Kidney Function Test (KFT) should be carried out every year for patients suffering from diabetes, hypertension, individuals above the age of sixty and those who have family history of kidney disease. Mostly, patients in initial stages of kidney disease will have no symptoms at all, apart from occasional fatigue, unexplained tiredness, etc. A nephrologist must be consulted for investigation and confirmation of kidney disease. Blood sugar and blood pressure may behave erratically in spite of taking right dose of medicines. Also, urine will show abnormalities as kidney is not able to filter the wastes from the body. The main urine abnormality that will suggest a kidney disease is the presence of protein and/or blood in urine which is most often caused by having heavy proteinuria rather than actual chronic renal insufficiency. The sooner the disease is identified and treatment is started, the better. Delay in treatment is a major cause of rapid progression of chronic kidney disease (CKD).
In stage 1 and Stage 2 of CKD, serum creatinine levels will be in the range of 2-5. Typically, there are no symptoms in initial stage of kidney disease. Kidney continues to filter wastes effectively even when it is damaged 50%. However, taking medicines with advice of nephrologist, diet and lifestyle changes with consultation of dietitian, managing blood sugar and pressure, daily walking and exercise and maintaining a healthy wait goes a long way in delaying kidney disease progression.
In Stage 1 and Stage 2 of CKD, treatment may involve some mild dietary changes (a lower protein diet may in some cases be recommended), and a blood pressure medication may be prescribed even if blood pressure is not really elevated much. Anemia may rarely occur at this stage. It is advised that a dietician be consulted for meal plan. Kidney filters the wastes from whatever we ingest. If the right kind of food is ingested, lesser waste products will be formed and there will be lesser pressure on the kidney.
Eat fresh, less spicy, home-made food. Avoid excess salt intake, avoid potassium rich food too (various salt substitute products are rich in potassium). Eat easily digestible fish, avoid the ones which release their own oil (eg. hilsa). Reduce potion size (quantity) of food slowly. Include variety of vegetables and eat them in small quantities. All vegetables have sodium and potassium so eating less is key. Say no to red meat and purine rich food (like tomato). Stay away from refined food, like refined salt, refined sugar (crystal sugar, use jaggery if required), refined rice (basmati, atop chaal), refined flour (maida), refined oil from your diet. Make your environment clean and healthy so that the patient does not catch infection. remember, diaorrhea and flu are also infection. Make it a point to do some exercise or atleast walking regularly to keep fit. Without doctor’s permission, strenuous exercise must not be done at all. Walking is subtle yet effective exercise. Meet with friends and family and socialize or do things to shift focus from your disease.
At this stage it is important to talk to the doctor regarding vaccinations for chronic kidney disease. Vaccination ensure that infections of various types are kept at bay at subsequent stages of CKD.
In Stage 3 of Chronic kidney disease, some symptoms might start showing up. Initially puffiness will be observed around eyes, as if the under eyes are bulging out. Ankle and feet swelling occurs subsequently, sometimes so much swelling happens that it is difficult to walk. Patients might sleep a lot during the day, and generally feel tired and drained out. Back pain is usually felt as a dull ache anywhere in the mid-to-lower portion of the back, on one side or the other. There could be changes in appetite and mood swings as digestion is slowed and varying degrees of gastroparesis (inactive stomach muscles) may occur. Persistent high blood pressure may be observed. In this phase, patient is sick, tired and has reduced energy levels. In stage three CKD, anaemia (a shortage of red blood cells) and / or early bone disease may appear and should be treated immediately.
In stage 4, there may be instances when the regular medicines for diabetes or hypertension fails to maintain the required levels. This happens because kidney is unable to secrete the hormones which regulate hypertension. Serum creatinine will be typically in the range of 5-8. Changes in urination in terms of amount, colour and frequency may be observed. Urine may look clear at this point, rather than abnormal. This is because little is actually being filtered into it by the kidneys. Previously high proteinuria and/or hematuria may actually improve. The nephrologist must be immediately consulted for regulating doses for hypertension and diabetes. The eGFR level, which measure kidney functioning is in the range of 15 to 29, in CKD stage 4.
In this stage, hyperkalemia is also quite frequent, wherein a patient’s potassium levels rise which is very dangerous as it may cause cardiac arrest and even death. Follow the blood tests minutely for increased potassium levels or other irregularities and in case of high potassium levels, hospitalize the patient if they become numb and sink. In this stage, kidney struggles to filter wastes and therefore doctors advise limited water intake, no protein intake (red meat, daal, rajma, chhole, etc See diet section for more details). In case there is high potassium in blood, patient should be closely monitored by family members as chances of hyperkalemia increases, requiring immediate medical attention or hospitalization. There could be phases of pass out as well, wherein patient loses consciousness and may fall down.
Due to irrational behaviour of the kidney, blood sugar and blood pressure may not be under control for prolonged period. Doctor may advise higher dosage of medication. The caregiver to the patient, who is mainly the spouse or children or parents should understand from the doctor the timing and dosage and write it down to avoid any kind of excess dosage or wrong medication, which could be fatal to the patient’s health.
In this stage, it is important to plan out the subsequent course of action, in consultation with kidney doctor (nephrologist). At this stage, doctor might ask to perform a procedure called AV Fistula to create access for dialysis. There are instances when patient do not require dialysis at all if kidney transplant is resorted to. However, an access site in the non-dominant arm is always suggested. Once AV Fistula is done, the arm should be exercised by daily squeezing sponge balls as many times a day as possible to strengthen the veins. People often don’t understand the correct timing of dialysis and only after a sudden occurrence of hypokalemia or similar experience, go for unplanned dialysis. Unplanned dialysis may lead to infection. Therefore it is better to coordinate with one’s nephrologist and go for planned dialysis and get an AV Fistula procedure performed for future dialysis requirement, if need be. Some patients don’t even need to undergo dialysis if they undergo a successful kidney transplant but having a AV fistula helps.
Consult the doctor for water intake limits and strictly adhere to the same. Understand that body is unable to flush out toxins so water intake is limited. It is advised that dietitian be re-consulted for a revised meal plan at this stage as protein intake will be significantly reduced.
Advanced and irreversible kidney failure means that the kidneys can no longer perform its functions well enough. This can result in many symptoms that include fatigue, decrease appetite, metallic taste, nausea, vomiting, weight gain and swelling from excess fluid retention, breathing difficulty, itching, sleep disturbances and in late stages changes in level of consciousness. When this occurs, the patient shall need renal replacement therapy.
Renal replacement therapy or dialysis is a life sustaining treatment that is offered when the kidneys are too damaged to continue to work properly. Dialysis options include hemodialysis, home hemodialysis, nocturnal hemodialysis, and peritoneal dialysis. The decision of what type of dialysis to pursue is a personal decision that is undertaken with the support and guidance of your nephrologist. Many factors are taken into consideration, including your preferences, level of independence, social supports, and overall health status. Hemodialysis does not prevent or reverse kidney failure. It can replace some of the functions of healthy kidneys, but not all. Read on the next section on dialysis for further details.
In case of kidney failure, kidney transplant may be resorted to by the nephrologist subject to availability of matching medical parameters of the donee and donor of kidney.