Chronic kidney disease (CKD)
What is it?
Chronic kidney disease (CKD) is defined as a pathological condition characterized by a persistent reduction in glomerular filtration rate (GFR) that prevents the purification of the blood from toxins and metabolic waste materials. It therefore causes alterations in the blood concentration of electrolytes and metabolites. To define this condition as chronic, as opposed to acute kidney damage, it should be persistent for at least 3-6 months. Based on GFR values estimated with formulas based on creatinemia and the presence of other markers of kidney damage (proteinuria, albuminuria, hematuria), it is possible to distinguish 5 stages of CKD. Chronic kidney disease is now a major public health problem due to the marked increase in its prevalence in recent decades worldwide. Prevalence rates vary among countries between 5 and 13%. In particular in Italy chronic kidney disease is estimated to affect 7% of the population. The main causes of CKD are primarily represented by diseases associated with vascular damage (hypertension, diabetes), followed by primary or secondary glomerular diseases, polycystic kidney and tubulo-interstitial diseases.
Which are the symptoms?
Reduced GFR and increased albuminuria values are associated with a proggressive increase in cardiovascular events and mortality risk, but clinical manifestations depend on the degree of renal function impairment. Typically, with the exception of predialytic advanced renal failure, CKD is not characterized by obvious symptoms, although hypertension, lower extremity edema, and anemia may occur. Poor clinical symptoms unfortunately account for the widespread underestimation of chronic kidney disease and late recognition of nephropathic patients. In an advanced phase of the disease, the patient may show signs and symptoms that may lead to the diagnostic suspicion: itching, lack of appetite, nausea, vomiting, muscle cramps, asthenia, and insomnia. However, the most alarming manifestations of the uremic stage are volume overload resulting in weight gain, edema, pulmonary congestion, dyspnea, hypertension, hyperpotassemia, and confusion.
How is it diagnosed?
Evaluation of renal function should always be performed in subjects with risk factors for CKD such as advanced age, family history of kidney disease, arterial hypertension, diabetes, previous cardiovascular events, obesity, dyslipidemia, metabolic syndrome. It should be remembered that determination of GFR and search for albuminuria are two key indicators of kidney function and being low cost can be easily evaluated in the general population for early identification of CKD. Gradual decline in GFR is oligosymptomatic even in moderate-to-advanced CKD patients. A patient often comes for examination because, during routine examinations, he has shown alterations in the value of creatinemia and azotemia or urine test showed proteinuria and / or hematuria. Ultrasonographic examination in CKD may show small kidneys with poor cortico-midline differentiation.
How is it treated?
The treatment of CKD and its complications involves an integrated approach between drug therapy, lifestyle modifications and nutritional therapy with the aim of slowing down the evolution of CKD. Arterial hypertension is one of the main causes of progression of kidney damage: the first choice treatment for blood pressure control in proteinuric patients is represented by inhibitors of the renin-angiotensin-aldosterone axis associated with a hyposodic diet. The treatment of CKD includes monitoring and correction of any electrolyte dyscrasias (potassium, sodium, phosphate, calcium, acid-base balance), treatment of anemia using the various types of commercially available recombinant erythropoietin, and treatment of hyperuricemia and hyperparathyroidism. Despite these measures, CKD can worsen to the point where residual renal function is so reduced that it no longer ensures adequate removal of molecules and maintains the patient's water and electrolyte homeostasis. In these cases, patient survival can only be guaranteed by dialysis or renal transplantation.
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