1/28/2018 Chronic Kidney Disease Clinical Presentation: History, Physical Examination

Updated: May 01, 2017

Author: Pradeep Arora, MD; Chief Editor: Vecihi Batuman, MD, FASN more...

PRESENTATION

History
Patients with chronic kidney disease (CKD) stages 1-3 (glomerular filtration rate [GFR] >30
mL/min/1.73 m²) are frequently asymptomatic; in terms of possible “negative” symptoms related
simply to the reduction in GFR, they do not experience clinically evident disturbances in water or
electrolyte balance or endocrine/metabolic derangements.

Generally, these disturbances become clinically manifest with CKD stages 4-5 (GFR <30 mL/min/1.73
m²). Patients with tubulointerstitial disease, cystic diseases, nephrotic syndrome, and other conditions
associated with “positive” symptoms (eg, polyuria, hematuria, edema) are more likely to develop signs
of disease at earlier stages.

Uremic manifestations in patients with CKD stage 5 are believed to be primarily secondary to an
accumulation of multiple toxins, the full spectrum and identity of which is generally not known.
Metabolic acidosis in stage 5 may manifest as protein-energy malnutrition, loss of lean body mass,
and muscle weakness. Altered salt and water handling by the kidney in CKD can cause peripheral
edema and, not uncommonly, pulmonary edema and hypertension.

Anemia, which in CKD develops primarily as a result of decreased renal synthesis of erythropoietin,
manifests as fatigue, reduced exercise capacity, impaired cognitive and immune function, and reduced
quality of life. Anemia is also associated with the development of cardiovascular disease, the new
onset of heart failure, the development of more severe heart failure, and increased cardiovascular
mortality.

Other manifestations of uremia in end-stage renal disease (ESRD), many of which are more likely in
patients who are inadequately dialyzed, include the following:

Pericarditis: Can be complicated by cardiac tamponade, possibly resulting in death

Encephalopathy: Can progress to coma and death
Peripheral neuropathy
Restless leg syndrome
Gastrointestinal symptoms: Anorexia, nausea, vomiting, diarrhea
Skin manifestations: Dry skin, pruritus, ecchymosis
Fatigue, increased somnolence, failure to thrive
Malnutrition
Erectile dysfunction, decreased libido, amenorrhea
Platelet dysfunction with tendency to bleed

Physical Examination
A careful physical examination is imperative. It may reveal findings characteristic of the condition that
is underlying chronic kidney disease (CKD) (eg, lupus, severe arteriosclerosis, hypertension) or its
complications (eg, anemia, bleeding diathesis, pericarditis). However, the lack of findings on physical
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1/28/2018 Chronic Kidney Disease Clinical Presentation: History, Physical Examination

examination does not exclude kidney disease. In fact, CKD is frequently clinically silent, so screening
of patients without signs or symptoms at routine health visits is important.

Screening for depression

Forty-five percent of adult patients with CKD have depressive symptoms at initiation of dialysis
therapy, as assessed using self-report scales. However, these scales may emphasize somatic
symptoms—specifically, sleep disturbance, fatigue, and anorexia—that can coexist with chronic
disease symptoms.

Hedayati et al reported that the 16-item Quick Inventory of Depressive Symptomatology-Self Report
(QIDS-SR[16]) and the Beck Depression Inventory (BDI) are effective screening tools and that scores
of 10 and 11, respectively, were the best cutoff scores for identification of a major depressive episode
in their study's patient population. [38] The study compared the BDI and QIDS-SR(16) with a gold-
standard structured psychiatric interview in 272 patients with CKD stages 2-5 who had not been
treated with dialysis.

Differential Diagnoses

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