Dr Alan Almeida is the Section Head – Nephrology and Consultant – Nephrologist and Transplant Physician at the P D Hinduja Hospital and Medical Research Centre, in Khar, Mumbai.
Dr Alan Almeida has done his MBBS, MD (Internal Medicine), MNAMS (Nephrology), Post – Doctoral Fellow of the University of Missouri, Columbia (USA) Fellow, Indian Society of Nephrology.
The kidneys play a role in:
- Removing excess toxins and water from our body
- It maintains a balance between all the acids and bases and the electrolytes (eg- sodium, potassium, chloride, etc.) present in our body
- It helps in maintaining the blood pressure
- It helps in the formation of haemoglobin by giving colour to our blood with the help of a factor called the erythropoietin
- The kidneys contribute to our bone health
- Eliminating drugs and and its metabolites
- Chronic kidney disease is a situation in which the kidneys have failed.
- Occasionally it can also present in individuals who have had an acute kidney illness in the past from which the individual recovered completely but has now developed chronic kidney disease.
- It can also be a stuttering progress towards kidney failure, this can be seen in patients with renal stones, recurrent urinary infections, inflammation/ swelling of the filters of the kidney which is referred to as the glomerular disease/ glomerulonephritis.
- It can, in some cases, also present as a sudden recognition of a failed kidney.
Types of kidney dysfunction:
- Acute (recoverable/ reversible): takes place over a few days/ weeks
- Chronic (progressive/ irreversible)
- Chronic kidney disease can be defined as a reduction in the Glomerular Filtration Rate (GFR) to < 60 mL/ min and / or if your GFR is > 60mL/ min but there is evidence of kidney damage such as proteinuria (protein in urine), hematuria (blood in urine) or abnormal renal imaging and pathological abnormalities for more than or equal to 03 months, it is called CKD.
- It is a progressive, irreversible decline in kidney function.
- The kidney consists of a filter and these filters traverse through tunes and ultimately pour out the filtrate into the collecting system, and out through the ureter and to the bladder. The glomerulus is the filter. And whatever is filtered is passed as urine.
- The tubules in the kidney that collect that filtrate modify and reabsorb certain substances and water.
- The GFR varies with your age.
- It can be graded from Grade 1 to grade 5 on the basis of the individuals’ GFR and the presence of albumin in urine.
Implications of aging kidney changes:
- Females have a slightly lower GFR than males
- GFR declines with age. There are no proven theories to halt/ reverse the age-related decline in the GFR.
- Lower GFR puts older adults at a higher risk for acute kidney injury- which is a reversible loss of kidney function
- The age related decline in GFR has little to no effect on the life expectancy of the individual
- Change in the volume of the kidneys with age
- Loss of maximum urine concentrating and diluting capability leading to increased risk of hyponatremia ie low sodium in blood and a tendency to develop hyperkalemia ie high potassium levels in blood
When our kidneys fail it results in a disturbed internal environment
Causes of kidney disease include:
- Acute kidney injury which can be caused due to consumption of nephrotoxic medication, volume depletion in the body, severe urinary tract infection leading to sepsis, urinary tract obstruction, acute cardiovascular events
- Diabetes mellitus
- Hypertension
- Cardiovascular disease
- Glomerulonephritis: the inflammation of the filters can lead to leakage of blood and / or protein in the urine
- Autoimmune diseases
- Renal stones
- Obstruction in the urinary system leading to back pressure changes
- Urinary incontinence: it can be stress urinary incontinence, urge urinary incontinence, etc.
- Renovascular disease: the blood vessels going to the kidney become narrowed, thereby restricting the blood of blood to a vital organ
- Hereditary kidney diseases eg- Autosomal Dominant Polycystic Kidney Disease
- Drug induced interstitial nephritis
Risk factors for age related kidney diseases are:
- Age more than 60 years
- Diabetes
- Obesity
- Hypertension
- An established cardiac disease or stroke
- Smoking
- History of acute kidney injury
- Positive family history of kidney failure
- Age is a significant risk factor for CKD.
- The combination of advancing age and cardiovascular disease there is a larger risk of genesis of chronic kidney disease
- Screening helps in identifying CKD in all the individuals with risk factors
Symptoms of chronic kidney disease include:
- Some patients may be symptomless during the early stages of the disease and may present when kidney function has either failed or when complications develop
- Urinary symptoms: passage of small or large quantities of urine ie oliguria or polyuria respectively, increased frequency of urine, foamy urine, increased urine at night- quantity or frequency
Difficulty to pass urine: strain or force the urine out or the urine flow is interrupted
Burning sensation, blood in the urine, passage of stones
- Increasing weight accompanied with swelling on face or feet
- Shortness of breath
- Poor appetite, nausea, vomiting, hiccups, loss of weight, altered taste- metallic taste, occasionally your breath also smells like urine
- Itching all over the body
- Cramps or achy muscles or bone pains, difficulty in getting up from squatting position or climbing stairs
- Altered sleep pattern (reversed sleep pattern)
- Easy fatigability, loss of concentrating capacity
Urinary Incontinence:
It is the unintentional passing of urine
Types of urinary incontinence include:
- Stress incontinence: urine leaks out involuntarily when your bladder in under pressure for eg: while you’re coughing or laughing
- Urge incontinence: a sudden intense urge to pee or the urine leaks soon after passing urine
- Overflow incontinence (Chronic Urinary Retention): the individual is unable to empty his bladder which causes frequent leaking of urine. This can be due to a neurological defect
- Total incontinence: the bladder cannot store any urine at all, which results in the individual passing urine constantly and/ or have frequent leaking of urine
Investigations done for kidney disease:
- Urinalysis- routine and microscopic
- Quantification of protein excretion- spot urine protein or albumin or 24 hour urine- these help in making a diagnosis and monitoring the disease/ therapy
- Blood investigations such as
- Hemogram
- Specific blood tests to identify the ethology
- BUN and creatinine
- Electrolytes
- Bicarbonates
- Bone profile: calcium, phosphorus, albumin
- Uric acid
- Iron studies
- Ultrasonography and doppler and other specialised radiological studies as and if advised by your nephrologist
- ECG, 2D Echo: this tells us about an accompanying cardiac disease, if any
- Viral markers: often patients with kidney disease might require dialysis for treatment which is why they need to be vaccinated against Hep B
Management of Chronic Kidney Disease includes:
- Well controlled blood pressure
- Managing the hemoglobin by use of erythropoiesis stimulating agents
- Management of acidosis
- Management of the cardiovascular disease
- Timing of access creation with the help of dialysis
- Iron supplementation
- Insulin management
- Vitamin D supplementation for management of bone disease
- Having a proper and healthy diet
