Chronic Kidney Disease Clinical Presentation

Updated: May 01, 2017
  • Author: Pradeep Arora, MD; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Presentation

History

Patients with chronic kidney disease (CKD) stages 1-3 (glomerular filtration rate [GFR] >30 mL/min/1.73 m²) are frequently asymptomatic; in terms of possible “negative” symptoms related simply to the reduction in GFR, they do not experience clinically evident disturbances in water or electrolyte balance or endocrine/metabolic derangements.

Generally, these disturbances become clinically manifest with CKD stages 4-5 (GFR <30 mL/min/1.73 m²). Patients with tubulointerstitial disease, cystic diseases, nephrotic syndrome, and other conditions associated with “positive” symptoms (eg, polyuria, hematuria, edema) are more likely to develop signs of disease at earlier stages.

Uremic manifestations in patients with CKD stage 5 are believed to be primarily secondary to an accumulation of multiple toxins, the full spectrum and identity of which is generally not known. Metabolic acidosis in stage 5 may manifest as protein-energy malnutrition, loss of lean body mass, and muscle weakness. Altered salt and water handling by the kidney in CKD can cause peripheral edema and, not uncommonly, pulmonary edema and hypertension.

Anemia, which in CKD develops primarily as a result of decreased renal synthesis of erythropoietin, manifests as fatigue, reduced exercise capacity, impaired cognitive and immune function, and reduced quality of life. Anemia is also associated with the development of cardiovascular disease, the new onset of heart failure, the development of more severe heart failure, and increased cardiovascular mortality.

Other manifestations of uremia in end-stage renal disease (ESRD), many of which are more likely in patients who are inadequately dialyzed, include the following:

  • Pericarditis: Can be complicated by cardiac tamponade, possibly resulting in death
  • Encephalopathy: Can progress to coma and death
  • Peripheral neuropathy
  • Restless leg syndrome
  • Gastrointestinal symptoms: Anorexia, nausea, vomiting, diarrhea
  • Skin manifestations: Dry skin, pruritus, ecchymosis
  • Fatigue, increased somnolence, failure to thrive
  • Malnutrition
  • Erectile dysfunction, decreased libido, amenorrhea
  • Platelet dysfunction with tendency to bleed
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Physical Examination

A careful physical examination is imperative. It may reveal findings characteristic of the condition that is underlying chronic kidney disease (CKD) (eg, lupus, severe arteriosclerosis, hypertension) or its complications (eg, anemia, bleeding diathesis, pericarditis). However, the lack of findings on physical examination does not exclude kidney disease. In fact, CKD is frequently clinically silent, so screening of patients without signs or symptoms at routine health visits is important.

Screening for depression

Forty-five percent of adult patients with CKD have depressive symptoms at initiation of dialysis therapy, as assessed using self-report scales. However, these scales may emphasize somatic symptoms—specifically, sleep disturbance, fatigue, and anorexia—that can coexist with chronic disease symptoms.

Hedayati et al reported that the 16-item Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR[16]) and the Beck Depression Inventory (BDI) are effective screening tools and that scores of 10 and 11, respectively, were the best cutoff scores for identification of a major depressive episode in their study's patient population. [38] The study compared the BDI and QIDS-SR(16) with a gold-standard structured psychiatric interview in 272 patients with CKD stages 2-5 who had not been treated with dialysis.

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