Chronic kidney disease

Medicine > Renal

Differential Diagnosis Schema 🧠

Glomerular Diseases

Diabetic nephropathy: Persistent albuminuria, history of diabetes mellitus, retinal changes consistent with diabetic retinopathy
IgA nephropathy: Recurrent episodes of hematuria, often following upper respiratory tract infections, common in young adults
Membranous nephropathy: Associated with nephrotic syndrome, thickened glomerular basement membrane on biopsy, may be secondary to malignancy or autoimmune conditions
Post-infectious glomerulonephritis: Recent streptococcal infection, nephritic syndrome (hematuria, hypertension, oliguria), low complement levels

Vascular Diseases

Hypertensive nephrosclerosis: Long-standing hypertension, gradually declining renal function, small kidneys on ultrasound
Renal artery stenosis: Uncontrolled hypertension, flash pulmonary edema, abdominal bruit, asymmetry in kidney sizes
Thrombotic microangiopathy: Acute kidney injury, hemolytic anemia, thrombocytopenia, may be seen in conditions like hemolytic uremic syndrome or thrombotic thrombocytopenic purpura

Tubulointerstitial Diseases

Chronic interstitial nephritis: Often due to prolonged use of NSAIDs, analgesics, or exposure to heavy metals, characterized by bland urine sediment and small, shrunken kidneys
Polycystic kidney disease: Autosomal dominant, multiple renal cysts, associated with liver cysts and intracranial aneurysms
Reflux nephropathy: History of vesicoureteral reflux, recurrent urinary tract infections, renal scarring on imaging

Obstructive Uropathy

Prostatic hypertrophy: Common in older men, nocturia, hesitancy, incomplete bladder emptying, bladder wall thickening on ultrasound
Kidney stones: Flank pain, hematuria, possible hydronephrosis on imaging
Pelvic malignancy: May cause extrinsic compression of the urinary tract, unexplained weight loss, hematuria, abdominal/pelvic mass

Key Points in History 🥼

Symptoms of CKD

Fatigue: Common and non-specific, related to anemia or uremia
Edema: Periorbital in the morning, peripheral later in the day, suggests nephrotic syndrome or severe CKD
Dyspnea: May indicate fluid overload or heart failure secondary to CKD
Nocturia: Early sign of CKD due to loss of renal concentrating ability
Pruritus: Common in advanced CKD, often due to uremia
Confusion or lethargy: May suggest severe uremia

Background

Past medical history: Diabetes, hypertension, recurrent urinary tract infections, autoimmune diseases such as lupus, or a history of renal stones or nephritis are significant
Drug history: Prolonged NSAID use, ACE inhibitors, or nephrotoxic drugs (e.g., aminoglycosides) may contribute to CKD
Family history: Polycystic kidney disease and other hereditary nephropathies
Social history: Smoking, alcohol use, occupational exposure to nephrotoxins, and diet (high protein intake)
Surgical history: History of urinary tract surgeries or catheterization

Possible Investigations 🌡️

Blood Tests

Serum creatinine and eGFR: Primary tests for assessing kidney function, with eGFR used to stage CKD
Electrolytes: Hyperkalemia, hypocalcemia, and hyperphosphatemia are common in advanced CKD
Hemoglobin: Anemia of chronic disease is common due to reduced erythropoietin production
Parathyroid hormone (PTH): Often elevated in CKD due to secondary hyperparathyroidism
Urine albumin-to-creatinine ratio (ACR): Detects albuminuria, an early marker of kidney damage

Imaging

Renal ultrasound: First-line imaging, useful for assessing kidney size and echogenicity, detecting cysts, stones, or obstructions
CT/MRI: May be needed if renal ultrasound is inconclusive or if malignancy or renal artery stenosis is suspected
Doppler ultrasound: Used to assess renal blood flow in suspected renal artery stenosis
Nuclear medicine scans: Assess function in individual kidneys, particularly in cases of obstructive uropathy or renal artery stenosis

Urinalysis

Dipstick analysis: Detects proteinuria, hematuria, and glucose; presence of nitrites and leukocytes suggests infection
Microscopy: Identifies casts (e.g., red cell casts in glomerulonephritis, white cell casts in interstitial nephritis)
24-hour urine collection: Measures total protein excretion, helps quantify degree of proteinuria

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