CHRONIC KIDNEY DISEASE Risk Factors for Chronic Kidney Disease and Its Outcomes* Risk Factor Definition

Examples Susceptibility factors: Increase susceptibility to kidney damage; Ex: Older age, family history of chronic kidney disease, reduction in kidney mass, low birthweight, U.S. racial or ethnic minority status, low income or education Initiation factors: Directly initiate kidney damage; Ex: Diabetes, high blood pressure, autoimmune diseases, systemic infections, urinary tract infections, urinary stones, lower urinary tract obstruction, drug toxicity Progression factors: Cause worsening kidney damage and faster decline in kidney function after initiation of kidney damage; Ex: Higher level of proteinuria, higher blood pressure, poor glycemic control in diabetes, smoking End-stage factors: Increase morbidity and mortality in kidney failure; Ex: Lower dialysis dose (Kt/V), temporary vascular access, anemia, low serum albumin level, late referral * Kt/V dialyzer urea clearance multiplied by time divided by volume of distribution of urea. Modied and reprinted with permission from reference 7. National Kidney Foundation Kidney Disease Outcomes Quality Initiative Classification, Prevalence, and Action Plan for Stages of Chronic Kidney Disease* Stage Description GFR, mL/min/1.73 m2 Action At increased risk 60 (with chronic kidney disease risk factors) Screening; chronic kidney disease risk reduction 1 Kidney damage with normal or increased GFR 90 5 900 000 (3.3) Diagnosis and treatment; treatment of comorbid conditions; slowing progression; CVD risk reduction 2 Kidney damage with mild decreased GFR 6089 5 300 000 (3.0) Estimating progression 3 Moderately decreased GFR 3059 7 600 000 (4.3) Evaluating and treating complications 4 Severely decreased GFR 1529 400 000 (0.2) Preparation for kidney replacement therapy 5 Kidney failure 15 (or dialysis) 300 000 (0.1) Kidney replacement (if uremia present) ACUTE GLOMERULONEPHRITIS History
A thorough history should focus on the identification of an underlying systemic disease (if any) or recent infection. Most often, the patient is a boy, aged 2-14 years, who suddenly develops puffiness of the eyelids and facial edema in the setting of a poststreptococcal infection. The urine is dark and scanty, and the blood pressure may be elevated. Onset of symptoms is usually abrupt.

Nonspecific symptoms include weakness, fever, abdominal pain, and malaise. In the setting of a postinfectious acute nephritis, a latent period of up to 3 weeks occurs before onset of symptoms. However, the latent period may vary; typically 1-2 weeks for postpharyngitis cases and 2-4 weeks for cases of postdermal infection (ie, pyoderma). Onset of nephritis within 1-4 days of streptococcal infection suggests preexisting renal disease. Symptoms of acute glomerulonephritis include the following: y y y y y y Hematuria is a universal finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric patients. Oliguria Edema (peripheral or periorbital) is reported in approximately 85% of pediatric patients; edema may be mild (involving only the face) to severe, bordering on a nephrotic appearance. Headache may occur secondary to hypertension; confusion secondary to malignant hypertension may be seen in as many as 5% of patients. Shortness of breath or dyspnea on exertion secondary to heart failure or pulmonary edema; usually uncommon, particularly in children. Possible flank pain secondary to stretching of the renal capsule. Patients may also present with symptoms specific to an underlying systemic disease that can precipitate an acute glomerulonephritis. These disease entities are briefly described in Causes. Classic presentations include the following: Triad of sinusitis, pulmonary infiltrates, and nephritis suggesting Wegener granulomatosis Nausea/vomiting, abdominal pain, and purpura observed with Henoch-Schnlein purpura Arthralgias associated with systemic lupus erythematosus (SLE) Hemoptysis occurring with Goodpasture syndrome or idiopathic progressive glomerulonephritis Skin rashes observed with a hypersensitivity vasculitis or systemic lupus erythematosus; also possibly due to the purpura that can occur in hypersensitivity vasculitis, cryoglobulinemia, and Henoch-Schnlein purpura

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(physical)
This description does not include all the physical findings that can be associated with the nonnephritic features of an infectious process (eg, fever), renal etiology, or systemic etiology, as such a description is beyond the scope of this article. Patients often have a normal physical examination and blood pressure; most frequently, however, patients present with a combination of edema, hypertension, and oliguria. Edema frequently involves the face, specifically the periorbital area. Hypertension is seen in as many as 80% of affected patients. Hematuria, either macroscopic (gross) or microscopic, may be noted. Skin rashes (ie, malar rash frequently seen with lupus nephritis) may be observed. Abnormal neurologic examination or altered level of consciousness occurring because of malignant hypertension or hypertensive encephalopathy. Arthritis may be noted. Other signs include the following: y y y y y y y Pharyngitis Impetigo Respiratory infection Pulmonary hemorrhage Heart murmur may indicate endocarditis Scarlet fever Weight gain

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Abdominal pain Anorexia Back pain Skin pallor Palpable purpura in patients with Henoch-Schnlein purpura Oral ulcers

ACUTE PYELONEPHRITIS

History
y Patients may present with minimal or severe symptoms. Symptoms usually develop over hours or over the course of a day. Infrequently, symptoms develop over days and may even be present for a few weeks before a patient presents for evaluation. Symptoms of lower UTI may or may not be present to varying degrees. Internal dysuria usually refers to the urinary tract. External dysuria most commonly refers to the vagina. Symptoms may include urinary frequency, hesitancy, lower abdominal pain, and urgency. Gross hematuria (hemorrhagic cystitis) is present in 30-40% of female cases, most often young adults. It may occur in males but is unusual and a more serious cause must be considered. The description of suprapubic symptoms varies and may include discomfort, heaviness, pain, or pressure. Symptoms of acute pyelonephritis may be present to varying degrees. Severity of pain may be mild, moderate, or severe. Flank pain may be unilateral or sometimes bilateral. Discomfort or pain may be present in the back (lower or middle) and/or the suprapubic area. Upper abdominal pain is unusual, and radiation of pain to the groin is suggestive of a ureteral stone. Fever is not always present. When present, it is not unusual for the temperature to exceed 103F (39.4C). The patient may demonstrate rigor, and chills may be present in the absence of demonstrated fever. Malaise and weakness may also be present. Gastrointestinal symptoms vary. Anorexia is common. Nausea and vomiting vary in frequency and intensity from absent to severe. Diarrhea occurs infrequently.

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Physical
y o o o Vital signs There may or may not be a fever. The temperature may be greater than 103F (39.4C), or it may be subnormal in patients with associated sepsis. Tachycardia may or may not be present, depending on associated fever, dehydration, and sepsis. Blood pressure is usually within the reference range, unless the patient has underlying hypertension; in cases of underlying hypertension, the pressure may be elevated above the patient's baseline. A systolic blood pressure less than 90 mm Hg suggests shock secondary to sepsis or perinephric abscess. Appearance The patient's appearance is variable. Most commonly, the patient is uncomfortable or appears ill. Patients usually do not have a toxic appearance unless an underlying problem, such as sepsis, perinephric abscess, or significant dehydration, is present. Abdominal examination Suprapubic tenderness usually ranges from mild to moderate without rebound. Abdominal tenderness other than in the suprapubic area suggests another diagnosis. Usually, abdominal rebound, rigidity, or guarding is not found. Bowel sounds are often normoactive. Flank or costovertebral angle (CVA) tenderness is most commonly unilateral over the involved kidney, although bilateral discomfort may be present. Discomfort varies from absent to severe. This is usually not subtle and may be elicited with mild or moderately firm palpation. Pelvic examination A pelvic examination should be performed. Tenderness of the cervix, uterus, and adnexa should be absent. Any positive finding suggests an additional or alternative diagnosis.

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If any doubt remains as to the diagnosis, if any signs or symptoms of urethritis or vaginitis are present, or if a history of dyspareunia is present, a gynecologic cause of the symptoms should be pursued.