Aetiology and a clinical picture of chronic renal failure

Czech version

Authors: J. Zadražil
Authors‘ workplace: III. interní nefrologická, revmatologická a endokrinologická klinika Lékařské fakulty UP a FN Olomouc, přednosta prof. MUDr. Vlastimil Ščudla, CSc.
Published in: Vnitř Lék 2011; 57(7&8): 607-613
Category: 136th internal medicine day, XXIV. Vanýskův den, Brno 2011

Overview

The term chronic renal failure (CRF) usually means the final stage of chronic kidney disease (CKD) with a decline in glomerular filtration rate (GF) below 0.25 mL/s. CRF is a world-wide serious health and economic issue with an increasing incidence and prevalence. CRF patients are, in comparison to other patients, hospitalized more often and for longer and, despite improvements in care, their quality of life is usually low and morbidity and mortality high. We present an overview of the most important CKD risk factors and the diseases most likely to result in CRF. Diabetic nephropathy, followed by various forms of ischemic renal disease and primary and secondary glomerulopathy, chronic tubulointerstitial nephritis and autosomal dominant polycystic kidney disease are the leading causes of CRF. We provide a brief overview of other disease states that may result in renal failure. Clinical manifestations of CRF are discussed, mainly cardiovascular, gastrointestinal, haematological and neurological symptoms. Breathlessness is a consequence of hypervolaemia, metabolic acidosis and anaemia. The disease often presents with symptoms, such as headache and visual disturbances, resulting from arterial hypertension. Gastrointestinal symptoms and fatigue, usually caused by anaemia, are frequent. Platelet dysfunction is manifested as an increased bleeding time. Paradoxically, apart form tendency to abnormal bleeding, CRF also tends to be associated with thromboembolic complications. Patients may experience itching, bone, joint and muscle aches, are more prone to infections. They may suffer from insomnia, concentration disorders and apathy. The signs of peripheral mixed sensory-motor neuropathy include paraesthesia, paresis and restless leg syndrome. However, renal failure may also be oligosymptomatic or asymptomatic. Cardiovascular complications are the most frequent cause of morbidity and mortality of CRF patients.

Key words:
chronic kidney disease – glomerular filtration rate – MDRD formula – renal failure – cardiovascular complications – anaemia – trombocytopathy – uremia

Sources

1. Levey AS, Coresh J, Balk E et al. National Kidney Foundation. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003; 139: 137–147.

2. National Kidney Foundation. Kidney Disease Outcome Quality Initiative (K/DOQI) clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39 (Suppl 1): 1–266.

3. Tesař V, Schück O et al. Klinická nefrologie. Praha: Grada Publishing 2006.

4. Teplan V et al. Praktická nefrologie. 2. vyd. Praha: Grada Publishing 2006.

5. Levey AS, Bosch J, Lewis JB et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction Equation. Modification of Diet in Renal Disease Study Group. Ann Int Med 1999; 130: 461–470.

6. Zima T, Teplan V, Tesař V et al. Doporučení České nefrologické společnosti a České společnosti klinické biochemie ČLS JEP k vyšetřování glomerulární filtrace. Klinická biochemie a metabolismus 2009; 2: 109–117.

7. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16: 31–34.

8. Glassock RJ, Winearls C. An epidemic of chronic kidney disease: fact or fiction? Nephrol Dial Transplant 2008; 23: 1117–1121.

9. United States Renal Data System. Excerpts from USRDS 2009 Annual Data Report. U.S. Department of Health and Human Services. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Am J Kidney Dis 2010; 55 (Suppl 1): S1.

10. Taddei S, Nami R, Bruno RM et al. Hypertension, left ventricular hypertrophy and chronic kidney disease. Heart Fail Rev 2010; DOI 10.1007/s10741–010–9197–z.

11. Eschbach JW. The anemia of chronic renal failure: Pathophysiology and the effects of recombinant erythropoietin. Kidney Int 1989; 35: 134–148.

12. Muntner P, He J, Hamm L et al. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol 2002; 13: 745–753.

13. Longenecker JC, Coresh J, Powe NR et al. Traditional cardiovascular disease risk factors in dialysis patients compared with the general population: the CHOICE Study. J Am Soc Nephrol 2002; 13:1918–1927.

14. Ok E, Basnakian AG, Apostolov EO et al. Carbamylated low-density lipoprotein induces death of endothelial cells: a link to atherosclerosis in patients with kidney disease. Kidney Int 2005; 68: 173–178.

15. Di Benedetto A, Marcelli D, D’Andrea A et al. Risk factors and underlying cardiovascular disease in incident ESRD patients. J Nephrol 2005; 18: 592–598.

16. Busch M, Franke S, Müller A et al. Potential cardiovascular risk factors in chronic kidney disease: AGEs, total homocysteine and metabolites, and the C-reactive protein. Kidney Int 2004; 66: 338–334.

17. Drüeke TB, Massy ZA. Atherosclerosis in CKD: differences from the general population. Nat Rev Nephrol 2010; 6: 723–735.

18. Ohtake T, Kobayashi S, Moriya H et al. High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination. J Am Soc Nephrol 2005; 16: 1141–1148.

19. Goldsmith DL, Covic A. Coronary artery disease in uremia: Etiology, diagnosis and therapy. Kidney Int 2001; 60: 2059–2072.

20. McCullough PA. Coronary artery disease. Clin J Am Soc Nephrol 2007; 2: 611–616.

21. McCullough PA, Sandberg KR, Dumler F et al. Determinants of coronary vascular calcification in patients with chronic kidney disease and end-stage renal disease: a systematic review. J Nephrol 2004; 17: 205–215.

22. Huffman C, Wagman G, Fudim M et al. Reversible cardiomyopathies – a review. Transpl Proc 2010; 42: 3673–3678.

23. Alpert MA, Ravenscraft MD. Pericardial involvement in end-stage renal disease. Am J Med Sci 2003; 325: 228–236.

24. Shirazian S, Radhakrishan J. Gastrointestinal disorders and renal failure: exploring the connection. Nat Rev Nephrol 2010; 6: 480–492.

25. Chen R, Young GB. Metabolic Encephalopathies. In: Bolton CF, Young GB (eds). Baillere’s Clinical Neurology. London: Balliere Tindall 1996.

26. Krishnan AV, Kiernan MC. Uremic neuropathy: clinical features and new pathophysiological insights. Muscle Nerve 2007; 35: 273–290.

27. Lankhorst CE, Wish JB. Anemie in renal disease: diagnosis and management. Blood Rev 2010; 24: 39–47.

28. Spivak JL. The clinical physiology of erythropoietin. Sem Hematol 1993; 30 (Suppl 6): 2–11.

29. Donnelly S. Why is erytropoietin made in the kidney? The kidney function as a Critmeter. Am J Kidney Dis 2001; 38: 415–425.

30. Erslev AJ, Besarab A. Erythropoietin in the pathogenesis and treatment of the anemia of chronic renal failure. Kidney Int 1997; 51: 622–630.

31. Zadražil J, Papajík T, Bachleda P et al. Účast nedostatku železa na rozvoji chudokrevnosti u nemocných v pravidelném dialyzačním léčení. Vnitř Lék 1994; 40: 362–366.

32. Kushner D, Beckman B, Nquyen L et al. Polyamines in the anemia of end-stage renal disease. Kidney Int 1991; 31: 725–732.

33. NKF-K/DOQI Clinical Practice Quidelines for Anemia of Chronic Kidney Disease. Update 2000. Am J Kidney Dis 2001; 37 (Suppl 1): 182–232.

34. Locatelli F, Aljama P, Bárány P et al. European Best Practice Guidelines Working Group. Revised European Best Practice Guidelines for the Management of Anaemia in Patients with Chronic Renal Failure. Nephrol Dial Transplant 2004; 19 (Suppl 2): 1–46.

35. Noris M, Remuzzi G. Uremic Bleeding: Closing the circle after 30 years of controversies? Blood 1999; 94: 2569–2574.

36. Hörl WH. Thrombocytopathy and blood complications in uremia. Wien Klin Wochenschr 2006; 118: 134–150.

37. Jalal DI, Chonchol M, Targher G. Disorders of hemostasis associated with chronic kidney disease. Semin Thromb Hemost 2010; 36: 34–40.

38. Majewska E, Baj Z, Sulowska Z et al. Effects of uremia and haemodialysis on neutrophil apoptosis and expression of apoptosis-related proteins. Nephrol Dial Transplant 2003; 18: 2582–2588.

39. Anding K, Gross P, Rost JM et al. The influence of uremia and haemodialysis on neutrophil phagocyty and antimicrobial killing. Nephrol Dial Transplant 2003; 18: 2067–2073.

40. Kaptein EM. Thyroid hormone metabolism and thyroid diseases in chronic renal failure. Endocr Rev 1996; 17: 45–63.

41. Chonchol M, Lippi G, Salvagno G et al. Prevalence of subclinical hypothyroidism in patients with chronic kidney disease. Clin J Am Soc Nephrol 2008; 3: 1296–1300.

42. Ho KY, Evans WS, Thorner MO. Disorders of prolactin and growth hormone secretion. Clin Endocrinol Metab 1985; 14: 1–32.

43. Briley LP, Szczech LA. Leptin in renal disease. Semin Dial 2006; 19: 54–59.

44. Mak RH, Cheung W. Adipokines and gut hormones in end-stage renal disease. Perit Dial Int 2007; 27 (Suppl 2): 298–302.

45. Mak RH, Cheung W, Cone RD et al. Leptin and inflammation-associated cachexia in chronic kidney disease. Kidney Int 2006; 69: 794–797.

46. Kojima M, Kangawa K. Ghrelin: structure and function. Physiol Rev 2005; 85: 495–522.

47. Yoshimoto A, Mori K, Sugawara A. Plasma ghrelin and desacyl ghrelin concentrations in renal failure. J Am Soc Nephrol 2002; 13: 2748–2752.

48. Anantharaman P, Schmidt RJ. Sexual function in chronic kidney disease. Adv Chronic Kidney Dis 2007; 14: 119–125.

49. Finkelstein FO, Shirani S, Wuerth D et al. Therapy Insight: sexual dysfunction in patients with chronic kidney disease. Nat Clin Pract Nephrol 2007; 3: 200–207.

50. Palmer BF. Sexual dysfunction in men and women with chronic kidney disease and end-stage kidney disease. Adv Ren Replace Ther 2003; 10: 48–60.