End Stage Kidney Disease: Causes and Management

This refers to the final stage of chronic kidney disease where there is severe irreversible deterioration in the function of the kidney. Individuals with end stage kidney disease are dependent on dialysis to replace the function of the kidney and ultimately need kidney transplant to survive. Chronic kidney disease is extremely common, affecting 11 to 13% of the population according to a recent study. Of these, approximately 0.1% are in the final stage with end stage kidney disease.

Causes of End Stage Kidney Disease

Any insult to the kidney can ultimately lead to end stage disease. Therefore, the causes are extensive. Some of the common ones are listed below

• Diabetes Mellitus with diabetic nephropathy
• Hypertension
• Glomerular diseases
• Focal Segmental Glomerulosclerosis
• IgA nephropathy
• Systemic Lupus Erythematosus
• Polycystic Kidney Disease which is a genetic disorder
• Drugs: NSAIDs like diclofenac or ibuprofen, amphotericin, vancomycin etc.
• Renal Artery Stenosis
• Severe shock and sepsis with irreversible kidney damage

Symptoms of End Stage Kidney Disease

• Fatigue
• Swelling in the body most prominent around the eyes, spreading to the abdomen, arms and legs.
• Decrease in urine output due to inability of the kidney to produce urine
• Pale skin due to anemia
• Abnormal mental status which can occur with severe build-up of urea which is normally excreted by the kidney
• Shortness of breath from heart failure

Diagnosis of End Stage Kidney Disease

While there are no specific criteria for diagnosing end stage kidney disease, a person may be considered to have this condition based on dependence on dialysis for survival. The symptoms and underlying history of a kidney disease prompts clinicians to look out for end stage disease even before the individual reaches a critical stage. The following investigations are generally performed during evaluation.

• Kidney function tests: This includes serum creatinine and blood urea nitrogen.
• Glomerular filtration rate: this assesses the functional capacity of the kidney. It is usually calculated from the serum creatinine value for a particular person’s age and gender.
• Serum electrolytes: sodium, potassium, calcium and phosphates get deranged with kidney disease.
• Urine dipstick for protein and blood.
• Urine routine and microscopy.
• 24 hour urine collection may be attempted to measure 24 hour protein.
• Abdominal ultrasound to look at the Kidney, Ureter and Bladder.

Treatment of End Stage Kidney Disease

The definitive treatment of End Stage Kidney Disease is Kidney replacement. This is achieved through a kidney transplant of a live donor kidney or a deceased donor kidney which is obtained from a cadaver. Patients who require a kidney are placed on the transplant waitlist and need to undergo many tests to identify a suitable donor match. Meanwhile the following measures are taken to manage their Kidney failure

• Renal Replacement Therapy: This is essentially the process of using external machines to take over the role of the kidney. There are many types:
  • Hemodialysis (HD): This is the process of taking blood out of the body and running it over a ‘filter’ made of cellophane which passes through a liquid into which all the toxins get transferred. The ‘clean’ blood is then sent back into the body. The individual would require HD multiple times a week at a dialysis centre to prevent acute rise in blood urea nitrogen.
  • Peritoneal dialysis: This is a similar process of removing toxins but uses the peritoneal lining as the filter. The dialysis fluid is inserted into the peritoneum through a catheter and the fluid is drained out at a later time after the toxins are transferred to it. This process has the advantage of being managed at home by the patient, but carries the risk of infecting the peritoneum
• Treatment of Anemia: The kidney is responsible for producing erythropoietin which is the substance responsible for producing red blood cells. Therefore, these individuals regular erythropoietin injections along with iron supplements
• Vitamin D: Deficiency of Vitamin D develops due to absence of an activator of Vitamin D. therefore, the activated form is generally supplemented
• Management of phosphate excess: A low phosphate diet and use of phosphate binders is recommended to prevent excess build up in the body.

Prognosis of End Stage Kidney Disease

End Stage Kidney Disease, when untreated ultimately results in death. The build up of urea in the body can affect the brain causing uremic encephalopathy and the fluid overload can lead to heart failure. Chronic dialysis can support the patient but carries the risk of infection. Ultimately, a new kidney is required for survival.

References:

• Hill NR, Fatoba ST, Oke JL, Hirst JA, O’Callaghan CA, Lasserson DS, et al. Global Prevalence of Chronic Kidney Disease – A Systematic Review and Meta-Analysis. PLoS One [Internet]. 2016 Jul 6 [cited 2018 Jul 21];11(7).
• Rosenberg M. Overview of the management of chronic kidney disease in adults. Accessed July 15, 2018.
• Choosing a Treatment for Kidney Failure | NIDDK [Internet]. National Institute of Diabetes and Digestive and Kidney Diseases. [cited 2018 Jul 21]