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Definition of Chronic Kidney Disease

Explain about the case study on Acute Kidney Injury And Chronic Kidney Disease as Interconnected Syndromes?

Chronic Kidney Disease is considered as the condition that can be characterized by the loss of kidney function over a span of time. This disorder is also referred to as the Chronic Renal Failure. It can be clearly estimated that almost 15,000,000 people dies due to the Chronic Kidney Disorder.

CKD, which is formally as known as Chronic Kidney generally, focuses towards the loss of kidney functioning among the patients. It is been often observed that kidney tend to filter the excess fluids which are associated to the blood along with other waste materials efficiently. These particles are then excreted through urine (Thadhani et al. 2012). Thereby, it can be stated that when a patient suffers from such disease, then there are huge abnormal symptoms observed. Some of the most significant accumulations include electrolytes, toxic fluids and wastes.

The primary stage of the CKD is symbolized by limited symptoms. It can be stated that in the primary stage, the disorder may not become apparent physically. The treatment for the Chronic Kidney Disorder mainly focuses toward the condition where there is a limitation to the kidney metabolism to a huge extent (Stevens and Levin 2013). The adverse effect of Kidney impairment finally results in complete failure of the kidney. On the large extent, Artificial Filtering Protocol (which is also known as Dialysis) or the Kidney Transplant therapy are considered as effective measures to prevent patients suffering from Chronic Kidney Disorder significantly.

The various stages of Chronic Kidney Disorder are stated in the table below, which tend to estimate (or measure) the factors of GFR (Glomerular Filtration Rate). One a basic note, Chronic Kidney Disorder is characterized by five stages, where the primary stages (Stage 1 and 2) and considered to be the minimal affecting stages for a Kidney Disorder.

Table 1: Table representing the Stages associated to Chronic Kidney Disorder

Stages

Glomerular Filtration Rate

Description of the Event

Treatment

1

85+

There is a normal functioning of the urine, however there are structural abnormalities or the genetic trait point

Controlling the blood pressure and thereby managing the effect of Stages 1 & 2 CKD

2

55-80

The kidney functioning is mildly reduced.

Controlling the blood pressure and thereby managing the effect of Stages 1 & 2 CKD

3A

40-55

There is a moderate reduction of the kidney function

Controlling the blood pressure and thereby managing the effect of Stage 3 CKD

3B

32-40

4

16-31

The kidney functioning is significantly reduced

Effective planning for the stage of renal limitation, supported by the management of Stage 4 & 5 CKD

5

 

The condition is very severe, often highlights to complete failure of the kidney (Renal Failure)

Effective planning for the stage of renal limitation, supported by the management of Stage 4 & 5 CKD


(Source: Thadhani et al. 2012)

Biochemical

A large number of Biochemical investigation therapies are generally carried out in case of Chronic Kidney Disease (CKD). The most common types of therapies that are carried out include the following factors:

Serum Sodium: The level of serum sodium is usually diagnosed to be normal but the level of serum sodium is found to be comparatively low in case of patients suffering from Chronic Kidney Disease (CKD)

Classification of Chronic Kidney Disease

Plasma Glucose: Monitoring of the plasma glucose helps in detecting the undiagnosed diabetes. This in turn helps in assessing the diabetes of control.

Serum Bicarbonate: In comparison to the normal patients, the sodium bicarbonate level of the affected person is found to be very low.

Serum Potassium: In comparison to the level in case of normal patients, the serum potassium levels in case of patients who are suffering from Chronic Kidney Disease are generally found to be high in comparison to the standard value.

Serum Albumin: In case of nephritic and /or malnourished patients, the Hypoalbuminaemia in patients are found to be low.

Serum Calcium: The level of serum calcium for patients who are suffering from Chronic Kidney Disease is found to be normal. But in many cases, patients with high levels of serum calcium have been also diagnosed due to initiation of different kind sof metabolism.

Serum Phosphate: Patients suffering from Chronic Kidney Disease has been diagnosed with high levels of serum phosphate.

Serum Alkaline Phosphate: Higher value of serum alkaline phosphate has been observed for patients suffering from CKD.

Serum Cholesterol and Triglycerides: Dyslipidaemia is a common disease that is generally found among patients suffering from Chronic Kidney Disease.

Serum Parathyroid Hormone: The level of Serum Parathyroid Hormone tends to increase considerably that is directly associated with deterioration of the renal functioning.

e-FGR is a cell surface protein. The “cell surface protein” specifically binds to the ‘epidermal growth factor’. The protein on binding with the ligand produces a change associated with dimerization of the receptor along with autophosphorylation of the Tyrosine residue. This in turn causes proliferation of cells. Mutation in the given gene causes lung cancer.

e-GFR is primarily used for screening. It also helps in monitoring the status of the kidney for a particular patient. It is generally performed by initiating a creatinine test that specifically helps to calculate the rate of glomerular filtration thus estimated. The creatinine test forms a component of the routine ‘Comprehensive Metabolic Panel (CMP)’ and ‘Basic Metabolic Panel (BMP)’. The creatinine test thus helps a care provider to estimate present position of the patient’s kidney. The mechanism of the e-GFR is proficiently determined without involving any kind of added testing. Similarly the blood sample has been effectively sent for the measurement of the cretainine efficiency at the same period of time. The National Kidney Foundation has clearly stated that the creatinine efficiency can be automatically measured each time when a patient is subjected for a creatinine test. In order to evaluate the renal functioning for a particular individual, a creatinine test along with e-GFR is always initiated. Thus, the health practitioner who forms an effective part of the health diagnosis considers it as an important part. Thus, it is also applicable for patients suffering from renal dysfunctioning or for those who have been suspected by the health care giver. The warning signs of the mechanisms are discussed below:

Biochemical Investigation of Chronic Kidney Disease

Swelling and puffiness is generally observed around the eyes and also in face, thighs, ankles, wrists and abdomen.

The color of urine formed is either bloody or coffee.

Patients suffering from renal disorder have a decrease in the amount of urine formation

Different kinds of urination problems are also observed that specifically includes abnormal discharge during the process of urination or burning feeling. This is also associated with change in urination frequency (during the night time).

Patients are diagnosed with a very high blood pressure (hypertension)

Thus, implementation of the e-GFT test helps to detect kidney diseases. This is considered more consistent than the normal Creatinine test because it provides a better calculation of works. This particularly aims in measuring the reduction and deterioration of the kidney functioning.  As per the concepts of National Kidney Foundation (NFK) it can be thus analyzed that the actual values is found to be around ‘<60mL/min’. As the normal value tends to vary between “ 90-120 mL/min”, which is found below the average value (i.e 60 mL/min), it is thus recommended that there has been formation of different kinds of kidney impairment in an individual (Zhang et al. 2013).

Table 2: Table representing the Kidney Damage Stages and the Subsequent Findings

Stages related to the Kidney Damage

Observation

Glomerular Filtration Rate

Associated Findings

1

Minimal or the Normal Kidney damage associated to the normal function of GFR

Above 90

The Albumin or the Protein Concentration are considered to be higher

2

Mild decrease in the GFR concentration

55-85

The Albumin or the Protein Concentration are considered to be higher

3

Moderate decrement in the GFR

32-54

4

Effective Decrease in the GFR

14-25

5

Complete Failure of the Kidney Functioning

<15


(Source: Qaseem et al. 2013)

Creatinine Clearance

Creatinine Clearance Test mainly provides the information regarding the normal functioning of the kidneys. This test is mainly associated to the comparison study regarding the creatinine level found in the urine along with the level found in blood. The level of creatinine is mainly found to be considered as breakdown of the final product of creatinine, which is important for muscular development.

Creatinine Clearance Test is considered to be highly useful for both the blood and urine sample as it has a shelf life of only 1 day (24 hours). This test is used in order to estimate the GFR level associated to the sample. The factor of GFR can be measured in order to ensure the normal functioning of the kidney filtering (glomeruli) units. On a normal scale, this Clearance Test estimates 96 to 136 ml/min (in case of male) and 87 to 127 ml/min (in case of female).

ACR and PCR

ACR is commonly known as Albumin Creatinine Ration is mainly used to screen people suffering from various chronic disorders. This includes the factors of high blood pressure and diabetes, thereby triggering the consequence of Chronic Kidney Disorder. Identification of the patients suffering from the disorder at a very early stafe often helps the patient for treatment. Controlling the parameters of diabetes along with Hypertension generally helps to maintain the glycemic control. This often helps in reducing the effective blood pressure which helps in preventing the progression of kidney disease. As soon as the traces of Albumin is detercted in the urine sample, the test need to be repeated to confirm the concentration of the other periods. The test is generally measured by calculating the ratio of Albumin/Creatinine (A/C) ratio. Thie effective helps to determine the Albumin level which tend to escape from the kidney and enters to urine. This concentration of urine tend to vary throughout the day.

e-GFR for Chronic Kidney Disease

The PCR, which is also known as Protein Creatinine Ratio provide the number of milligrams (proteins) associated to sample. This test reports the ration associated to protein of creatinine. When the Protein/ Creatinine (of Urine) ratio is higher than 100mg protein/ g of Creatinine, then it indicates towards the occurance of the disorder. When this ratio exceeds more than 3000, then it can be clearly noted that there is a serious damage of the kidney.

ACR possess higher specificity along with positive predicative value (better than PCR, >100mg/mmol)

When the value of ACR is >60mg/mmol, then it signifies towards the identification of proteinuria in the primary care

The cut off value associated to ACR>45mg/mmol are found to be higher than the normal Statistical Value as compared to ACR>60mg/mmol along with PCR>100mg/mmol

The ACR>45MG/MMOL can be considered to be acceptable for referring proteinuria

The reporting value of ACR>45mg/mmol are considered necessary in order to monitor and manage proteinuria (24 hours measurement). This helps to quantify the proteinuria after the referral of secondary care (Jamal et al. 2013).

ECG and Imaging of the Renal Tracking Protocol

This system is mainly detects the ventricular hypertrophy and ischemia. This helps to assess the cardiac functioning of the patient. Often it is observed that a patient suffering from Chronic Kidney Disease tend to develop effective malfunctioning in the cardiac muscles. Thus, implementing ECG becomes a subordinate parameter, which is essential in investigating the normal functioning of the heart.

Imaging plays a crucial role in investigating the renal functioning of a person. Two types of renal functioning are commonly encountered for investigating Chronic Kidney Disease. These are as follows:

Plain Abdominal X-Ray: This may show radio opaque stones or nephrocalcinosis for the patients suffering from Chronic Kidney Disease

Intravenous (IV) Pyelogram: This is not often used for the patients suffering from renal disorders. This is because it has a potential for contrast nephropathy.

Apart from these, there are significant parameters associated to Renal Ultrasound. IN renal ultrasound mechanism, small echogenic kidneys are seen in the advanced Chronic Kidney Disease stage. It has been estimated that the kidneys are observed to be of larger size, which ultimately becomes of normal size in advanced diabetic nephropathy. Moreover, structural abnormalities are also observed in the cased of polycystic kidneys (Mencarelli, Busutti and Montini 2015). Finally, it is used for screening hydronephrosis, which is mainly caused by Urinary Track Obstrction, or due to the involvement of the retroperitoneum with fibrosis, diffuse adenopathy or tumor.

Warning Signs of Chronic Kidney Disease

Renal Ultrasound Scanning can be efficiently advised to every patient suffering from Chronic Kidney Disorder. To be more specific about the consequences, which need to be analyzed for Renal Ultrasound parameter, involves the following factors:

Having accelerated progression associated to Chronic Kidney Disease

Have a possible visible or persistent invisible haematuria

Having effective symptoms identifying Urinary Tract Obstruction

Having a family record history of Polycystic Kidney Disease (may be genetical factor) and are aged over 20 years

Having a GFR of less than 30ml/ minute/ 1.73 m2

Considered by Nephrologists in order to highlight towards the parameters of renal biopsy

The Renal Pyelogram tends to indicate towards the clinical suspicion of obstruction despite a negative ultrasound study finding (Gansevoort et al. 2013).

Radionuclide scan generally helps in various parameters. These are as follows:

It is estimated to be useful to screen for renal artery stenosis when performed with captopril administration. However, many of the medical practitioners believe that Renal Radionuclide Scan is unreliable for GFR of less than 30 ml/ minute (Findlay and Isles 2015).

Moreover, this scanning mechanism also quantifies differential renal contribution to the total GFR.

CT scan

CT scan defines the renal masses along with the presence of cysts, which are clearly highlighted by observing under the influence of ultrasounds. This is considered as the most sensitive test, which is used for identifying renal stones (Olesen et al. 2012).

Magnetic Resonance Angiography (MRI)

Some patients require CT scan but cannot receive the IV contrast. For such patients, MRI scanning becomes an effective parameter to investigate the presence of renal disorders associated to the individual (Coca, Singanamala and Parikh 2012). The benefits, which are associated to MRI scanning, are as follows:

Like the protocol of CT scan and renal venography, MRI scanning is considered as a reliable mechanism that is mainly used for diagnosing the presence or renal vein thrombosis.

Magnetic Resonance Angiography is also considered as a useful protocol, which mainly targets for diagnosing renal artery stenosis, although the renal arteriography remains the investigation of choice for such patients.

Other Investigation Mechanisms

The other commonly accepted Chronic Kidney Disease Investigation mechanisms includes:

Micturating Cystourethrogram: This is used mainly for diagnosing vesicoureteric reflux (Chawla et al. 2014)

Renal Biopsy: After surgery, the removed tissue is often encountered for a renal biopsy test. The test is often used to detect the presence of oncogenes in the tissue. Positive Biopsy Test generally indicates towards the fact that the patient is highly susceptible in developing cancer in the future.

Interconnectedness of Acute Kidney Injury and Chronic Kidney Disease

The parameter of Monitoring mainly triggers towards wide range of parameters. These parameters are efficiently described below:

The factor of e-GFR need to be monitored systematically. The occurrence of frequency generally depend on severity of renal impairment

The patients suffering from Chronic Kidney Disorder generally possesses higher level of Proteinuris. Assessment of CKD needs to be conducted yearly.

The parameter of Proteinuria needs to be assessed by measuring the PCR or ACR values.

The detection of primary abnormal e-GFR protocol results to promote the clinical assessment of patients. This is followed by a repetition test within the two weeks in order to ensure the fluctuation of GFR rate. When the mechanism is found to be stable, then advanced test need to be performed by 90 days to completely evaluate the occurance of CKD

When the diagnosis of CKD is completely confirmed, then it can be assumed that e-GFR assessment therapy should not be followed within 3 months

The detection at the primary level of proteinuria (equivalent to <0.6g/day of total protein) need early confirmation because of the repeat tests. This is generally performed on the early morning specimen of urine.

Chronic Kidney Disorder triggers effective and immediate consequences which generally formulates higher immunological alterations. In the primary stage, CKD causes various chronic simulations associated to the Rennin Angiotensin Aldosterone System (RAAS). Based on this parameter, the effective simulation causes polarization associated to the TH17 cells. The effective alterations generally occur due to the presence of dendritic polarized cells along with the retention of the sodium level (Coca, Singanamala and Parikh 2012).

Second of all, Chronic Kidney Disease results to yhe deficiency of Vitamin D level causing uremic barrier in the intestine and thereby resulting to the dysfunction. It often results the cytokine accumulation resulting to the consequences. The combo effect result in formation of the systemic inflammation (Chawla et al. 2014).

Finally, Chronic Kidney Disorder forms immune-suppression. This is mainly associated to the accumulation of metabolites (toxic) causing renal failure.

Conclusion

Thus, it can be concluded from the above study that CKD at the early stage can be cured if effective strategies are implemented. The mechanism of Kidney Dialysis along with Transplantation is considered to be highly accepted medical tool which tend to limit the dysfunctioning of kidneys to a large extent. Countries such as the United Kingdom or the United States of America focuses towards the development of more effective strategies to prevent Chronic Kidney Disorder in a more logical and systemic manner.

Treatment of Chronic Kidney Disease

References

Chawla, L.S., Eggers, P.W., Star, R.A. and Kimmel, P.L., 2014. Acute Kidney Injury And Chronic Kidney Disease As Interconnected Syndromes. New England Journal of Medicine, 371(1), pp.58-66.

Coca, S.G., Singanamala, S. and Parikh, C.R., 2012. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis.Kidney international, 81(5), pp.442-448.

de Zeeuw, D., Akizawa, T., Audhya, P., Bakris, G.L., Chin, M., Christ-Schmidt, H., Goldsberry, A., Houser, M., Krauth, M., Lambers Heerspink, H.J. and McMurray, J.J., 2013. Bardoxolone methyl in type 2 diabetes and stage 4 chronic kidney disease. New England Journal of Medicine, 369(26), pp.2492-2503.

Findlay, M. and Isles, C., 2015. Managing Pain in Chronic Kidney Disease. In Clinical Companion in Nephrology (pp. 171-175). Springer International Publishing.

Gansevoort, R.T., Correa-Rotter, R., Hemmelgarn, B.R., Jafar, T.H., Heerspink, H.J.L., Mann, J.F., Matsushita, K. and Wen, C.P., 2013. Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. The Lancet, 382(9889), pp.339-352.

Hering, D., Esler, M.D. and Schlaich, M.P., 2013. Chronic kidney disease: role of sympathetic nervous system activation and potential benefits of renal denervation. EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, 9, pp.R127-35.

Jamal, S.A., Vandermeer, B., Raggi, P., Mendelssohn, D.C., Chatterley, T., Dorgan, M., Lok, C.E., Fitchett, D. and Tsuyuki, R.T., 2013. Effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease: an updated systematic review and meta-analysis. The Lancet, 382(9900), pp.1268-1277.

Jha, V., Garcia-Garcia, G., Iseki, K., Li, Z., Naicker, S., Plattner, B., Saran, R., Wang, A.Y.M. and Yang, C.W., 2013. Chronic kidney disease: global dimension and perspectives. The Lancet, 382(9888), pp.260-272.

Levey, A.S. and Coresh, J., 2012. Chronic kidney disease. The Lancet,379(9811), pp.165-180.

Mencarelli, F., Busutti, M. and Montini, G., 2015. Chronic Kidney Disease. InPediatric Urology (pp. 353-363). Springer Milan.

Olesen, J.B., Lip, G.Y., Kamper, A.L., Hommel, K., Køber, L., Lane, D.A., Lindhardsen, J., Gislason, G.H. and Torp-Pedersen, C., 2012. Stroke and bleeding in atrial fibrillation with chronic kidney disease. New England Journal of Medicine, 367(7), pp.625-635.

Parsa, A., Kao, W.L., Xie, D., Astor, B.C., Li, M., Hsu, C.Y., Feldman, H.I., Parekh, R.S., Kusek, J.W., Greene, T.H. and Fink, J.C., 2013. APOL1 risk variants, race, and progression of chronic kidney disease. New England Journal of Medicine, 369(23), pp.2183-2196.

Qaseem, A., Hopkins, R.H., Sweet, D.E., Starkey, M. and Shekelle, P., 2013. Screening, monitoring, and treatment of stage 1 to 3 chronic kidney disease: A clinical practice guideline from the American College of Physicians. Annals of internal medicine, 159(12), pp.835-847.

Stevens, P.E. and Levin, A., 2013. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Annals of internal medicine, 158(11), pp.825-830.

Thadhani, R., Appelbaum, E., Pritchett, Y., Chang, Y., Wenger, J., Tamez, H., Bhan, I., Agarwal, R., Zoccali, C., Wanner, C. and Lloyd-Jones, D., 2012. Vitamin D therapy and cardiac structure and function in patients with chronic kidney disease: the PRIMO randomized controlled trial. Jama, 307(7), pp.674-684.

Tonelli, M., Muntner, P., Lloyd, A., Manns, B.J., Klarenbach, S., Pannu, N., James, M.T., Hemmelgarn, B.R. and Alberta Kidney Disease Network, 2012. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. The Lancet, 380(9844), pp.807-814.

Trialists’Collaboration, B.P.L.T., 2013. Blood pressure lowering and major cardiovascular events in people with and without chronic kidney disease: meta-analysis of randomised controlled trials.

Vaziri, N.D., Wong, J., Pahl, M., Piceno, Y.M., Yuan, J., DeSantis, T.Z., Ni, Z., Nguyen, T.H. and Andersen, G.L., 2013. Chronic kidney disease alters intestinal microbial flora. Kidney international, 83(2), pp.308-315.

Yale, J.F., Bakris, G., Cariou, B., Yue, D., David‐Neto, E., Xi, L., Figueroa, K., Wajs, E., Usiskin, K. and Meininger, G., 2013. Efficacy and safety of canagliflozin in subjects with type 2 diabetes and chronic kidney disease.Diabetes, Obesity and Metabolism, 15(5), pp.463-473.

Zhang, L., Wang, F., Wang, L., Wang, W., Liu, B., Liu, J., Chen, M., He, Q., Liao, Y., Yu, X. and Chen, N., 2012. Prevalence of chronic kidney disease in China: a cross-sectional survey. The Lancet, 379(9818), pp.815-822.

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