    • Appetite loss, which may include a bad taste in the mouth
    • Difficulty sleeping
    • Darkening of the skin
    • Excess protein in the blood
    • With high doses ofpenicillin,people with kidney failure may experienceseizures[23]

Causes[edit]

Acute kidney injury[edit]

Main article:Acute kidney injury

Acute kidney injury (previously known as acute renal failure) – or AKI – usually occurs when the blood supply to the kidneys is suddenly interrupted or when the kidneys become overloaded with toxins. Causes of acute kidney injury include accidents, injuries, or complications from surgeries in which the kidneys are deprived of normal blood flow for extended periods of time. Heart-bypass surgery is an example of one such procedure.[citation needed]

Drug overdoses, accidental or from chemical overloads of drugs such as antibiotics or chemotherapy, along with bee stings[24]may also cause the onset of acute kidney injury. Unlike chronic kidney disease, however, the kidneys can often recover from acute kidney injury, allowing the person with AKI to resume a normal life. People with acute kidney injury require supportive treatment until their kidneys recover function, and they often remain at increased risk of developing future kidney failure.[25]

Among the accidental causes of renal failure is thecrush syndrome,when large amounts oftoxinsare suddenly released in theblood circulationafter a long compressedlimbis suddenly relieved from the pressure obstructing the blood flow through its tissues, causingischemia.The resulting overload can lead to the clogging and the destruction of the kidneys. It is areperfusion injurythat appears after the release of the crushing pressure. The mechanism is believed to be the release into the bloodstream of muscle breakdown products – notablymyoglobin,potassium,andphosphorus– that are the products ofrhabdomyolysis(the breakdown of skeletal muscle damaged byischemicconditions). The specific action on thekidneysis not fully understood, but may be due in part tonephrotoxicmetabolitesof myoglobin.[citation needed]

Chronic kidney failure[edit]

Main article:Chronic kidney disease

Chronic kidney failure has numerous causes. The most common causes of chronic failure arediabetes mellitusand long-term, uncontrolledhypertension.[26]Polycystic kidney diseaseis another well-known cause of chronic failure. The majority of people affected with polycystic kidney disease have a family history of the disease. Systemic lupus erythematosus (SLE) is also a known cause of chronic kidney failure. Other genetic illnesses cause kidney failure, as well.[citation needed]

Overuse of common drugs such asibuprofen,andacetaminophen(paracetamol) can also cause chronic kidney failure.[27]

Some infectious disease agents, such ashantavirus,can attack the kidneys, causing kidney failure.[28]

Genetic predisposition[edit]

TheAPOL1gene has been proposed as a major genetic risk locus for a spectrum of nondiabetic renal failure in individuals of African origin, these includeHIV-associated nephropathy(HIVAN), primary nonmonogenic forms offocal segmental glomerulosclerosis,and hypertension affiliatedchronic kidney diseasenot attributed to other etiologies.[29]Two western African variants in APOL1 have been shown to be associated with end stage kidney disease in African Americans and Hispanic Americans.[30][31]

Diagnostic approach[edit]

Measurement for CKD[edit]

Stages of kidney failure

Chronic kidney failure is measured in five stages, which are calculated using the person's GFR, orglomerular filtration rate.Stage 1 CKD is mildly diminished renal function, with few overt symptoms. Stages 2 and 3 need increasing levels of supportive care from their medical providers to slow and treat their renal dysfunction. People with stage 4 and 5 kidney failure usually require preparation towards active treatment in order to survive.Stage 5 CKDis considered a severe illness and requires some form of renal replacement therapy (dialysis) orkidney transplantwhenever feasible.[citation needed]

Glomerular filtration rate

A normal GFR varies according to many factors, including sex, age, body size and ethnic background. Renal professionals consider the glomerular filtration rate (GFR) to be the best overall index of kidney function.[32]The National Kidney Foundationoffers an easy to use on-line GFR calculator[33]for anyone who is interested in knowing their glomerular filtration rate. (A serumcreatininelevel, a simple blood test, is needed to use the calculator.)

Use of the termuremia[edit]

Before the advancement of modern medicine, renal failure was often referred to as uremic poisoning. Uremia was the term for the contamination of the blood with urea. It is the presence of an excessive amount of urea in blood. Starting around 1847, this included reduced urine output, which was thought to be caused by the urine mi xing with the blood instead of being voided through the urethra.[citation needed]The termuremiais now used for the illness accompanying kidney failure.[34]

Renal failure index[edit]

Two other urinary indices, are thefractional sodium excretion(FENa) index and the renal failure index (RFI).[35]The renal failure index is equal to urine sodium times plasma creatinine divided by urinecreatinine.[35]A FENa score greater than 3% or a renal failure index (RFI) greater than 3 are helpful in confirming acute renal failure.[36]

Complications[edit]

Those with end stage renal failure who undergo haemodialysis have higher risk of spontaneous intra-abdominal bleeding than the general population (21.2%) andnon-occlusive mesenteric ischemia(18.1%). Meanwhile, those undergoingperitoneal dialysishave a higher chance of developingperitonitisandgastrointestinal perforation.However, the rate ofacute pancreatitisdoes not differ from the general population.[37]

Treatment[edit]

The treatment of acute kidney injury depends on the cause.[7]The treatment of chronic kidney failure may include renal replacement therapy:hemodialysis,peritoneal dialysis,orkidney transplant.[2]

Diet[edit]

In non-diabetics and people withtype 1 diabetes,a low protein diet is found to have a preventive effect on progression of chronic kidney disease. However, this effect does not apply to people withtype 2 diabetes.[38]A whole food,plant-based dietmay help some people with kidney disease.[39]A high protein diet from either animal or plant sources appears to have negative effects on kidney function at least in the short term.[40]

Slowing progression[edit]

People who receive earlier referrals to a nephrology specialist, meaning a longer time before they must start dialysis, have a shorter initial hospitalization and reduced risk of death after the start of dialysis.[41]Other methods of reducing disease progression include minimizing exposure tonephrotoxinssuch asNSAIDsandintravenous contrast.[42]

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External links[edit]

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