Chronic Kidney Disease Differential Diagnoses

  • Author: Pradeep Arora, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Mar 28, 2012
 
 

Diagnostic Considerations

Because of anatomic and physiologic changes, elderly patients with chronic kidney disease may behave differently, in terms of progression and response to pharmacologic treatment, than younger patients. A serum creatinine value of 1.2 mg/dL in a 70-kg, 25-year-old man represents an estimated glomerular filtration rate (eGFR) of 74 mL/min/1.73m2, but in a 70-kg, 80-year-old man, that same value represents an eGFR of 58 mL/min/1.73m2.

Thus, in a 70-kg, 80-year-old man, what might appear to be only mild renal impairment with a serum creatinine of 2 mg/dL actually represents severe renal impairment when the eGFR is calculated to be 32 mL/min/1.73m2.

Therefore, in elderly patients an eGFR must be determined, using a formula such as the Modification of Diet in Renal Disease (MDRD) equation, which includes age as a variable. This will allow appropriate drug dosing adjustments to be made and nephrotoxins to be avoided in patients who have more extensive chronic kidney disease than would be suggested by the serum creatinine value alone.

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Pradeep Arora, MD  Assistant Professor of Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences; Attending Nephrologist, Veterans Affairs Western New York Healthcare System

Disclosure: Nothing to disclose.

Specialty Editor Board

Laura Lyngby Mulloy, DO, FACP  Professor of Medicine, Chief, Section of Nephrology, Hypertension, and Transplantation Medicine, Glover/Mealing Eminent Scholar Chair in Immunology, Medical College of Georgia

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George R Aronoff, MD  Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Mauro Verrelli, MD to the development and writing of the source article.

References

  1. [Best Evidence] Bash LD, Erlinger TP, Coresh J, Marsh-Manzi J, Folsom AR, Astor BC. Inflammation, hemostasis, and the risk of kidney function decline in the Atherosclerosis Risk in Communities (ARIC) Study. Am J Kidney Dis. Apr 2009;53(4):596-605. [Medline]. [Full Text].

  2. Thakar CV, Christianson A, Himmelfarb J, Leonard AC. Acute kidney injury episodes and chronic kidney disease risk in diabetes mellitus. Clin J Am Soc Nephrol. Nov 2011;6(11):2567-72. [Medline].

  3. [Best Evidence] Choi AI, Rodriguez RA, Bacchetti P, Bertenthal D, Hernandez GT, O'Hare AM. White/black racial differences in risk of end-stage renal disease and death. Am J Med. Jul 2009;122(7):672-8. [Medline]. [Full Text].

  4. Schold JD, Srinivas TR, Braun WE, et al. The relative risk of overall graft loss and acute rejection among African American renal transplant recipients is attenuated with advancing age. Clin Transplant. Sep 2011;25(5):721-30. [Medline].

  5. Hicks PJ, Langefeld CD, Lu L, Bleyer AJ, Divers J, Nachman PH, et al. Sickle cell trait is not independently associated with susceptibility to end-stage renal disease in African Americans. Kidney Int. Dec 2011;80(12):1339-43. [Medline].

  6. Vivante A, Afek A, Frenkel-Nir Y, et al. Persistent asymptomatic isolated microscopic hematuria in Israeli adolescents and young adults and risk for end-stage renal disease. JAMA. Aug 17 2011;306(7):729-36. [Medline].

  7. Tangri N, Stevens LA, Griffith J, Tighiouart H, Djurdjev O, Naimark D, et al. A predictive model for progression of chronic kidney disease to kidney failure. JAMA. Apr 20 2011;305(15):1553-9. [Medline].

  8. Sens F, Schott-Pethelaz AM, Labeeuw M, Colin C, Villar E. Survival advantage of hemodialysis relative to peritoneal dialysis in patients with end-stage renal disease and congestive heart failure. Kidney Int. Nov 2011;80(9):970-7. [Medline].

  9. United States Renal Data System. 2009 Annual Report United States Renal Data System. Available at http://www.usrds.org. Accessed October 8, 2010.

  10. Raphael KL, Wei G, Baird BC, Greene T, Beddhu S. Higher serum bicarbonate levels within the normal range are associated with better survival and renal outcomes in African Americans. Kidney Int. Feb 2011;79(3):356-62. [Medline].

  11. Friedman DJ, Kozlitina J, Genovese G, Jog P, Pollak MR. Population-Based Risk Assessment of APOL1 on Renal Disease. J Am Soc Nephrol. Nov 2011;22(11):2098-105. [Medline].

  12. Isakova T, Xie H, Yang W, Xie D, Anderson AH, Scialla J, et al. Fibroblast growth factor 23 and risks of mortality and end-stage renal disease in patients with chronic kidney disease. JAMA. Jun 15 2011;305(23):2432-9. [Medline]. [Full Text].

  13. [Best Evidence] Hedayati SS, Minhajuddin AT, Toto RD, Morris DW, Rush AJ. Validation of depression screening scales in patients with CKD. Am J Kidney Dis. Sep 2009;54(3):433-9. [Medline].

  14. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. Mar 16 1999;130(6):461-70. [Medline].

  15. [Best Evidence] Stevens LA, Schmid CH, Greene T, Zhang YL, Beck GJ, Froissart M, et al. Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/1.73 m2. Am J Kidney Dis. Sep 2010;56(3):486-95. [Medline]. [Full Text].

  16. Peralta CA, Norris KC, Li S, et al. Blood Pressure Components and End-stage Renal Disease in Persons With Chronic Kidney Disease: The Kidney Early Evaluation Program (KEEP). Arch Intern Med. Jan 9 2012;172(1):41-47. [Medline].

  17. [Best Evidence] Fishbane S, Chittineni H, Packman M, Dutka P, Ali N, Durie N. Oral paricalcitol in the treatment of patients with CKD and proteinuria: a randomized trial. Am J Kidney Dis. Oct 2009;54(4):647-52. [Medline].

  18. Plantinga L, Grubbs V, Sarkar U, et al. Nonsteroidal Anti-Inflammatory Drug Use Among Persons With Chronic Kidney Disease in the United States. Ann Fam Med. September-October 2011;9(5):423-430. [Medline]. [Full Text].

  19. Hallan SI, Orth SR. Smoking is a risk factor in the progression to kidney failure. Kidney Int. Sep 2011;80(5):516-23. [Medline].

  20. Wald R, Yan AT, Perl J, et al. Regression of left ventricular mass following conversion from conventional hemodialysis to thrice weekly in-centre nocturnal hemodialysis. BMC Nephrol. Jan 19 2012;13(1):3. [Medline].

  21. Shurraw S, Hemmelgarn B, Lin M, Majumdar SR, Klarenbach S, Manns B, et al. Association Between Glycemic Control and Adverse Outcomes in People With Diabetes Mellitus and Chronic Kidney Disease: A Population-Based Cohort Study. Arch Intern Med. Nov 28 2011;171(21):1920-1927. [Medline].

  22. London G, Coyne D, Hruska K, Malluche HH, Martin KJ. The new kidney disease: improving global outcomes (KDIGO) guidelines - expert clinical focus on bone and vascular calcification. Clin Nephrol. Dec 2010;74(6):423-32. [Medline].

  23. [Best Evidence] de Brito-Ashurst I, Varagunam M, Raftery MJ, Yaqoob MM. Bicarbonate supplementation slows progression of CKD and improves nutritional status. J Am Soc Nephrol. Sep 2009;20(9):2075-84. [Medline]. [Full Text].

  24. Lameire N, Van Biesen W. The initiation of renal-replacement therapy--just-in-time delivery. N Engl J Med. Aug 12 2010;363(7):678-80. [Medline].

  25. Suckling RJ, He FJ, Macgregor GA. Altered dietary salt intake for preventing and treating diabetic kidney disease. Cochrane Database Syst Rev. Dec 8 2010;CD006763. [Medline].

  26. Hermida RC, Ayala DE, Mojón A, Fernández JR. Bedtime Dosing of Antihypertensive Medications Reduces Cardiovascular Risk in CKD. J Am Soc Nephrol. Dec 2011;22(12):2313-21. [Medline].

  27. Slagman MC, Waanders F, Hemmelder MH, et al. Moderate dietary sodium restriction added to angiotensin converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: randomised controlled trial. BMJ. Jul 26 2011;343:d4366. [Medline]. [Full Text].

  28. Vegter S, Perna A, Postma MJ, et al. Sodium Intake, ACE Inhibition, and Progression to ESRD. J Am Soc Nephrol. Jan 2012;23(1):165-73. [Medline].

  29. Goraya N, Simoni J, Jo C, Wesson DE. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney Int. Jan 2012;81(1):86-93. [Medline].

  30. Sakaguchi Y, Shoji T, Kawabata H, Niihata K, Suzuki A, Kaneko T, et al. High prevalence of obstructive sleep apnea and its association with renal function among nondialysis chronic kidney disease patients in Japan: a cross-sectional study. Clin J Am Soc Nephrol. May 2011;6(5):995-1000. [Medline]. [Full Text].

  31. Navaneethan SD, Schold JD, Arrigain S, et al. Low 25-Hydroxyvitamin D Levels and Mortality in Non-Dialysis-Dependent CKD. Am J Kidney Dis. Oct 2011;58(4):536-43. [Medline]. [Full Text].

  32. Hart RG, Pearce LA, Asinger RW, Herzog CA. Warfarin in atrial fibrillation patients with moderate chronic kidney disease. Clin J Am Soc Nephrol. Nov 2011;6(11):2599-604. [Medline].

 
Previous
Next
 
The tracing shows a wide QRS and very large T waves. In the setting of a minimally symptomatic patient with renal failure, this must be treated as hyperkalemia until the potassium level is not elevated. Hyperkalemia may be completely asymptomatic until a lethal arrhythmia occurs. Calcium salts are the most rapid acting of the agents used to treat hyperkalemia.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.