Kidney disease, chronic complications

Diabetes mellitus is a complicated, chronic disorder characterized by either insufficient insulin production by the beta cells of die pancreas or by cellular resistance to insulin. Insulin insufficiency results in elevated blood glucose levels, or hyperglycemia As a result of the disease, individuals with diabetes are at greater risk for a number of disorders, including myocardial infarction, cerebrovascular accident (stroke), blindness, kidney disease, and lower limb amputations. 

See Chap. 46, Chronic Kidney Disease Progression-Modifying Therapies, authored by Melanie S. Joy, Abhijit Kshirsagar, and Nora Franceschini, and Chap. 47, Chronic Kidney Disease Management of Complications, authored by Joanna Q. Hudson, for a more detailed discussion of this topic. 

ACE inhibitors are well tolerated in most patients but are not absent of side effects. ACE inhibitors decrease aldosterone and can increase potassium serum concentrations. Usually the increase in potassium is small, but hyperkalemia is possible. It is seen primarily in patients with chronic kidney disease or diabetes mellitus and in those on concomitant ARBs, nonsteroidal anti-inflammatory drugs, potassium supplements, or potassium-sparing diuretics. Judicious monitoring of potassium and serum creatinine values within 4 weeks of starting or increasing the dose of an ACE inhibitor often can identify these abnormalities before they evolve into more serious complications. 

The GFR remains the single best index of functioning renal mass. As renal mass declines in the presence of age-related loss of nephrons or coexisting disease states such as hypertension or diabetes, there is aprogressive decline in GFR. The GFR can be used to predict the time to onset of ESKD as well as the risk of complications of chronic kidney disease. Furthermore, accurate assessment of GFR in clinical practice allows proper dosing of drugs excreted renally in order to maximize therapeutic efficacy and avoid potential drug toxicity. 

Chronic Kidney Disease Therapeutic Approach for the Management OF Complications... 

Cardiovascular complications are prevalent in the chronic kidney disease population and are the leading cause of mortality in patients with Stage 5 disease. 

Guidelines by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-K/DOQI) should be used as a basis for the work-up of chronic kidney disease and the design of appropriate therapy for associated complications. 

CHAPTER 44 CHRONIC KIDNEY DISEASE MANAGEMENT OF COMPLICATIONS... 

Sarnak Ml. Cardiovascular complications in chronic kidney disease. Am J Kidney Dis 2003 41(5 Suppl) ll-17. 

Renal osteodystrophy (ROD)—The condition resulting from sustained metabolic changes that occur with chronic kidney disease including secondary hyperparathyroidism, hyperphosphatemia, hypocalcemia, and vitamin D deficiency. The skeletal complications associated with ROD include osteitis fibrosa cystica (high bone turnover disease), osteomalacia (low bone turnover disease), adynamic bone disease, and mixed bone disorders. 

Several metabolic diseases affect kidney function leading to chronic complications including osteoporosis, hypertension, anania, and electrolyte abnormalities. 

The kidneys act to filter toxins out of the blood for excretion in the urine. There are complex mechanisms to recover electrolytes, carbohydrates, and amino acids. The kidney is also an endocrine organ, regulating vitamin D metabolism and signaling red blood cell proliferation through erythropoietin. While each of these unique roles is not specifically tied to an inborn error of metabolism, the kidneys are affected by several disorders and may be the source of chronic complications of disease. Symptoms of chronic kidney disease include osteoporosis, hypertension, anemia, and electrolyte abnormalities with the primary means of therapy being hemodialysis or transplant (Box 4.5). 

Immunologic Antibody formation, although a rare complication, became apparent in 1998 owing to a sudden increase of epoetin-alfa-induced antibodies associated with pure red cell aplasia in patients with chronic kidney disease. In a 65-year-old... 

Lead nephropathy has also been complicated by the toxicological interactions of chronic kidney disease with adverse cardiovascular effects such as hypertension. Hypertension, as noted in this chapter, is a risk factor for Pb-associated and non-Pb-associated kidney disease, while mechanisms for inducing hypertension include the participation of kidney biochemistry and physiology via, for example, the renin—angiotensin pathway. 

For patients with chronic kidney disease (CKD), overall recommendations are to delay progression of both kidney disease and its complications. Treatment of hypertension, proteinuria, dyslipidemia, calcium-phosphate regulation and anemia are the key elements. 

Cardiovascular The relationships among chronic kidney disease (CKD), acute kidney injury (AKI) and potential benefits by post-bypass dexmedetomidine use in patients xmdergoing cardiac surgery were evaluated in a retrospective cohort study in 1133 patients [16 -]. This study suggested that post-bypass dexmedetomidine use was associated with a significant decrease in postoperative AKI (adjusted OR, 0.7033 95% Cl, 0.540-0.916 p = 0.0089), particularly in patients with normal preoperative kidney functions and mild CKD. Post-bypass dexmedetomidine use was also associated with a decrease in postoperative in-hospital and 30-day mortalities and the incidence of any complication. 

Similarly, in patients with chronic kidney disease, a meta-regression analysis examining the association of ESAs with adverse effects independent of target or achieved haemoglobin indicated that a high ESA dose might be associated with cardiovascular complications (and mortality of all causes) independent cf haemoglobin levels [16 ]. 

Kocak T, Nane I, Ander H et al (2004) Urological and surgical complications in 362 consecutive living related donor kidney transplantations. Urol Int 72 252-256 Lameire N, Jager K, Van Biesen W et al (2005) Chronic kidney disease a European perspective. Kidney Int Suppl S30-S38... 

---