Chronic Kidney Disease (CKD): Stages, Causes, Symptoms, and Treatment

What is Chronic kidney disease (CKD)

Chronic kidney disease (CKD), also referred to as chronic renal disease, is a condition where the kidneys sustain long-term damage and lose their ability to function properly. The kidneys play a crucial role in filtering waste, toxins, and excess fluids from the blood, while also contributing to red blood cell production and bone health. As CKD progresses, waste accumulates in the bloodstream, leading to various complications.

CKD is termed "chronic" because kidney function declines gradually over time. While some individuals with CKD may not develop kidney failure,untreated CKD can lead to end-stage kidney disease (ESKD), requiring dialysis or a kidney transplant for survival.

CKD is characterized by structural changes in the kidneys, including damage to blood vessels and nephrons, and is defined by an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73 m² persisting for three months or more. The disease progresses through five stages, with worsening kidney function over time. Most cases of CKD are mild or moderate (stages 1-3).

Although there is no cure for CKD, early detection and management can slow its progression. Lifestyle modifications, medication, and dietary changes are essential in preserving kidney function and preventing complications.

Risk factors for CKD

Anyone can get chronic kidney disease. However, individual at more risk for chronic kidney disease are;

• A family history of CKD
• Heart disease
• Diabetes
• High blood pressure
• Being over 60 years
• Have a long history of taking NSAID pain relievers.

Causes of CKD

Chronic kidney disease (CKD) is caused by long-term damage to the kidneys, leading to a gradual loss of function. Several conditions contribute to CKD development. Common Causes of CKD:

• Diabetes
• High Blood Pressure(Hypertension)
• Aging

Other Causes of CKD:

• Certain Medications: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs), lithium, ciclosporin, and tacrolimus can contribute to kidney damage.
• Glomerular Diseases: Conditions such as glomerulonephritis
• Renal Artery Stenosis
• Polycystic Kidney Disease (PKD): A genetic disorder characterized by multiple fluid-filled cysts in the kidneys
• Obstructions in the Urinary Tract: Kidney stones,enlarged prostate, or tumors can block urine flow, leading to kidney damage.
• Recurrent Kidney Infections such as pyelonephritis
• Autoimmune Diseases like lupus and Goodpasture syndrome
• Previous Kidney Injury
• Congenital Conditions
• Membranous nephropathy
• Vesicoureteral reflux
• Nephrotic syndrome

Stages of Chronic Kidney Disease

Chronic kidney disease (CKD) is classified into five stages based on kidney function and the ability to filter waste from the blood. The stages are determined by blood and urine tests that measure the glomerular filtration rate (GFR), which indicates how well the kidneys are functioning. The stages range from very mild (stage 1) to kidney failure(stage 5).

Pathophysiology of CKD

Chronic kidney disease (CKD) involves the gradual and irreversible loss of kidney function due to sustained structural damage. Unlike acute kidney injury (AKI),which may recover, CKD leads to persistent fibrosis and deterioration of kidney structure, affecting the glomeruli, tubules, interstitium, and blood vessels. These changes impair glomerular filtration, leading to proteinuria. Blood vessels narrowing and hardening limit oxygen and nutrient delivery resulting in apoptosis and necrosis, further progressing kidney tissue loss and functional decline. These processes, if left untreated, eventually leads to end-stage renal disease.

Signs & Symptoms of CKD

Early CKD stages are asymptomatic, and Symptoms tend to develop when chronic kidney disease becomes severe, thus, in stages 4 or 5. Some common symptoms and signs at these stages of CKD include:

• Weight loss
• Dry, itchy skin
• Foamy urine
• Trouble concentrating
• Nausea
• Vomiting
• Loss of appetite
• Fatigue and weakness
• Sleep disturbance
• Oliguria
• Muscle cramps
• Swelling of feet and ankles
• Persistent pruritus
• Shortness of breath
• Hypertension
• Loss of appetite
• Headaches
• Bruising

Diagnostic Investigations & Test

Chronic kidney disease (CKD) is diagnosed through a combination of blood tests, urine tests, imaging studies, and, in some cases, a kidney biopsy.

• Estimated Glomerular Filtration Rate (eGFR): A blood test that assesses kidney function by measuring how well the kidneys filter waste. An eGFR below 60 mL/min/1.73 m² for more than three months indicates CKD.
• Serum Creatinine
• Proteinuria (Urine Albumin-to-Creatinine Ratio - UACR)
• Blood Urea Nitrogen (BUN)
• Urinalysis
• Imaging tests such as Ultrasound, MRI, or CT scans evaluate kidney size, structure, and abnormalities.
• Kidney Biopsy

Treatment of CKD

The management of chronic kidney disease (CKD) focuses on slowing disease progression, treating underlying causes, and addressing complications. While there is no cure for CKD, effective treatment can help preserve kidney function and improve quality of life.

• Managing Underlying Conditions - Treating diabetes, hypertension, and other conditions that contribute to CKD progression is essential.
• Blood Pressure Control - Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) help lower blood pressure and protect kidney function.
• Blood Sugar Control - For patients with diabetes, maintaining optimal blood glucose levels can reduce kidney damage.
• Lifestyle Modifications - A kidney-friendly diet, regular exercise, weight management, smoking cessation, and limiting alcohol intake help slow CKD progression.

Medications for CKD Management:

• ACE (angiotensin-converting enzyme) inhibitors like Altace (ramipril), Vasotec (enalapril, captopril and lisinopril) and Angiotensin receptor blockers (ARBs), such as (losartan, valsartan, candesartan, telmisartan) to help reduce blood pressure
• SGLT2 Inhibitors: Medications like dapagliflozin can slow kidney function decline and are often recommended for patients with proteinuria.
• Diuretics: Loop diuretics like Lasix (furosemide) to manage fluid retention and reduce swelling.
• Phosphate Binders: Control phosphate levels to prevent bone disease.
• Erythropoietin Therapy: Used to treat anemia associated with CKD.
• Vitamin D and Calcium Supplements: Help prevent bone loss.
• Antidiabetic drugs like Farxiga (dapagliflozin) that reduce blood sugar
• Anti-cholesterol (Statin) drugs like Lipitor (atorvastatin) and Zocor (simvastatin) that lower cholesterol
• Potassium binders like Lokelma (sodium zirconium cyclosilicate) that treat high potassium

In severe cases, advanced treatment options include;

• Dialysis: Required for patients with end-stage kidney disease (ESKD) when kidney function is severely impaired. Hemodialysis and peritoneal dialysis help remove waste and excess fluids from the body.
• Kidney Transplant: A long-term solution for patients with ESKD, offering improved survival and quality of life compared to dialysis.

Dialysis and Kidney Transplant

For individuals who progress to end-stage renal disease (ESRD), dialysis may be necessary to remove waste from the body. There are two primary types of dialysis:

Hemodialysis

Blood is filtered through a machine that removes waste, products, excess water and excess salt and then returned back to the body. It is typically performed three times a week for four hours.

Peritoneal Dialysis:

A dialysis solution is infused into the abdomen to absorb waste through a catheter. The solution absorbed waste is then removed via the same catheter. Fresh solution is added to continue the process of cleaning. This process can be done at home, with options for manual or machine-assisted processes. There are two types of peritoneal dialysis which are; continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD). CAPD involves a change in dialysis solution four times a day while CCPD uses a machine to automatically fill, remove and refill the fluid during the nighttime.

Lifestyle Modifications for Chronic Kidney Disease

Lifestyle changes are crucial at every stage of chronic kidney disease (CKD) to promote health and slow disease progression. Recommended modifications include:

• Limiting Salt Intake: People with CKD and hypertensionshould consume no more than 2,400 milligrams (mg) of sodium daily from all sources
• Limiting Protein Intake: Consultation with a healthcare provider is essential to determine the appropriate protein intake based on CKD stage
• Quitting Smoking: Smoking narrows blood vessels, reducing kidney blood flow. It also worsens diabetes control, increasing CKD risk
• Maintaining a Healthy Weight: Regular exercise (at least 150 minutes per week) and a balanced diet help lower blood pressure and blood sugar levels, reducing CKD progression risk

Nursing Management of CKD

These measures are crucial for the optimal care of individuals with CKD

Observation
• Monitor for potential complications
• Temperature, pulse, respiration and blood pressure 4 hourly
• Strict intake and output should be kept Assess cognitive level and document any seizures
• Assess urine for potassium and oedema and report any deviations
• Observe patient for signs of pericarditis
• Weigh patient daily and record

• Avoid high sodium, potassium foods / Give small nutritious meals frequently
• Give high vitamins
• Restrict fluids to about 500 - 600mls plus previous day's output
• Ensure that your patient does not get constipated

• Daily bed bath or assisted bath with mild soap taking care of perineum
• Keep patient's skin dry with towel
• Care for fingernails short
• Change bed linen frequently to prevent sweating
• Pad fingernails if possible to prevent possible body scratch.

• Encourage patient to drink limited amount of fluids when thirsty
• Patient can save of his allotted fluid for ice cubes to be sucked when thirsty
• Eat before drinking to avoid possible dry mouth
• Use other substances such as chewing gum to moisten the mouth
• Weigh every morning to assess possible fluid overload.

• Establish rapport for good communication
• Encourage patient to express his or her fears, feelings and anxieties
• Educate the patient and family on disease condition and be ready to give simple answers to the questions
• Explain the series of procedures and investigations to the patient

• Ensure comfort and rest for patient
• Maintain a well - ventilated environment and lighted room
• Encourage deep breathing and coughing exercises to prevent pulmonary congestion
• Provide passive exercises for bedridden patients
• Protection from injury
• Pad the side rails to prevent injury and ecchymosis
• Turn patient often in bed to prevent bed sores
• Convoluted mattresses may be used to avoid skin breakdown v Keep patient close to the nurses' station if possible

Preventions of CKD

• Quit smoking, if you smoke
• Avoid tobacco use
• Manage your high blood pressure
• Eat a well-balanced diet
• Exercise regularly
• Maintain a healthy weight
• Manage your blood sugar if you have diabetes
• Limit alcohol-containing beverages