Tests Used to Investigate CKD

You are likely to have routine urine dipstick tests from time to time to check for blood and protein in the urine. Also, blood tests may be done from time to time to check on your blood level of chemicals such as sodium, potassium, calcium and phosphate. Exams and tests are very important to be performed to determine kidney functions related to any underlying kidney condition, slow down the progression of kidney damage and to relieves symptoms of kidney disease either acute or chronic.

The exams and tests are:
Creatinine is a waste product in your blood that comes from muscle activity. Higher levels of creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products.

A fasting blood glucose test is done to detect high blood sugar levels as high blood sugar level lead to damage blood vessels in the kidneys.

Glomerular Filtration Rate (GFR): The estimated glomerular filtration rate (eGFR) is
estimation of the volume of blood that is filtered by the glomeruli in your kidneys over a given period of time. A normal eGFR is 90 ml/min/1.73 m or more.

Urine Protein: When your kidneys are damaged, protein leaks into urine. Normally there is little or no protein in urine. Kidney disease can cause increased protein in the urine. Persistent protein in the urine is an early sign of chronic kidney disease.

Blood Urea Nitrogen (BUN): A blood urea nitrogen test measures the amount of urea nitrogen that's in your blood. Your liver produces ammonia — which contains nitrogen — after it breaks down proteins used by your body's cells. A BUN test is done to see how well your kidneys are working. It is normally removed from your blood by your kidneys. If your kidneys are not able to remove urea from the blood normally, your BUN level rises.

Serum Albumin: Albumin is a protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood. Low albumin levels can reflect diseases in which the kidneys cannot prevent albumin from leaking from the blood into the urine and being lost. In this case, the amount of albumin or protein in the urine also may be measured (see microalbumin).

TSAT and Serum Ferritin: Serum ferritin in chronic kidney disease: reconsidering the upper limit for iron treatment. TSAT (pronounced tee-sat) and serum ferritin (pronounced ferry-tin) are measures of iron in the body. TSAT should be above 20 percent and your serum ferritin should be above 100.

Urine Creatinine: This test estimates the concentration of your urine and helps to give an accurate protein result. Low levels of creatinine in the urine may point to a kidney disease, certain muscular and neuromuscular disorders, or an obstruction of the urinary tract.

Protein-to-Creatinine Ratio: This estimates the amount of protein you excrete in your urine in a day and avoids the need to collect a 24-hour sample of your urine.

Hemoglobin: Hemoglobin is the part of red blood cells that carries oxygen from your lungs to all parts of your body. This test is often part of a comprehensive test called a complete blood count (CBC) or complete blood test. In patients who have kidney disease, the doctor will look at your hemoglobin and hematocrit levels (You will feel less tired and have more energy when your hematocrit reaches at least 33 to 36 percent) both taken from analyzing your red blood cells. The test is performed throughout the early stages of chronic kidney disease and the later stages, including end stage renal disease (ESRD).

The microalbumin test detects very small amounts of albumin in the urine. Albumin is protein. One of the early signs of damaged kidneys is the presence of albumin in the urine. In the early diagnostic stage of chronic kidney disease. Yearly for people with diabetes or high blood pressure.

Parathyroid Hormone (PTH): High levels of parathyroid hormone (PTH) may result from a poor balance of calcium and phosphorus in the body. Blood tests will be done to check calcium, phosphorus, and PTH levels. Phosphorus levels will be low if you have absorption problems, and high if you have kidney failure.This can cause bone disease. Caution: Do not take over-the-counter vitamin D unless ordered by your doctor.

Potassium: Potassium is a mineral in your blood that helps your heart and muscles work properly. A potassium level that is too high or too low may weaken muscles and change your heartbeat. This test to diagnose or monitor kidney disease. The most common cause of high potassium levels is kidney disease.

Total Cholesterol: Cholesterol is a fat-like substance found in your blood. A high cholesterol level may increase your chance of having heart and circulation problems. Having too much cholesterol in the blood is not a disease in itself, but can lead to the hardening and narrowing of the arteries (atherosclerosis) in the major vascular systems and kidney problems. High cholesterol is also seen in connection with other diseases such as kidney diseases and diabetes.

HDL Cholesterol: HDL cholesterol is a type of "good" cholesterol that protects your heart. High-density lipoprotein (HDL) cholesterol, is the “good” before fit sort of cholesterol, which helps to be the low-density lipoprotein, before LDL, commencing causing wound to your kidneys. For many patients, the target level for HDL cholesterol is above 40.

LDL Cholesterol: LDL cholesterol is a type of "bad" cholesterol. A high LDL level may increase your chance of having heart and circulation problems. For many patients, the target level for LDL cholesterol is below 100. Increased LDLlevels can be caused by certain kidney diseases.

Calcium: Calcium is a mineral that is important for strong bones. Blood calcium is tested to screen for, diagnosis, and monitor a range of conditions relating to the bones, heart, nerves, kidneys and teeth. Calcium need to be checked in kidney disease because low calcium is especially common in those with kidney failure.

Phosphorus: A high phosphorus level can lead to weak bones. While phosphorus tests are most commonly performed on blood samples, phosphorus is sometimes measured in urine samples to monitor elimination by the kidneys. Higher than normal levels of phosphorus (hyperphosphatemia) may be due to or associated with Kidney failure and hypoparathyroidism.

Blood Pressure: For hypertension patients, make sure to follow all the steps in prescribed treatment, which may include taking high blood pressure medications, cutting down on the amount of salt in your diet, losing excess weight and following a regular exercise program.

Triglyceride: Triglyceride is a type of fat found in your blood. A high triglyceride level along with high levels of total and LDL cholesterol may increase your chance of heart and circulation.

Perform an ultrasound or CT scan to get a picture of your kidneys and urinary tract.

Kidney disease runs in families, so encourage close family members to have their kidney function tested. If kidney disease is found early stage, treatment can be started to slow or stop the damage of kidney.

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General Management

Early recognition and intervention are crucial to slow  disease progression, maintaining quality of life, and improving outcomes. Family physicians have the opportunity to screen at-risk patients, identify affected patients, and ameliorate the impact of chronic kidney disease by initiating early therapy and monitoring disease progression.

These are general treatment that may be required for anyone with failing kidneys, whatever the cause.

• Restrict fluid and salt intake
  Reducing sodium in your diet helps you control high blood pressure, keeps you from being thirsty, and prevents your body from holding onto extra fluid. A low-salt diet is usually needed. When your kidneys are not healthy, extra sodium and fluid build up in your body. This can cause swollen ankles, puffiness, a rise in blood pressure, shortness of breath, and/or fluid around your heart and lungs. You need to restrict salt intake. Occasionally people have the opposite problem, and need to take extra fluid and salt. Avoid eating junk food,canned food, smoked meat, chips, processed cheese, and crackers. Look for food labels that say Low sodium, No salt added, Sodium-free, Sodium reduced, and Unsalted. DO not use salt substitutes because they contain potassium.
• Lowering blood pressure
  BP target that should be achieved to slow the progression of renal damage, and the influence of baseline and current proteinuria on the renoprotective effects of antihypertensive therapy. Additional research suggests that nighttime BP, removed from physical, emotional and other stresses, may be a better measure of a patient's actual BP status and his or her risk for cardiovascular problems. Excellent blood pressure control has been shown to slow down the progression of chronic renal failure, in addition to the benefits to the heart and blood vessels elsewhere in the body. It is recommended that people with chronic kidney disease use whatever therapy is necessary, including lifestyle changes and medicines, to keep their blood pressure below 130/80.
• Treat anaemia
  All patients with chronic kidney disease, regardless of stage or cause, should be screened for anemia, which should be diagnosed and evaluated when Hb level is less than 12.0 g/dL in adult women and less than 13.5 g/dL in adult men. The anaemia that goes with renal failure is mainly due to a deficiency of a hormone called erythropoietin (Epo). Epo is produced by the kidney to stimulate red blood cell production from the bone marrow. A deficiency of Epo leads to anaemia.
• Diet
  The purpose of this diet is to maintain a balance of electrolytes, minerals, and fluid in patients who are on dialysis. In kidney patients, typically the calcium level in the blood becomes low and the phosphate level high. Your recommended diet may change over time if kidney disease gets worse. For stages 3 and 4 CKD, the protein intake in your diet should be limited. The amount allowed will depend on your body size and the condition of your kidneys. Potassium is needed to help keep your heart beating steadily. A daily diet containing the following mineral ingredients should be strictly maintained. Kidney diseases and salt are almost synonymous. Higher the salt intake, higher the risk of the CKD, high blood pressure and heart disease. fluid intake must be watched. Some fruits like orange, apples, grapes and vegetables like lettuce also contain a lot of water. So, avoid such fruits. Alfacalcidol or calcitriol: these are active forms of Vitamin D, which is often short in renal failure, as the kidneys fail to process it.
• Prevention of heart disease, stroke and vascular disease
  People with kidney disease are at greatly increased risk of heart disease, stroke and problems with the circulation.
• Acidaemia
  In chronic kidney disease the kidneys are unable to excrete the normal acid waste products of the body, so neutralising acidemia is very important by taking bicarbonate tablet. People in renal failure often have too much acid in the blood (acidaemia) and have to take bicarbonate tablets to neutralise this.

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Management of CKD

The goal of therapy is to slow down or halt the progression of CKD to stage 5. Control of blood pressure and treatment of the original disease, whenever feasible, are the broad principles of management.

CKD Management: Stage 1 and 2 (eGFR more than 60 mL/min/1.73m2)
Reducing blood pressure is very important, weight (reduced or gained) and urine dipstick (microalbuminuria if diabetes present), diagnose and treat kidney disease, reduce cardiovascular risk and slow progression of kidney disease. Additionally, any medications should be reviewed, as the dose may need to be altered and some drugs may need to be avoided as they could damage the kidneys further. Laboratory assessment including :obtain creatinine and electrolytes, fasting lipids, biochemical profile including urea, fasting glucose can reduces the rate of progression of kidney diseasa, observe eGFR: Once the GFR falls below 30, an additional important task is to prepare the patient for a smooth transition to renal replacement therapy.

CKD management Stage 3 (eGFR 30–59mL/min/1.73m2)
Adjustment of medication doses and treat complications, appropriate for kidney functions, avoidance of renally-excreted and nephrotoxic medicines, reduce cardiovascular risk and reduce progression of kidney disease. Laboratory assessment including:  observe for fasting lipids, iron stores, full blood count, eGFR, parathyroid hormone, fasting glucose calcium and phosphate.


CKD management Stage 4 and 5
Prepare for kidney replacement therapy and Initiate kidney replacement therapy
(dialysis or transplantation) if uremia is present. In CKD stages 4 and 5 it is usually necessary to get advice from a kidney specialist, especially in stage 5 because kidney failure may become life threatening.

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Who are at risks of CKD?

Modifiable risk factors:

• Hypertension (high blood pressure)
• Have diabetes mellitus
• Obesity
• Smoking
• lifestyle modification: physical activity, nutrition, alcohol)
  

Non-modifiable risk factors:

• Family history of kidney disease
• Age over 50 years
• Autoimmune disease
• Aboriginal or Torres Strait Islander heritage

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Complications

Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, Anaemia . Chronic kidney failure can affect almost every part of your body. These complications are:

• Renal osteodystrophy(including the role of secondary hyperparathyroidism).Renal osteodystrophy is a bone disease that occurs when your kidneys fail to maintain the proper levels of calcium and phosphorus in your blood. Secondary hyperparathyroidism (SHPT) is a complication of chronic kidney disease. SHPT occurs when the parathyroid glands overproduce parathyroid hormone (PTH) as a result of low calcium levels.The overproduction of parathyroid hormone in the parathyroid glands in the neck is also known as Hyperparathyroidism. An active form of Vitamin D is produced by the healthy kidneys. Less calcium in the body let the parathyroid gland to release parathyroid hormone. The pathogeny of renal osteodystrophy is related to metabolic disorders Of Calcium, Phosphorus and Vitamin D.
• lLack of bone mineralization causes weak bones and an increased risk of bone fractures.
• Inflammation: Decreased immune response, which makes you more vulnerable to infection. Pericarditis as inflammation of the sac-like membrane that envelops your heart (pericardium) The consequences of a chronically activated immune system impact on the myocardial fibrosis, development of heart dysfunction, acceleration of atherosclerosis, increased muscle catabolism, vascular calcification and such as vascular degeneration, loss of appetite, insulin resistance, and anemia.
• Bleeding problems are also very common among people with chronic kidney disease. This is because of the complex blood factor changes that happens in the patients' body. The Symptoms are: prolonged clotting time, easy bruising, blood in stools, nose bleeding and gastrointestinal bleeding.
• Nutritional disturbances (such as protein-energy malnutrition)
• Kidney disease patients , especially when in the chronic stage will have respond sleep disturbances. Sleeping problems are really common among people with kidney failure.
• Anemia: Anemia is defined as a reduction in one or more of the major red blood
  cell measurements: hemoglobin concentration, hematocrit, or red blood cell count. The World Health Organization defines anemia as a hemoglobin level less than 13 g/dL in men and postmenopausal women, and less than 12 g/dL in premenopausal women. Normally, kidneys produces a hormone called "erythropoeitin" or EPO. EPO triggers the bone marrow to produce red blood cells. It follows when the kidneys fail, there is less EPO being produced and so there would be less RBC therefore anemia would occur. RBCs carry hemoglobin (Hgb), a protein which carries oxygen all throughout the body. in healthy kidneys, it senses the blood flow through the kidneys. If it does not have enough blood flow, then what happens is that it goes and stimulates erythropoeitin to go and act on the cells to produce bone marrow and develop new red blood cells. For the patient who is anemic, who's not delivering enough oxygen to the organs and tissues of the body, the heart has to work harder to compensate for this, and a well known compensation for anemia is that the heart will beat harder -- cardiac output increases, heart rate increases, stroke volume increases, and, over the years of increased work, left ventricular hypertrophy, a maladaptive compensation state, develops. When you have an adequate amount of blood, that then induces the kidney to turn off the production of erythropoeitin. decreased erythropoietin synthesis is the most important and specific etiology causing kidney disease associated anemia.
• Risk of cardiovascular disease. Cardiovascular problems can be a cause and complication of chronic kidney disease. Irrespective of diagnosis, the increased risk of cardiovascular disease in individuals with chronic kidney disease can be involved.
• Nerve damage: Chronic kidney disease is a critical and rapidly growing global health problem. Neurological disturbances as one of complications occur in almost all patients with kidney patients over time, potentially affecting all levels of the nervous system. Damage to your central nervous system, which can cause difficulty concentrating, personality changes or seizures. Autonomic dysfunction is a common and potentially life-threatening complication of kidney disease which is chronic, and can occur in the absence of length-dependent uremic neuropathy. Usually, patients on dialysis has cognitive impairment typically manifesting as a vascular-type dementia with prominent deficits in executive functions. Decreased sex drive or impotence is also common symptom of autonomic dysfunction in kidney disease patients, and it happen in male patients. Other common clinical features include bladder and bowel dysfunction, impaired sweating, and orthostatic intolerance.
• Fluid retention, which could lead to swelling in your arms and legs, hypertension or fluid in your lungs (pulmonary edema).
• Pregnancy complications that carry risks for the mother and the developing fetus
  Irreversible damage to your kidneys (end-stage kidney disease), eventually requiring either dialysis or a kidney transplant for survival.
• A sudden rise in potassium levels in your blood (hyperkalemia), which could impair your heart's ability to function and may be life-threatening Cardiovascular disease. Hyperkalemia describe the situation when blood potassium level surpass 5.5mmol/L. Generally, hyperkalemia commonly occurs to patients with renal disease,and especially to patients who has signs from Anuria or oliguria.

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Signs and Symptos of Kidney Disease

Kidney neither beats like heart, nor aches like stomach for eating too much. It grins and bears, acting as a scavenger silently, filtering and cleaning metabolites. That is the reason why it always hurts silently (chronic) over time.

However, for people at any stage of kidney disease, knowledge is power. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell. Knowing signs and symptoms of kidney disease can help you get the best treatment.

Signs and Symptoms show that Chronic Kidney Disease will emerge:

• Hyperkalemia with a range of symptoms including malaise and potentially fatal cardiac arrhythmias.
• Hypertention: increased due to fluid overload and production of vasoactive hormones created by the kidney via the RAS (renin-angiotensin system).
• Unexplained anemia, itchy skin: Kidneys remove wastes from the bloodstream. When the kidneys fail, the buildup of wastes in your blood can cause severe itching, cramps, bleeding gums and so on.Urea is excreted by sweating and crystallizes on skin ("uremic frost").
• Metabolic acidosis caused by accumulation of phosphates, sulfates, uric acid etc.
• You may have to get up at night to urinate.
• Swelling in the legs, ankles, feet, face, and/or hands.Have swollen in the legs, face, feet and ankles.
• Urine may be foamy or bubbly. You may urinate more often, or in greater amounts than usual, with pale urine, and urine protein excretions increase.
• You may urinate less often, or in smaller amounts than usual with dark colored urine, urine may contain blood (hematuria). A buildup of wastes in the blood (called uremia) can make food taste different (have a poor appetite) and cause bad breath (Ammonia Breath).
• Fatigue.
• Feel tired, soreness of waist and lumbago.
• Shortness of Breath.
• Leg/Flank Pain.
• Have muscle cramping at night.
• Have trouble concentrating.

Remember, some of the signs and symptoms can be due to reasons other than acute or chronic kidney disease. So, consult to your doctor is recommended.

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Causes Kidney Disease

The common causes of chronic kidney disease are diabetes and high blood pressure, and glomerulonephritis which are responsible for up to two-thirds of the cases. Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidney disease. Untreated or poorly treated high blood pressure is a major cause of CKD.

The etiological agent for this disease is hypertension leads to Renal Damage mainly through Renal Ischemia, and also damages from high TMP and high filtration inside glomerulus.

Other conditions that affect the kidneys are:

• Inherited diseases, Tubulointerstitial such as Polycystic Kidney Disease, which causes large cysts to form in the kidneys and damage the surrounding tissue.
• Obstructions caused by bilateral kidney stones and diseases of the prostate
  Malformations that occur as a baby develops in its mother's womb. For example, a narrowing may occur that prevents normal outflow of urine and causes urine to flow back up to the kidney. This causes infections and may damage the kidneys.
• Vascular, includes large vessel disease such as bilateral renal artery stenosis and small vessel disease such as  vasculitis, ischemic nephropathy and hemolytic-uremic syndrom.
• Glomerulonephritis can cause inflammation and damage to the filtration system units. These disorders are the third most common type of kidney disease. Postinfectious conditions is the most  causes of glomerulonephritis.
• Getting urinary infections very often. A bladder infection usually is not serious if it is treated right away. If you do not take care of a bladder infection, it can spread to your kidneys. A kidney infection is serious and can cause permanent damage of kidney.
• Lupus and other diseases that affect the body's immune system. Systemic lupus erythemotosus (SLE) or lupus is a chronic inflammatory disease. It causes the immune system to attack various systems of the body including blood vessels, the skin, joints, heart, lungs, nervous system, and kidneys. It is called systemic because it can affect the whole body. With people who are suffering from lupus, the tiny filters in their kidneys are damaged resulting in a loss of kidney function. This may cause fluid retention with swelling, weight gain called edema. Puffiness in fingers ankles and the legs often the first complaint of lupus nephritis patients.

However, this list is not complete and there are many other uncommon causes chronic kidney disease.

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Who are at Risk?

Anyone can get chronic kidney disease at any age. However, some people are more likely than others to develop kidney disease. Some people are more likely to have acute or chronic CKD than others. Risk factors make it more likely that a disease will develop later. High risk groups include:

• Those with diabetes. Almost 40% of new dialysis patients have diabetes, making it the fastest growing risk factor for kidney disease. Type 2 diabetes is the number one cause of kidney failure, responsible for more than one of every three new cases. Lowering blood sugar can help prevent it.
• People who have heart disease
• hypertension. Hypertention puts more stress on blood vessels throughout the body, including the kidney filters (nephrons). Hypertension is the number two cause of kidney failure. Control blood pressure—and perhaps prevent or slow the progress from kidney disease over time.
• Certain illnesses, like glomerulonephritis (inflammation of the filtering units of the kidneys), can damage the kidneys, sometimes enough to cause CKD.
• family history of kidney disease. Be aware of your family history and share it with your doctor.
• Over 60 years old. Since kidney function is reduced in older people, the older you are, the greater your risk.

Some racial and ethnic groups are also more likely to have kidney disease. These include:

• Asian and Pacific Islanders
• Hispanics/Latinos
• Native Americans
• African Americans

Discuss to your doctor about your risk factors. It is important to diagnose Chronic kidney disease early.

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Overview

The kidneys are a pair of bean-shaped organs that lie on either side of the spine in the lower middle of the back. Each kidney contains approximately one million filtering units called nephrons. Each nephron is made of a glomerulus and a tubule. A glomerulus is a capillary tuft that performs the first step in filtering blood to form urine.

Chronic kidney disease is gradually becoming the main chronic non-communicable disease, which threatens human being's health. One of the unfortunate realities for patients with chronic kidney disease is that they are at a much greater risk for cardiovascular disease than the general population. This is because kidney patients have higher incidences of many major risk factors, such as diabetes or hypertension.

Chronic kidney disease is also known as chronic renal disease. It is a progressive disease over a long period. The symptoms of worsening kidney functions are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Chronic kidney disease occurs when your kidneys are damaged and no longer work as well as well.

Normally, healthy kidneys remove waste from the blood. In addition to removing wastes and fluid from your body, the kidneys perform these other important regulations: make red blood cells, regulate your body water and other chemicals in your blood such as sodium, potassium, phosphorus and calcium, regulate blood pressure, and remove drugs toxins, promote strong bones, maintaining acid-base homeostasis, concentrating urine. The kidneys receive blood from the paired renal arteries, and drain into the paired renal veins. Each kidney excretes urine into a ureter, itself a paired structure that empties into the urinary bladder. This is important because the kidneys' main role is to filter water soluble waste products from the blood. The other attachment of the kidneys are at their functional endpoints the ureters, which lies more medial and runs down to the trigone of urinary bladder.

Kidney disease is most often caused by diabetes mellitus or hypertention (high blood pressure). Diabetes and hypertention damage the blood vessels in the kidneys, so the kidneys are not able to filter the blood as well as they should. Usually this damage occurs gradually over many years. As more and more blood vessels are damaged, the kidneys eventually stop working.

Kidney disease is progressive. Kidney disease does not go away. Instead, it usually gets worse over time. Kidney disease can lead into kidney failure, at which point dialysis or a kidney transplant is needed. Kidney disease can be treated if detected early. The right treatment management can help prevent further kidney damage and slow down kidney disease.

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