Are symptoms in patients with advanced chronic kidney disease related to Glomerular filtration rate and comorbidities? Less GFR means more symptoms and more severity of symptoms? more comorbidities means more symptoms?
Chronic kidney disease (CKD) is divided into five stages. The last stage is called end stage renal disease and is the time when dialysis or transplant is needed to stay alive. Advanced chronic kidney disease includes stages 4 and 5 of the CKD classification. Sou this term similar.
Often symptoms may start to become present in stage 3.
Are symptoms in patients with advanced chronic kidney disease related to Glomerular filtration rate and comorbidities? - YES.
Less GFR means more symptoms and more severity of symptoms? - in general YES.
More comorbidities means more symptoms? - YES.
It's my opinion. But it is not the last...
This is known as the silent killer because despite the stages outlined, patients actually present with few symptoms of CKD and more with comorbidities. The rate of mortality is highest in stage 3 especially when linked with cardio renal outcomes.
Nausea and vomiting, lethargy, anemia and itching are a few symptoms but may or not present until GFR leas than 15 ml/min.
Hope this information helps,
In T2DM with CKD , mortality due to Coronary Artery Disease ( CAD ) can lead to mortality in stage 3 CKD as highlighted by Dawn Koonkongsatian . Type 4 RTA , due to JGA atrophy can cause hyperkalemia in T2DM with mild CKD , if ACEI or Beta blockers are added . In addition , Bilateral renal artery stenosis due to atherosclerosis can cause flash pulmonary edema with mild CKD , or when ACEI is added leading to worsening of CKD . These are situations , where comorbidities can lead to symptoms & increase mortality . It is the combination of macrovascular & microvascular complications in T2DM , which is the cause of increased mortality .
Thank you Dawn and Singh. Is there any study that reported relationship between GFR and symptoms and comorbidities and symptoms?
National Kidney Foundation (www.kidney.org) has done alot of work with the development of guidelines for principles and practices, especially how to decide whether to classify as ESRD and initiate dialysis. The guidelines in USA is 15 ml/min for diabetic pts and 10 ml/min for non diabetic patients to decide whether to initiate RRT.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3017247/
Hope these help
Article Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic...
There is a debate , whether dialysis should be started in CKD Stage 5 at a GFR of 15ml/min or at a lower GFR , when the patient has symptoms of uremia/ pulmonary edema / hyperkalemia refractory to conservative treatment . The original criteria to diagnose ESRD was GFR of 5ml/min, which meant that the patient could not survive 2-3 weeks without dialysis . There is no survival benefit if dialysis is started earlier at a higher GFR . This has also been highlighted in the reference given above .
As maintenance dialysis is an expensive treatment modality & once started is a lifelong modality , it is preferable to start dialysis later , when the patient has symptoms .
When the GFR has reached 5 ml / min under optimal treatment in ESRD, there is no use to wait with the dialysis treatment because uraemic symptoms are already present or may appear rapidly. Dialysis treatment should be started just before there are uraemic symptoms because hyperkalemia may be dangerous and troublesome to treat pericarditis.
@ Josef Evers
I fully agree with you that it is preferable to start dialysis before GFR reaches 5 ml/min . The article given above by Dawn Koonkongsatian ' Glomerular Filtration Rate and initiation of Dialysis ' has referred to the RCT on the ' Initiating Dialysis Early and Late Study ( IDEAL ) ' in which 'early ' initiation of dialysis at GFR of 10-14 ml/min ( mean : 9 ml/min ) compared to ' late' initiation of dialysis at GFR of 5-7 ml/min ( 7.2ml /min ) did not show survival benefit . The late initiation was based on uremic symptoms plus GFR.
The symptoms which appear with advancing renal failure are due in the large part to the accumulation of metabolites and to changes in renal physiology. A good example is the reduction in excretion and then accumulation of phosphorus and the development of secondary hyperparathyroidism. Another example is the development of metabolic acidosis. Decrease in the excretion of several other metabolites may result in symptoms depending on their role in normal physiology. It is the development of the accumulation of metabolites and the physiologic response which results in the symptoms and development of comorbidities. Thus the development may be different in different diseases and in different individuals. For instance a diabetic with diabetic nephropathy and nephrotic syndrome, will develop symptoms early on. Although one should follow the guidelines in treating patients with CKD, the actual follow-up should be individualized to the patient, his symptomatology and speed of decrease in eGFR. In practice, a patient with an eGFR of 20 to 30 ml/min, should be followed closely for symptomatology and treatment of comorbidities. Below 20 he should be referred to a pre-dialysis clinic to investigate his condition, to ascertain the best method of treatment (hemodialysis, peritoneal dialysis, pre-emptive transplantation) and to start to prepare them. Some patients show very slow progression and may thus be treated in a slower fashion, whereas others may require more intensive treatment.
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