NATURAL HEALTH

Many people who have chronic kidney disease don't know it, because the early signs can be very subtle. It can take many years to go from chronic kidney disease (CKD) to kidney failure. Some people with CKD live out their lives without ever reaching kidney failure.

However, for people at any stage of kidney disease, knowledge is power. Knowing the symptoms of kidney disease can help you get the treatment you need to feel your best. If you or someone you know has one or more of the following symptoms of kidney disease, or you are worried about kidney problems, see a doctor for blood and urine tests. Remember, many of the symptoms can be due to reasons other than kidney disease. The only way to know the cause of your symptoms is to see your doctor.

Symptom 1: Changes in Urination

Kidneys make urine, so when the kidneys are failing, the urine may change. How?

• You may have to get up at night to urinate.
• Urine may be foamy or bubbly. You may urinate more often, or in greater amounts than usual, with pale urine.
• You may urinate less often, or in smaller amounts than usual with dark colored urine.
• Your urine may contain blood.
• You may feel pressure or have difficulty urinating.

What patients said:

"When you go to use the restroom, you couldn't get it all out. And it would still feel just like tightness down there, there was so much pressure."

"My urine is what I had started noticing. Then I was frequently going to the bathroom, and when I got there, nothing's happening. You think, 'Hey, I've got to go to the john,' and you get there: two, three drops."

"I was passing blood in my urine. It was so dark it looked like grape Kool-Aid. And when I went to the hospital they thought I was lying about what color it was."

Symptom 2: Swelling

Failing kidneys don't remove extra fluid, which builds up in your body causing swelling in the legs, ankles, feet, face, and/or hands.

What patients said:

"I remember a lot of swelling in my ankles. My ankles were so big I couldn't get my shoes on."

"My sister, her hair started to fall out, she was losing weight, but her face was really puffy, you know, and everything like that, before she found out what was going on with her."

"Going to work one morning, my left ankle was swollen, real swollen, and I was very exhausted just walking to the bus stop. And I knew then that I had to see a doctor."

Symptom 3: Fatigue

Healthy kidneys make a hormone called erythropoietin (a-rith'-ro-po'-uh-tin) that tells your body to make oxygen-carrying red blood cells. As the kidneys fail, they make less erythropoietin. With fewer red blood cells to carry oxygen, your muscles and brain become tired very quickly. This condition is called anemia, and it can be treated.

What patients said:

"I was constantly exhausted and didn't have any pep or anything."

"I would sleep a lot. I'd come home from work and get right in that bed."

"It's just like when you're extremely tired all the time. Fatigued, and you're just drained, even if you didn't do anything, just totally drained."

Symptom 4: Skin Rash/Itching

Kidneys remove wastes from the bloodstream. When the kidneys fail, the buildup of wastes in your blood can cause severe itching.

What patients said:

"It's not really a skin itch or anything, it's just right down to the bone. I had to get a brush and dig. My back was just bloody from scratching it so much."

"My skin had broke out, I was itching and scratching a lot."

Symptom 5: Metallic Taste in Mouth/Ammonia Breath

A buildup of wastes in the blood (called uremia) can make food taste different and cause bad breath. You may also notice that you stop liking to eat meat, or that you are losing weight because you just don't feel like eating.

What patients said:

"Foul taste in your mouth. Almost like you're drinking iron."

"You don't have the appetite you used to have."

"Before I started dialysis, I must have lost around about 10 pounds."

Symptom 6: Nausea and Vomiting

A severe buildup of wastes in the blood (uremia) can also cause nausea and vomiting. Loss of appetite can lead to weight loss.

What patients said:

"I had a lot of itching, and I was nauseated, throwing up all the time. I couldn't keep anything down in my stomach."

"When I got the nausea, I couldn't eat and I had a hard time taking my blood pressure pills."

Symptom 7: Shortness of Breath

Trouble catching your breath can be related to the kidneys in two ways. First, extra fluid in the body can build up in the lungs. And second, anemia (a shortage of oxygen-carrying red blood cells) can leave your body oxygen-starved and short of breath.

What patients said:

"At the times when I get the shortness of breath, it's alarming to me. It just fears me. I think maybe I might fall or something so I usually go sit down for awhile."

"I couldn't sleep at night. I couldn't catch my breath, like I was drowning or something. And, the bloating, can't breathe, can't walk anywhere. It was bad."

"You go up a set of stairs and you're out of breath, or you do work and you get tired and you have to stop."

Symptom 8: Feeling Cold

Anemia can make you feel cold all the time, even in a warm room.

What patients said:

"I notice sometimes I get really cold, I get chills."

"Sometimes I get really, really cold. It could be hot, and I'd be cold."

Symptom 9: Dizziness and Trouble Concentrating

Anemia related to kidney failure means that your brain is not getting enough oxygen. This can lead to memory problems, trouble with concentration, and dizziness.

What patients said:

"I know I mentioned to my wife that my memory—I couldn't remember what I did last week, or maybe what I had 2 days ago. I couldn't really concentrate, because I like to work crossword puzzles and read a lot."

"I was always tired and dizzy."

"It got to the point, like, I used to be at work, and all of the sudden I'd start getting dizzy. So I was thinking maybe it was my blood pressure or else diabetes was going bad. That's what was on my mind."

Symptom 10: Leg/Flank Pain

Some people with kidney problems may have pain in the back or side related to the affected kidney. Polycystic kidney disease, which causes large, fluid-filled cysts on the kidneys and sometimes the liver, can cause pain.

What patients said:

"About 2 years ago, I was constantly going to the bathroom all the time, the lower part of my back was always hurting and I was wondering why...and they diagnosed that kidney problem."

"And then you're having to get up all time through the night, and then you have the side ache, a backache, and you can't move."

"At night, I would get a pain in my side. It was worse than labor pain. And I'd be crying and my husband would get up, everybody, rubbing my legs."

Dialysis

In end-stage renal disease, kidney functions can be replaced only by dialysis or by kidney transplantation. See the Transplant section for more information about transplants. There are two types of dialysis 1) hemodialysis and 2) peritoneal dialysis.

Hemodialysis

Hemodialysis involves circulation of blood through a filter on a dialysis machine. Blood is cleansed of waste products and excess water. The acid levels and the concentration of various minerals such as sodium and potassium in the blood are normalized. The blood is then returned to the body.

• Long-term dialysis requires access to a blood vessel so that the machine has a way to remove and return blood to the body. This may be in the form of a dialysis catheter or an arteriovenous fistula or graft.
  
  
• A catheter may be either temporary or permanent. These catheters are either placed in the neck or the groin into a large blood vessel. These catheters are prone to infection and may also cause blood vessels to clot or narrow.
  
  
• The preferred access for hemodialysis is an arteriovenous fistula wherein an artery is directly joined to a vein. The vein takes two to four months to enlarge and mature before it can be used for dialysis. Once matured, two needles are placed into the vein for dialysis. One needle is used to draw blood and run through the dialysis machine. The second needle is to return the cleansed blood.
  
  
• An arteriovenous graft is placed in patients who have small veins or in whom a fistula has failed to develop. The graft is made of artificial material and the dialysis needles are inserted into the graft directly.
  
  
• These venous access devices usually can be placed with local anesthesia on an outpatient basis.
  
  
• Hemodialysis typically takes three to five hours and is needed three times a week.
  
  
• You will need to travel to a dialysis center for hemodialysis.
  
  
• Home hemodialysis is possible in some situations. A care partner is needed to assist you with the dialysis treatments. A family member or close friend are the usual options, though occasionally patients may hire a professional to assist with dialysis. Home hemodialysis may be performed as traditional three times a week treatments, long nocturnal (overnight) hemodialysis, or short daily hemodialysis. Daily hemodialysis and long nocturnal hemodialysis offer advantages in quality of life and better control of high blood pressure, anemia, and bone disease.

Peritoneal dialysis

Peritoneal dialysis utilizes the lining membrane (peritoneum) of the abdomen as a filter to clean blood and remove excess fluid. A catheter is implanted into the abdomen by a minor surgical procedure. Peritoneal dialysis may be performed manually or by using a machine to perform the dialysis at night.

• About 2 to 3 liters of dialysis fluid are infused into the abdominal cavity through this catheter. This fluid contains substances that pull wastes and excess water out of neighboring tissues.
  
  
• The fluid is allowed to dwell for two to several hours before being drained, taking the unwanted wastes and water with it.
  
  
• The fluid typically needs to be exchanged four to five times a day.
  
  
• Peritoneal dialysis offers much more freedom compared to hemodialysis since patients do not need to come to a dialysis center for their treatment. You can carry out many of your usual activities while undergoing this treatment. This may be the preferable therapy for children.

Most patients are candidates for both hemodialysis and peritoneal dialysis. There are little differences in outcomes between the two procedures. Your physician may recommend one kind of dialysis over the other based on your medical and surgical history. It is best to choose your modality of dialysis after understanding both procedures and matching them to your life style, daily activities, schedule, distance from the dialysis unit, support system, and personal preference.

There is no cure for chronic kidney disease. The four goals of therapy are as follows:

1. To slow the progression of disease

2. To treat underlying causes and contributing factors

3. To treat complications of disease

4. To replace lost kidney function

Strategies for slowing progression and treating conditions underlying chronic kidney disease include the following:

• Control of blood glucose: Maintaining good control of diabetes is critical. People with diabetes who do not control their blood glucose have a much higher risk of all complications of diabetes, including chronic kidney disease.
  
  
• Control of high blood pressure: This also slows progression of chronic kidney disease. It is recommended to keep your blood pressure below 130/80 mm Hg if you have kidney disease. It is often useful to monitor blood pressure at home. Blood pressure medications known as angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) have special benefit in protecting the kidneys.
  
  
• Diet: Diet control is essential to slowing progression of chronic kidney disease and should be done in close consultation with your health care provider and a dietitian. For some general guidelines, see the Self-Care at Home section of this article.

The complications of chronic kidney disease may require medical treatment.

• Fluid retention can be treated with any of a number of diuretic medications, which remove excess water from the body. However, these drugs are not suitable for all patients.
  
  
• Anemia can be treated with erythropoiesis stimulating agents. Erythropoiesis stimulating agents are a group of drugs that replace the deficiency of erythropoietin, which is normally produced by healthy kidneys. Often, patients treated with such drugs require either to take iron by mouth or sometimes even intravenously.
  
  
• Bone disease develops in patients due to an inability to excrete phosphorus and a failure to form activated Vitamin D. In such circumstances, your physician may prescribe drugs binding phosphorus in the gut, and may prescribe active forms of vitamin D.
  
  
• Acidosis may develop with kidney disease. The acidosis may cause breakdown of proteins, inflammation and bone disease. If the acidosis is significant, your doctor may use drugs such as sodium bicarbonate (baking soda) to correct the problem.

Chronic kidney disease usually causes no symptoms in its early stages. Only lab tests can detect any developing problems. Anyone at increased risk for chronic kidney disease should be routinely tested for development of this disease.

• Urine, blood, and imaging tests (x-rays) are used to detect kidney disease, as well as to follow its progress.
  
  
• All of these tests have limitations. They are often used together to develop a picture of the nature and extent of the kidney disease.
  
  
• In general, this testing can be performed on an outpatient basis.

Urine tests

Urinalysis: Analysis of the urine affords enormous insight into the function of the kidneys. The first step in urinalysis is doing a dipstick test. The dipstick has reagents that check the urine for the presence of various normal and abnormal constituents including protein. Then, the urine is examined under a microscope to look for red and white blood cells, and the presence of casts and crystals (solids).

Only minimal quantities of albumin (protein) are present in urine normally. A positive result on a dipstick test for protein is abnormal. More sensitive than a dipstick test for protein is a laboratory estimation of the urine albumin (protein) and creatinine in the urine. The ratio of albumin (protein) and creatinine in the urine provides a good estimate of albumin (protein) excretion per day.

Twenty-four-hour urine tests: This test requires you to collect all of your urine for 24 consecutive hours. The urine may be analyzed for protein and waste products (urea, nitrogen, and creatinine). The presence of protein in the urine indicates kidney damage. The amount of creatinine and urea excreted in the urine can be used to calculate the level of kidney function and the glomerular filtration rate (GFR).

Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min in men and 85-115 mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of waste products in the 24-hour urine or by using special markers administered intravenously. Patients are divided into five stages of chronic kidney disease based on their GFR (see Table 1 above).

Blood tests

Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine are the most commonly used blood tests to screen for, and monitor renal disease. Creatinine is a breakdown product of normal muscle breakdown. Urea is the waste product of breakdown of protein. The level of these substances rises in the blood as kidney function worsens.

Estimated GFR (eGFR): The laboratory or your physician may calculate an estimated GFR using the information from your blood work. It is important to be aware of your estimated GFR and stage of chronic kidney disease. Your physician uses your stage of kidney disease to recommend additional testing and suggestions on management.

Electrolyte levels and acid-base balance: Kidney dysfunction causes imbalances in electrolytes, especially potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a particular concern. The acid-base balance of the blood is usually disrupted as well.

Decreased production of the active form of vitamin D can cause low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise. Testicular or ovarian hormone levels may also be abnormal.

Blood cell counts: Because kidney disease disrupts blood cell production and shortens the survival of red cells, the red blood cell count and hemoglobin may be low (anemia). Some patients may also have iron deficiency due to blood loss in their gastrointestinal system. Other nutritional deficiencies may also impair the production of red cells.

Other tests

Ultrasound: Ultrasound is often used in the diagnosis of kidney disease. An ultrasound is a noninvasive type of test. In general, kidneys are shrunken in size in chronic kidney disease, although they may be normal or even large in size in cases caused by adult polycystic kidney disease, diabetic nephropathy, and amyloidosis. Ultrasound may also be used to diagnose the presence of urinary obstruction, kidney stones and also to assess the blood flow into the kidneys.

Biopsy: A sample of the kidney tissue (biopsy) is sometimes required in cases in which the cause of the kidney disease is unclear. Usually, a biopsy can be collected with local anesthesia only by introducing a needle through the skin into the kidney. This is usually done as an outpatient procedure, though some institutions may require an overnight hospital stay.

The kidneys are remarkable in their ability to compensate for problems in their function. That is why chronic kidney disease may progress without symptoms for a long time until only very minimal kidney function is left.

Because the kidneys perform so many functions for the body, kidney disease can affect the body in a large number of different ways. Symptoms vary greatly. Several different body systems may be affected. Notably, most patients have no decrease in urine output even with very advanced chronic kidney disease.

• Fatigue and weakness (from anemia or accumulation of waste products in the body)
  
  
• Loss of appetite, nausea and vomiting
  
  
• Need to urinate frequently, especially at night
  
  
• Swelling of the legs and puffiness around the eyes (fluid retention)
  
  
• Itching, easy bruising, and pale skin (from anemia)
  
  
• Headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered mental status (encephalopathy from the accumulation of waste products or uremic poisons), and restless legs syndrome
  
  
• High blood pressure, chest pain due to pericarditis (inflammation around the heart)
  
  
• Shortness of breath from fluid in lungs
  
  
• Bleeding (poor blood clotting)
  
  
• Bone pain and fractures
  
  
• Decreased sexual interest and erectile dysfunction

• Chronic kidney disease is a growing health problem in the United States. A report by the Centers for Disease Control (CDC) determined that 16.8% of all adults above the age of 20 years have chronic kidney disease. Thus, one in six individuals have kidney disease, and over 400,000 patients are on dialysis or have received kidney transplants. About 67,000 people die each year because of kidney failure.
  
  
• The prevalence of chronic kidney disease has increased by 16% from the previous decade. The increasing incidence of diabetes mellitus, hypertension (high blood pressure), obesity, and an aging population have led to this increase in kidney disease.
  
  
• Chronic kidney disease is more prevalent among individuals above 60 years of age (39.4%).
  
  
• Kidney disease is more common among Hispanic, African American, Asian or Pacific Islander, and Native American people.

Although chronic kidney disease sometimes results from primary diseases of the kidneys themselves, the major causes are diabetes and high blood pressure.

• Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidney disease in the United States.
  
  
• High blood pressure (hypertension), if not controlled, can damage the kidneys over time.
  
  
• Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys and can cause kidney failure. Postinfectious conditions and lupus are among the many causes of glomerulonephritis.
  
  
• Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiple cysts.
  
  
• Use of analgesics such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil) regularly over long durations of time can cause analgesic nephropathy, another cause of kidney disease. Certain other medications can also damage the kidneys.
  
  
• Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a condition called ischemic nephropathy, which is another cause of progressive kidney damage.
  
  
• Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings), or cancers may also cause kidney disease.
  
  
• Other causes of chronic kidney disease include HIV infection, sickle cell disease, heroin abuse, amyloidosis, kidney stones, chronic kidney infections, and certain cancers.

If you have any of the following conditions, you are at higher-than-normal risk of developing chronic renal disease. Your kidney functions may need to be monitored regularly.