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End-stage renal disease (ESRD)

Overview

End-stage renal disease (ESRD) is the last stage of chronic kidney disease, characterized by progressive, slow, and irreversible deterioration of kidney function over months to years. Kidneys are paired structures near the back wall of your abdomen and side areas called flank, one on each side of the spine, whose function is to filter the waste materials out of the blood and produce urine as a by-product. Some diseases such as high blood pressure, diabetes, polycystic kidney disease, and glomerulonephritis adversely affect your kidneys, reducing their filtering abilities and accumulating harmful substances. In ESRD, kidneys work at less than 15% of normal levels. The symptoms range from fatigue, leg swelling, nausea, and vomiting to confusion and coma.

 

It is managed by treating the underlying disease, improving the symptoms, and adopting techniques and lifestyles that can slow the progression of the disease. Poorly managed ESRD can result in complications such as hypertension, bone disease, heart disease, and anemia. 

Causes

Several conditions that can adversely affect the kidneys, in the long run, can cause chronic kidney disease, which will ultimately lead to ESRD by slow progression. Some causes of ESRD include;

 

  • Autoimmune diseases: Some autoimmune diseases also cause kidney diseases, such as lupus, scleroderma, and glomerulonephritis.
  • Genetic factors: Some studies have shown the association of The APOL1 gene in the development of kidney disease affiliated with HIV,  focal segmental glomerulosclerosis, and hypertension.
  • Structural birth defects: Some deformities of kidney structure present from birth can also cause chronic kidney disease and  ESRD.
  • Polycystic kidney disease: It is an inherited disorder in which cysts (pockets of fluid) develop in the kidneys.
  • Diabetes: Long-standing diabetes is one of the most common causes of ESRD in the USA.
  • Other diseases: uncontrolled chronic high blood pressure and heart disease
  • Obstructive causes: Kidney stones, bladder stones, cancers of the urinary tract, and repeated infections can cause ESRD.
  • Medications: Taking aspirin, ibuprofen, naproxen sodium, chemotherapeutic medications, antibiotics, and dyes.

Epidemiology

Chronic kidney disease has been found to be present in around 37 million people in the USA. It is the ninth most common cause of death in the USA. Its incidence increases with age. 

Risk Factors

If you have any of the following risk factors, you're more likely to develop ESRD;

·         Pre-existing kidney disease

·         Obesity

·         Diabetes, particularly if uncontrolled

·         Hypertension

·         Heart disease

·         Smoking

·         Family history

·         Older age

 

·         Race: Black, Asian, Hispanic, American Indian

Signs And Symptoms

If you have ESRD, you may experience the following signs and symptoms;

·         Lethargy, fatigue

·         Decreased appetite

·         Low urine output

·         Swelling in your lower limb due to fluid retention.

·         Potassium levels that rise dramatically can cause irregular cardiac rhythms.

·         The pain in the flanks

·         Difficulty in breathing

·         Confusion

·         Headache  and vomiting

·         Pain or pressure in the chest

 

·         Seizures

Diagnosis

If you notice the symptoms of ESRD, contact your healthcare provider. He will take a detailed history of your symptoms, previous and current diseases, family history, etc. He would examine you thoroughly. You may be advised to undergo some tests for the confirmation of the disease. For the diagnosis of ESRD, the criteria used is the GFR which is the filtration rate at which kidneys filter the blood. Its value differs for different ages, sex, body size, and ethnicities. Kidney disease is labeled ESRD when the Glomerular Filtration Rate (GFR) becomes less than 15% of the normal.

Blood tests: CBC and Peripheral Smear,  Kidney function tests; Blood urea nitrogen (BUN), and serum creatinine. With the help of these, your GFR will be calculated.

Urine tests: Urine analysis and urinary electrolytes. Your doctor may ask you to collect urine for 24 hours to look for decreased urine volume for Urine output assessment.

Imaging: Your clinician may be using imaging studies such as ultrasound of your kidneys and computed tomography (CTscan) to get a detailed picture of your kidneys.

Biopsy: A piece of kidney tissue is removed for testing. Your doctor may suggest a renal biopsy to extract a sample of kidney tissue for examination in some cases to detect the cause of ESRD. 

Differential Diagnosis

Some other disorders that may present like ESRD include;

                    Acute Kidney Injury

                    Chronic Glomerulonephritis

                    Diabetic Nephropathy

                    Multiple Myeloma

                    Nephrolithiasis

                    Nephrosclerosis

 

                    Rapidly Progressive Glomerulonephritis

Treatment

The type of treatment you receive will be determined by the cause of your chronic kidney disease. The aim is to improve your symptoms, slow down the progression and prevent and treat the complications of ESRD. An evaluation is usually performed by a kidney expert known as a "nephrologist”.

Your diet, the number and amount of liquids you consume, and drink will be restricted by your doctor. This will prevent toxins from accumulating in the kidneys. A high-carbohydrate, low-protein, low-salt, and low-potassium diet is commonly prescribed.

Your condition would be managed by considering the following measures;

Treating high blood pressure: ACE inhibitors are among the best medications used for bringing blood pressure down, as they also decrease the quantity of protein excreted in the urine and slow the progression of chronic kidney disease (CKD). Lisinopril, captopril, and enalapril are examples of medicines in this group. Angiotensin II receptor blockers (ARBs), which include losartan and valsartan, are another class of medications that function in a similar pattern.

Treating fluid retention: Diuretics may aid in the removal of fluid from your kidneys. Furosemide is used to treat fluid excess. They appear to help maintain fluid balance and are widely utilized. Spironolactone and thiazides (hydrochlorothiazide, metolazone) are two others.

Treating high cholesterol: Statins are drugs that decrease the cholesterol concentration in your body. They include fluvastatin, simvastatin, and rosuvastatin.

Treating high potassium levels: Calcium and insulin can help bring down and protect you from increased potassium levels in your blood, which could be dangerous for your heart.

Correcting anemia: Low hemoglobin (anemia) is one of the complications of ESRD. Anemia can be treated by giving iron by vein. A hormone generally produced by the kidneys to boost red blood cell production can also be given as a supplement.

Preventing bone disease: You may be started on active vitamin D supplements to prevent the development of bone disease, which is also an important complication of ESRD.

Procedure

Dialysis: If toxins accumulate in the bloodstream, you may need dialysis to aid in eliminating them from the body. Dialysis is required if your mental state worsens or if you stop urinating. If you develop pericarditis, you may need dialysis. It can assist in the removal of nitrogen waste products from the body. There are two types of dialysis;

Hemodialysis: In hemodialysis, a machine pumps blood out of your body and filters it through a dialysis machine. After that, the blood is restored to your body. One of the major veins of your body will be accessed for this purpose.

Peritoneal dialysis: in this type, a plastic tube is placed in your belly through which a solution runs that collects all the waste and brings it out of the body.

 

Kidney Transplant: During this procedure, the diseased kidney is replaced by a new one that a living or dead donor would provide. Before the procedure, you may be required to undergo a few tests to match the blood and organ type with the donor and would be prescribed some medicines to depress your immune system so that the organ can survive in your body. 

Prognosis

Chronic kidney disease will progress to end-stage renal disease and kidney failure. The rate of progression depends on many factors including age, underlying disease, treatment provided, and preventive measures. Timely intervention is imperative to improve the overall condition and the outcome. 

Lifestyle Modifications

Stay focused on treatment plans and implement your doctor's instructions to manage your health if you have renal disease or another condition that raises your risk of ESRD, like high blood pressure or diabetes.

                    If you have hypertension or diabetes, start taking medications for it.

                    Eat healthy meals and drink plenty of water to keep your kidneys healthy.

                    Get vaccinated for contagious diseases, particularly if you deal with people who have hepatitis or some other conditions.

                    Perform mild exercises regularly to keep you active.

                    Always ask your doctor if you need to take Aspirin, ibuprofen, and similar pain medications very often. Consuming too many of these medications can put your kidneys at risk. Specifically, if you have pre-existing kidney disease, diabetes, or high blood pressure.

                    Consult a dietician for a diet plan to keep your weight according to your BMI to prevent obesity as it is bad for chronic kidney disease.

                    Try to get good sleep and keep your body relaxed.

 

                    Always seek help or support from your loved ones or support groups if you feel depressed. 

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