Chronic Kidney Disease Workup
- Author: Pradeep Arora, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...
Approach Considerations
Testing typically includes a complete blood count (CBC), basic metabolic panel, and urinalysis, with calculation of renal function. Serum phosphate, 25 hydroxy vitamin D, alkaline phosphatase, and intact parathyroid hormone (PTH) levels are obtained to look for evidence of renal bone disease. Renal ultrasound and other imaging studies may be indicated.
Normochromic normocytic anemia is commonly seen in chronic kidney disease. Other underlying causes of anemia should be ruled out. The blood urea nitrogen (BUN) and creatinine levels will be elevated in patients with chronic kidney disease. Hyperkalemia or low bicarbonate levels may be present in patients with chronic kidney disease.
Serum albumin levels may also be measured, as patients may have hypoalbuminemia due to urinary protein loss or malnutrition.
A lipid profile should be performed in all patients with chronic kidney disease because of their increased risk of cardiovascular disease.
In certain cases, the following tests may be ordered as part of the evaluation of patients with chronic kidney disease:
- Serum and urine protein electrophoresis - Screen for a monoclonal protein possibly representing multiple myeloma
- Antinuclear antibodies (ANA), double-stranded DNA antibody levels - Screen for systemic lupus erythematosus
- Serum complement levels - May be depressed with some glomerulonephritides
- Cytoplasmic and perinuclear pattern antineutrophil cytoplasmic antibody (C-ANCA and P-ANCA) levels - Helpful if positive in diagnosis of Wegener granulomatosis and polyarteritis nodosa
- Perinuclear pattern antineutrophil cytoplasmic antibody (P-ANCA) - Helpful if positive in diagnosis of microscopic polyangiitis
- Anti–glomerular basement membrane (anti-GBM) antibodies - Highly suggestive of underlying Goodpasture syndrome
- Hepatitis B and C, HIV, Venereal Disease Research Laboratory (VDRL) serology - Conditions associated with some glomerulonephritides
Urinalysis
Dipstick proteinuria may suggest a glomerular or tubulointerstitial problem. The urine sediment finding of RBCs, RBC casts, suggests proliferative glomerulonephritis. Pyuria and/or WBC casts are suggestive of interstitial nephritis (particularly if eosinophiluria is present) or urinary tract infection.
Although 24-hour urine collection for total protein and creatinine clearance (CrCl) can be performed, spot urine collection for total protein-to-creatinine ratio allows reliable approximation (extrapolation) of total 24-hour urinary protein excretion. A value of greater than 2 g is considered to be within the glomerular range, and a value of greater than 3-3.5 g is within the nephrotic range; less than 2 is characteristic of tubulointerstitial problems.
Renal Function Formulas
The Cockcroft-Gault formula for estimating CrCl should be used routinely as a simple means to provide a reliable approximation of residual renal function in all patients with chronic kidney disease. The formulas are as follows:
- CrCl (male) = ([140-age] × weight in kg)/(serum creatinine × 72)
- CrCl (female) = CrCl (male) × 0.85
Alternatively, the Modification of Diet in Renal Disease (MDRD) Study equation could be used to calculate the GFR. This equation does not require a patient's weight.[14]
However, MDRD underestimates measured GFR at levels >60 mL/min/1.73 m2. Stevens et al found that the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is more accurate than the MDRD Study equation overall and across most subgroups, and it can report eGFR ≥60 mL/min/1.73 m2.[15]
Imaging Studies
Renal ultrasonography
Renal ultrasonography is useful to screen for hydronephrosis, which may not be observed in early obstruction, or involvement of the retroperitoneum with fibrosis, tumor, or diffuse adenopathy.
Small echogenic kidneys are observed in advanced renal failure. Kidneys usually are normal in size in advanced diabetic nephropathy, where affected kidneys initially are enlarged from hyperfiltration. Structural abnormalities, such as polycystic kidneys, also may be observed.
Radiography
A retrograde pyelogram may be indicated if a high index of clinical suspicion for obstruction exists despite a negative finding on renal ultrasonography. Intravenous pyelography is not commonly performed because of the potential for renal toxicity from the intravenous contrast; however, this procedure is often used to diagnose renal stones.
Plain abdominal x-ray is particularly useful to look for radio-opaque stones or nephrocalcinosis.
A voiding cystourethrogram (VCUG) is the criterion standard for diagnosis of vesicoureteral reflux
CT, MRI, and radionuclide scan
A computed tomography (CT) scan is useful to better define renal masses and cysts usually noted on ultrasound. Also, it is the most sensitive test for identifying renal stones.
IV contrast–enhanced CT scans should be avoided in patients with renal impairment to avoid acute renal failure; this risk significantly increases in patients with moderate-to-severe chronic kidney disease. Dehydration also markedly increases this risk.
Magnetic resonance imaging (MRI) is very useful in patients who require a CT scan but who cannot receive intravenous contrast. It is reliable in the diagnosis of renal vein thrombosis, as are CT scan and renal venography. Magnetic resonance angiography also is becoming more useful for diagnosis of renal artery stenosis, although renal arteriography remains the criterion standard.
A renal radionuclide scan is useful to screen for renal artery stenosis when performed with captopril administration; it also quantitates differential renal contribution to total GFR. However, radionuclide scans are unreliable in patients with a GFR of less than 30 mL/min.
Renal Biopsy
Percutaneous renal biopsy is performed most often with ultrasound guidance and the use of a mechanical gun. It generally is indicated when renal impairment and/or proteinuria approaching the nephrotic range are present and the diagnosis is unclear after appropriate other workup. It is not indicated when renal ultrasound reveals small echogenic kidneys on ultrasound because this finding represents severe scarring and chronic irreversible injury.
The most common complication of this procedure is bleeding, which can be life threatening in a minority of occurrences. Surgical open renal biopsy can be considered when the risk of renal bleeding is felt to be great, occasionally with solitary kidneys, or when percutaneous biopsy is technically difficult to perform.
Renal histology in chronic kidney disease reveals findings compatible with the underlying primary renal diagnosis and, generally, findings of segmental and globally sclerosed glomeruli and tubulointerstitial atrophy, often with tubulointerstitial mononuclear infiltrates.
[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].
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].
[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].
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].
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].
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].
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].
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].
United States Renal Data System. 2009 Annual Report United States Renal Data System. Available at http://www.usrds.org. Accessed October 8, 2010.
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].
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].
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].
[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].
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].
[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].
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].
[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].
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].
Hallan SI, Orth SR. Smoking is a risk factor in the progression to kidney failure. Kidney Int. Sep 2011;80(5):516-23. [Medline].
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].
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].
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].
[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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Print
