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Nephrology

Other Conditions and Diseases

Chronic Kidney Disease (CKD)

About Chronic Kidney Disease

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Stages of Chronic Kidney Disease

Your Glomerular Filtration Rate (GFR) is the best indicator of how well your kidneys are working. In 2002, the National Kidney Foundation published treatment guidelines that identified five stages of Chronic Kidney Disease (CKD) based on declining GFR measurements. The guidelines recommend different actions based on the stage of kidney disease.

  • Increased risk of CKD. A GFR of 90 or above is considered normal. Even with a normal GFR, you may be at increased risk for developing CKD if you have diabetes, high blood pressure, or a family history of kidney disease. The risk increases with age: People over 65 are more than twice as likely to develop CKD as people between the ages of 45 and 65. African Americans also have a higher risk of developing CKD.

  • Stage 1: Kidney damage with normal GFR (90 or above). Kidney damage may be detected before the GFR begins to decline. In this first stage of kidney disease, the goals of treatment are to slow the progression of CKD and reduce the risk of heart and blood vessel disease.

  • Stage 2: Kidney damage with mild decrease in GFR (60 to 89). When kidney function starts to decline, your health care provider will estimate the progression of your CKD and continue treatment to reduce the risk of other health problems.

  • Stage 3: Moderate decrease in GFR (30 to 59). When CKD has advanced to this stage, anemia and bone problems become more common. Work with your health care provider to prevent or treat these complications.

  • Stage 4: Severe reduction in GFR (15 to 29). Continue following the treatment for complications of CKD and learn as much as you can about the treatments for kidney failure. Each treatment requires preparation. If you choose hemodialysis, you will need to have a procedure to make a vein in your arm larger and stronger for repeated needle insertions. For peritoneal dialysis, you will need to have a catheter placed in your abdomen. Or you may want to ask family or friends to consider donating a kidney for transplantation.

  • Stage 5: Kidney failure (GFR less than 15). When the kidneys do not work well enough to maintain life, you will need dialysis or a kidney transplant.
Early Chronic Kidney Disease (Stages 1 and 2)
  • Physical symptoms: Usually few or no physical symptoms that you can feel (other than those you may experience if you have a lot of protein in your urine).

  • Blood work: Blood work results will show abnormalities - mainly a slightly elevated serum creatinine.

  • Urinalysis: Urine will show abnormalities. Urine can be checked by dipstick in the doctor's office (as an initial check) and followed up with a more complete urinalysis. The main urine abnormality that will suggest a kidney disease is the presence of protein and/or blood. Either will usually trigger further investigation. Importantly, blood and/or protein in the urine does not say anything about actual kidney function.

  • Treatment: Treatment may involve some mild dietary changes (a lower sodium diet is often recommended) and a blood pressure medication may be prescribed (usually of the ACE inhibitor class or the angiotensin II receptor blocker class) even if blood pressure is not really elevated much.

  • Blood pressure: Some people start having high blood pressure even in early chronic kidney disease.

  • Anemia: Anemia may rarely occur at this stage. In this case, it is most often caused by having a lot of protein in the urine rather than actual chronic kidney disease.
Advanced Chronic Kidney Disease Stages 3 to 4
  • Physical symptoms: You may still feel completely normal at this stage, or you may begin to experience one or more of the following symptoms:
    Tiredness or fatigue
    Puffiness or swelling (obvious in the hands or feet and ankles, but the puffiness will often first be seen around the eyes).
    Back pain. Usually felt as a dull ache anywhere in the mid-to-lower portion of the back, on one side or the other - this is sometimes referred to as flank pain, or loin pain.
    Changes in appetite or eating pattern. Foods may start tasting "funny."
  • Urine: Changes in urination (amount, color, frequency). Urine may in fact look exceptionally clear at this point. This is because little is actually being filtered by your kidneys. Some patients that previously had blood or protein in the urine may see these findings improve.

  • Blood pressure: High blood pressure (also referred to as hypertension) is common.

  • Digestion: Poor digestion (varying degrees of gastroparesis, which means that digestion is slowed).

  • Treatment
    Diet: Dietary changes may be ordered (Kidney diet: low potassium, low phosphorus, low sodium, and higher calorie). Occasionally a lower protein diet may be advised.
  • Medication

  • High blood pressure medications: It is common to need more than one medication at this stage (often 3 or more).

  • Other drugs/supplements may be prescribed if needed. Including vitamin D and kidney vitamins (not a regular multi-vitamin, as these contain too much vitamin A for the typical advanced kidney disease patient).

  • High Phosphorus levels: You may be asked to begin taking a calcium supplement with meals as a phosphorus binder. These medications help keep phosphorus levels in the normal range which helps protect your blood vessels from harmful build up.
End-Stage Renal Disease (Or Late Chronic Kidney Disease) (ESRD)

The terms end-stage renal failure and end-stage renal disease are used interchangeably, and the abbreviation ESRD is commonly used. Typically, patients will have kidney function in the area of 5-10% or so. These are the common symptoms you may experience at this stage (and some people may start experiencing some of these earlier):

  • Anemia (may begin earlier than this)
  • Easy bleeding and bruising
  • Headache
  • Fatigue and drowsy feeling (more than normal or usual for you)
  • Weakness
  • Mental symptoms such as lowered mental alertness, trouble concentrating, confusion, seizures
  • Nausea, vomiting, and generally less desire to eat
  • Thirst
  • Muscle cramps, muscle twitching
  • Increased night-time urination
  • Numb sensation in the extremities
  • Diarrhea
  • Itchy skin, itchy eyes
  • Skin color changes (grayish complexion, sometimes yellowish-brownish tone)
  • Swelling and puffiness (more than you had while in advanced kidney disease, and most likely in the feet and/or ankles)
  • Difficulty breathing (due to fluid in the lungs, anemia)
  • High blood pressure
  • Decreased sexual interest
  • Changes in menstrual cycle (and difficulty getting pregnant)
  • Decreased urine output (however, you should be aware that some people with ESRD will continue to get rid of water as urine, but not wastes - therefore, the urine may be very clear and normal-looking, and some may have increased urine output rather than decreased).
  • Poor digestion (varying degrees of gastroparesis)
Treatment

The exact time that dialysis starts varies slightly depending on multiple factors. Consult your nephrologist.

  • Dialysis
  • Kidney transplant
What happens when you approach ESRD?
It is at this stage that you are on the threshold of needing renal replacement therapy (any form of dialysis or a kidney transplant). When this actually happens will depend on your symptoms and lab results. It will occur as you get close to 10% kidney function (by which time the special kidney diet and medications will no longer be enough to keep you healthy). You will be considered to be approaching ESRD when you are under 20% kidney function (as measured by Glomerular Filtration Rate), and more actively as you approach 10% kidney function.

Sequence of Events When You Approach ESRD
Some localities, such as many major urban centers, may have a very complete "system" that patients come under or have access to as they approach or reach ESRD. Other areas might not. The sequence of events given below is typical, but it's possible that some of the items listed might not be available where you live, or your nephrologist may vary it slightly. It is provided as a guide so that you will know what to expect and what to discuss with your nephrologist.

20-30% kidney function

Refer for Renal Replacement Therapy classes, also referred to as pre-dialysis classes. This is where patients are introduced to the concept of the kidney diet and have the renal replacement options explained to them, i.e. hemodialysis, peritoneal dialysis, and kidney transplantation. This allows patients to make an informed choice of treatment method when the time comes. In some areas, handouts may be used in place of actual classes. Around this time, you will probably also be told to start taking calcium with meals as a phosphorus binder, if you haven't already (don't do this on your own).

15-20% kidney function (or thereabouts)

Sometime during this timeframe your nephrologist will want you to choose a dialysis method so that the dialysis access to your body can be arranged. This is also the time when patients can be evaluated for kidney transplantation. Your nephrologist may also ask if you have any potential kidney donors.
Arteriovenous Fistula (for hemodialysis)
Called AV fistula for short, or just fistula. This is considered the best way of performing hemodialysis. A fistula is really just a vein near the surface of your lower or upper arm, that has been connected to an artery by a vascular surgeon. It requires surgery in your arm (usually in a day surgery setting). Surgery should usually be scheduled a good 6 months before the date dialysis is expected to be needed because a fistula needs time to develop. It's not too early to have it done a year before expected dialysis. That way, if you have to start dialysis earlier than expected (as often happens), your fistula will be ready for use by the time you need it. Preparing in this way helps you start dialysis without requiring a catheter inserted in your chest. Importantly, it doesn't hurt to have that fistula ready and waiting if it turns out you don't need to start dialysis right away.

Graft or Shunt for hemodialysis
This is similar to an AV fistula, but whereas the fistula uses a natural vein in your arm, a graft is an artificial piece of tubing that is implanted in your arm to serve the same purpose. People who choose hemodialysis but who don't have suitable veins for fistula surgery may need to have a graft instead of a fistula. The word shunt is often used, but it is an obsolete term in this context. Some health professionals in dialysis may even refer to a fistula as a shunt.

Abdominal Catheter (for peritoneal dialysis)
If you choose peritoneal dialysis (PD), a surgeon will have to insert a plastic tube in your abdomen, through which you will perform your dialysate fluid exchanges. This can be placed closer to the need for dialysis (about 1 month before the need).

Potential kidney donors (for pre-emptive transplant)
Some people may want to consider having a kidney transplant when they reach ESRD rather than having to go on dialysis. This is called a pre-emptive transplant. Obviously, this requires having a suitable and pre-qualified donor lined up. As both the patient's pre-evaluation as a potential kidney transplant recipient, and the donor's pre-evaluation as a potential kidney donor can take some time (weeks or months in some cases), this is best performed well-ahead of time (i.e. the year leading up to anticipated ESRD). There can be many medical or psychological/social reasons that a potential kidney donor is rejected, and, unfortunately, it's not unheard of for a qualified kidney donor to back out of it very late in the process. Or sometimes, an illness will make it impossible to get the transplant at the time it's needed. For that reason, many nephrologists will suggest that you also choose a method of dialysis just in case it's needed (given the lead time that is required for the access surgery). Therefore, even a patient with a donor all pre-qualified for an expected pre-emptive transplant might still have fistula surgery performed, or a PD catheter inserted.

Kidney transplant waiting list

If you do not plan to have a pre-emptive kidney transplant, it's still a good idea to go through your evaluation as a potential kidney transplant recipient before you start dialysis. That way, you will be on the waiting list and able to receive a kidney if one should come along soon after you start dialysis. Otherwise, you could miss out if your evaluation is only started once you are on dialysis.

Some important information about getting listed:

Getting on the waiting list does not happen automatically. Make sure your nephrologist knows you want a transplant, and that however it happens, you do actually get referred to a kidney transplant center. Once this happens, you will need to go through a potential kidney transplant recipient evaluation, which usually includes a complete medical evaluation, medical tests (such as various heart tests), a psychological and/or social worker evaluation, interviews with a transplant nephrologist and a transplant surgeon. This evaluation can easily take a number of months. It usually can be completed before you actually reach the point of needing dialysis.

In Canada, you can be evaluated while you are pre-dialysis, but the exact rules which govern may vary from Province to Province, and from region to region within each province. Using the Province of Ontario as an example, no matter when you complete the evaluation, before or after having started dialysis, your time on the waiting list begins the exact date that you start dialysis, not before (it is retroactive if you completed the evaluation after having started dialysis). If you have a potential live donor, you will be put on hold from the waiting list while that person is being evaluated. This is done because a kidney from a live donor is considered to be superior to one from the waiting list. The reasoning behind starting everyone's time on the waiting list as of the date of first dialysis is that evidence has shown that the longer a person is on dialysis, the more overall health declines. Therefore, it is believed to be more fair to everyone that time on the list begins on the date of first dialysis. Some people may have completed their evaluation before dialysis, some after. Some may have been on hold one or more times because of other illnesses, etc., but nobody is penalized for having had delays in their potential recipient evaluation or for having had other illnesses during the course of dialysis.

In the United States, you can usually be evaluated as a potential kidney transplant recipient within the 2-3 year period before you would be expected to start dialysis. If you have done so, credit for waiting time on the waiting list begins when you have reached 20% kidney function (more precisely, a GFR of less than 20, as per a rule change implemented by UNOS in 1998). Since dialysis is typically started when GFR is about 10%, it is therefore possible to obtain a cadaveric kidney transplant before having actually started dialysis.

15 to 10% kidney function (more or less). It will vary based on a patient's symptoms, but this is the timeframe when dialysis is started. A person who is diabetic will often be started at 15% kidney function, while most IgAN patients would start at about 10%. It's common practice these days to start dialysis in a planned manner, rather than waiting until it becomes an emergency situation (thankfully!). Most people will either start dialysis or have the pre-emptive kidney transplant done when or slightly before they reach 10% kidney function. Some people may reach 10% without experiencing any major symptoms, but, generally, dialysis will be started at this point, if not slightly before, in a planned fashion, even if the patient doesn't feel any significant symptoms. Since there is still about 10% kidney function at this point, it may be possible to continue quite some time without dialysis, but starting dialysis early increases chances of an easier transition, and it allows time to initiate dialysis in a way that minimizes stress on the body.

Contrary to popular misconception, there is no advantage to being able to delay dialysis even if no symptoms of renal failure are felt once kidney function (glomerular filtration rate) reaches about 10%, and there may in fact be significant disadvantages for the patient in terms of mortality and morbidity.

Glomerulonephritis

Topic written or edited by:

Walter F. Piering, MD, FACP
Kevin R. Regner, MD, MS, FASN

Glomerulonephritis is the term used to describe a group of diseases that damage the part of the kidney that filters blood. When the kidney is damaged, it cannot get rid of wastes and extra fluid in the body. If the illness continues, the kidneys may stop working completely. Some other terms you may hear used are nephritis and nephrotic syndrome.

About Glomerulonephritis

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What are the kidneys and what do they do?
The two kidneys are bean-shaped organs located near the middle of the back, just below the rib cage to the left and right of the spine. Each about the size of a fist, these organs act as sophisticated filters for the body. They process about 200 quarts of blood a day to sift out about 2 quarts of waste products and extra water that eventually leave the body as urine.

Blood enters the kidneys through arteries that branch inside the kidneys into tiny clusters of looping blood vessels. Each cluster is called a glomerulus, which comes from the Greek word meaning filter. The plural form of the word is glomeruli. There are approximately 1 million glomeruli, or filters, in each kidney. The glomerulus is attached to the opening of a small fluid-collecting tube called a tubule. Blood is filtered in the glomerulus, and extra water and wastes pass into the tubule and become urine. Eventually, the urine drains from the kidneys into the bladder through larger tubes called ureters.

Each glomerulus-and-tubule unit is called a nephron. Each kidney is composed of about 1 million nephrons. In healthy nephrons, the glomerular membrane that separates the blood vessel from the tubule allows waste products and extra water to pass into the tubule while keeping blood cells and protein in the bloodstream.
How do Glomerular diseases interfere with kidney function?
Glomerular diseases damage the glomeruli, letting protein and sometimes red blood cells leak into the urine. Sometimes a glomerular disease also interferes with the clearance of waste products by the kidney, so they begin to build up in the blood. Furthermore, loss of blood proteins like albumin in the urine can result in a fall in their level in the bloodstream. In normal blood, albumin acts like a sponge, drawing extra fluid from the body into the bloodstream, where it remains until the kidneys remove it. But when albumin leaks into the urine, the blood loses its capacity to absorb extra fluid from the body. Fluid can accumulate outside the circulatory system in the face, hands, feet, or ankles and cause swelling.

What are the symptoms of glomerular disease?

The signs and symptoms of glomerular disease include:

  • Proteinuria: large amounts of protein in the urine
  • Hematuria: blood in the urine
  • Reduced glomerular filtration rate: inefficient filtering of wastes from the blood
  • Hypoproteinemia: low blood protein
  • Edema: swelling in parts of the body

One or more of these symptoms can be the first sign of kidney disease. But how would you know, for example, whether you have proteinuria? Before seeing a doctor, you may not. But some of these symptoms have signs, or visible manifestations:

  • Proteinuria may cause foamy urine. Blood may cause the urine to be pink or cola-colored.
  • Edema may be obvious in hands and ankles, especially at the end of the day, or around the eyes when awakening in the morning, for example.
How is glomerular disease diagnosed?
Patients with glomerular disease have significant amounts of protein in the urine, which may be referred to as “nephrotic range” if levels are very high. Red blood cells in the urine are a frequent finding as well, particularly in some forms of glomerular disease. Urinalysis provides information about kidney damage by indicating levels of protein and red blood cells in the urine. Blood tests measure the levels of waste products such as creatinine and urea nitrogen to determine whether the filtering capacity of the kidneys is impaired. If these lab tests indicate kidney damage, the doctor may recommend ultrasound or an x ray to see whether the shape or size of the kidneys is abnormal. These tests are called renal imaging. But since glomerular disease causes problems at the cellular level, the doctor will probably also recommend a kidney biopsy—a procedure in which a needle is used to extract small pieces of tissue for examination with different types of microscopes, each of which shows a different aspect of the tissue. A biopsy may be helpful in confirming glomerular disease and identifying the cause.

What causes glomerular disease?
A number of different diseases can result in glomerular disease. It may be the direct result of an infection or a drug toxic to the kidneys, or it may result from a disease that affects the entire body, like diabetes or lupus. Many different kinds of diseases can cause swelling or scarring of the nephron or glomerulus. Sometimes glomerular disease is idiopathic, meaning that it occurs without an apparent associated disease.

Points to remember
  • The kidneys filter waste and extra fluid from the blood.
  • The filtering process takes place in the nephron, where microscopic blood vessel filters, called glomeruli, are attached to fluid-collecting tubules.
  • A number of different disease processes can damage the glomeruli and thereby cause kidney failure. Glomerulonephritis and glomerulosclerosis are broad terms that include many forms of damage to the glomeruli.
  • Some forms of kidney failure can be slowed down, but scarred glomeruli can never be repaired.
  • Treatment for the early stages of kidney failure depends on the disease causing the damage.
  • Early signs of kidney failure include blood or protein in the urine and swelling in the hands, feet, abdomen, or face. Kidney failure may be silent for many years.

Types of Glomerular Diseases

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Goodpasture Syndrome

Goodpasture Syndrome is an uncommon disease that affects both the kidneys and the lungs. If you have the disease, usually you will:

  • Bleed from the lungs
  • Cough up blood
  • Have inflamed kidneys (glomerulonephritis).

Usually, symptoms will occur because your body is making antibodies that hurt the lining of your lungs and kidneys. It is not known why your antibodies begin to attack your own body. Usually they only do helpful things such as fight infections. This problem is most common in people between the ages of 15 and 35 or after age 55. It is not contagious and it is more common in men and Caucasians. Goodpasture Syndrome may cause life-threatening bleeding in the lungs, but does not usually cause long-term damage in that area. The harm done to your kidneys, however, can result in kidney failure. Early diagnosis and treatment are the best ways to prevent kidney damage. Your doctor will give you medicine that will fight the harmful antibodies. The doctor may suggest that you undergo a special blood filtering process (plasmapheresis) to remove harmful antibodies. Usually, your body will make the antibodies for a short time, anywhere from a few weeks to two years. Once this stops, you should not have any more problems with your lungs. However, your kidneys may have been harmed a little or a lot.

Lupus
Lupus is a short name for a disease called "lupus erythematosus." The word lupus means wolf in Latin. The skin rash that some patients get can form a butterfly pattern over the bridge of the nose, resembling the bite of a wolf. Lupus is called an "autoimmune" disease because the immune system, which usually protects the body from disease, turns against the body, causing harm to organs and tissues. There are two types of lupus. Systemic lupus erythematosus can harm your skin, joints, kidneys and brain and may be fatal. The other type, called "discoid" lupus erythematosus, affects only your skin. No one knows what causes the disease. Your family history and things in your environment such as infections, viruses, toxic chemicals or pollutants (car fumes, factory smoke) may play a role in causing the disease. Men and women of all ages and races get lupus. However, it is about 10 times more common in women than in men. About 500,000 Americans have lupus. Different people get different symptoms. These may include skin rashes, joint pain, hair loss, sun sensitivity, tiredness, weight loss, fever, swelling of lymph glands, chest pain and nerve involvement. About 90 percent of lupus patients will have some kidney damage, but only two to three percent actually develop kidney disease severe enough to require treatment. The kidney disease may be "silent" and not cause any symptoms. However, you may have dark urine, flank pain, high blood pressure, weight gain from extra fluid and swelling around your eyes and in your hands and feet. Lupus is treated with drugs that block your body's immune system. Some of these are prednisone, azathioprine, cyclophosphamide or cyclosporine.

IgA Nephropathy
IgA nephropathy is a form of glomerular disease that results when immunoglobulin A (IgA) forms deposits in the glomeruli, where it creates inflammation. The most common symptom of IgA nephropathy is blood in the urine, but it is often a silent disease that may go undetected for many years. It appears to affect men more than women. Although IgA nephropathy is found in all age groups, young people rarely display signs of kidney failure because the disease usually takes several years to progress to the stage where it causes detectable complications. No treatment is recommended for early or mild cases of IgA nephropathy when the patient has normal blood pressure and less than 1 gram of protein in a 24-hour urine output. When proteinuria exceeds 1 gram/day, treatment is aimed at protecting kidney function by reducing proteinuria and controlling blood pressure. Blood pressure medicines—angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs)—that block a hormone called angiotensin are most effective at achieving those two goals simultaneously.

Acute Post-Streptococcal Glomerulonephritis (PSGN)
Acute post-streptococcal glomerulonephritis (PSGN) can occur after an episode of strep throat or, in rare cases, impetigo (a skin infection). The Streptococcus bacteria do not attack the kidney directly, but an infection may stimulate the immune system to overproduce antibodies, which are circulated in the blood and finally deposited in the glomeruli, causing damage. PSGN can bring on sudden symptoms of swelling (edema), reduced urine output (oliguria), and blood in the urine (hematuria). Tests will show large amounts of protein in the urine and elevated levels of creatinine and urea nitrogen in the blood, thus indicating reduced kidney function. High blood pressure frequently accompanies reduced kidney function in this disease. PSGN is most common in children between the ages of 3 and 7, although it can strike at any age, and it most often affects boys. It lasts only a brief time and usually allows the kidneys to recover. In a few cases, however, kidney damage may be permanent, requiring dialysis or transplantation to replace renal function.

Bacterial Endocarditis
Bacterial endocarditis, infection of the tissues inside the heart, is also associated with subsequent glomerular disease. Researchers are not sure whether the renal lesions that form after a heart infection are caused entirely by the immune response or whether some other disease mechanism contributes to kidney damage. Treating the heart infection is the most effective way of minimizing kidney damage. Endocarditis sometimes produces chronic kidney disease (CKD).

HIV
HIV, the virus that leads to AIDS, can also cause glomerular disease. Between 5 and 10 percent of people with HIV experience kidney failure, even before developing full-blown AIDS. HIV-associated nephropathy usually begins with heavy proteinuria and progresses rapidly (within a year of detection) to total kidney failure. Researchers are looking for therapies that can slow down or reverse this rapid deterioration of renal function, but some possible solutions involving immunosuppression are risky because of the patients’ already compromised immune system.

Focal Segmental Glomerulosclerosis (FSGS)
Focal segmental glomerulosclerosis (FSGS) describes scarring in scattered regions of the kidney, typically limited to one part of the glomerulus and to a minority of glomeruli in the affected region. FSGS may result from a systemic disorder or it may develop as an idiopathic kidney disease, without a known cause. Biopsy may confirm the presence of glomerular scarring if the tissue is taken from the affected section of the kidney. But finding the affected section is a matter of chance, especially early in the disease process, when lesions may be scattered. Confirming a diagnosis of FSGS may require repeat kidney biopsies. No universal remedy has been found, and most patients with FSGS progress to total kidney failure over 5 to 20 years. Treatments involving steroids or other immunosuppressive drugs appear to help some patients by decreasing proteinuria and improving kidney function. ACE inhibitors and ARBs may also be used in FSGS to decrease proteinuria. Treatment should focus on controlling blood pressure and blood cholesterol levels, factors that may contribute to kidney scarring.

Membranous Nephropathy
Membranous nephropathy, also called membranous glomerulopathy, is the second most common cause of the nephrotic syndrome (proteinuria, edema, high cholesterol) in U.S. Diagnosis of membranous nephropathy requires a kidney biopsy, which reveals unusual deposits of immunoglobulin G and complement C3, substances created by the body’s immune system. Fully 75 percent of cases are idiopathic, which means that the cause of the disease is unknown. The remaining 25 percent of cases are the result of other diseases like systemic lupus erythematosus, hepatitis B or C infection, or some forms of cancer. About 20 to 40 percent of patients with membranous nephropathy progress, usually over decades, to total kidney failure, but most patients experience either complete remission or continued symptoms without progressive kidney failure. ACE inhibitors and ARBs are generally used to reduce proteinuria. Additional medication to control high blood pressure and edema is frequently required. Some patients benefit from steroids, but this treatment does not work for everyone. Additional immunosuppressive medications are helpful for some patients with progressive disease.

Minimal Change Disease (MCD)
Minimal change disease (MCD) is the diagnosis given when a patient has the nephrotic syndrome and the kidney biopsy reveals little or no change to the structure of glomeruli or surrounding tissues when examined by a light microscope. MCD may occur at any age, but it is most common in childhood.

High Blood Pressure

Topic written or edited by:

Ehab R. Saad, MD, FACP, FASN, MA
Samuel S. Blumenthal, MD
Barbara A. Bresnahan, MD
Liliana Osadchuk, MD
Kevin R. Regner, MD, MS, FASN

Hope Through Research

In recent years, researchers have learned a great deal about kidney disease. NIDDK sponsors several programs aimed at understanding kidney failure and finding treatments to stop its progression.

NIDDK's Division of Kidney, Urologic, and Hematologic Diseases supports basic research into normal kidney function and the diseases that impair normal function at the cellular and molecular levels, including diabetes, high blood pressure, glomerulonephritis, and polycystic kidney disease.

About High Blood Pressure

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High Blood Pressure and Kidney Disease
Your kidneys play a key role in keeping your blood pressure under control. Blood pressure, in turn, can damage your kidneys. High blood pressure, also called hypertension, can damage the kidneys.

How will I know whether I have kidney damage?
Kidney damage, like hypertension, can be unnoticeable and detected only through medical tests. Blood tests will show whether your kidneys are removing wastes efficiently. The test to look at your kidney function is your serum creatinine. Having too much creatinine in your blood is a sign that you have kidney damage. The doctor should use the serum creatinine to estimate the main kidney function called glomerular filtration rate, or GFR.

Another sign is proteinuria, or protein in your urine. Proteinuria has also been shown to be associated with heart disease and damaged blood vessels.
What is high blood pressure?
Hypertension can result from too much fluid in normal blood vessels or from normal fluid in narrow blood vessels. Blood pressure that remains high over time is called hypertension. Extra salt and fluid in your body increases the amount of fluid in your blood vessels and makes your blood pressure higher. Narrow or clogged blood vessels also raise your blood pressure. If you have high blood pressure, see your doctor regularly.

How does high blood pressure hurt my kidneys?
High blood pressure makes your heart work harder and, over time, can damage blood vessels throughout your body. If the blood vessels in your kidneys are damaged, kidneys may stop removing wastes and extra fluid from your body. The extra fluid in your blood vessels may then raise blood pressure even more. It's a dangerous cycle.

High blood pressure is one of the leading causes of kidney failure, also commonly called end-stage renal disease (ESRD). People with kidney failure must either receive a kidney transplant or go on dialysis. Every year, high blood pressure causes more than 25,000 new cases of kidney failure in the United States.
How will I know whether I have high blood pressure?
Most people with high blood pressure have no symptoms. The only way to know whether your blood pressure is high is to have a health professional measure it with a blood pressure cuff. The result is expressed as two numbers. The top number, which is called the systolic pressure, represents the pressure when your heart is beating. The bottom number, which is called the diastolic pressure, shows the pressure when your heart is resting between beats. Your blood pressure is considered normal if it stays below 120/80 (expressed as "120 over 80"). People with a systolic blood pressure of 120 to 139 or a diastolic blood pressure of 80 to 89 are considered pre-hypertensive and should adopt health-promoting lifestyle changes to prevent diseases of the heart and blood vessels. If your systolic blood pressure is consistently 140 or higher or your diastolic pressure is 90 or higher, you have high blood pressure and should talk with your doctor about the best ways to lower it.

How can I prevent high blood pressure from damaging my kidneys?
If you have kidney damage, you should keep your blood pressure below 130/80. The National Heart, Lung, and Blood Institute (NHLBI), one of the National Institutes of Health (NIH), recommends that people with kidney disease use whatever therapy is necessary, including lifestyle changes and medicines, to keep their blood pressure below 130/80.

How can I control my blood pressure?

NHLBI has found that six lifestyle changes can help control blood pressure:

  1. Maintain your weight at a level close to normal. Choose fruits, vegetables, grains, and low-fat dairy foods.

  2. Limit your daily sodium (salt) intake to 2,000 milligrams or lower if you already have high blood pressure. Read nutrition labels on packaged foods to learn how much sodium is in one serving. Keep a sodium diary.

  3. Get plenty of exercise, which means at least 30 minutes of moderate activity, such as walking, most days of the week.

  4. Avoid consuming too much alcohol. Men should limit consumption to two drinks (two 12-ounce servings of beer or two 5-ounce servings of wine or two 1.5-ounce servings of "hard” liquor) a day. Women should have no more than a single serving on a given day because metabolic differences make women more susceptible to the effects of alcohol.

  5. Limit caffeine intake.

  6. Quit cigarette smoking.
Are there medicines that can help?
Many people need medicine to control high blood pressure. Two groups of medications called ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) lower blood pressure and have an added protective effect on the kidney in people with diabetes. Additional studies have shown that ACE inhibitors and ARBs also reduce proteinuria and slow the progression of kidney damage in people who do not have diabetes. You may need to take a combination of two or more blood pressure medicines to stay below 130/80. Your doctor may also prescribe a diuretic in addition to your ACE inhibitor or ARB. Diuretics are also called "water pills" because they help you urinate salt and water from your body.

What groups are at risk for kidney failure related to high blood pressure?
All racial groups have some risk of developing kidney failure from high blood pressure. African Americans, however, are more likely than Caucasians to have high blood pressure and to develop kidney problems from it – even when their blood pressure is only mildly elevated. In fact, African Americans are about six times more likely than Caucasians to develop hypertension-related kidney failure.

People with diabetes also have a substantially increased risk for developing kidney failure. People who are at risk both because of their race and because of diabetes should have early management of high blood pressure.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), also part of NIH, sponsored the African American Study of Kidney Disease and Hypertension (AASK) to find effective ways to prevent high blood pressure and kidney failure in this population. The results, released in 2003, showed that an ACE inhibitor was better at slowing the progression of kidney disease in African Americans than either of two other drugs.

Kidney Stones

About Kidney Stones

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When should I call a doctor?

If you have a kidney stone, you may already know how painful it can be. Most kidney stones pass out of the body without help from a doctor. But sometimes a stone will not just go away. It may even get larger. Your doctor can help.

You should call a doctor when you have:

  • Extreme pain in your back or side that will not go away
  • Blood in your urine
  • Fever and chills
  • Vomiting
  • Urine that smells bad or looks cloudy
  • A burning feeling when you urinate

These may be signs of a kidney stone that needs a doctor's care.

What is a kidney stone?
A kidney stone is a solid piece of material that forms in the kidney out of substances in the urine. A stone may stay in the kidney or break loose and travel down the urinary tract. A small stone may pass all the way out of the body without causing too much pain. A larger stone may get stuck in a ureter, the bladder, or the urethra. A problem stone can block the flow of urine and cause great pain.

Are all kidney stones alike?

No. There are four major types of kidney stones.

  1. The most common type of stone contains calcium (KAL-see-um). Calcium is a normal part of a healthy diet. Calcium that is not used by the bones and muscles goes to the kidneys. In most people, the kidneys flush out the extra calcium with the rest of the urine. People who have calcium stones keep the calcium in their kidneys. The calcium that stays behind joins with other waste products to form a stone.
  2. A struvite (STROO-vite) stone may form after an infection in the urinary system. These stones contain the mineral magnesium (mag-NEE-zee-um) and the waste product ammonia (uh-MOH-nyuh).
  3. A uric (YOOR-ik) acid stone may form when there is too much acid in the urine. If you tend to form uric acid stones, you may need to cut back on the amount of meat you eat.
  4. Cystine (SIS-teen) stones are rare. Cystine is one of the building blocks that make up muscles, nerves, and other parts of the body. Cystine can build up in the urine to form a stone. The disease that causes cystine stones runs in families.
What do kidney stones look like?
Kidney stones may be as small as a grain of sand or as large as a pearl. Some stones are even as big as golf balls. Stones may be smooth or jagged. They are usually yellow or brown.

What can my doctor do about a problem stone?
If you have a stone that will not pass by itself, your doctor may need to take steps to get rid of it. In the past, the only way to remove a problem stone was through surgery.
Now, doctors have new ways to remove problem stones. The following section describes a few of these methods.
What are methods of treatment for kidney stones?
Shock Waves
Your doctor can use a machine to send shock waves directly to the kidney stone. The shock waves break a large stone into small stones that will pass through your urinary system with your urine.

Two types of shock wave machines exist. With one machine, you sit in a tub of water. With the other type of machine, you lie on a table. The full name for this method is extracorporeal (EKS-truh-kor-POR-ee-ul) shockwave lithotripsy (LITH-oh-TRIP-see). Doctors often call it ESWL for short. Lithotripsy is a Greek word that means stone crushing.

Tunnel Surgery
In this method, the doctor makes a small cut into the patient's back and makes a narrow tunnel through the skin to the stone inside the kidney. With a special instrument that goes through the tunnel, the doctor can find the stone and remove it. The technical name for this method is percutaneous (PER-kyoo-TAY-nee-us) nephrolithotomy (NEF-roh-lih-THAH-tuh-mee).

Ureteroscope
A ureteroscope (yoo-REE-ter-uh-scope) looks like a long wire. The doctor inserts it into the patient's urethra, passes it up through the bladder, and directs it to the ureter where the stone is located. The ureteroscope has a camera that allows the doctor to see the stone. A cage is used to catch the stone and pull it out, or the doctor may destroy it with a device inserted through the ureteroscope. Ask your doctor which method is right for you.
How will my doctor find out what kind of stone I have?
Try to catch a stone in a strainer. The best way for your doctor to find out what kind of stone you have is to test the stone itself. If you know that you are passing a stone, try to catch it in a strainer. Your doctor may ask for a urine sample or take blood to find out what is causing your stones. You may need to collect your urine for a 24-hour period. These tests will help your doctor find ways for you to avoid stones in the future.

Why do I need to know the kind of stone?
The therapy your doctor gives you depends on the type of stone you have. For example, a medicine that helps prevent calcium stones will not work if you have a struvite stone. The diet changes that help prevent uric acid stones may have no effect on calcium stones. Therefore, careful analysis of the stone will help guide your treatment.

What can I do to avoid more stones?
Drink more water. Try to drink 12 full glasses of water a day. Drinking lots of water helps to flush away the substances that form stones in the kidneys. You can also drink ginger ale, lemon-lime sodas, and fruit juices. But water is best. Limit your coffee, tea, and cola to one or two cups a day because the caffeine may cause you to lose fluid too quickly.

Your doctor may ask you to eat more of some foods and to cut back on other foods. For example, if you have a uric acid stone, your doctor may ask you to eat less meat, because meat breaks down to make uric acid. The doctor may give you medicines to prevent calcium and uric acid stones.

View the Kidney Stone Oxalate Diet (PDF)
Points to remember
  • Most stones will pass out of the body without a doctor's help.
  • See your doctor if you have severe pain in your back or side that will not go away.
  • See your doctor if you have blood in your urine (urine will appear pink).
  • Drink lots of water to prevent more kidney stones from forming.
  • When you pass a stone, try to catch it in a strainer to show to your doctor.
  • Talk to your doctor about how to avoid more stones.

Renal and Pancreas Transplant

Topic written or edited by:

Barbara A. Bresnahan, MD
Ehab R. Saad, MD, FACP, FASN, MA
Liliana Osadchuk, MD

A simultaneous kidney-pancreas transplant (SKP) is an operation to place both a kidney and a pancreas – at the same time – into someone who has kidney failure-related diabetes. In many cases, both transplanted organs may come from the same deceased (nonliving) donor (someone who died recently). However, it is also possible for the kidney to come from a living donor (a family member or friend) and the pancreas from a deceased (nonliving) donor.

Although in most cases, both transplanted organs come from the same deceased donor, in certain cases it is also possible for the kidney to come from a living donor (a family member or friend), and the pancreas from a deceased donor. The procedure treats both kidney failure and diabetes because the new organs replace the function of the failed kidney and the pancreas.

View Froedtert Hospital's Pancreas Transplant site for more information

View Froedtert Hospital's Kidney Transplant site for more information

About Renal and Pancreas Transplants

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Who is a candidate?
Adults whose kidneys have failed because of diabetes are possible candidates for a kidney-pancreas transplant. In type 1 diabetes, the pancreas does not make enough insulin, a hormone that regulates the blood sugar level in your body. The transplanted pancreas can produce insulin and correct this type of diabetes. People with type 2 diabetes might be candidates for a combined kidney-pancreas transplant as well. In type 2 diabetes, the pancreas makes insulin, but the patient's body tissues are not able to use this insulin properly.

Indications for Simultaneous Kidney-Pancreas (SKP) Transplantation
Usually, patients who have insulin dependent (Type 1, juvenile diabetes) diabetes whose kidneys have failed ("end stage renal disease" (ESRD)) and who require dialysis, or expect to require dialysis in the next 12 months, may be considered for SPK transplantation.

Contraindications for Simultaneous Kidney-Pancreas (SKP) Transplantations

There are certain medical situations in which a kidney-pancreas transplant is usually not an option:

  • Untreated cancer and cancer that has spread
  • Severe mental health diagnoses
  • Substance abuse
  • Severe mental retardation
  • Severe coronary artery disease and/or congestive heart failure

Is it possible to have kidney and pancreas transplants at different times?
Yes. Sometimes, a patient who has kidney failure because of type 1 diabetes may have a kidney transplant first, followed by a pancreas transplant later.

How long is the wait?
Once you are added to the national organ transplant waiting hst, you may receive an organ that day, or you may wait many years. Factors affecting how long you wait include how well you match with the donor, how sick you are, and how many donors are available in your local area compared to the number of patients waiting.

how successful are kidney-pancreas transplants?
At the University of Wisconsin in Madison, the second largest pancreas transplant center in the world, 85 percent of the kidney-pancreas transplants are still functioning well two years after the operation. The national average for survival rates of kidney/pancreas transplants is about 95 percent still functioning well one year after the operation, and 92.5 percent at three years.

The best results are usually achieved with a closely matched kidney from a living Donor (usually from a brother or a sister). Statistics show that the next best results are achieved with a kidney from a less closely matched living donor (such as a spouse or friend). The success rates are also good for combined kidney-pancreas transplants from deceased donors. The best results are usually achieved when both the pancreas and a kidney come from the same donor: a deceased donor. This is because the risk of rejection is significantly reduced. However, there have been several transplants performed using a living donor, with one kidney and a pancreas segment being donated.
What does my operation involve?
In the kidney-pancreas operation, the pancreas is placed on the right side of your lower abdomen, and the pancreatic vessels are attached to the right iliac artery and vein. The pancreas is also attached to the intestines or bladder to drain its secretions. Then, the kidney is placed in the left side of the lower abdomen, the renal vessels are attached to the left iliac vessels and the ureter is attached to the bladder. Usually, your own kidneys and pancreas are not removed.

The surgical procedure usually lasts four to six hours, and your hospital stay is typically one to two weeks. Once connected, the pancreas begins to make insulin within hours, and the blood sugar is normalized. From this point on, insulin shots are usually not required unless the body rejects the new pancreas. Studies show that the new pancreas may help slow the progression of other problems related to diabetes, such as nerve and eye damage, and decrease the chance that diabetic changes may occur in the transplanted kidney.
What should I expect after the operation?
The post-operative care of the kidney/pancreas recipient is very like the recipient of a kidney alone. While the recipient of a kidney transplant is not usually monitored in the intensive care unit, the recipient of a kidney/pancreas may spend a day or so there for careful monitoring of both kidney and pancreas functioning. If there are no complications such as rejection or infection, you should be able to go home in seven to ten days. Remember that you will need to take special medicines, called immunosuppressive or anti-rejection medications, following your transplant surgery to help prevent your body from rejecting your newly transplanted organ. It is necessary to take these medications exactly as the doctor prescribes for the rest of your life. In addition, you will have regularly scheduled tests as an outpatient to monitor the function of your transplanted organ and will be encouraged to maintain a healthy lifestyle through diet and exercise.

What complications may occur?
The main complications that may occur are infection and rejection. To prevent rejection, it is important to take your medications faithfully, exactly as ordered by your doctor. The symptoms of rejection you need to watch for may include tenderness around the grafts, decreased urine output, increase in blood glucose level, fever, abdominal pain and vomiting.

If you have any of these symptoms, speak to your transplant team right away. You will be evaluated regularly at the transplant center. Sometimes, early symptoms of rejection are hard to notice, but they can be detected in your blood work and treated. Most kidney-pancreas transplant patients will have a rejection episode during the first few months, and they will need to return to the hospital for treatment.

The medications you need to take to prevent rejection lower your body's immune defenses, which increases your chance of getting an infection. This risk is higher right after your transplant because the doses of your medications are higher. During this time, it is important to avoid large crowds and people who are sick, especially with contagious illnesses such as colds or flu. You should wash your hands often. After a while, the doses of your medications will be reduced, and the chance of getting infections will be less.
Diet and Exercise
Transplant recipients need to be aware of the important role of a healthy diet and exercise plan in healing. Prior to your discharge from the hospital, talk to your doctor or dietitian about your goals and requirements. Since each person is different, know that you can ask for help in developing a plan that fits your needs, likes and dislikes.

Diet after a transplant

After your transplant, you will be feeling better and looking forward to returning to your normal lifestyle. A major part of that normal lifestyle is the ability to enjoy eating again. However, some of the drugs you will be taking after your transplant affect the way your body processes food. This may cause you to eat more, causing you to gain weight.

Excessive weight gain can be harmful to your health because it increases the risk of heart disease, diabetes and high blood pressure. The following tips may help you avoid unwanted weight gain:

  • Eat a balanced diet with plenty of fruits and vegetables.
  • Eat a minimum amount of salt, processed foods and snacks.
  • Use herbs and spices to add flavor, instead of salt.
  • Watch your food intake and drink plenty of water (unless you are told to limit fluids).
  • Try to eat high-fiber foods, such as raw vegetables and fruits, which make you feel full.
  • Add calcium to your diet by eating calcium-rich foods, such as low-fat dairy products and green, leafy vegetables or calcium supplements.
  • Eat as little fat and oil as possible.
  • Read food labels so that you can be smart when food shopping.
  • Become more aware of serving sizes that are listed on food labels.
  • Because protein helps your build muscles and tissue, which will help you heal after surgery, eat foods high in protein, such as meat, poultry (i.e. chicken), fish, eggs, nuts (without salt) and beans.
  • Select healthier condiments, such as mustard, and low-fat mayonnaise and salad dressings.
  • Choose healthy cooking methods. Instead of frying, try baking, grilling, broiling or steaming foods. And instead of oil, use nonstick, fat-free spray or sauces.
  • When dining out, try to eat smaller portions and avoid high-fat entrees.
  • Don't drink alcohol or use any drugs that aren’t prescribed by your physician, as these may harm your new organ. If you have a problem with drugs or alcohol, talk with your social worker, who can help arrange for counseling and other support services.
Exercise after a transplant
Most people are weak after any surgery. Thus, exercise and muscle strain should be limited when you return home. Talk with your doctor about what to expect.

As you start to feel better, regular exercise will help you regain your strength. Because you may feel tired at first, you should take rest breaks during exercise. Gradually, increase the amount and type of physical activity you enjoy.