Description
Chronic kidney disease is a gradual loss of kidney function. you will explore this disease in more detail using the scenario below.Scenario:
Your parent has recently been diagnosed with chronic kidney disease. Your parent is confused about what this means and asks you to help them navigate their care. You decide to research the disease to help support your parent..To complete this , do the following:1. Research this disease using a minimum of 2 source(s). You can use your textbook for one of the sources. Choose the remaining sources from the GALE Virtual Reference Library provided on the.2 address the following:Explain how chronic kidney disease develops and the potential causes.Describe the treatment options that exist.
research sourcesDavidson, Tish. “Kidney Disease.” The Gale Encyclopedia of Medicine, edited by Jacqueline L. Longe, 5th ed., vol. 5, Gale, 2015, pp. 2851-2853.Davidson, Tish. “Kidney Disease.” The Gale Encyclopedia of Medicine, edited by Laurie J. Fundukian, 4th ed., vol. 3, Gale, 2011,pp. 2475-2478.Woldin, Barbara. “End-Stage Renal Disease.” Magill’s Medical Guide, edited by Bryan C. Auday, et al., 7th ed., vol. 2, Salem Press, 2014, pp. 749-751.
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Chronic Kidney Disease
Author: Margaret Alic
Editor: Jacqueline L. Longe
Date: 2013
From: The Gale Encyclopedia of Environmental Health(Vol. 1. )
Publisher: Gale, a Cengage Company
Document Type: Disease/Disorder overview
Length: 2,257 words
Chronic Kidney Disease
DEFINITION
Chronic kidney disease (CKD) is a progressive deterioration of kidney function. The kidney damage is irreversible, and
uncontrolled CKD can lead to kidney failure and the need for kidney dialysis or a kidney transplant.
DESCRIPTION
Humans have two fist-sized kidneys. These organs filter wastes and excess water from the blood to produce urine.
The kidneys are responsible for maintaining chemical balances in the body, especially electrolytes such as sodium,
calcium, potassium, and phosphate. They also produce hormones and help to control blood pressure. Damage to the
kidneys causes CKD, in which the kidneys do not properly filter the blood. In addition to the buildup of waste products
in the body, CKD can cause a variety of other health problems, including poor nutritional health, high blood pressure,
anemia (a low blood count), weakened bones, and nerve damage. CKD also increases the risk of heart and blood
vessel disease. If CKD progresses to the point where the kidneys are very badly damaged and stop functioning,
patients develop kidney failure or end-stage renal disease (ESRD).
Risk factors
The major risk factors for CKD, at least in developed countries such as the United States, are diabetes,
hypertension (high blood pressure), and obesity. Americans eat generally large amounts of sugar, which puts
them at risk for the diseases such as diabetes, hypertension, and heart disease that are also risk factors for
CKD. A family history of CKD and advanced age are risk factors. African Americans, Hispanics, Native
Americans, and Asians are at higher risk for CKD.
Perfluorooctane sulfonate (PFOS) is a global persistent organic pollutant that was widely used in fabric
protectors and stain repellents, It accumulates in the human body and is associated with an increased risk of
chronic kidney disease. It appears that, at least in developing countries, other unidentified environmental
factors put people at risk for CKD.
DEMOGRAPHICS
CKD is a serious public health concern in the United States and other developed countries. The incidence of CKD is
increasing along with increases in diabetes and obesity. Based on tests of kidney function, it is estimated that 31
million Americans have CKD, although a large proportion of them are unaware of it. Many millions more Americans are
at risk for CKD because of hypertension and/or diabetes. Those over age 60, African Americans, Hispanic Americans,
Asians, Pacific Islanders, and Native Americans are more likely than others to suffer from CKD. These groups also
have higher rates of diabetes and high blood pressure. Almost 400,000 Americans and two million people around the
world depend on kidney dialysis because of CKD. In the United States in 2008, CKD accounted for approximately 23%
of total Medicare spending. The prevalence of CKD is also increasing worldwide. The United Kingdom and China, in
particular, have increasing CKD rates.
CAUSES AND SYMPTOMS
CKD is closely associated with diabetes, high blood pressure, and heart disease. As many as two-thirds of CKD cases
are caused by diabetes and high blood pressure. High blood sugar from diabetes damages the kidneys, as well as
other organs, and uncontrolled or poorly controlled hypertension also damages the kidneys. In addition to causing
CKD, diabetes and obesity speed its progression. Furthermore, in addition to being caused by hypertension, CKD can
cause high blood pressure. Infections and urinary blockages are other causes of CKD.
CKD is called the “silent” disease, because most people have no early symptoms. In fact, many people do not have
any symptoms until their kidneys are about to fail. However, as CKD progresses, waste products build up in the body
and act as poisons, causing symptoms of illness. These may include:
lack of energy
fatigue
weakness
loss of appetite
trouble sleeping
muscle cramping at night
puffiness around the eyes, especially in the morning
dry, itchy skin
frequent need to urinate, especially at night
swelling of the feet and ankles
vomiting
difficulty concentrating
confusion
coma
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DIAGNOSIS
Early diagnosis of CKD is very important for preventing its progression. Diagnosis usually begins with a medical history
and a blood pressure test, since blood pressure above 120/80 can suggest the possibility of CKD. People with
diabetes or prediabetes may be given an A1C test that measures their average blood glucose level over the past three
months, since high blood sugar is a risk factor for CKD. CKD is then diagnosed by blood and urine tests that measure
kidney function.
The estimated glomerular filtration rate (eGFR) is the most accurate test for CKD and also indicates the stage of CKD
progression. The GFR measures how well the kidneys are filtering the blood. The eGFR is calculated from the serum
level of creatinine, a waste product in the blood, and the patient’s age, race, gender, and other factors. An eGFR of 60
or above is within the normal range. An eGFR below 60 for three months or longer may be a sign of kidney disease.
An eGFR of 15 or below can indicate kidney failure.
Urine tests measure albumin, a protein in the blood that passes into the urine if the kidneys are damaged. Urine tests
also indicate whether there is blood in the urine. Either protein or blood in the urine can be a sign of kidney disease.
eGFR and urine albumin are also used to monitor CKD and assess the effectiveness of treatment.
Patients with CKD may be referred to a kidney specialist called a nephrologist. An ultrasound or computed tomography
(CT) scan may be performed to visualize the kidneys and urinary tract and determine whether there is a structural
problem or a kidney stone or tumor. Scans can also determine whether the kidneys are enlarged or are too small.
Sometimes a kidney biopsy is performed by removing a small amount of kidney tissue for microscopic examination. A
biopsy may be used to diagnose specific types of kidney disease, assess kidney damage, and help to plan a course of
treatment.
TREATMENT
The goal of CKD treatment is to prevent further reduction in the GFR. Treatment can significantly slow the progression
of the disease and prevent or delay kidney failure, although it cannot reverse kidney damage. The most important
treatment for slowing CKD is controlling high blood pressure. Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin-II receptor blockers (ARBs) are blood pressure medicines that can slow CKD progression and delay
kidney failure by lowering blood pressure. They are useful for treating CKD even in people who do not have high blood
pressure. Often, two or more blood pressure medicines must be taken simultaneously. A diuretic or water pill may also
be required. Medications for controlling or lowering blood sugar levels in diabetics and lowering blood cholesterol are
also used to treat CKD.
Exercise and a healthy diet are very important for controlling blood sugar and blood pressure and can have a
significant impact on CKD. People who smoke with CKD must quit smoking immediately, since smoking damages the
kidneys, raises blood pressure, and interferes with the activities of blood pressure medications.
Diet is very important in the treatment of CKD. Patients are often referred to a nutritionist or dietician for meal planning,
since CKD may require a special diet or choosing foods that are easier on the kidneys. CKD can also cause appetite
loss. Reading food nutrition labels is particularly important, especially when it comes to choosing foods with less salt.
Important dietary choices for controlling CKD include:
less salt (sodium)
less protein, since excess protein places increased demands on kidney function
lean meats and “good” protein such as fish
“heart healthy” foods, including skinless chicken, fish, fruits, vegetables, and beans
apple, grape, or cranberry juices rather than orange juice for patients who need to limit phosphorus intake
light-colored sodas, such as lemon-lime, homemade iced tea, and lemonade if it is necessary to limit
phosphorus, since dark-colored sodas, fruit punch, and canned iced teas may have high levels of
phosphorus
little or no alcohol
Patients with CKD must have regular kidney function tests and checkups to monitor for and treat other problems that
can result from CKD. These include high triglyceride levels, a type of fat in the blood that is often higher in patients with
kidney disease. CKD can also cause anemia, in which the blood does not have enough hemoglobin or red blood cells
to efficiently carry oxygen throughout the body. Fatigue and weakness are symptoms of anemia. CKD may affect the
utilization of calcium and phosphorus, resulting in weakened bones. It may be necessary for patients to avoid certain
foods so that these minerals are better utilized.
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PUBLIC HEALTH ROLE AND RESPONSE
CKD is a serious public health problem in developed countries, where it is being addressed through campaigns against
the growing epidemic of obesity and diabetes. However, in parts of the developing world, especially in Central America
and parts of South Asia, newly recognized epidemics of CKD cannot be explained by the usual culprits and indicate
that environmental factors may be involved. CKD patients in these regions have little or no access to the treatments
available to patients in the developed world, so they are far more likely to die from this disease.
As of 2012, Chichigalpa, a Nicaraguan city of almost 60,000, was being referred to as the “Island of Widows,” because
hundreds or thousands of men had died of CKD in the previous decade. In all, more than 16,000 Central Americans,
primarily male sugarcane workers, had died of CKD by late 2012. In El Salvador and Nicaragua, the death rate from
CKD rose five-fold between 1992 and 2012. Many residents believe that CKD is being caused by chemicals sprayed
on sugarcane fields while the men are working or that the chemicals are seeping into the water supply. However, the
sugar industry claims that only acceptable amounts of standard fertilizers are used. As of 2012, American researchers
suspected that the CKD is linked to a combination of strenuous labor, dehydration, and environmental conditions,
possibly including chemicals. In communities affected by the CKD epidemic, some children as young as 12 have signs
of kidney damage, which suggests that young men may already have damaged kidneys by the time they go to work in
the fields, and the damage is exacerbated by long days working in heat above 90°F (32°C) and repeated dehydration.
Because it is the only work available, many workers continue in the fields after being diagnosed with CKD. The sugar
industry, meanwhile, blamed the CKD epidemic on alcohol consumption among the workers or contamination of water
supplies by active volcanoes.
KEY TERMS
Albumin—
A protein in the blood; albumin in the urine is an indication of kidney disease.
Anemia—
A deficiency in red blood cells, in the hemoglobin component of red blood cells or in total blood volume.
Angiotensin-II receptor blockers (ARBs)—
Medications for lowering blood pressure and treating heart, blood vessel, and kidney diseases.
Angiotensin-converting enzyme (ACE) inhibitors—
Medications for lowering blood pressure and treating heart, blood vessel, and kidney diseases.
Creatinine—
A protein produced by muscles and filtered out by the kidneys; high creatinine levels in the blood are indicators of
kidney disease.
Diabetes—
Type 2 diabetes, the most common form, develops in obese adults and, increasingly, in children, and is
characterized by high blood sugar (hyperglycemia); it can cause chronic kidney disease.
Dialysis—
Mechanical procedure for removing waste from the blood in patients with kidney failure.
Diuretic—
Medication for increasing urine excretion, often called a water bill.
Electrolytes—
Elements such as sodium, potassium, calcium, and phosphorus that are dissolved in bodily fluids, that regulate or
affect most metabolic processes, and whose balance is controlled by the kidneys.
End-stage renal disease (ESRD)—
The final stage of kidney failure, with a complete or near-complete and irreversible loss of kidney function.
Estimated glomerular filtration rate (eGFR)—
A method for estimating kidney function from the level of creatinine in the blood serum.
Hemoglobin A1C (A1C test)—
A test for determining the average blood sugar level for the previous two to three months.
Hypertension—
High blood pressure, which can cause or be caused by chronic kidney disease.
Perfluorooctane sulfonate (PFOS)—
A global persistent organic pollutant that was widely used in fabric protectors and stain repellents and that
bioaccumu-lates in wildlife and humans and is associated with increased risk for chronic kidney disease.
Prediabetes—
A condition characterized by blood glucose levels above normal, but lower than levels with diabetes; a precursor
to type 2 diabetes.
Triglycerides—
Neutral fats; lipids formed from glycerol and fatty acids that circulate in the blood as lipoprotein; elevated
triglyceride levels are common in patients with chronic kidney disease.
High CKD rates have also been found in rural villages in India and among workers in Sri Lankan
Page 173
rice paddies. Research in Sri Lanka has indicated that chemicals may be causing the disease, specifically the heavy
metals cadmium and arsenic that are present in fertilizers and pesticides. Although tested workers have had levels of
cadmium and arsenic that are below those that the World Health Organization officially designates as dangerous,
some researchers believe that long-term exposure, most likely through the food chain, is probably responsible for the
CKD epidemics.
PROGNOSIS
Kidney damage from CKD is usually irreversible. CKD is a progressive disease that, without treatment, worsens over
time, eventually leading to kidney failure that requires dialysis or a kidney transplant. For some patients, CKD
progresses rapidly to kidney failure. However, with treatment, including medications, diet, and lifestyle changes,
patients can survive for many years without having dialysis. Unfortunately, many people with CKD do not receive
treatment. Furthermore, CKD patients may develop anemia, bone disease, heart and blood vessel disease, or other
conditions.
PREVENTION
Several studies have suggested that people who drink more fluids may have a significantly lower risk of CKD
compared with those who drink the least amount of fluids. Other measures for preventing CKD or slowing its
progression are:
having diets that are low in salt and fat
maintaining blood pressure below 130/80
exercising daily
avoiding tobacco
limiting alcohol
maintaining a healthy weight
controlling blood sugar levels
having regular physical checkups
WHAT TO ASK YOUR DOCTOR
What caused my chronic kidney disease?
What treatment(s) do you recommend for my chronic kidney disease?
Should I change my diet or follow a special diet?
Will exercise help my chronic kidney disease?
Will I need dialysis or a kidney transplant?
Resources
BOOKS
Bomback, Andrew S., and George L. Bakris. Chronic Kidney Disease (CKD) and Hypertension Essentials. Sudbury, MA:
Physicians’ Press/Jones & Bartlett Learning, 2011.
Daugirdas, John T. Handbook of Chronic Kidney Disease Management. Philadelphia: Wolters Kluwer/Lippincott Williams &
Wilkins Health, 2011.
Rettig, Richard A. Chronic Kidney Disease: A Quiet Revolution in Nephrology: Six Case Studies. Santa Monica, CA: RAND,
2010.
Thomas, Lynn K., and Jennifer Bohnstadt Othersen. Nutrition Therapy for Chronic Kidney Disease. Boca Raton, FL: CRC,
2012.
PERIODICALS
Kovesdy, Csaba P., and Kamyar Kalantar-Zadeh. “Enter the Dragon: A Chinese Epidemic of Chronic Kidney
Disease?” Lancet 379, no. 9818 (March 3–9, 2012):
783–785.
Levey, Andrew S., and Josef Coresh. “Chronic Kidney Disease.” Lancet 379, no. 9811 (January 14–20, 2012):
165–180.
O’Connor, Anahad. “The Claim: Drink Eight Glasses of Water a Day to Protect the Kidneys.” New York Times
(November 8, 2011): D5.
WEBSITES
American Kidney Fund. “Chronic Kidney Disease (CKD).” http://www.kidneyfund.org/kidney-health/kidney-problems/chronickidney-disease.html (accessed November 1, 2012).
National Kidney Disease Education Program. “Chronic Kidney Disease: What Does it Mean for Me?”
http://www.nkdep.nih.gov/resources/kidney-disease-mean-for-me.shtml (accessed November 1, 2012).
National Kidney Foundation. “About Chronic Kidney Disease.” http://www.kidney.org/kidneydisease/aboutckd.cfm (accessed
November 1, 2012).
MedlinePlus. “Chronic Kidney Disease.” http://www.nlm.nih.gov/medlineplus/chronickidneydisease.html (accessed November
1, 2012).
Sanders, Kerry, and Lisa Riordan Seville. “Mystery Kidney Disease Decimates Central America Sugarcane Workers.” NBC
News. NBC News. October 16, 2012. http://openchannel.nbcnews.com/_news/2012/10/16/13866856-mystery-kidney-diseasedecimates-central-merica-sugarcane-workers?lite (accessed November 1, 2012).
Snively, C. S., and C. Gutierrez. “Chronic Kidney Disease.” FamilyDoctor.org . November 2010.
http://familydoctor.org/familydoctor/en/diseases-conditions/chronic-kidney-disease.printerview.all.html (accessed November 1,
2012).
ORGANIZATIONS
American Kidney Fund, 11921 Rockville Pike, Ste. 300, Rockville, MD 20852, (800) 638-8299, http://www.kidneyfund.org .
Page 174
National Institute of Diabetes and Digestive and Kidney Diseases, Office of Communications & Public Liaison, NIDDK, NIH
Building 31, Rm. 9A06, 31 Center Dr., MSC 2560, Bethesda, MD 20892-2560, (301) 496-3583, http://www2.niddk.nih.gov .
National Kidney Disease Education Program, 3 Kidney Information Way, Bethesda, MD 20892, (866) 4-KIDNEY (454-3639),
Fax: (301) 402-8182, nkdep@info.niddk.nih.gov, http://www.nkdep.nih.gov .
National Kidney Foundation, 30 East 33rd St., New York, NY 10016, (212) 889-2210, (800) 622-9010, Fax: (212) 689-9261,
http://www.kidney.org .
Margaret Alic, PhD
Full Text: COPYRIGHT 2013 Gale, Cengage Learning
Source Citation
Alic, Margaret. “Chronic Kidney Disease.” The Gale Encyclopedia of Environmental Health, edited by Jacqueline L. Longe, vol. 1,
Gale, 2013, pp. 170-174. Gale eBooks, link.gale.com/apps/doc/CX2760200064/GVRL?u=mnarasmuss&sid=bookmarkGVRL&xid=98eba8bd. Accessed 6 Feb. 2022.
Gale Document Number: GALE|CX2760200064
End-stage renal disease • 749
nervous system.
Arboviruses, which are responsible for epidemics, are
spread by mosquitoes (such as in eastern equine encephalitis)
and ticks (as in Powassan encephalitis). For natural reasons
related to their vectors (carriers), these infections, at least in
northerly climes, peak in late summer.
If a mosquito ingests a blood meal from an infected vertebrate, over a period of one to three weeks, the virus replicates
in the mosquito’s gut and then moves to its salivary glands.
When the mosquito bites a human, the virus lurks in the person’s visceral organs and then passes by means of the blood to
the nervous system. A possible route to the central nervous
system (CNS) is through the brain capillaries. Infection of
neurons, and glial cells, which constitute the non-nervous tissue of the brain and spinal cord, follows, leading to cell dysfunction and death. The body’s own immune response, which
includes infusing white blood cells into the cerebrospinal
fluid, contributes to the brain edema and inflammation.
In diagnosis, physicians use blood and deoxyribonucleic
acid (DNA) tests and analyze the cerebrospinal fluid for a
too-high count of white blood cells and elevated protein levels and fluid pressure. Neuroimaging and electroencephalograms (EEGs), which record electrical activity in the brain,
are used to eliminate other possibilities, such as clotting because of the rupture of a blood vessel (hematoma). Isolation
of the virus itself, with some exceptions, is difficult. Biopsy
of brain tissue for evidence of the virus has largely been
replaced by less invasive procedures.
Symptoms may occur within a few hours or over the
course of several days and initially are nonspecific, which
complicates the diagnosis. Although they vary depending on
the virus and the extent and length of infection, symptoms
generally include fever, headache, muscle ache, stiff neck, respiratory symptoms, sensitivity to light, abdominal pain,
vomiting, dizziness, an altered level of consciousness that
may range from lethargy to coma, personality changes that
may progress to behavior that appears psychotic, intellectual
deficit, and a host of neurological deficiencies, such as tremors, loss of muscular coordination, partial paralysis, and
ocular (eye) fixation.
Treatment and Therapy
For some types of encephalitis, such as Japanese encephalitis,
effective vaccines exist. In bacterial cases, antibiotics are prescribed. In patients in whom the herpes simplex virus is implicated, the antiviral acyclovirin is useful. In general, however, treatment, often initially in an intensive care unit (ICU),
is supportive and designed to control complications. For example, steroids are sometimes administered to reduce brain
swelling and anticonvulsants, if seizures occur.
The disease runs its course in one to two weeks. Mortality
rates depend on the type of virus and the age of the patient, the
very young and elderly being more vulnerable. Most cases of
encephalitis are mild. In eastern equine encephalitis, the mortality rate is about 33 percent; in western equine encephalitis,
it is about 3 percent in older patients and as high as 30 percent
in younger patients. Residual symptoms after recovery vary,
again according to the agent and extent of infection. In eastern equine encephalitis, 80 percent of patients suffer
neurologic aftereffects.
Perspective and Prospects
Some historians of medicine believe that viral encephalitis
appeared early in the Mediterranean area. The evidence is indirect, with the mention in the Hippocratic corpus (fifth century BCE and later) of genital and labial lesions consistent
with the herpes virus, a leading cause of the disease. It was not
until the nineteenth and twentieth centuries that the numerous
agents and vectors for encephalitis were successfully identified, such as the rabies virus (isolated by Louis Pasteur’s dog
experiments), the spirochete of syphilis, and more recently
human immunodeficiency virus (HIV).
A firm connection between the great influenza pandemic
of 1918 and the repeated global outbreaks of encephalitis
lethargica in the 1920s was not established until 1982. In the
1990s, aspirin therapy in children’s influenza was implicated
in the sometimes fatal brain edema known as Reye syndrome.
Research has focused on oral antiviral drug therapy. Interferon alpha-2b therapy and ribovarin, related to the vitamin B
complex, have been tested on patients with West Nile virus,
but their value has not been conclusively established. Emphasis therefore has remained on prevention: proper vaccinations
and, for arboviruses, mosquito spraying campaigns, application of effective insect repellents, and limited outside exposure during the early evening hours.
—David J. Ladouceur, Ph.D.
See also Bites and stings; Brain; Brain damage; Brain disorders;
Dementias; Hemiplegia; Inflammation; Insect-borne diseases; Lice,
mites, and ticks; Nervous system; Neuroimaging; Neurology; Neurology, pediatric; Parasitic diseases; Sleeping sickness; Viral infections; West Nile virus.
For Further Information:
American Medical Association. American Medical Association
Family Medical Guide. 4th rev. ed. Hoboken, N.J.: John Wiley &
Sons, 2004.
Bloom, Ona, and Jennifer Morgan. Encephalitis. Philadelphia:
Chelsea House, 2006.
Carson-DeWitt, Rosalyn, and Rimas Lukas. “Encephalitis.” Health
Library, Sept. 30, 2012.
“Encephalitis.” MedlinePlus, Mar. 4, 2013.
Fauci, Anthony S., et al., eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill, 2012.
Goldman, Lee, and Dennis Ausiello, eds. Cecil Textbook of Medicine. 23d ed. Philadelphia: Saunders/Elsevier, 2007.
Professional Guide to Diseases. 9th ed. Philadelphia: Lippincott
Williams & Wilkins, 2009.
End-stage renal disease
Disease/Disorder
Anatomy or system affected: Blood, blood vessels, circulatory
system, endocrine system, heart, kidneys, urinary system
Specialties and related fields: Cardiology, endocrinology, geriatrics and gerontology, internal medicine, nephrology,
vascular medicine
Definition: Stage 5 of chronic kidney disease, which causes irre-
(c) 2014 Salem Press. All Rights Reserved.
750
• End-stage renal disease
versible damage to and near-complete failure of the kidneys.
Key terms:
creatinine clearance: a test that measures levels of the waste
product creatinine in blood and in a twenty-four-hour
urine sample
diabetic nephropathy: a kidney disease associated with longstanding diabetes
dialysis: a mechanical means of cleansing the blood; an exchange of water and solute filters waste products out
through diffusion
fistula: a surgically created opening that joins an artery and vein
glomerular filtration rate: the amount of glomerular filtrate
formed each minute in nephrons of both kidneys; calculated from the rate of creatinine clearance and adjusted for
body-surface area
renal osteodystrophy: a bone disease of chronic renal failure
uremia: a syndrome occurring with deteriorating renal function and characterized by combination of metabolic, fluid,
electrolyte, and hormone imbalances
Causes and Symptoms
End-stage renal disease (ESRD) is stage 5 of chronic kidney
disease, defined as kidney function at less than 10 percent of
normal and a glomerular filtration rate of less than 15 milliliters per minute. Both diseases are characterized by the inability to remove wastes and concentrate urine, have poor outcomes, and are usually the result of long-standing diabetes
and/or uncontrolled hypertension.
ESRD is a serious, life-threatening systematic disease characterized by renal failure, decreased production of red blood
cells and active vitamin D3, and excess excretion of acid, potassium, salt, and water. Many metabolic abnormalities and
imbalances occur, causing complications, such as anemia,
acidemia or acidosis, hyperkalemia, hyperphosphatemia,
hyperparathyroidism, and hypocalcemia. Symptoms include
swollen feet and ankles, fatigue, lethargy or weakness, itching,
skin color changes, loss of mental alertness, shortness of
breath, and recurrent or chronic heart failure.
Tests that measure the level of creatinine and urea in blood
and urine are conducted to determine the extent of kidney
damage and the filtration capacity of the kidneys. High levels
of these waste products found in the blood but not in the urine
are signs of kidney damage. ESRD may be suspected when
very high levels of protein are detected in the urine
(proteinuria). The results of a creatinine clearance are used to
determine the glomerular filtration rate, the standard measurement used to assess kidney function.
Diabetes mellitus is the most common cause of ESRD, due
to its underlying kidney disease—diabetic nephropathy. Approximately 20 to 40 percent of patients with diabetes develop the disease, and nearly half of them progress to ESRD
within five to ten years. Diabetic nephropathy develops with
changes in the microvasculature (tiny blood vessels) of the
glomerulus and is characterized by a progressive and aggressive disease course: wastes increase, building up in the blood;
kidneys leak larger amounts of albumin, causing proteinuria;
and nodular glomerulosclerosis lesions proliferate and
Information on End-Stage Renal Disease
Causes: Diabetes and hypertension
Symptoms: Swollen feet and ankles, fatigue/lethargy/
weakness, itching, pale skin, loss of mental alertness, shortness of breath, recurrent or chronic heart
failure
Duration: Variable, fatal if not treated
Treatments: Dialysis or kidney transplant
destroy the glomeruli.
Hypertension (high blood pressure) is a major cause of
ESRD, estimated at approximately 30 percent of all cases.
Although arteries are elastic, they can become overstretched
from hypertension and narrow, weaken, or harden. This is especially deadly in the kidneys, which are highly vascular and
carry large volumes of blood. Damaged blood vessels and filters prevent the kidneys from functioning adequately, including reducing the hormone that they normally produce to help
the body regulate its own blood pressure. Thus, hypertension
is both a cause and a symptom of ESRD.
Uremia is a syndrome that develops with ESRD when metabolic, fluid, electrolyte, and hormone imbalances emerge
concurrently. Clinical symptoms include nausea or vomiting,
fatigue, weight loss, muscle cramps, pruritus (itching), mental status changes, visual disturbances, and increased thirst.
Renal osteodystrophy is a degenerative bone disease that
develops with metabolic imbalances in the minerals phosphorus and calcium. High levels of phosphorus in the blood
draw calcium out of the bones, causing them to become brittle
and break. The excess of phosphorus and calcium salts in the
blood deposit and harden, forming metastatic calcifications
in the skin, blood vessels, and other soft tissues.
Treatment and Therapy
Dialysis and kidney transplantation are the only treatments
for ESRD and provide a means of prolonging a patient’s life
span and maintaining quality of life.
Dialysis is a means of cleansing the blood when the kidneys do not function and is done by the process of diffusion,
in which blood is passed through a filter in contact with a
dialysate (salt solution), separating the smaller molecules
(solute particles) from the larger molecules (colloid particles). There are two types of dialysis—hemodialysis and
peritoneal dialysis—each of which has several variants.
In hemodialysis, blood is filtered by diverting it outside
the body through a fistula and flows across a semipermeable
membrane in the dialysis unit in a direction countercurrent to
the dialysate. Hemodialysis takes three to four hours to complete and must be done three to five times a week, usually in a
dialysis clinic. In peritoneal dialysis, blood is filtered internally through the peritoneum, a thin membrane inside the abdomen and peritoneal dialysis fluid is infused into the cavity
via a catheter. Exchanges are repeated four to six times a day
by the patient, and the process must be done every day.
Kidney transplants are another option for most ESRD pa-
(c) 2014 Salem Press. All Rights Reserved.
Endarterectomy • 751
tients. The United Network for Organ Sharing recommends
that patients be put on the cadaveric renal transplant list when
their glomerular filtration rate is less than 18 milliliters per
minute. Improvements in their policies provide for a more
equitable allocation system, broaden the classification of expanded donor criteria, and are expected to increase the donor
pool. Unfortunately, thousands of patients die each year
waiting for an available kidney.
Endarterectomy
Perspective and Prospects
Chronic kidney disease and ESRD represent a growing public health problem and reflect the disturbing health profile of
present-day society—rising numbers of people with obesity,
diabetes, hypertension, cardiovascular disease, and metabolic syndrome. The prevalence of chronic kidney disease
has risen steadily since the 1980s. Changes in lifestyle and
increased awareness of disease risk—including the monitoring of one’s blood sugar levels and blood pressure—are key
to preventing chronic kidney disease and reducing the
number of patients who progress to ESRD.
—Barbara Woldin
See also Diabetes mellitus; Dialysis; Hypertension; Kidney disorders; Kidney transplantation; Kidneys; Nephrology; Polycystic kidney disease; Proteinuria; Pyelonephritis; Renal failure; Transplantation; Uremia.
For Further Information:
“Chronic Kidney Disease.” MedlinePlus, Apr. 23, 2013.
“Kidney Failure.” MedlinePlus, Apr. 23, 2013.
Offer, Daniel, Marjorie Kaiz Offer, and Susan Offer Szafir. Dialysis
Without Fear: A Guide to Living Well on Dialysis for Patients and
Their Families. New York: Oxford University Press, 2007.
Savitsky, Diane, and Adrienne Carmack. “Kidney Failure.” Health
Library, Oct. 31, 2012.
Townsend, Raymond R., and Debbie Cohen. One Hundred Q&A
About Kidney Disease and Hypertension. Sudbury, Mass.: Jones
& Bartlett, 2008.
Walser, Mackenzie, and Betsy Thorpe. Coping with Kidney Disease:
A Twelve-Step Treatment Program to Help You Avoid Dialysis.
Hoboken, N.J.: John Wiley & Sons, 2004.
Wein, Alan, et al., eds. Campbell-Walsh Urology. 10th ed. Philadelphia: Saunders/Elsevier, 2012.
Endarterectomy
Procedure
Anatomy or system affected: Blood vessels, circulatory system, neck
Specialties and related fields: General surgery, vascular medicine
Definition: A surgical procedure used to remove plaque from
the lining of the carotid arteries in the neck.
Indications and Procedures
The internal carotid artery lies in the side of the neck, slightly
in front of and beneath the sternocleidomastoid muscle. A
skin incision is made anterior to this muscle. The branches of
the carotid artery, adjacent blood vessels, and nerves are freed
and inspected. A clamp is applied to the common carotid artery. Two additional clamps are applied to the external and
The excision of plaque deposits from the carotid artery in the neck is
called endarterectomy; the inset shows the location of the carotid artery.
internal carotid arteries to prevent bleeding and to prevent
emboli from migrating to the brain during the procedure.
A lengthwise incision is made in the internal carotid artery
from a point about 3.8 centimeters (1.5 inches) above the beginning of the vessel into the common carotid artery, about
2.5 centimeters (1 inch) below the beginning of the vessel.
The edges of the artery are retracted, and the interior is exposed. The plaque can usually be scraped off the walls of the
artery. The internal lining of the artery is carefully closed, and
any tears are sutured. The carotid artery is then sewed together with fine suture material. If the underlying disease has
been extensive or if the lining of the artery is damaged, a portion of the saphenous vein in the patient’s leg is used to repair
the arterial wall.
Restoring blood flow is crucial; it is important to avoid
both leaks in the artery and the formation of emboli. The
clamp on the external carotid artery is briefly released, and a
small amount of blood is allowed to flow back into the repaired area to check for leaks under low pressure. This clamp
is reapplied. The clamp on the common carotid artery is removed to check for leaks under high pressure. The clamp to
the external carotid artery is removed next. Blood is allowed
to flow, flushing any emboli from the operative site and away
from the brain. If all is well, the clamp on the internal carotid
artery is removed.
The structures that were pulled away from the carotid ar-
(c) 2014 Salem Press. All Rights Reserved.
Results
The chorionic villus cells are cultured and photographed through a microscope during cell division to
obtain images of the chromosomes. The images are
sorted, identified, and reported in a karyotype.
Humans have 23 pairs of chromosomes, including
the sex chromosomes. The karyotype allows detection
of aneuploidies (extra copies of chromosomes),
chromosomal deletions, and gross chromosomal
translocations. The gender of the fetus is identified
from the sex chromosomes, and can be reported to
the parents upon request.
DNA studies are performed when indicated by a
family history of genetic disorders. DNA is the biochemical molecule that stores genetic information in
the chromosomes. The DNA is extracted from the
chorionic villus cells, and analysis of the DNA allows
prenatal diagnosis of over 200 diseases, including TaySachs disease, cystic fibrosis, sickle-cell anemia, and
muscular dystrophy.
Health care team roles
The genetic counselor, physician, or other health
care provider will provide information to the couple
considering CVS and explain the procedure and its
risks, and alternative procedures. Counselors can
also advise parents of their options when they learn
that their unborn child has an inherited disorder and/
or help them prepare emotionally for the delivery of a
child with a birth defect.
The obstetrics team carries out the ultrasound and
CVS procedure, and ensures that the chorionic villus
cells are properly handled for transport to a cytogenetics laboratory. The team of physician(s) and nurses
also provide practical and psychological support for
the couple undergoing prenatal diagnosis.
Technologists in the cytogenetics laboratory perform cell culture on the chorionic villus cells, fix a
sample of cells during cell division, prepare the cells
on a slide for microscopic analysis, and make photographs of the chromosomes of dividing cells to be
collated in a karyotype. Cytogenetic technologists
are also involved in the extraction of DNA from the
cells and the biochemical testing of the DNA.
Resources
BOOKS
Evans, Mark I. ed. Prenatal Diagnosis. New York:
McGraw-Hill Medical Pub. Division, 2005.
PERIODICALS
Cunniff, Christopher. ‘‘Prenatal Screening and Diagnosis
for Pediatricians.’’ Pediatrics 114 (September 2004):
889-895.
‘‘Prenatal Diagnosis: Amniocentesis and CVS.’’ American
Family Physician 78 (October 2005).
Walling, Anne D. ‘‘Earlier Amniocentesis and Chorionic
Villus Sampling.’’ American Family Physician 71
(March 2005): 1011.
ORGANIZATIONS
March of Dimes. 1275 Mamaroneck Avenue, White Plains,
NY 10605. http://www.marchofdimes.org.
Patricia L. Bounds, Ph.D.
Tish Davidson, A.M.
Chromosome studies see Genetic testing
Chronic kidney failure
Definition
Chronic kidney failure occurs when disease or
disorder damages the kidneys so that they can no
longer adequately remove fluids and wastes from the
body or maintain proper levels of kidney-regulated
chemicals in the bloodstream.
Description
Chronic kidney failure, also known as chronic
renal failure, affects over 250,000 Americans annually.
It may be caused by a number of diseases and inherited
disorders, but the progression (end result) of chronic
kidney failure is always the same. The kidneys, which
serve as the body’s natural filtration system, gradually
lose their ability to remove fluids and waste products
(urea) from the bloodstream. They also fail to regulate
certain chemicals in the bloodstream and allow
protein to leak into the urine. Chronic kidney failure
is irreversible and eventually leads to total kidney
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Chronic kidney failure
Mosaicism occurs when cells have two or more
distinct chromosome counts. This occurs when nondisjunction (failure of chromatids to separate) occurs
in germ line cells (after fertilization). The fetus
may be normal, and the only way to rule out actual
mosaicism is to follow up with amniocentesis. There
is also a risk that insufficient chorionic villi are
collected for analysis, or that the cells collected are
contaminated with cells of maternal origin. In this
case, a second sampling procedure is performed
about a week later, or amniocentesis may be offered
as an alternative.
Chronic kidney failure
failure, known as end-stage renal disease (ESRD).
Without treatment and intervention to remove wastes
and fluids from the bloodstream, ESRD is inevitably
fatal.
Bad breath or a bad taste in mouth. Urea in the saliva
may cause an ammonia-like taste in the mouth.
Bone and joint problems. The kidneys produce vitamin D, which aids in the absorption of calcium and
keeps bones strong. In patients with kidney failure,
bones may become brittle, and in children, normal
growth may be stunted. Joint pain may also occur as
a result of unchecked phosphate levels in the blood.
Edema. Puffiness or swelling around the eyes and
legs.
Frequent urination.
Foamy or bloody urine. Protein in the urine may
cause it to foam significantly. Blood in the urine
may indicate bleeding from diseased or obstructed
kidneys, bladder, or ureters.
Headaches. High blood pressure may trigger
headaches.
Hypertension, or high blood pressure. The retention
of fluids and sodium causes blood volume to
increase, which in turn causes blood pressure to rise.
Increased fatigue. Toxic substances in the blood and
the presence of anemia may cause feelings of
exhaustion.
Itching. Phosphorus, which is typically eliminated in
the urine, accumulates in the blood of patients with
kidney failure. This heightened phosphorus level
may cause itching of the skin.
Low back pain. Pain where the kidneys are located,
in the small of the back below the ribs.
Nausea, loss of appetite, and vomiting. Urea in the
gastric juices may cause upset stomach. This can lead
to malnutrition and weight loss.
Causes and symptoms
Kidney failure is caused by acquired disease or
hereditary disorders in the kidneys. The four most
common causes of chronic kidney failure include:
Diabetes. Diabetes mellitus (DM), both insulin
dependant (IDDM) and non-insulin dependant
(NIDDM), occurs when the body cannot produce
and/or use insulin, the hormone necessary for the
body to process glucose. Long-term diabetes may
cause the glomeruli, the filtering units located in the
nephrons of the kidneys, to gradually lose function.
Hypertension. High blood pressure is both a cause
and a result of kidney failure. The kidneys can
become stressed and ultimately sustain permanent
damage from blood pushing through them at excessive pressures over long periods of time.
Glomerulonephritis. Glomerulonephritis is an
inflammation of the glomeruli, or filtering units of
the kidney. Certain types of glomerulonephritis are
treatable, and may only cause a temporary disruption of kidney functioning.
Polycystic kidney disease. Polycystic kidney disease
is an inherited disorder that causes cysts to form in
the kidneys. These cysts impair the regular functioning of the kidney.
Less common causes of chronic kidney failure
include kidney cancer, obstructions such as kidney
stones, pyelonephritis, reflux nephropathy, systemic
lupus erythematosus, amyloidosis, sickle cell anemia,
Alport syndrome, and oxalosis.
Diagnosis
Most symptoms of chronic kidney failure are not
apparent until kidney disease has progressed significantly. Common symptoms include:
Kidney failure is typically diagnosed and treated
by a nephrologist, a physician specializing in kidney
disease. The patient suspected of having chronic kidney failure will undergo an extensive blood work-up,
usually performed by a laboratory technologist or
technician. Blood tests will assess the levels of creatinine, blood urea nitrogen (BUN), uric acid, phosphate, sodium, and potassium in the blood. Urine
samples will also be collected, usually over a 24-hour
period, to assess protein loss.
Anemia. The kidneys are responsible for the production of erythropoietin (EPO), a hormone that stimulates red cell production. If kidney disease causes
shrinking of the kidney, this red cell production is
hampered.
Uncovering the cause of kidney failure is critical
to proper treatment. A full assessment of the kidneys is
necessary to determine if the underlying disease is
treatable and if the kidney failure is chronic or acute.
X ray, MRI, computed tomography scan, ultrasound,
Initially, symptoms of chronic kidney failure
develop slowly. Even individuals with mild to moderate kidney failure may have few symptoms in spite of
increased urea in their blood. Among signs and symptoms that may be present at this point are frequent
urination during the night and high blood pressure.
568
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Treatment
Chronic kidney failure is an irreversible condition.
Hemodialysis, peritoneal dialysis, or kidney transplantation must be employed to replace the lost function of
the kidneys if the failure progresses to ESRD. In addition, dietary changes and treatment to relieve specific
symptoms such as anemia and high blood pressure are
critical to the treatment process.
Hemodialysis
Hemodialysis is the most frequently prescribed
type of dialysis treatment in the United States. Most
hemodialysis patients require treatment three times
a week, for an average of three to four hours per
dialysis ‘‘run’’ depending on the type of dialyzer
used and their current physical condition. The treatment involves circulating the patient’s blood outside
of the body through an extracorporeal circuit
(ECC), or dialysis circuit. The dialysis circuit consists of plastic blood tubing, a two-compartment
filter known as a dialyzer, or artificial kidney, and
a dialysis machine that monitors and maintains
blood flow and administers dialysate, a chemical
bath used to draw waste products out of the blood.
The patient’s blood leaves and enters the body
through two needles inserted into the patient’s
vein, called an access site, and is pushed through
the blood compartment of the dialyzer. Once the
patient’s blood is inside the dialyzer, excess fluids
and toxins are pulled out of the bloodstream and
into the dialysate compartment, where they are carried out of the body. At the same time, electrolytes
and other chemicals in the dialysate solution move
from the dialysate into the bloodstream. The purified, chemically balanced blood is then returned to
the body. Specially trained nurses and dialysis technicians supervise and monitor patients during
treatment.
Peritoneal dialysis
In peritoneal dialysis (PD), the peritoneum, (lining of the abdomen) acts as a blood filter. A catheter is
surgically inserted into the patient’s abdomen. During
treatment, the catheter is used to fill the abdominal
cavity with liquid dialysate. Waste products and excess
fluids move from the patient’s bloodstream into the
dialysate solution. After a waiting period of 6 to 24
hours, depending on the treatment method used, the
waste-filled dialysate is drained from the abdomen,
and replaced with clean dialysate. There are three
types of peritoneal dialysis, which vary by treatment
time and administration method: continuous ambulatory peritoneal dialysis (CAPD), continuous cyclic
peritoneal dialysis (CCPD), and intermittent peritoneal dialysis (IPD).
Kidney transplantation
Kidney transplantation involves surgically
implanting a functioning kidney, known as a graft,
from a brain dead organ donor (a cadaver transplant),
or from a living donor, to a patient with ESRD.
Patients with chronic renal disease who need a transplant and do not have a living donor register with
UNOS (United Network for Organ Sharing), the federal organ procurement agency. UNOS places patients
on a waiting list for a cadaver kidney transplant.
Kidney availability is based on the patient’s health
status. When the new kidney is transplanted, the
patient’s diseased kidneys may or may not be
removed, depending on the circumstances surrounding the kidney failure. A regimen of immunosuppressive (anti-rejection) medication is required after
transplantation surgery.
Dietary management
A diet low in sodium, potassium, and phosphorous, three substances that healthy kidneys excrete, is
critical in managing kidney disease. Other dietary
restrictions, such as a reduction in protein, may be
prescribed depending on the cause of kidney failure
and the type of dialysis treatment employed. Patients
with chronic kidney failure also need to limit their
fluid intake. Patients may receive instruction about
appropriate dietary measures from registered dietitians, nutritionists, nurses, or health educators.
Medications and dietary supplements
Kidney failure patients with hypertension typically take medication to control their high blood pressure. Epoetin alfa, or EPO (Epogen), a hormone
therapy, and intravenous or oral iron supplements
are used to manage anemia, especially if the kidneys
have been surgically removed. A multivitamin may be
prescribed to replace vitamins lost during dialysis
treatments. Vitamin D, which promotes the absorption of calcium, along with calcium supplements, may
also be prescribed.
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Chronic kidney failure
renal biopsy, and/or arteriogram of the kidneys may
be employed to determine the cause of kidney failure
and level of remaining kidney function. X rays and
ultrasound of the bladder and/or ureters may also be
taken. Most imaging studies are performed by radiology technicians.
Chronic kidney failure
KEY TERMS
End-stage renal disease (ESRD)—Total kidney
failure; chronic kidney failure is diagnosed as
ESRD when kidney function falls to 5-10% of
capacity.
Nephrotic syndrome—Characterized by protein
loss in the urine, low protein levels in the blood,
and fluid retention.
Ureters—The two ducts that pass urine from each
kidney to the bladder.
Since 1973, Medicare has reimbursed up to 80%
of ESRD treatment costs, including the costs of
dialysis and transplantation as well as the costs of
some medications. To qualify for benefits, a patient
must be insured or eligible for benefits under Social
Security, or be a spouse or child of an eligible
American. Private insurance and state Medicaid programs often cover the remaining 20% of treatment
costs.
transplant surgeon. Registered dietitians, nutritionists, and nurses instruct patients about dietary changes
to manage their disease.
Resources
BOOKS
Brenner, Barry M., and Floyd C. Rector, Jr., eds. The
Kidney, 5th edition. Philadelphia: W.B. Saunders
Company, 1996.
Cameron, J. S. Kidney Failure: The Facts. New York:
Oxford Univ. Press, 1996.
Ross, Linda M., ed. Kidney and Urinary Tract Diseases and
Disorders Sourcebook. Vol. 21. Health Reference
Series. Detroit: Omnigraphics, 1997.
U.S. Renal Data System. USRDS 1997 Annual Data Report.
Bethesda, MD: The National Institutes of Health,
National Institute of Diabetes and Digestive and
Kidney Diseases, 1996. (Available in paper and microfiche versions from National Technical Information
Service (NTIS), Springfield, VA.)
The Washington Manual of Medical Therapeutics, 30th
Edition. Philadelphia: Lippincott Williams &
Wilkins., 2001, pp. 267-270.
PERIODICALS
Prognosis
Early diagnosis and treatment of kidney failure is
critical to improving length and quality of life in
chronic kidney failure patients. Patient outcome varies; it depends on the cause of chronic kidney failure
and the method chosen to treat it. Overall, patients
with chronic kidney disease leading to ESRD have a
shortened life span. According to the United States
Renal Data System (USRDS), the life span of an
ESRD patient is 18-47% of the life span of the agesex-race matched general population. ESRD patients
on dialysis have a life span that is 16-37% of the
general population.
The demand for kidneys to transplant continues
to exceed supply. Cadaver kidney transplants have a
50% chance of functioning nine years, and living
donor kidneys that are well-matched (have two matching antigen pairs) have a 50% chance of functioning
for 24 years. However, some transplant grafts have
functioned for more than 30 years.
Health care team roles
Patients with chronic kidney failure are treated by
a team that includes nephrologists, dialysis technicians, nurses, radiology technicians, and laboratory
technicians. Patients undergoing kidney transplant
are cared for by a transplant team headed by a
570
Friedman, Elia A. ‘‘End-stage Renal Disease Therapy: An
American Success Story.’’ Journal of the American
Medical Association 275 (April 1996): 1118-22.
Taylor, Judy H. ‘‘End-stage Renal Disease in Children:
Diagnosis, Management, and Interventions.’’ Pediatric
Nursing 22 (Nov-Dec 1996): 481-92.
ORGANIZATIONS
American Association of Kidney Patients (AAKP). 100
S. Ashley Drive, Suite 280, Tampa, FL 33602.
(800)749-2257. .
American Kidney Fund (AKF). Suite 1010, 6110 Executive
Boulevard, Rockville, MD 20852. (800)638-8299.
.
National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK). Natcher Building – 6AS-13K,
45 Center Drive, Bethesda, MD 20892-6600.
.
National Kidney Foundation (NKF). 30 East 33rd Street,
New York, NY 10016. (800)622-9020. .
United States Renal Data System (USRDS). USRDS
Coordinating Center, 315 W. Huron, Suite 240, Ann
Arbor, MI 48103. (313)998-6611. .
Barbara Wexler
Chronic leukemias see Leukemias, chronic
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