Chronic Kidney Disease

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

Is this topic for you?

This topic provides information about chronic kidney disease. If you are looking for information about sudden kidney failure, see the topic Acute Renal Failure.

What is chronic kidney disease?

Having chronic kidney disease means that for some time your kidneys have not been working the way they should. Your kidneys have the important job of filtering your blood. They remove waste products and extra fluid and flush them from your body as urine. When your kidneys do not work right, wastes build up in your blood and make you sick.

Chronic kidney disease may seem to have come on suddenly. But it has been happening bit by bit for many years as a result of damage to your kidneys.

Each of your kidneys has about a million tiny filters, called nephrons. If nephrons are damaged, they stop working. For a while, healthy nephrons can take on the extra work. But if the damage continues, more and more nephrons shut down. After a certain point, the nephrons that are left cannot filter your blood well enough to keep you healthy.

There are things you can do to slow or stop the damage to your kidneys. Taking medicines and making some lifestyle changes can help you manage your disease and feel better.

What causes chronic kidney disease?

Chronic kidney disease is caused by damage to the kidneys. By far the most common causes of this damage are:

• High blood pressure.
• High blood sugar (diabetes).

Other things that can lead to chronic kidney disease include:

• Kidney diseases and infections, such as polycystic kidney disease, pyelonephritis, and glomerulonephritis, or a kidney problem you were born with.
• A narrowed or blocked renal artery. The renal artery carries blood to the kidneys.
• An enlarged prostate gland, kidney stones, or a tumor that keeps urine from flowing out of the kidneys.
• Lead poisoning.
• Long-term use of medicines that can damage the kidneys. Examples include pain medicines, like acetaminophen (such as Tylenol) and ibuprofen (such as Advil), and certain antibiotics.

What are the symptoms?

You may start to have symptoms only a few months after your kidneys begin to fail. But most people do not have symptoms early on. In fact, many do not have symptoms for as long as 30 years or more. This is called the "silent" phase of the disease.

How well your kidneys work is called kidney function. As your kidney function gets worse, you may:

• Urinate less than normal.
• Have swelling from fluid buildup in your tissues. This is called edema (say "ih-DEE-muh").
• Feel very tired or sleepy.
• Not feel hungry, or you may lose weight without trying.
• Often feel sick to your stomach (nauseated) or vomit.
• Have trouble sleeping.
• Have headaches or trouble thinking clearly.

How is chronic kidney disease diagnosed?

Your doctor will do blood and urine tests to help find out how well your kidneys are working. These tests can show signs of kidney disease and anemia. (You can get anemia from having damaged kidneys.) You may have other tests to help rule out other problems that could cause your symptoms.

Your doctor will ask questions about any past kidney problems, whether you have a family history of kidney disease, and what medicines you take—both prescription and over-the-counter drugs.

You may have a test that lets your doctor look at a picture of your kidneys, such as an ultrasound or CT scan. These tests can help your doctor measure the size of your kidneys, estimate blood flow to the kidneys, and see if urine flow is blocked. In some cases, your doctor may take a tiny sample of kidney tissue (biopsy) to help find out what caused your kidney disease.

How is it treated?

Chronic kidney disease is usually caused by another condition. So the first step is to treat the disease that is causing kidney damage.

Diabetes and high blood pressure cause most cases of chronic kidney disease. If you keep your blood pressure and blood sugar near normal, you may be able to slow or stop the damage to your kidneys. Losing weight and getting more exercise can help. You may also need to take medicines.

Kidney disease is a complex problem. You will probably need to take a number of medicines and have many tests. To stay as healthy as possible, work closely with your doctor. Go to all your appointments, and take your medicines just the way your doctor says to.

Lifestyle changes are an important part of your treatment. Taking these steps can help slow down kidney disease and reduce your symptoms. They may also help with high blood pressure, diabetes, and other problems that make kidney disease worse.

• Follow a diet that is easy on your kidneys. A dietitian can help you make an eating plan with the right amounts of salt (sodium) and protein. You may also need to watch how much fluid you drink each day.
• Get some exercise every day. Work with your doctor to design an exercise program that is right for you.
• Do not smoke or use tobacco.
• Do not drink alcohol.

Always talk to your doctor before you take any new medicine, including over-the-counter remedies, prescription drugs, vitamins, or herbs. Some of these can hurt your kidneys.

What happens if my kidney disease gets worse?

When kidney function falls below a certain point, it is called kidney failure. Kidney failure affects your whole body. It can cause serious heart, bone, and brain problems and make you feel very ill.

Once you have kidney failure, you will probably have two choices: start dialysis or get a new kidney (transplant). Both of these treatments have risks and benefits. Talk with your doctor to decide which would be best for you.

• Dialysis is a process that filters your blood when your kidneys no longer can. It is not a cure, but it can help you feel better and live longer.
• Kidney transplant may be the best choice if you are otherwise healthy. With a new kidney, you will feel much better and will be able to live a more normal life. But you may have to wait for a kidney that is a good match for your blood and tissue type. And you will have to take medicine for the rest of your life to keep your body from rejecting the new kidney.

Making treatment decisions when you are very ill is hard. It is normal to be worried and afraid. Discuss your concerns with your loved ones and your doctor. It may help to visit a dialysis center or transplant center and talk to others who have made these choices.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	What type of dialysis should I have?
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	Eating plan for chronic kidney disease
	Home blood sugar monitoring
	Monitoring your blood pressure at home

The cause of chronic kidney disease is not always known. But any condition or disease that damages blood vessels or other structures in the kidneys can lead to kidney disease. The most common causes of chronic kidney disease are:

• Diabetes. Diabetes causes about 35% of all chronic kidney disease. High blood sugar levels caused by diabetes damage blood vessels in the kidneys. If the blood sugar level remains high, this damage gradually reduces the function of the kidneys.
• High blood pressure (hypertension). High blood pressure causes another 30% of all kidney disease. Because blood pressure often rises with chronic kidney disease, high blood pressure may further damage kidney function even when another medical condition initially caused the disease.

Other conditions that can damage the kidneys and cause chronic kidney disease include:

• Kidney diseases and infections, such as polycystic kidney disease, pyelonephritis, and glomerulonephritis, or a kidney problem you were born with.
• Having a narrowed or blocked renal artery. The renal artery carries blood to the kidneys.
• Having an enlarged prostate gland, kidney stones, or a tumor that keeps urine from flowing out of the kidneys.
• Lead poisoning.
• Long-term use of medicines that can damage the kidneys. Examples include pain medicines, like acetaminophen (such as Tylenol) and ibuprofen (such as Advil), and certain antibiotics.

Diabetes and high blood pressure are the most common causes of chronic kidney disease that leads to kidney failure. Diabetes or high blood pressure may also speed up the progression of chronic kidney disease in someone who already has the disease.

Many people who develop chronic kidney disease do not have symptoms at first. This is known as the "silent" phase of the disease.

As your kidney function gets worse, you may:

• Urinate less than normal.
• Have swelling from fluid buildup in your tissues (edema).
• Feel very tired.
• Lose your appetite or have an unexpected weight loss.
• Feel nauseated or vomit.
• Be either very sleepy or unable to sleep.
• Have headaches or trouble thinking straight.

Chronic kidney disease can greatly impact your life as it gets worse (progresses). At first, the kidneys are still able to regulate the balance of fluids, salts, and waste products in your body. But as kidney function decreases, complications begin to develop. The number and severity of complications caused by chronic kidney disease increase as kidney function gets worse.

If you are not able to control the disease, your kidney function will continue to get worse. When kidney function falls below a certain point, it is called kidney failure. Kidney failure has harmful effects throughout your body. It can cause serious heart, bone, and brain problems and make you feel very ill.

Once you develop kidney failure, either you will need to have dialysis or you will need a new kidney. Both choices have risks and benefits. Talk with your doctor to decide which would be best for you.

Complications of chronic kidney disease

Regardless of what causes chronic kidney disease, serious problems occur when the kidneys cannot adequately filter and remove all of the waste products from the body. As these waste products build up, symptoms and serious complications start to occur. Complications of severe chronic kidney disease may include:

• Uremic syndrome. In uremic syndrome, urea and creatinine levels in the bloodstream rise. Fatigue and weight loss are common symptoms. Uremic syndrome can affect many body systems, such as the intestines, nerves, and heart.
• Anemia. Anemia occurs when the kidneys do not produce enough of a protein called erythropoietin for the body to make new red blood cells. The more damage that has occurred in the kidneys, the more severe the anemia may be.
• Electrolyte imbalance. Electrolyte imbalance occurs when the kidneys cannot adequately filter out certain chemicals from the blood, such as potassium, phosphate, and acids.
• Heart disease. Chronic kidney disease speeds up hardening of the arteries (atherosclerosis) and increases the risk of heart attack and heart failure. Heart disease is the most common cause of death in people with kidney failure.
• Bone disease (osteodystrophy). The kidneys must be able to maintain a healthy balance of substances such as calcium, phosphate, and vitamin D to help keep bones strong. Kidney disease causes abnormal levels of these substances. This leads to renal bone disease.
• Fluid imbalances. As kidney function continues to decline, the kidneys are increasingly unable to filter fluids and maintain salt balance. When the kidneys are no longer able to properly remove salt and water from the body, fluid builds up in the tissues of the body (edema). Fluid buildup in the lungs (pulmonary edema) can cause heart failure.

Some of the things that lead to chronic kidney disease are related to your age and your genetic makeup. You may be able to control other things that increase your risk, such as dietary habits and exercise.

Things you cannot control:

The main risk factors for the development of chronic kidney disease are:

• Age. The kidney begins to get smaller at about age 35. By age 80, most people have lost about 30% of their kidney mass.
• Race. African-Americans and Native Americans are more likely to develop chronic kidney disease.
• Gender. Men have a higher risk of developing chronic kidney disease than women.
• Family history. Family history is a factor in the development of both diabetes and high blood pressure, the major causes of chronic kidney disease. Polycystic kidney disease is one of several inherited diseases that cause kidney failure.

Things you may be able to control:

You may be able to slow the progression of chronic kidney disease and prevent or delay the development of kidney failure by controlling things that increase your risk of kidney damage, such as:¹

• High blood pressure, which gradually damages the tiny blood vessels in the kidneys.
• Diabetes. A persistently high blood sugar level can damage blood vessels in the kidneys. Over time, kidney damage can progress, and the kidneys may stop working altogether.
• Eating protein and fats. Eating a diet low in protein and fat helps keep your kidneys healthy.
• Certain medicines. Avoid long-term use of medicines that can damage the kidneys, such as pain relievers called NSAIDs and certain antibiotics.

Call 911 or other emergency services if you have chronic kidney disease and you develop:

• A very slow or very rapid heart rate.
• Chest pain or severe shortness of breath.
• Severe muscle weakness.

Call your doctor immediately if you:

• Develop symptoms of uremic syndrome, such as increasing fatigue, nausea and vomiting, loss of appetite, or inability to sleep.
• Vomit blood or have blood in your stools.

Call your doctor if you:

• Are feeling more tired or weak.
• Develop signs of a serious illness that are not caused by a cold or the flu.
• Have swelling of the arms or feet.
• Have muscle weakness.
• Bruise often or easily.

Call your doctor if you are being treated with dialysis and you:

• Develop signs of a serious illness that are not caused by a cold or the flu.
• Have excessive bleeding or bruising.
• Develop abdominal pain while being treated with peritoneal dialysis.
• Have signs of infection at your catheter or dialysis access site, such as pus draining from the area.
• Have any other problem that your dialysis instruction manual or nurse's instructions indicate you should call about.

If you have uncontrolled weight loss, discuss this with your doctor during your next visit.

Watchful Waiting

A wait-and-see approach is not a good idea if you could have chronic kidney disease. See your doctor. If you have been diagnosed with chronic kidney disease, follow your treatment plan, and call your doctor if you notice any new symptoms.

Who To See

Health professionals who can diagnose and treat chronic kidney disease include:

• Family medicine physicians.
• Internists.
• Kidney specialists (nephrologists).
• Pediatricians.
• Nurse practitioners.
• Physician assistants (PA).

Soon after you have been diagnosed with chronic kidney disease, your doctor may refer you to a nephrologist. A nephrologist can treat kidney disease and other conditions that may be contributing to it and help you make other decisions about treatment. Nephrologists also often take over the care of people who have kidney failure once they need dialysis or after they receive a kidney transplant.

If you are to receive dialysis, you will be referred to a surgeon who will prepare a dialysis access. A dialysis access is a site on your body where blood or other fluids can be removed, filtered, and returned to the body during dialysis. You will be referred to a surgeon if you are being considered for a kidney transplant.

You may also be referred to a:

• Dietitian, to help you with meal planning. Because of the many restrictions in your diet, you may find it hard to get enough calories to maintain your weight. A dietitian can help you make wise food choices.
• Psychologist or social worker, to help you and your family with emotional stress or financial issues.

To prepare for your appointment, see the topic Making the Most of Your Appointment

People who have chronic kidney disease may not have symptoms of the disease until kidney function has decreased to a very low level. Tests are vital to help determine:

• Whether kidney disease has developed suddenly or as a long-term process (acute renal failure versus chronic kidney disease). Some of the tests used to evaluate acute renal failure may also be used if a person with chronic kidney disease has a sudden drop in kidney function.
• What is causing the kidney damage.
• The best type of treatment to help slow the progression of kidney damage.
• How well treatment is working.
• When to begin dialysis or have a kidney transplant.

Once you are diagnosed with chronic kidney disease, blood and urine tests can help monitor the disease.

Tests to check kidney function

When kidney function is decreased, substances such as urea, creatinine, and certain electrolytes begin to build up in the bloodstream. The following blood and urine tests measure changing levels of these substances in the bloodstream and can help estimate how well your kidneys are working.

• A fasting blood glucose test is done to measure your blood sugar. High blood sugar levels damage blood vessels in the kidneys.
• Creatinine and creatinine clearance tests measure the level of creatinine in the blood and how well the kidneys clear this substance from the body. The amount of creatinine in the blood increases when the kidneys are damaged and are not functioning normally.
• Blood urea nitrogen (BUN) test measures the amount of urea in the blood. If the kidneys are not able to remove urea from the blood normally, the BUN level increases. Heart failure, dehydration, or a diet high in protein can also increase the BUN level.
• A blood test measures your levels of electrolytes, which are filtered out of the body by the kidneys. Altered levels of electrolytes, such as sodium and potassium, may mean the kidneys are not functioning adequately.
• A blood test for parathyroid hormone (PTH) checks the level of PTH in the blood. PTH helps control calcium and phosphorus levels in the blood. A high parathyroid hormone level can be caused by conditions that lead to low blood calcium levels, such as chronic kidney disease.
• Urine tests, such as urinalysis (UA) and random urine test for microalbumin, measure the amount of protein in the urine. Normally there is little or no protein in urine. Kidney disease can cause increased protein in the urine.

Since kidney disease runs in families, encourage close family members to have their kidney function tested. If kidney disease is found early, treatment can be started to slow or stop the damage.

Tests for anemia

If the kidneys do not produce enough of the protein erythropoietin needed to make red blood cells, anemia can develop. This type of anemia is treated with a medicine called human recombinant erythropoietin (rhEPO) that helps your body make new red blood cells.

Tests to monitor anemia include:

• Complete blood count (CBC). A CBC measures the hematocrit and the hemoglobin level, which indicates how well dialysis or rhEPO therapy is working.
• Reticulocyte count. A low reticulocyte count often means decreased production of red blood cells by the bone marrow. Iron deficiency or low levels of erythropoietin can cause decreased production of red blood cells by the bone marrow.
• Iron studies. Your body needs iron for the proper function of hemoglobin, the protein in red blood cells that carries oxygen. Decreased production of red blood cells or the inability to store iron in the body can cause a low iron level.
• Serum ferritin test, to measure the protein that binds to iron in the body. Decreased production of red blood cells or the inability to store iron in the body can cause a low level of serum ferritin.

Other tests

Your doctor may use other tests to monitor reduced kidney function or to determine whether another kidney disease or condition is contributing to reduced kidney function.

• An ultrasound of the kidney (renal ultrasound) accurately measures the size of the kidneys, which may help estimate how long chronic kidney disease has been present and to check whether urine flow from the kidneys is blocked. An ultrasound also may help identify other possible causes of kidney disease, such as obstruction or polycystic kidney disease.
• A duplex Doppler study or angiogram of the kidney may be done to check for problems caused by restricted blood flow (renal artery stenosis).
• A kidney biopsy may help determine the cause of chronic kidney disease. It may also be used after kidney transplant when organ rejection is suspected.

The dye used during CT scan and intravenous pyelogram (IVP) may damage the kidneys further, so these tests are not usually used to evaluate kidney disease.

Early screening for chronic kidney disease

Experts recommend screening tests for chronic kidney disease in high-risk groups, such as people with diabetes or high blood pressure. Being diagnosed with kidney disease before it has progressed gives you the best chance to control the disease.

Screening tests for people who have diabetes

Kidney damage caused by diabetes is called diabetic nephropathy. Doctors diagnose diabetic nephropathy with a urine test for microalbumin that detects protein in the urine. Normally there is little or no protein in urine. Kidney disease can cause increased protein in the urine, or proteinuria. The results of two tests done within a 3- to 6-month period are needed to diagnose diabetic nephropathy.

When to begin testing for protein in the urine depends on the type of diabetes you have; once testing begins, you should have it every year.

• Type 1 diabetes : Since it takes a few years before people with type 1 diabetes start showing signs of kidney damage, testing for protein in the urine should be done yearly after you have had the disease for 5 years. For children, testing usually begins at the time of puberty and continues yearly throughout life.
• Type 2 diabetes : Since people with type 2 diabetes have usually had the disease for several years before it is diagnosed, diabetes may have already caused some kidney damage. Testing for protein in the urine should be done yearly after the diagnosis of type 2 diabetes.

For more information, see the topic Diabetic Nephropathy.

Screening tests for people who have high blood pressure

When you are first diagnosed with high blood pressure, you should have two tests to check your kidney function: blood urea nitrogen (BUN) and creatinine and creatinine clearance. If your kidney function is normal and your blood pressure is normal with treatment, you will need to see your doctor yearly to have your overall health and kidney function evaluated.

Experts recommend that people with kidney disease keep their blood pressure below 130/80.²

During your yearly visit, your doctor may order a chemistry screen, which includes BUN and creatinine tests, and a urine test to measure the amount of protein in the urine. If your test results are normal and your blood pressure is under control, no further testing is needed. If initial tests are abnormal, more tests may be needed to evaluate your kidney function.

For more information, see the topic High Blood Pressure (Hypertension).

The goal of treatment for chronic kidney disease is to prevent or slow additional damage to your kidneys. Another condition such as diabetes or high blood pressure usually causes kidney disease, so it is important to identify and manage the condition that is causing your kidney disease. It is also important to prevent diseases or avoid situations that can cause kidney damage or make it worse.

Initial treatment

One of the most important parts of treatment for chronic kidney disease is to control the disease that is causing it. If you have diabetes or high blood pressure, you and your doctor will develop a plan to aggressively treat and manage your condition to help slow additional damage to your kidneys.

Your doctor will also check you for other conditions or diseases that may cause kidney damage, including a blockage (obstruction) in the urinary tract or long-term use of medicines that can damage the kidneys, such as some antibiotics or pain relievers (such as NSAIDs).

You can take steps at home to help control your kidney disease:

• Follow an eating plan that is good for your kidneys. A dietitian can help you make an eating plan with the right amounts of sodium, fluids, and protein. For more information, see:

  Eating plan for chronic kidney disease.

• Participate in a daily exercise program. Work with your doctor or other health professional to design an exercise program that is right for you. Exercise may help you control diabetes and high blood pressure, which can lead to kidney disease.
• Avoid taking medicines that can damage your kidneys, like ibuprofen (such as Advil) and naproxen (such as Aleve). Be sure that your doctor knows about all prescription, over-the-counter, and herbal medicines you are taking.
• Avoid dehydration. Get treatment right away for illnesses, such as diarrhea, vomiting, or fever, that can cause you to lose fluids. Be especially careful when you exercise or during hot weather. For more information, see the topic Dehydration.
• Do not smoke or use other tobacco products. Smoking can lead to atherosclerosis, which reduces blood flow to the kidneys and increases blood pressure. For more information on how to quit, see the topic Quitting Tobacco Use.
• Do not drink alcohol or use illegal drugs.

Ongoing treatment

As part of your ongoing treatment for chronic kidney disease, you may be prescribed a blood pressure medication, such as an ACE inhibitor or an angiotensin II receptor blocker (ARB). These medications are used to increase the blood supply to the kidneys, reduce protein in the urine, and help manage high blood pressure. The recommended target blood pressure for people with kidney disease is less than 130/80.²

If you have diabetes, it is important to control your blood sugar levels with diet, exercise, and medicines. A persistently high blood sugar level can damage the blood vessels in the kidneys.

Your doctor will use blood and urine tests to regularly check how well your kidneys are functioning and whether changes to your treatment plan are needed. These tests include:

• Creatinine and creatinine clearance tests, which measure the level of creatinine in the blood and how well the kidneys clear this substance from the body.
• Blood urea nitrogen (BUN) test, which measures the amount of urea in the blood.
• Glomerular filtration rate (GFR), which determines how well the kidneys filter the blood.

Depending on the stage of your disease, you may be able to take steps at home to help control your kidney disease:

Follow the eating plan your dietitian developed for you. Your eating plan will balance your need for calories with your need to limit certain foods, such as sodium, fluids, and protein. For more information, see:

Eating plan for chronic kidney disease.

• Participate in a daily exercise program. Exercise may help you control diabetes and high blood pressure.
• Avoid taking medicines that can damage your kidneys. Be sure that your doctor knows about all prescription medicines, over-the-counter medicines, and herbs you are taking.
• Avoid dehydration. Get treatment right away for illnesses, such as diarrhea, vomiting, or fever, that can cause you to become dehydrated. Be especially careful when you exercise or during hot weather. For more information, see the topic Dehydration.
• Do not smoke or use other tobacco products, alcohol, or illegal drugs. Smoking can lead to atherosclerosis, which reduces blood flow to the kidneys and increases blood pressure. For more information on how to quit, see the topic Quitting Tobacco Use.

Treatment if your condition gets worse

Chronic kidney disease is often progressive. If the disease gets worse, your symptoms, such as fatigue, nausea, and loss of appetite, may occur more frequently or become more severe. Work with your doctor to develop a treatment plan to help control these symptoms. An eating plan that limits the amount of protein, fluids, and salt in your diet is usually needed to help slow the progression of kidney failure.

Uremic syndrome (uremia) is a serious complication of chronic kidney disease. It occurs when waste products build up in the body because the kidneys are not able to eliminate them. These substances can become poisonous (toxic) to the body if they reach high levels. Uremic syndrome can affect many body systems, including the intestines, nerves, and heart. If it develops, the mechanical removal of wastes and fluids (dialysis) or replacement with a donor kidney (kidney transplant) will be needed.

When the kidneys do not produce enough of the protein that the body needs to produce new red blood cells (erythropoietin), anemia develops. This type of anemia is treated with a medicine called human recombinant erythropoietin (rhEPO) that helps your body make new red blood cells. Treatment with rhEPO may also help improve your appetite and general sense of well-being.

Treatment for kidney failure

If you are not able to control chronic kidney disease, your kidney function will continue to get worse. When kidney function falls below a certain point, it is called kidney failure. Kidney failure has harmful effects throughout your body. It can cause serious heart, bone, and brain problems and make you feel very ill.

Once you develop kidney failure, either you will need to have dialysis or you will need a new kidney. Both choices have risks and benefits. Talk with your doctor to decide which would be best for you.

Dialysis is a process that performs the work of healthy kidneys by clearing wastes and extra fluid from the body and restoring the proper balance of chemicals (electrolytes) in the blood. You may use dialysis for many years, or it may be a short-term measure while you are waiting for a kidney transplant.

The two types of dialysis used to treat severe chronic kidney disease are hemodialysis and peritoneal dialysis .

• Hemodialysis uses a man-made membrane called a dialyzer to clean your blood. You are connected to the dialyzer by tubes attached to your blood vessels. Before hemodialysis treatments can begin, your doctor creates a site where blood can flow in and out of your body. This is called the dialysis access. Usually the doctor creates the access by joining an artery and a vein in the forearm or by using a small tube to connect an artery and a vein. An access may be created on a short-term basis by putting a small tube into a vein in your neck, upper chest, or groin.
• Peritoneal dialysis uses the lining of your belly, which is called the peritoneal membrane, to filter your blood. Before you can begin peritoneal dialysis, your doctor will need to place a catheter in your belly to be the dialysis access.

For more information about dialysis, see:

Which type of dialysis should I have?

Kidney transplant is often a better treatment option for kidney failure because it may allow you to live a fairly normal life. But there are some drawbacks:

• If no one you know can donate a kidney, the wait for a transplant may be long. You will probably need to have dialysis while you wait for a kidney.
• It may be difficult to find a good match for your blood and tissue types. Sometimes, even when the match is good, the body rejects the new kidney.
• You will have to take medicine to suppress your immune system (immunosuppressants) for the rest of your life. These medicines help prevent your body from attacking your new kidney (rejection). Not taking the medicines properly is a common cause of rejection.
• Immunosuppressant medicines work by lowering your body’s disease-fighting ability, so they increase your risk of getting infections or cancer.
• In some cases, kidney transplant is not successful. If this is the case, transplant can be tried again.

For more general information about transplant, see the topic Organ Transplant.

Palliative care

As your disease gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have diseases that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life—not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care may help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term disease, make future plans around your medical care, or help your family better understand your disease and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

Chronic kidney disease progresses to kidney failure when damage to the kidneys is so severe that dialysis or a kidney transplant is needed to control symptoms and prevent complications and death. Many people have successful kidney transplants or live for years using dialysis. But at this point you may wish to talk with your family and doctor about health care and other legal issues that arise near the end of life.

A time may come when your goals or the goals of your loved ones may change from treating or curing your disease to maintaining comfort and dignity. You may find it helpful and comforting to state your health care choices in writing (with an advance directive such as a living will) while you are still able to make and communicate these decisions. Think about your treatment options and which kind of treatment will be best for you. You may wish to choose a health care agent, usually a family member or loved one, to make and carry out decisions about your care if you become unable to speak for yourself. You also have the option to refuse or stop treatment. For more information, see the topic Care at the End of Life.

What To Think About

If you have severe chronic kidney disease but have not yet developed kidney failure, discuss with your doctor which type of dialysis is best for you. The type of dialysis you have may sometimes depend on how quickly you need to begin dialysis.

Learning about dialysis (predialysis education) is an important step in preparing for dialysis. Most dialysis clinics offer predialysis services to help you better understand your choices.

Dialysis can be expensive. But Medicare or insurance may cover most or all of the costs. The dialysis center or hospital can help you find the best way to pay for your treatment.

Making treatment decisions when you are very ill is difficult. It is normal to be fearful and worried about the risks involved. Discuss your concerns with your family and your doctor. It may be helpful to visit the dialysis center or transplant center and talk to others who have chosen these options.

Chronic kidney disease may sometimes be prevented by controlling the other diseases or factors that can contribute to kidney disease. Since chronic kidney disease is often caused by high blood pressure and diabetes, keeping your blood pressure and blood sugar levels near normal can help prevent damage to your kidneys.

The sooner you change factors that damage your kidneys, the better. Controlling the following factors may slow the progression of kidney damage in a person who has chronic kidney disease. People who have already developed kidney failure also need to focus on these things to prevent the complications of kidney failure.

• Keep your blood pressure below 130/80. Learn to check your blood pressure at home. For more information, see:

  Home blood pressure monitoring.

• If you have diabetes, keep your blood sugar as close to normal as possible. Your doctor will want you to check your blood sugar several times each day. For more information, see:

  Home blood sugar monitoring.

• Maintain a healthy weight. This can help you prevent other diseases, such as diabetes, high blood pressure, and heart disease. For more information, see the topic High Blood Pressure (Hypertension).
• Maintain healthy levels of fats (lipids), such as cholesterol and triglycerides. For more information, see the topic High Cholesterol.
• Do not smoke or use other tobacco products. Smoking can lead to atherosclerosis, which reduces blood flow to the kidneys and increases blood pressure. For more information on how to quit, see the topic Quitting Tobacco Use.

If you already have chronic kidney disease, make sure that you:

• Avoid dehydration by promptly treating illnesses, such as diarrhea, vomiting, or fever, that cause it. Be especially careful when you exercise or during hot weather. For more information, see the topic Dehydration.
• Reduce your risk of heart disease. Lifestyle changes such as eating a low-fat diet, quitting smoking, and exercising regularly can help reduce your overall risk of developing heart disease and stroke. For more information, see the topic Coronary Artery Disease.
• Treat other problems, such as kidney stones, an enlarged prostate, or bladder problems, that may block the normal flow of urine out of the kidneys.
• Avoid the use of medications that can harm the kidneys. Be sure that your doctor knows about all prescription, nonprescription, and herbal medicines you are taking.
• Avoid X-ray tests that require IV dye (contrast material), such as angiogram, intravenous pyelogram (IVP), and some CT scans. IV dye can cause further kidney damage.
• Avoid situations where you risk losing large amounts of blood, such as unnecessary surgeries.

There are many things you can do at home to slow the progression of chronic kidney disease.

Lifestyle changes

• Keep your blood pressure below 130/80. Learn to check your blood pressure at home. For more information, see:

  Monitoring your blood pressure at home.

• If you have diabetes, keep your blood sugar as close to normal as possible. For more information, see:

  Home blood sugar monitoring.

• Maintain a healthy weight. This can also reduce your risk for coronary artery disease, diabetes, high blood pressure, and stroke. For more information, see the topic Healthy Weight.
• Follow an eating plan for kidney disease. Talk with a dietitian to determine how much protein you need each day. Studies have shown that a low-protein diet can help lower the risk of kidney damage. For more information, see:

  Eating plan for chronic kidney disease.

• Get some exercise every day. Work with your doctor to design an exercise program that is right for you. Exercise may lower your risk for diabetes and high blood pressure, which can lead to kidney disease.

What to avoid

• Avoid taking medications that can harm your kidneys. Be sure that your doctor knows about all prescription, over-the-counter, and herbal medicines you are taking.
• Avoid dehydration by promptly treating illnesses, such as diarrhea, vomiting, or fever, that cause it. Be especially careful when you exercise or during hot weather. For more information, see the topic Dehydration.
• Do not smoke or use other tobacco products. Smoking can lead to atherosclerosis, which reduces blood flow to the kidneys and increases blood pressure. For more information on how to quit, see the topic Quitting Tobacco Use.
• Do not drink alcohol or use illegal drugs.

Although medicine cannot reverse chronic kidney disease, it is often used to help treat symptoms and complications and to slow further kidney damage.

Medication Choices

Medicines to treat high blood pressure

From 80% to 90% of people with chronic kidney disease have problems with high blood pressure at some time during their disease. Medicines to lower blood pressure (antihypertensives) are used to keep blood pressure in a safe range and slow the progression of kidney damage that is caused by high blood pressure. The target is to keep your blood pressure below 130/80. The type of blood pressure medicine used is thought to be less important than how well the medicine lowers blood pressure.

Common blood pressure medicines include:^{3, 4}

• Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors decrease blood pressure by opening (dilating) blood vessels. ACE inhibitors slow damage to the kidneys caused by diabetes and other kidney diseases.
• Angiotensin II receptor blockers. These medicines block the action of a hormone that causes blood vessels to narrow. As a result, blood vessels relax and open, reducing blood pressure. Angiotensin II receptor antagonists reduce blood pressure as effectively as ACE inhibitors but without some of the side effects, such as a cough.
• Calcium channel blockers. Calcium channel blockers dilate blood vessels by relaxing the muscles in the vessel walls. This makes it easier for blood to flow through the vessels and helps lower blood pressure.
• Diuretics. Diuretics help remove extra sodium and fluid from the body, decreasing the volume of circulating blood and lowering blood pressure.
• Beta-blockers. Beta-blockers decrease blood pressure by decreasing heart rate and cardiac output. They also relax blood vessels.
• Direct renin inhibitors block the enzyme renin from starting a process that helps regulate blood pressure. As a result, blood vessels relax and widen, making it easier for blood to flow through the vessels, which lowers blood pressure.

You may need to try several blood pressure medicines before you find the medicine that controls your blood pressure well without bothersome side effects. Most people need to take a combination of medicines to get the best results.

Medicines to treat complications of chronic kidney disease

Other medicines may be used to treat complications of chronic kidney disease, such as:

• Erythropoietin (rhEPO) therapy and iron replacement therapy for anemia. Anemia occurs during chronic kidney disease, because as kidney function declines, the kidneys produce too little erythropoietin, which is needed to make new red blood cells.
• Medicines for electrolyte imbalances. Specific medications are sometimes needed to treat imbalances of electrolytes, such as high potassium, high phosphate, and low calcium levels.
• Diuretics to treat fluid buildup caused by chronic kidney disease.
• ACE inhibitors for heart failure. Regular blood tests are required to make sure that these medicines do not raise potassium levels (hyperkalemia) or make kidney function worse. For more information, see the topic Heart Failure.

Medicines used during dialysis

Both erythropoietin (rhEPO) therapy and iron replacement therapy may also be used during dialysis to treat anemia, which often develops in advanced chronic kidney disease.

• Erythropoietin (rhEPO) stimulates the production of new red blood cells and may decrease the need for blood transfusions. This therapy may also be started before dialysis is needed when anemia is severe and causing symptoms.⁵
• Iron therapy can help increase levels of iron in the body when rhEPO therapy alone is not effective.

What To Think About

Talk with your doctor about what types of immunizations you should have if you have chronic kidney disease. Also, be sure to discuss medication precautions. Make sure you tell your doctor about all prescription, over-the-counter, and herbal medicines you are currently taking.

Some complications of kidney failure are best treated with dialysis.

If you have chronic kidney disease that progresses, you may have the option of a kidney transplant. Most experts agree that it is the best option for people with kidney failure. In general, people who have kidney transplants live longer than people treated with dialysis.

If you have kidney failure, your doctor may recommend a kidney transplant if you are a good candidate for surgery. You will probably be considered a good candidate if you do not have significant heart or lung disease or other diseases, such as cancer, which might decrease your life span.

After a kidney transplant, you will have to take medicines called immunosuppressants. Immunosuppressants, such as cyclosporine or tacrolimus, help prevent your body from rejecting your new kidney.

• It is very important to take your medicines exactly as prescribed. This will help keep your body from rejecting your new kidney.
• You will need to take these medicines for the rest of your life.
• Because these medicines weaken the function of your immune system, you will have an increased risk of developing serious infections.

Even if you take your medicines, there is a chance that your body will reject your new kidney. If this happens, you will have to resume dialysis or have another kidney transplant.

The success of the transplant also depends on what kind of donor kidney you are receiving. The closer the donor kidney matches your genetic makeup, the better the chances that your body will not reject it.

What to think about

A kidney transplant does not guarantee that you will live longer than you would have without a new kidney.

Kidney transplant surgery is expensive but has been covered by Medicare since the 1970s.

You may have to wait for a kidney to be donated. If so, you will need to have dialysis while you wait.

Dialysis is a mechanical process that performs the work that healthy kidneys would do. It clears wastes and extra fluid from the body and restores the proper balance of chemicals (electrolytes) in the blood. When chronic kidney disease becomes so severe that your kidneys are no longer working properly, you may need dialysis. You may use dialysis to replace the work of the kidneys for many years, or it may be a short-term measure while you are waiting for a kidney transplant.

Before starting dialysis, you will have to arrange with your doctor to have a dialysis access placed in your body to transfer blood or body fluids between your body and the machine. The type of access that you have depends on which type of dialysis you choose.

The two types of dialysis used to treat severe chronic kidney disease are hemodialysis and peritoneal dialysis .

• Hemodialysis uses a man-made membrane called a dialyzer to clean your blood. You are connected to the dialyzer by tubes attached to your blood vessels. Before hemodialysis treatments can begin, your doctor creates a site where blood can flow in and out of your body. This is called the dialysis access. Usually the doctor creates the access by joining an artery and a vein in the forearm or by using a small tube to connect an artery and a vein. An access may be created on a short-term basis by putting a small tube into a vein in your neck, upper chest, or groin.
• Peritoneal dialysis uses the lining of your belly, which is called the peritoneal membrane, to filter your blood. Before you can begin peritoneal dialysis, your doctor will need to place a catheter in your belly to be the dialysis access.

For more information about dialysis, see:

Which type of dialysis should I have?

What to think about

If you have severe chronic kidney disease but have not yet developed kidney failure, talk to your doctor about which type of dialysis would be best for you. Before starting dialysis, you will have to arrange with your doctor to have a dialysis access placed in your body.

Both types of dialysis can be expensive. But Medicare or insurance may cover most of the costs. The dialysis center or hospital can help you find the best way to pay for your treatment.

Organizations

• Acute Renal Failure
• Care at the End of Life
• Coronary Artery Disease
• Dehydration
• Diabetic Nephropathy
• Fitness
• High Blood Pressure (Hypertension)
• High Cholesterol
• Quitting Tobacco Use
• Type 1 Diabetes: Living With the Disease
• Type 2 Diabetes: Living With the Disease

Citations

1. Mackenzie H, Brenner BM (1998). Current strategies for retarding progression of renal disease. American Journal of Kidney Diseases, 31(1): 161–170.

2. Levey AS, et al. (2003). National Kidney Foundation practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Annals of Internal Medicine, 139(2): 137–147.

3. Stigant C, et al. (2003). Nephrology: 4. Strategies for the care of adults with chronic kidney disease. Canadian Medical Association Journal, 168(12): 1553–1560.

4. Toto RD (2004). Approach to the patient with kidney disease. In BM Brenner, ed., Brenner and Rector's The Kidney, 7th ed., vol. 1, pp. 1079–1106. Philadelphia: Saunders.

5. Remuzzi G, Minetti L (2000). Hematologic consequences of renal failure. In BM Brenner et al., eds., Brenner and Rector's The Kidney, 6th ed., vol. 2, pp. 2079–2094. Philadelphia: W.B. Saunders.

Other Works Consulted

• Burkart JM, et al. (2004). Peritoneal dialysis. In BM Brenner, ed., Brenner and Rector's The Kidney, 7th ed., pp. 2625–2695. Philadelphia: Saunders.

• Cohen DP (2004). Chronic renal failure and dialysis. In DC Dale, DD Federman, eds., ACP Medicine, section 10, chap. 10. New York: WebMD.

• Fouque D, et al. (2005). Low-protein diets for chronic renal failure in nondiabetic adults. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

• Gaston RS, et al. (2004). Transplantation in the diabetic patient with advanced chronic kidney disease: A task force report. American Journal of Kidney Diseases, 44(3): 529–542.

• Keith DS, et al. (2004). Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Archives of Internal Medicine, 164(6): 659–663.

• Klahr S, et al. (1994). The effects of dietary protein restriction and blood pressure control on the progression of chronic renal disease. New England Journal of Medicine, 330(13): 877–884.

• Magee CC, Pascual M (2004). Update in renal transplantation. Archives of Internal Medicine, 164(13): 1373–1388.

• Mitch WE, Walser M (2004). Nutritional therapy in renal disease. In BM Brenner, ed., Brenner and Rector's The Kidney, 7th ed., vol. 2, pp. 2491–2538. Philadelphia: Saunders.

• Remuzzi G, et al. (2004). Hematologic consequences of renal failure. In BM Brenner, ed., Brenner and Rector's The Kidney, 7th ed., vol. 2, pp. 2165–2188. Philadelphia: Saunders.

• Sarnak MJ, et al. (2005). The effect of lower target blood pressure on the progression of kidney disease: Long-term follow-up on the Modification of Diet in Renal Disease study. Annals of Internal Medicine, 142(5): 342–351.

• Schulman G, Himmelfarb J (2004). Hemodialysis. In BM Brenner, ed., Brenner and Rector's The Kidney, 7th ed., pp. 2563–2624. Philadelphia: Saunders.

• Shlipak MG, et al. (2005). Cardiovascular mortality risk in chronic kidney disease: Comparison of traditional and novel risk factors. JAMA, 293(14): 1737–1745.