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== | ==Overview== | ||
=== Measurement of Renal Function === | [[Chronic kidney disease]] is defined as the presence of markers of kidney damage for > 3 months, and may include abnormalities in markers in blood or urine, and imaging test and/or GFR < 60 mL/min/1.73 m2 for > 3 months with or without other signs of kidney damage. The [[kidney]]s play an important role in the regulation of serum concentration of electrolytes such as [[sodium]], [[potassium]], [[calcium]], [[phosphate]], [[bicarbonate]] and [[chloride]] as well as levels of [[hemoglobin]], [[hematocrit]], [[blood pressure]] and extracellular volume. Hence, chronic injury to the [[kidney]]s can lead to derangement in the normal values of above mentioned parameters. | ||
* Serum creatinine (Cr) | |||
*:* Determined by glomerular filtration rate (GFR) '''and''' by generation, tubular secretion and extrarenal clearance of | ==[[Urinalysis]]== | ||
*:* May be inaccurate estimate of function, particularly in patients with mild renal insufficiency | *[[Albuminuria]] | ||
*:* Drugs may inhibit tubular secretion of | ** Normal levels of urine protein, albumin are: | ||
* Creatinine clearance | *** 24 hour protein excretion = Normal < 150 mg, [[nephrotic]] range of protein excretion > 3.5 gram | ||
*:* Estimate: [(140-age) x body wt (kg)] / [Plasma | *** Albumin/creatinine = Normal < 30 mg, [[microalbuminuria]] = 30-300 mg, [[macroalbuminuria]] > 300 mg | ||
*:* Calculated based on 24-hour urine collection | *** Protein/creatinine = Normal < 200 mg/g, [[Proteinuria]] > 200 mg/g | ||
*:*:* | *[[Urine]] [[sodium]] excretion ([[Fractional excretion of sodium]]): | ||
*:* If [[GFR]] < 50, | *:* More useful for [[Acute renal failure]] to distinguish prerenal state from [[acute tubular necrosis]] (ATN) | ||
*:* May '''not''' be low in volume depleted [[chronic renal failure|CRF]] patients due to tubular dysfunction | |||
*[[Hematuria]] | |||
*[[Pyuria]] | |||
*Red cell or white cell [[casts]] and crystals | |||
*[[Urine]] [[creatinine]] levels | |||
==Fluid and Electrolyte disturbances== | |||
*[[Hypervolemia]] | |||
*[[Hyponatremia]] | |||
*[[Hyperkalemia]] | |||
*[[Hyperphosphatemia]] | |||
*[[Hyperchloremia]] | |||
*[[Metabolic acidosis]] | |||
*:*Most often is mild, [[pH]] is rarely below 7.35 | |||
*[[Hypocalcemia]] | |||
==Endocrine and Metabolic disturbances== | |||
*[[Hyperuricemia]] | |||
*[[Hypertriglyceridemia]] | |||
*Decreased [[HDL]] levels | |||
*[[Vitamin D deficiency]] | |||
*Increased [[Parathyroid hormone]] levels | |||
==Hematologic abnormalities== | |||
*[[Normocytic normochromic anemia]] | |||
*[[Lymphocytopenia]] | |||
*[[Leukopenia]] | |||
*[[Thrombocytopenia]] | |||
==Measurement of Renal Function== | |||
Chronic Kidney Disease is defined as: | |||
* Presence of markers of kidney damage for > 3 months, and may include abnormalities in markers in blood or urine, and imaging tests. | |||
* GFR < 60 mL/min/1.73 m2 for > 3 months with or without other signs of kidney damage. | |||
===Glomerular filtration rates=== | |||
The stages of CKD is based on the GFR and other renal function abnormalities. The different stages of chronic kidney diseases are as follow: | |||
* '''Stage 1''': GFR>90 ml/min/1.73m2 and evidence of kidney damage | |||
* '''Stage 2''': GFR 60-89 ml/min/1.73m2 and evidence of kidney damage | |||
* '''Stage 3''': GFR 30-59 ml/min/1.73m2 | |||
* '''Stage 4''': GFR 15-29 ml/min/1.73m2 | |||
* '''Stage 5''': GFR <15 ml/min/1.73m2 | |||
===Serum creatinine=== | |||
Using serum [[creatinine]] alone as an indicator of kidney function may be misleading. This is because the calculated creatinine levels depends on age, gender, race, nutritional status and muscle mass. At GFR levels ≥60 ml/min/1.73 m2, neither the Cockroft and Gault equation nor the MDRD equation provides a reliable measurement of kidney function. The CKD-EPI equation is more accurate than the Cockcroft and Gault equation and the MDRD equation at GFR levels ≥60 ml/min/1.73 m2. | |||
* [[Serum creatinine]] (Cr) | |||
*:* Determined by [[glomerular filtration rate]] ([[GFR]]) '''and''' by generation, tubular secretion and extrarenal clearance of [[creatinine]] | |||
*:* May be an inaccurate estimate of renal function, particularly in patients with mild [[Chronic renal insufficiency|renal insufficiency]] | |||
*:* Drugs may inhibit tubular secretion of [[creatinine]] and falsely report elevated serum [[creatinine]] ([[cimetidine]], [[trimethoprim]]) | |||
* [[Creatinine clearance]] | |||
*:* Estimate: [(140-age) x body wt (kg)] / [Plasma [[creatinine]] x 72] (multiply result x 0.85 for women) | |||
*:* Calculated based on 24-hour [[urine]] collection | |||
*:*:* [[Creatinine clearance]] (mL/min) = [Urine [[Creatinine]] (mg/dL) x Urine volume (mL/d)] / [Plasma [[Creatinine]] x 1440] | |||
*:* If [[GFR]] < 50, [[Creatinine clearance]] overestimates [[GFR]] | |||
*:*:* Calculate 24-hour [[blood urea nitrogen]] ([[BUN]]) clearance (underestimates [[GFR]]) | *:*:* Calculate 24-hour [[blood urea nitrogen]] ([[BUN]]) clearance (underestimates [[GFR]]) | ||
*:*:* Average of [[BUN]] and | *:*:* Average of [[BUN]] and [[Creatinine clearances]] = [[GFR]] | ||
=== Determination of Chronicity | |||
* Prior | ===Cystatin C=== | ||
* [[Acute Renal Failure]] (ARF) associated with: | [[Cystatin C]] allows a more precise testing of kidney function than [[creatinine]].<ref name="pmid23027318">{{cite journal| author=Schaeffner ES, Ebert N, Delanaye P, Frei U, Gaedeke J, Jakob O et al.| title=Two novel equations to estimate kidney function in persons aged 70 years or older. | journal=Ann Intern Med | year= 2012 | volume= 157 | issue= 7 | pages= 471-81 | pmid=23027318 | doi=10.7326/0003-4819-157-7-201210020-00003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23027318 }} </ref> | ||
*:* Precipitating factor ([[nephrotoxin]], volume depletion, obstruction) | |||
*:* More symptoms at given | Measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL) can help distinguish [[chronic kidney disease]] from [[acute kidney injury]].<ref name="pmid18519927">{{cite journal| author=Nickolas TL, O'Rourke MJ, Yang J, Sise ME, Canetta PA, Barasch N et al.| title=Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury. | journal=Ann Intern Med | year= 2008 | volume= 148 | issue= 11 | pages= 810-9 | pmid=18519927 | doi= | pmc=PMC2909852 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18519927 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19071879 Review in: ACP J Club. 2008 Dec 16;149(6):13] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19181952 Review in: Evid Based Med. 2009 Feb;14(1):20] </ref> | ||
==Determination of Chronicity== | |||
* Prior [[creatinine]] measurements if available | |||
* [[Acute Renal Failure]] (ARF) is associated with: | |||
*:* Precipitating factor ([[nephrotoxin]], volume depletion, [[urinary tract obstruction]]) | |||
*:* More symptoms at given bodily levels of [[creatinine]] | |||
*:* Lesser degree of [[anemia]], [[hypocalcemia]], [[hyperphosphatemia]] | *:* Lesser degree of [[anemia]], [[hypocalcemia]], [[hyperphosphatemia]] | ||
* | * [[Chronic renal failure]] is associated with: | ||
*:* Greater likelihood of hematologic and biochemical abnormalities | *:* Greater likelihood of hematologic and biochemical abnormalities | ||
*:* Bilateral small [[kidney]]s on [[ultrasound]] (though can be normal in chronic disease) | *:* Bilateral small [[kidney]]s on [[ultrasound]] (though can be normal in chronic disease) | ||
==References== | ==References== | ||
Latest revision as of 14:21, 2 March 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]
Overview
Chronic kidney disease is defined as the presence of markers of kidney damage for > 3 months, and may include abnormalities in markers in blood or urine, and imaging test and/or GFR < 60 mL/min/1.73 m2 for > 3 months with or without other signs of kidney damage. The kidneys play an important role in the regulation of serum concentration of electrolytes such as sodium, potassium, calcium, phosphate, bicarbonate and chloride as well as levels of hemoglobin, hematocrit, blood pressure and extracellular volume. Hence, chronic injury to the kidneys can lead to derangement in the normal values of above mentioned parameters.
Urinalysis
- Albuminuria
- Normal levels of urine protein, albumin are:
- 24 hour protein excretion = Normal < 150 mg, nephrotic range of protein excretion > 3.5 gram
- Albumin/creatinine = Normal < 30 mg, microalbuminuria = 30-300 mg, macroalbuminuria > 300 mg
- Protein/creatinine = Normal < 200 mg/g, Proteinuria > 200 mg/g
- Normal levels of urine protein, albumin are:
- Urine sodium excretion (Fractional excretion of sodium):
- More useful for Acute renal failure to distinguish prerenal state from acute tubular necrosis (ATN)
- May not be low in volume depleted CRF patients due to tubular dysfunction
- Hematuria
- Pyuria
- Red cell or white cell casts and crystals
- Urine creatinine levels
Fluid and Electrolyte disturbances
- Hypervolemia
- Hyponatremia
- Hyperkalemia
- Hyperphosphatemia
- Hyperchloremia
- Metabolic acidosis
- Most often is mild, pH is rarely below 7.35
- Hypocalcemia
Endocrine and Metabolic disturbances
- Hyperuricemia
- Hypertriglyceridemia
- Decreased HDL levels
- Vitamin D deficiency
- Increased Parathyroid hormone levels
Hematologic abnormalities
Measurement of Renal Function
Chronic Kidney Disease is defined as:
- Presence of markers of kidney damage for > 3 months, and may include abnormalities in markers in blood or urine, and imaging tests.
- GFR < 60 mL/min/1.73 m2 for > 3 months with or without other signs of kidney damage.
Glomerular filtration rates
The stages of CKD is based on the GFR and other renal function abnormalities. The different stages of chronic kidney diseases are as follow:
- Stage 1: GFR>90 ml/min/1.73m2 and evidence of kidney damage
- Stage 2: GFR 60-89 ml/min/1.73m2 and evidence of kidney damage
- Stage 3: GFR 30-59 ml/min/1.73m2
- Stage 4: GFR 15-29 ml/min/1.73m2
- Stage 5: GFR <15 ml/min/1.73m2
Serum creatinine
Using serum creatinine alone as an indicator of kidney function may be misleading. This is because the calculated creatinine levels depends on age, gender, race, nutritional status and muscle mass. At GFR levels ≥60 ml/min/1.73 m2, neither the Cockroft and Gault equation nor the MDRD equation provides a reliable measurement of kidney function. The CKD-EPI equation is more accurate than the Cockcroft and Gault equation and the MDRD equation at GFR levels ≥60 ml/min/1.73 m2.
- Serum creatinine (Cr)
- Determined by glomerular filtration rate (GFR) and by generation, tubular secretion and extrarenal clearance of creatinine
- May be an inaccurate estimate of renal function, particularly in patients with mild renal insufficiency
- Drugs may inhibit tubular secretion of creatinine and falsely report elevated serum creatinine (cimetidine, trimethoprim)
- Creatinine clearance
- Estimate: [(140-age) x body wt (kg)] / [Plasma creatinine x 72] (multiply result x 0.85 for women)
- Calculated based on 24-hour urine collection
- Creatinine clearance (mL/min) = [Urine Creatinine (mg/dL) x Urine volume (mL/d)] / [Plasma Creatinine x 1440]
- If GFR < 50, Creatinine clearance overestimates GFR
- Calculate 24-hour blood urea nitrogen (BUN) clearance (underestimates GFR)
- Average of BUN and Creatinine clearances = GFR
Cystatin C
Cystatin C allows a more precise testing of kidney function than creatinine.[1]
Measurement of urinary neutrophil gelatinase-associated lipocalin (NGAL) can help distinguish chronic kidney disease from acute kidney injury.[2]
Determination of Chronicity
- Prior creatinine measurements if available
- Acute Renal Failure (ARF) is associated with:
- Precipitating factor (nephrotoxin, volume depletion, urinary tract obstruction)
- More symptoms at given bodily levels of creatinine
- Lesser degree of anemia, hypocalcemia, hyperphosphatemia
- Chronic renal failure is associated with:
- Greater likelihood of hematologic and biochemical abnormalities
- Bilateral small kidneys on ultrasound (though can be normal in chronic disease)
References
- ↑ Schaeffner ES, Ebert N, Delanaye P, Frei U, Gaedeke J, Jakob O; et al. (2012). "Two novel equations to estimate kidney function in persons aged 70 years or older". Ann Intern Med. 157 (7): 471–81. doi:10.7326/0003-4819-157-7-201210020-00003. PMID 23027318.
- ↑ Nickolas TL, O'Rourke MJ, Yang J, Sise ME, Canetta PA, Barasch N; et al. (2008). "Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury". Ann Intern Med. 148 (11): 810–9. PMC 2909852. PMID 18519927. Review in: ACP J Club. 2008 Dec 16;149(6):13 Review in: Evid Based Med. 2009 Feb;14(1):20