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2) CLINICAL MANIFESTATIONS

Mr. Darnel Nzeogwu-Uba Asks:

“What makes you and the doctor think that my kidney disease has advanced to End-Stage Renal Failure from Stage Three?”

In the early stages of Chronic Kidney Disease (CKD), there may be few signs and symptoms. Signs and symptoms in the early stages may be confused for other physical problems because they are nonspecific and can indicate several other things.

Signs and symptoms of the earlier stages of CKD include nausea, vomiting, loss of appetite, fatigue and weakness, sleep problems, changes in urine output (can include amount either more or less, color, frequency) decrease in mental abilities (concentration, memory) muscle twitches and cramps, swelling (usually in the feet and ankles), persistent itching, and hypertension. A client may present with all of these symptoms, some of them or none of them at all.

A major issue with CKD is that, due to the fact that the kidneys are extremely adaptable, signs and symptoms may not appear until irreversible damage has occurred.

Signs and symptoms that can occur in the late stages of CKD include: changes in skin color, bone pain, breath odor, bruising and bleeding with little stimulus, excessive thirst, frequent hiccups, and shortness of breath.

Hypertension, nausea and vomiting may be present in both early and late-stage CKD.  As the disease progresses, if untreated, severe life threatening circumstances may develop such as metabolic acidosis (due to the inability of the kidney to reabsorb bicarbonate), hyperkalemia (due to the  kidneys’  inability to excrete potassium) which can lead to arrhythmias. Finally, Chronic Kidney Disease can lead to congestive heart failure, coma and death.

CKD & Fluid-Electrolyte Imbalances

Electrolytes or essential ions should always be in the state of homoeostasis. The fluid-electrolyte imbalances that we will look at in regards to CKD are, Sodium and water, Potassium, calcium and phosphorus and metabolic acidosis. Our kidneys play such an important role with the excretion of waste products, for metabolism, and the electrolyte balances. Because of this, the electrolytes, as mentioned above, are the ones that are affected when the kidneys no longer work properly, as is with CKD.

Sodium and Water Imbalance

When it comes to sodium and water, if the kidneys begin to shut down from overload or underproduction, then clients are at risk for developing hyponatremia or hypernatremia. These complications can cause severe irreversible damages not just to the kidneys but other organs as well.

Potassium Imbalance

With a potassium imbalance, there is less complication as the levels generally remain at near normal as long as the RAAS and distal nephron flow is maintained. The problem occurs if the client is oliguric, causing Hyperkalemia, or if they have an increased potassium intake due to medications. Because once the levels are high the kidneys cannot get rid of the excess of potassium efficiently anymore. This can lead to several complications, but mainly arrhythmia’s.

Calcium and Phosphorus Imbalance

Calcium and Phosphorus imbalances are related to the levels of parathyroid hormones. The more the kidneys decline, the higher the levels of calcium and phosphorus get, causing systemic problems.

Metabolic Acidosis

The kidneys are responsible for regenerating bicarbonate, and when they are not working properly due to CKD the result will be metabolic acidosis. This is because the kidneys cannot reabsorb the excess bicarbonate. Although if caught early enough there is hope for correcting this issue, chronic acidosis, as experienced by those with CKD, leads to muscle protein breakdown and in turn a reduced albumin synthesis.

Your Answer to Mr. Darnel Nzeogwu-Uba’s Question:

In the earlier stages of your CKD you presented with more general symptoms, and it took blood tests for us to realize that those symptoms were related to your kidneys. Now that your disease has progressed, there are obvious signs and symptoms that have appeared that indicated to us that you are at a later stage of CKD. The symptoms that you presented with include: bone pain, breath odour, shortness of breath, changes in colour and amount of your urine, and we suspect you may have something called metabolic acidosis because you are breathing so quickly and your breaths are shallow. 

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