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SOURCE

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Source: Hudson JQ, Wazny LD. Chronic kidney disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=134127380. Accessed January 2, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Chronic renal insufficiency.

  • Progressive kidney disease.

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DEFINITIONS

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  • Progressive loss of function over several months to years, characterized by gradual replacement of normal kidney architecture with parenchymal fibrosis.

  • Chronic kidney disease (CKD) categorized by level of kidney function:

    • Based on glomerular filtration rate (GFR).

    • Categories 1–5, each increasing number indicating more advanced stage of disease, as defined by declining GFR.

    • This classification system from the Kidney Disease: Improving Global Outcomes (KDIGO) also accounts for structural evidence of kidney damage.

    • CKD stage 5, previously referred to as end-stage renal disease (ESRD):

      • Occurs with GFR <15 mL/min/1.73 m2 (<0.14 mL/s/m2) and either chronic dialysis or kidney transplantation is needed to sustain life.

      • CKD 5D indicates a patient with ESRD who requires dialysis (hemodialysis or peritoneal dialysis).

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ETIOLOGY

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  • Susceptibility factors increase risk for kidney disease but do not directly cause kidney damage, including.

    • Advanced age.

    • US ethnic minority: African American, American Indian, Hispanic, Asian, or Pacific Islander.

    • Exposure to certain chemical and environmental conditions.

    • Low income/education.

  • Initiation factors are conditions that directly result in kidney damage and can be modified by drug therapy, including.

    • Diabetes mellitus.

    • Hypertension.

    • Obesity.

    • Autoimmune diseases.

    • Systemic infections.

    • Urinary tract infections.

    • Urinary stones.

    • Lower urinary tract obstruction.

    • Neoplasia.

    • Family history of CKD

    • Recovery from acute kidney injury.

    • Reduction in kidney mass.

    • Exposure to certain drugs.

    • Low birth weight.

  • Progression factors hasten decline in kidney function after initiation of kidney damage, including.

    • Glycemia in diabetics.

    • Hypertension.

    • Proteinuria.

    • Obesity.

    • Smoking.

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PATHOPHYSIOLOGY

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  • Most progressive nephropathies share final common pathway to irreversible renal parenchymal damage and ESRD (Fig. 1).

  • Key pathway elements:

    • Loss of nephron mass resulting from exposure to any of initiation risk factors.

    • Glomerular capillary hypertension resulting from compensatory hypertrophy.

    • Proteinuria as a result of direct cellular damage.

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FIGURE 1.

Proposed mechanisms for progression of renal disease. Reprinted with permission from Wells BG, DiPiro JT, Schwinghammer TL, et al. Pharmacotherapy Handbook. 10th ed. New York, NY: McGraw-Hill; 2017.

Graphic Jump Location
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EPIDEMIOLOGY

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  • Four most common causes of stage 5 CKD in the United States:

    • Diabetes mellitus.

    • Hypertension.

    • Glomerulonephritis.

    • Polycystic kidney disease.

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RISK FACTORS

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  • See Etiology.

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CLINICAL PRESENTATION

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  • CKD development and progression are insidious; early stages often undetected.

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SIGNS AND SYMPTOMS
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  • Symptoms associated with stages 4 or 5

    • Fatigue.

    • Weakness.

    • Shortness of breath.

    • Mental confusion.

    • Nausea/vomiting.

    • Bleeding.

    • Loss of appetite.

    • Itching.

    • Cold intolerance.

    • Peripheral neuropathies.

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