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Source: Derebail VK, Kshirsagar
AV, Joy MS. Chronic Kidney Disease: Progression-Modifying Therapies.
In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM.
Pharmacotherapy: A Pathophysiologic Approach. 8th edition. http://www.accesspharmacy.com/content.aspx?aid=7981349 and
Hudson JQ. Chronic Kidney Disease: Management of Complications.
In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM.
Pharmacotherapy: A Pathophysiologic Approach. 8th edition. http://www.accesspharmacy.com/content.aspx?aid=7981679.
Accessed August 13, 2012.
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- Chronic renal insufficiency
- Progressive kidney disease
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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)
- Stages 1–5, each increasing number indicating more
advanced stage of disease, as defined by declining GFR.
- This classification system from the National Kidney Foundation’s
Kidney Dialysis Outcomes and Quality Initiative (K/DOQI)
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/1.73m2 (<0.14
mL/s/m2) or in patients receiving renal
replacement therapy (RRT).
- For our purposes, ESRD refers specifically to patients receiving
chronic dialysis.
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- Susceptibility factors increase risk for kidney disease
but do not directly cause kidney damage, including:
- Advanced
age
- Reduced kidney mass and low birth weight
- Racial or ethnic minority
- Family history
- Low income or education
- Systemic inflammation
- Dyslipidemia
- Initiation factors are conditions that directly result in
kidney damage and can be modified by drug therapy, including:
- Diabetes mellitus
- Hypertension
- Autoimmune diseases
- Polycystic kidney disease
- Systemic infections
- Urinary tract infections
- Urinary stones
- Nephrotoxicity
- Progression factors hasten decline in kidney function after
initiation of kidney damage, including:
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- Most progressive nephropathies share final common pathway
to irreversible renal parenchymal damage and ESRD (Figure 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 result of direct cellular damage
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- Four most common causes of stage 5 CKD in United States:
- Diabetes mellitus
- Hypertension
- Glomerulonephritis
- Polycystic kidney disease
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- Screening studies should be done in older individuals
and those with family history of kidney disease.
- Serum
creatinine
- GFR measurement
- Urinalysis
- Imaging studies of the kidney
- Screen for presence of cardiovascular risk factors.
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- CKD development and progression are insidious; early stages
often undetected.
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- General symptoms associated with stages 1–4 (generally
absent in stages 1 and 2; minimal in stages 3 and 4):
- Edema
- Cold intolerance
- Shortness of breath
- Palpitations
...