Chapter 31

### Introduction

I have never yet examined the body of a patient dying with dropsy attended by albuminous urine, in whom some obvious derangement was not discovered in the kidneys.

Richard Bright 1827

##### Chronic kidney failure

In the diagnostic model the problem of chronic kidney failure (CKF) as a masquerade has been highlighted. The reason for this is that the dysfunction associated with progressive chronic kidney disease (CKD) can be difficult to diagnose as there may be no or minimal symptoms. In fact the patient may present with a subtle terminal illness. It is important that all general practitioners are aware of the seriousness of the problem and keep it in mind when the patient presents with apparent minor problems such as fatigue or weakness. Sometimes the kidneys can develop acute failure, which may recover or progress to chronicity.

If CKD is detected early and managed appropriately then the otherwise inevitable deterioration in kidney function can be reduced by as much as 50% and may even be reversible.1

Key facts and checkpoints

• 10% of people attending general practice1 have CKD but most do not know it.

• At least 95 people per million of the population are treated for end-stage kidney disease/kidney failure (ESKF) each year.

• Two-thirds of these are under 60 years of age.

• Important causes are glomerulonephritis (25%), diabetes mellitus (35%), polycystic kidney disease (8%), reflux nephropathy (8%) and hypertension (13%) (see Table 31.1).2

• The commonest cause of ESKF in Australia is diabetes mellitus.

• The commonest cause of nephritis leading to kidney failure in Australia is IgA nephropathy.

• In children the incidence of chronic kidney failure is quite low (1 to 2 per million of the population).2

• Warmer climates, poorer living conditions and certain genetic predispositions are associated with a higher prevalence of kidney failure.

• Kidney failure should be considered in the diagnosis of patients with unexplained anaemia, unexplained poor health and unusually high analgesic intake.2

• Uraemic symptoms are non-specific and usually are not recognised until the creatinine clearance is less than 20% of normal.

• CKF is characterised by the accumulation of uraemic toxins and a deficiency of kidney hormones that cause dysfunction of organs other than kidneys.

• This interaction can cause phosphate retention, secondary hyperparathyroidism and bone disorders such as osteomalacia.

• Age is an issue—we lose 1% of renal function per year

• It is possible to identify stages of kidney failure (see Table 31.2).

Table 31.1

Significant causes of chronic kidney failure (approximate order of prevalence)

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