Another important function of the kidneys is electrolyte handling, specifically phosphorus and potassium. When the kidneys are not functioning well, both potassium and phosphorus can build up in the blood. When the phosphorus is elevated, the calcium in your bones is decreased resulting in weak bone. Elevated potassium in the blood can cause problems with your heart rhythm and at certain levels is a medical emergency requiring ER evaluation.
The toxins or waste in the blood comes from the normal breakdown of muscle and the food you eat. Food is used by your body for self-repair and energy. Afterward, the waste is moved to the blood. When the kidneys are not working to remove the wastes, they would build up in the blood and can cause damage.
The filtering occurs inside your kidney. There are tiny units called nephrons. Each kidney has about 1 million nephrons. Here small blood vessels called capillaries combine with urine-carrying tubes known as tubules. Then a complicated chemical exchange happens, waste materials and excess water leave the blood and enter into the urinary system. The kidney then measures out electrolytes, such as phosphorus, sodium, and potassium and then releases them back to the blood.
There are several important hormones released from the kidney. Erythropoietin stimulates red blood cell production in the bones. Renin, regulates blood pressure and the active form of vitamin D helps maintain calcium for the bones and normal balance in the body.
The most common causes of kidney disease are hypertension and diabetes. Diabetes prevents your body from using sugar appropriately. When sugar stays in the blood instead of breaking down, it can become a poison. This causes damage to the kidney and is called diabetic nephropathy.
Uncontrolled blood pressure may cause damage to the small blood vessels in the kidney. When this happens, the damaged vessels are unable to filter poison from the blood. Your nephrologist may prescribe medications to treat the hypertension. There is a group of medications used to treat hypertension called ACE inhibitors that may give extra protection in patients with diabetes.
Some kidney diseases are inherited. Polycystic kidney disease, for example, is a genetic disorder that causes cysts grow in the kidneys. These cysts can slowly replace much of the mass of the kidneys, causing reduced kidney function and leading to kidney failure.
Some other causes are due to poisons or trauma, A direct forceful blow to the kidneys, may lead to kidney disease. Many over-the-counter medications may harm your kidneys when taken regularly over a long time. These medications often combine aspirin, acetaminophen, and other medications like ibuprofen can be dangerous to the kidney.
Unfortunately, there is not a cure for renal failure. However, if you are in the early stages of the disease, you may be able to slow the progression of disease and make the kidneys last longer.
– If you have diabetes, watch your blood sugar closely to keep it under control.
-Have your blood pressure checked regularly. Eat healthy diet with low salt
-Avoid pain pills that may make your kidney disease worse.
- CKD Stage 1 — GFR > 90
- CKD Stage 2 — GFR 60-89
- CKD Stage 3 — GFR 30-59
- CKD Stage 4 — GFR 15-29
- CKD Stage 5 — GFR < 15 or Dialysis
Urine Tests – Urinalysis, protein/creatinine ratio
Imaging Tests – A renal ultrasound may be completed to assess the size, shape and anatomy of your kidney.
Kidney Biopsy – A kidney biopsy is a test where a small piece of kidney tissue is removed by a needle. The tissue is examined under a microscope to determine the cause of kidney disease.
Hemodialysis – This modality cleans your blood using a machine with a filter called a dialyzer. During a hemodialysis treatment blood travels from your body through tubes to the dialyzer which filters out wastes and extra water. The cleaned blood flows through another set of tubes back into your body. This is usually performed in a dialysis unit three times a week for 4 hours each treatment.
Peritoneal Dialysis – removes wastes and extra water from your body using the lining of your abdomen to filter your blood. A solution travels through a soft tube into your abdomen. The solution draws wastes and extra water from tiny blood vessels in your abdomen back into the solution which is then drained from your abdomen through the soft tube. This form of dialysis is completed at your home every night.
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Swelling happens when fluid collects in small spaces around tissues and organs inside the body. Another word for swelling is “edema.” Some common parts of the body where people can have swelling are the:
- Lower legs or hands
- Chest – Swelling can occur in the lungs or in the space around the lungs.
Swelling in the legs, hands, and belly can be uncomfortable and can be a symptom of a more serious condition. Swelling in the lungs can be life-threatening, because it is usually a symptom of a serious heart problem.
Symptoms of swelling can include:
- Puffiness of the skin, which can cause the skin to look stretched and shiny – This often occurs with swelling in the lower legs or lower back, and can be worse after people sit or stand for a long time
- Increase in belly size (with swelling of the belly)
- Trouble breathing (with swelling in the chest)
Different conditions can cause swelling. Some of these include:
- Problems with veins (blood vessels) in the legs – Normally, veins carry blood from the body back to the heart. But if valves in the veins do not work well, the veins cannot pump enough blood back to the heart. This can cause swelling in the lower legs.
- Blood clots – People who have a blood clot blocking a leg vein can have swelling in the feet or ankles.
- Pregnancy – Pregnant women can have swelling in the hands, feet, or face.
- Monthly periods – Women can have swelling in different parts of their body before they get their period.
- Medicines – Swelling can be a side effect of some medicines, such as medicines for diabetes, high blood pressure, or pain.
- Kidney problems – People who have certain kidney problems can have swelling in the lower legs or around the eyes.
- Heart failure – Heart failure is a type of heart problem in which the heart cannot pump normally. People with heart failure can have swelling in the legs, belly, or lungs.
- Liver problems – People who have certain liver problems can have swelling in the belly or lower legs.
- Travel – People who sit for a long time when traveling can have swelling in the lower legs.
Call your doctor or nurse if you have new swelling:
- In one or both of your legs
- In your hands
- In your belly
- Around your eyes
You should also call your doctor or nurse if you travel and sit for a long time, and then have leg pain or swelling that does not go away after a few days.
Doctors can treat swelling in different ways, depending on the cause. Treatment can include 1 or more of the following:
- Treatment for the medical condition that is causing the swelling
- Diet changes to reduce the amount of salt in the food that you eat
- Medicines to help your body get rid of extra fluid
- Special socks called “compression stockings” – These fit tightly over the ankle and leg, and can reduce leg swelling. If your doctor or nurse recommends that you wear them, they will tell you which type to wear and how to put them on.
- Raising the legs up – Some people can reduce swelling in the legs, ankles, and feet by raising their legs up 3 or 4 times a day for 30 minutes each time. The legs need to be raised above the level of the heart.
Not all types of swelling need treatment. For example, swelling that occurs during pregnancy or before monthly periods usually does not need treatment.
To help prevent leg swelling on flights that are longer than 6 to 8 hours, you can:
- Stand up and walk around every hour or 2
- Not smoke before traveling
- Wear loose-fitting and comfortable clothes
- Ask if you can sit in the bulkhead or emergency exit row
- Point and flex your feet, and bend your knees from time to time
- Drink plenty of fluids, and avoid drinking alcohol
- Not take medicines such as sleeping pills that can prevent you from getting up and moving around
Protein in the urine (proteinuria)
The kidneys’ job is to remove wastes and excess water and salts from the blood. Kidneys receive blood through the renal arteries. The blood flows into parts of the kidney called nephrons. Each nephron is made of a glomerulus and a tubule. Each kidney contains hundreds of thousands of nephrons.
The glomeruli filter the blood, removing waste products from the blood. They also prevent some substances, such as protein, from being taken out of the blood. If the glomeruli are damaged, protein from the blood leaks into the urine.
Normally, you should have less than 150 milligrams (about 3 percent of a teaspoon) of protein in the urine per day. Having more than 150 milligrams per day is called proteinuria.
People with a small amount of proteinuria generally have no signs or symptoms. However, some patients have edema (swelling) in the face, legs, or abdomen if they lose large amounts of protein in their urine.
Proteinuria can be divided into three categories: transient (intermittent), orthostatic (related to sitting/standing or lying down), and persistent (always present).
Transient proteinuria — Transient (intermittent) proteinuria is by far the most common form of proteinuria. Transient proteinuria usually resolves without treatment. Stresses such as fever and heavy exercise may cause transient proteinuria.
Orthostatic proteinuria — Orthostatic proteinuria occurs when one loses protein in the urine while in an upright position but not when lying down. It occurs in 2 to 5 percent of adolescents but is unusual in people over the age of 30 years. The cause of orthostatic proteinuria is not known. Orthostatic proteinuria is not harmful, does not require treatment, and typically disappears with age.
Orthostatic proteinuria is diagnosed by obtaining a split urine collection. This requires collecting two urine samples: one while you are standing or sitting up (usually during the day) and another after you have been sleeping for several hours (eg, first thing in the morning).
Persistent proteinuria — In contrast to transient and orthostatic proteinuria, persistent proteinuria occurs in people with underlying kidney disease or other medical problems. Examples include:
- Kidney diseases
- Diseases that affect the kidney, such as diabetes mellitus or high blood pressure
- Diseases that cause the body to overproduce certain types of protein
Urine testing — Proteinuria is diagnosed by analyzing the urine (called a urinalysis), often with a dipstick test. However, dipstick testing is not very precise. Also, people should have the urine test repeated to determine whether or not the proteinuria is transient or persistent.
The urine should also be examined with a microscope to see whether there are cells, crystals, bacteria, or structures called casts. These urine elements can be signs of specific types of kidney problems (for example, diseases that injure the glomeruli). (
If two or more urinalyses show protein in the urine, the next step is to determine how much protein is in the urine. This can be measured from:
- A single urine sample collected at any time (a common and convenient method)
- Urine that has been collected over 24 hours (a more exact but somewhat inconvenient method)
If you have a known diagnosis of kidney disease or if you are already being treated for protein in your urine, your doctor may prefer that you collect your urine over 24 hours to determine the amount of protein in your urine.
If your doctor or nurse asks you to collect urine at home, try to keep it in a cool place, like the refrigerator. Urine is generally sterile, so it will not contaminate the food in your refrigerator.
Blood testing — Your doctor or nurse might also ask you to have blood tests to see how well your kidneys are working (called kidney function testing). These include measurement of blood urea nitrogen (BUN) and creatinine and then calculating how well the kidneys work with a formula to determine the glomerular filtration rate.
Kidney biopsy — Your doctor might recommend a test called a kidney biopsy. During a biopsy, a doctor takes a small piece of one kidney and then looks at the tissue under the microscope. The kidney biopsy is a procedure that is usually done as an outpatient and with local anesthesia. Most patients can resume regular activities the next day, except for heavy lifting and exercise.
Transient and orthostatic proteinuria are not harmful conditions, and no specific treatment is needed.
Patients with persistent low-grade proteinuria that is not associated with decreased kidney function or a systemic disease typically have no long-term complications, even if untreated. Many nephrologists use an antihypertensive drug, such as an angiotensin-converting enzyme (ACE) inhibitor, to reduce or eliminate proteinuria. However, patients with low-grade proteinuria should have it evaluated yearly to make sure it is not getting worse and that kidney function is stable.
In patients with persistent high-grade proteinuria who have decreased kidney function, the underlying condition is usually treated
- Normally, protein should not be found in the urine. A person who has protein in the urine is said to have proteinuria.
- Most people have no signs or symptoms of proteinuria.
- Proteinuria is usually discovered with a urine dipstick test that is done for another reason.
- There are three types of proteinuria: transient (temporary), orthostatic (related to sitting/standing or lying down), and persistent (always present).
- Certain types of urine testing are needed to determine the type of proteinuria. Depending upon these results, other tests may be needed, including blood tests and, sometimes, a kidney biopsy.
- Proteinuria should always be evaluated by a clinician.
- Transient and orthostatic proteinuria do not cause long-lasting health problems and do not usually need to be treated.
- Some people with persistent proteinuria have kidney problems that need to be treated.
The Nephrotic Syndrome
The term “nephrotic syndrome” refers to a group of symptoms and laboratory findings that may occur in people with certain kinds of kidney (renal) disease:
- High levels of protein (albumin) in the urine
- Low levels of the protein (albumin) in the blood
- Swelling (also called edema) of the face, legs, or ankles due to the abnormal collection of fluids in the tissues, usually accompanied by weight gain
This article will review the causes, evaluation, and treatment of nephrotic syndrome.
Nephrotic syndrome develops when there is damage to the glomeruli, the structures in the kidneys that work to filter the blood. This damage allows proteins in the blood (such as albumin) to leak into the urine, causing increased excretion of protein (proteinuria) (Eventually, blood levels of albumin become reduced. Accompanying abnormalities of kidney function lead to accumulation of fluid in the tissues (edema).
How are glomeruli damaged? — Many different disorders can cause damage to the glomeruli, resulting in nephrotic syndrome. In some cases, damage is confined to the kidneys alone. In other cases, organs other than the kidney are also affected (such as in diabetes mellitus or systemic lupus erythematosus):
- In children, the most common cause of glomerular damage is a condition known as minimal change disease.
- In adults, approximately 30 percent of people with nephrotic syndrome have an underlying medical problem, such as diabetes or lupus; the remaining cases are due to kidney disorders such as minimal change disease, focal segmental glomerulosclerosis (FSGS), or membranous nephropathy.
Minimal change disease — Minimal change disease is a kidney disease that can occur in both adults and children. People with minimal change disease have normal or very mild abnormalities of the glomeruli.
Focal segmental glomerulosclerosis — FSGS is the most common cause of nephrotic syndrome in adults. FSGS causes collapse and scarring of some glomeruli. The cause of primary FSGS is unknown, although some cases (usually in children or young adults) are the result of a genetic defect, an infection, or a toxic response to a drug.
Membranous nephropathy — Membranous nephropathy is a condition in which the walls of the glomerular blood vessels become thickened from the accumulation of protein deposits, causing increased “leakiness.” It is not clear why membranous nephropathy develops in most people, but an “auto-immune” mechanism is suspected (“auto-immune” = reaction to oneself).
Diabetes mellitus — Kidney disease is common in people with diabetes who have chronically elevated blood glucose levels and/or high blood pressure Some patients with more advanced disease can develop the nephrotic syndrome.
Lupus — Lupus is a disease that can affect multiple organs of the body, including the kidney. Nephrotic syndrome is common in people with severe lupus.
The most common symptoms of nephrotic syndrome are swelling, weight gain, fatigue, blood clots, and infections. Kidney failure may develop in some people. Increased excretion of protein may lead to “frothy” appearing urine in the toilet bowl.
Swelling (edema) — Swelling that occurs in people with nephrotic syndrome commonly affects the lining of the eye socket, which often causes swelling around the eyes upon waking in the morning. Swelling (edema) can also occur in the feet or ankles after sitting or standing for any period of time.
Weight gain — Weight gain can occur in people who develop swelling. Weight gain can occur rapidly.
Uncommonly, weight loss can occur in people who are losing large quantities of protein in the urine. This may be due to malnutrition or an underlying condition, such as poorly controlled diabetes mellitus, a chronic viral infection, or cancer.
Kidney failure — Some people with nephrotic syndrome have a gradual decline in kidney function, which causes no symptoms in the early stages. However, as kidney function continues to worsen, symptoms of kidney failure can develop, including shortness of breath, weakness and easy fatigability (from anemia), and loss of appetite.
Blood lipids — The concentration of lipids (cholesterol and/or triglycerides) can become greatly elevated in nephrotic syndrome. If persistent, this may increase the risk of coronary artery disease.
Blood clots — People with nephrotic syndrome are at an increased risk of blood clots in the veins or arteries. Clots in the veins can travel to the lungs. This can be dangerous, or even fatal.
Infection — People with severe nephrotic syndrome are at increased risk for infections (particularly children with minimal change disease), although the reasons for this are not well understood.
Nephrotic syndrome is diagnosed based upon a number of laboratory tests, including urine and blood tests.
Urine tests — Urine tests are often done to determine the amount of protein in the urine.
Blood tests — A number of blood tests may be recommended to help determine the underlying cause of nephrotic syndrome to assess the risk of complications and to evaluate overall kidney function.
Renal biopsy — Renal (kidney) biopsy is the standard procedure for determining the underlying cause of nephrotic syndrome when a cause cannot be identified by noninvasive laboratory testing.
Treat the underlying disease — The first line of treatment in nephrotic syndrome is to treat the underlying cause, if the cause is found. In addition, almost all patients are given an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), which lower blood pressure, prevent worsening of kidney disease, and reduce the amount of protein excreted in the urine.
Diabetes mellitus — The optimal treatment for diabetic kidney disease is not well understood, although the best approach likely includes intensive management of blood sugar levels, cholesterol, and blood pressure. Use of ACE and ARB medications are first line in the treatment of diabetic kidney disease because they lower the amount of protein in the urine and protect the kidney.
Lupus — People with lupus who have nephrotic syndrome or evidence of worsening kidney function can be treated with glucocorticoids (steroids) and other medications that suppress the immune system. Most people respond well to such a regimen.
Minimal change disease — People with minimal change disease almost always respond initially to treatment with glucocorticoids (steroids). However, relapses are common, and additional treatments are often required.
Focal segmental glomerulosclerosis — Prolonged treatment with glucocorticoids (steroids) is often recommended for people with primary focal segmental glomerulosclerosis (FSGS). Secondary FSGS is treated primarily with ACE inhibitors or ARBs.
Membranous nephropathy — The best treatment for membranous nephropathy is a source of debate. In many people, a period of “watch and wait” is recommended initially to determine if the condition is worsening or causing complications. During this time, an ACE inhibitor or ARB is recommended, and it is important to keep blood pressure and cholesterol levels controlled. Additional treatment, including medications that suppress the immune system, may be needed if membranous nephropathy progresses.
Without immunosuppressive treatment, approximately 10 to 30 percent of people with membranous nephropathy have a complete resolution of symptoms over several years, a further 10 to 30 percent of people have a partial remission, and approximately 40 percent of people slowly lose kidney function. As a result, most people with mild symptoms are advised to delay immunosuppressive treatment until/unless symptoms worsen.
Treating the symptoms of nephrotic syndrome — In addition to treating the underlying cause of nephrotic syndrome, the signs and symptoms of nephrotic syndrome can sometimes be treated.
Proteinuria — An ACE inhibitor or ARB is often recommended to reduce the loss of protein in the urine (proteinuria).
Edema — Swelling in the lower legs (edema) and collection of fluid in the abdomen (ascites) can occur in people with nephrotic syndrome. Edema and ascites often improve in people who follow a low-sodium diet and take a “water pill” (diuretic)
High cholesterol — High cholesterol levels are often seen in people with nephrotic syndrome. If nephrotic syndrome persists, treatment is needed to lower blood cholesterol. Most people are initially treated with a cholesterol-lowering medication called a statin.
Blood clots — If a blood clot forms in a blood vessel, treatment may include a blood thinner, such as warfarin (brand name: Jantoven), for as long as the nephrotic syndrome persists.
Kidney (renal) biopsy
A kidney biopsy, also called a renal biopsy, is a procedure that is used to obtain small pieces of kidney tissue to look at under a microscope. It may be done to determine the cause, severity, and possible treatment of a kidney disorder. The procedure is generally safe and can provide valuable information about your kidney disease.
This article discusses why you might need a kidney biopsy, how to prepare for it, and what complications might occur. More detailed information about kidney biopsy is available by subscription.
A kidney biopsy is recommended for certain people with kidney disease. It may be performed when other blood and urine tests cannot give enough information. The following are the most common reasons for kidney biopsy. You may have one or more of these problems, but not everyone with these problems needs a kidney biopsy:
- Blood in the urine (called hematuria).
- Protein in the urine (called proteinuria) – This occurs in many people with kidney problems. A kidney biopsy may be recommended if you have high or increasing levels of protein in the urine or if you have proteinuria along with other signs of kidney disease.
- Problems with kidney function – If your kidneys suddenly or slowly stop functioning normally, a kidney biopsy may be recommended, especially if the cause of your kidney problem is unclear.
Preparation — Before your biopsy, you may need testing to see whether you have a blood clotting abnormality or infection. To decrease the risk of bleeding, you should stop taking medicines that increase the risk of bleeding (such as aspirin, aspirin-like compounds, ibuprofen, or naproxen) for one to two weeks before the biopsy if recommended to be safe by your health care providers. Review your medicines with your health care provider to determine which ones are safe to continue.
If you take warfarin (brand name: Jantoven or Coumadin), heparin, clopidogrel (brand name: Plavix), rivaroxaban (brand name: Xarelto), apixaban (brand name: Eliquis), or other medicines that prevent blood clots, ask your clinician when to take these medications before your biopsy.
Biopsy procedure — Kidney biopsy is usually performed while you are awake, after a cleansing agent is applied, and you are given local anesthesia (numbing medicine) to minimize pain. The most common way to perform a biopsy is to use a needle, which is inserted through the skin and into the kidney.
In most cases, you will have an ultrasound, x-ray, or computed tomography (CT) scan so that the clinician knows exactly where to insert the needle. Once the needle is in the right position, the clinician will take samples of tissue from the kidney with the needle.
In some cases, a different approach is used to perform the biopsy. An open kidney biopsy involves sedating you with general anesthesia, and making a small cut in your skin, which is opened to obtain the kidney tissue. Rarely, transjugular or laparoscopic approaches could be used.
After the biopsy, the kidney tissue will be sent to a laboratory and examined with a microscope. This microscopic examination is looking for scarring, infection, or abnormalities in the kidney tissue. The results of the microscopic examination are usually available within one to two weeks after the biopsy. In urgent situations, the results can be available within a few hours.
After an open or needle biopsy, you will be kept in a recovery or an observation unit for several hours to monitor for potential complications, including pain and bleeding. You may have blood drawn or repeat x-rays to monitor for bleeding. In some instances, you could go home after several hours of monitoring. Alternatively, you may be observed in the hospital overnight.
Once it is deemed safe for you to go home, you are not to perform any heavy lifting or vigorous exercise for one to two weeks. You should continue to avoid aspirin-like drugs or blood thinning medications for at least one week or until your clinician has instructed you that it is safe to take these.
Serious complications of kidney biopsy are not common. Less serious complications can occur, and can include bleeding, pain, and development of an abnormal connection between two blood vessels (a fistula). Rare complications include infection, damage to blood vessels or other organs, or urine leaks.
Bleeding — Bleeding is the most common complication of kidney biopsy. Many people may notice blood in their urine for several days after a kidney biopsy. More severe bleeding occurring around the kidney or into the urine is uncommon, but if it occurs, you may need a blood transfusion. Very rarely, it may become life threatening and possibly require a procedure or surgery to stop the bleeding. If your urine is bright red or brown for longer than one week after your biopsy, call your health care provider.
Pain — Pain can occur after a kidney biopsy. You can be given medications to reduce pain after the procedure, and the pain usually resolves within a few hours. If you have severe or prolonged pain, call your health care provider immediately.
Arteriovenous fistula — The biopsy needle can rarely injure the walls of a nearby artery and vein, and this can lead to the development of a fistula (a connection between the two blood vessels). Fistulas generally do not cause problems and usually close on their own over time.