Chronic kidney disease

Dr Bruno Di Muzio et al.

Chronic kidney disease (CKD), also known as chronic renal failure, is a
progressive loss of glomerular function caused by a long-standing renal parenchymal
disease. It is present when the glomerular filtration rate (GFR) is less than 60
ml/min/1.73 m2 for three consecutive months or greater than or equal to this value in
patients with a kidney damage that is present for three or more months 1.

Epidemiology
CKD is a prevalent disease, affecting between 10-15% of the adult population
globally 4.

Clinical presentation
Clinical presentation depends a lot on aetiology. Children with chronic kidney disease
can have growth disorder, edema and cola colored urine (due to RBC casts). Adults
can have non-specific symptoms like nausea, vomiting, weight loss, and easy
fatigability. Hypertension is common in adults with chronic kidney disease.

Pathology
A variety of different diseases can affect and cause damage to the renal
parenchyma, the most common are 2:

diabetes (diabetic nephropathy)

hypertension
glomerulonephritis
polycystic kidney disease

Classification
Chronic kidney disease can be classified in a variety of ways. One such
classification, proposed in 2005, can be divided into five stages based on the GFR
(ml/min/1.73 m2) 1:

stage 1: >90: kidney damage with normal or elevated GFR

stage 2: 60-89: kidney damage with mild reduction in GFR
stage 3: 30-59: moderate reduction in GFR, this can be further sub divided as 5

o stage 3a: 59-45

o stage 3b: 44-30
stage 4: 15-29: severe reduction in GFR
stage 5: <15 (or dialysis): end-stage kidney disease (ESKD)
The same publication 1 suggests that chronic kidney disease can also be broadly
classified by treatment type:

kidney transplant recipient

CKD independent of dialysis
 CKD on dialysis

Contrast agents
Gadolinium contrast has been associated with nephrogenic systemic fibrosis
(NSF) in the setting of chronic kidney disease. The threshold that is a
contraindication for administration of gadolinium contrast is institution dependent and
also depends on the dose and type of contrast agent being used, but a GFR of 20-30
ml/min is considered a contraindication and a GFR of 30-60 ml/min usually
necessitates a smaller dose. Dialysis is a contraindication.

Radiographic features
There are no specific imaging features for CKD, and the diagnosis is based on
clinical and laboratory findings. Radiological exams, especially ultrasound, are
performed in most of the cases for aetiological investigation (e.g. renal artery
stenosis, polycystic kidney disease, hydronephrosis, etc.) and treatment follow-up.

Ultrasound
Ultrasound with Doppler examination of intrarenal vessels is usually performed in
patients with CKD, and it is common to have a normal exam.

Typical B-mode findings of a long-standing severe CKD (especially stage 5) are 2:

reduced renal length

reduced renal cortical thickness
increased renal cortical echogenicity
poor visibility of the renal pyramids and the renal sinus
marginal irregularities
papillary calcifications
cysts (see also: acquired cystic kidney disease)
Abnormal Doppler findings in these patients are 2:

reduced renal vascularity

increased resistance index (RI) values (segmental and interlobular arteries)

Treatment and prognosis

Stage 3 CKD patients are reported to be 20 times more likely to die of a
cardiovascular event than to reach end-stage renal disease 3. The chronic vascular
disease is a common CKD associated complication and deserves particular
attention 1. An extensive study evidenced that treatment and prevention of coronary
artery disease, congestive heart failure, diabetes mellitus, and anemia should be the
target treatment to reduce the mortality of patients with CKD 3.