Living with
Chronic Kidney Disease

What is chronic kidney disease?

Having chronic kidney disease (CKD), or chronic renal disease, means that your kidneys are damaged and cannot filter your blood properly like they should be able to.

Your kidneys are a pair of fist-sized organs located in your lower back region, on either side of your spine.
Your kidneys are responsible for balancing water and mineral levels in your body. They do this by filtering waste products and excess fluids from your blood into urine for excretion. Therefore, damage to your kidneys can lead to fluid and harmful waste products building up in your body.

CKD is usually a gradual process that worsens over time. It can lead to kidney failure when you may require dialysis or a kidney transplant.
To avoid these complications, manage the most common causes of CKD, diabetes and hypertension.

How do you know you have chronic kidney disease?

Kidney damage usually occurs gradually, with most signs and symptoms developing and progressing slowly over many years.

However, many people will only start displaying symptoms when chronic kidney disease reaches an advanced stage and waste products and fluid accumulate to dangerous levels in the body. Additionally, signs and symptoms of CKD are usually nonspecific, in other words, they occur in other common conditions as well.

Blood and urine tests are the only way to know if you have kidney disease and should be done routinely if you have diabetes or hypertension.

Signs and symptoms of kidney disease may include:

• Nausea and vomiting
• Loss of appetite
• Lethargy (tiredness), fatigue and weakness
• Urinating less or more often than you usually do
• Cloudy or foamy urine
• Confusion or a decrease in how sharp you feel mentally
• Muscle cramps or spasms
• Swelling (oedema), particularly in the ankles or feet (this may also show as puffiness around the eyes as well)
• Dry and persistently itchy skin
• Shortness of breath
• Difficulties with sleeping
• Unexplained weight loss.

What tests can be done to measure kidney function?

As you may not have any symptoms in the early stages of chronic kidney disease, testing may be the only way to know that your kidneys are not functioning as they should be.

Patients living with diabetes and people with high blood pressure should have one or more of the following tests done regularly to assess their kidney function:

• Urinalysis: A urine sample may be checked for the presence of protein and blood which are signs of impaired kidney function.
  However, there are many non-disease related causes of proteins in the urine, including infection and recent heavy physical activity. Therefore, your doctor may want to repeat this test after a few weeks to see if there is protein in your urine consistently.
  One protein your doctor will test for to check the function of your kidneys is albumin; levels of greater than 3 mg/mmol albumin in the urine may indicate poor kidney function.
  Your doctor may also ask you to provide a 24-hour urine collection sample. Your doctor will give you instructions to follow but the process is relatively simple. On the day that you start the test, urinate into the toilet as you normally would when you wake up, then for the rest of the day and night, urinate into the special container provided by your doctor. Keep the container capped and refrigerated during the collection period. To complete sample collection on the morning of the second day, urinate into the container when you get up. Follow your doctor’s instructions about where to drop the sample off.
• Serum creatinine test: This is a blood test that can check whether the protein, creatinine, is building up in your blood. The kidneys usually completely filter creatinine from the blood; therefore, a high level of creatinine suggests a kidney problem.
  A serum creatinine level higher than 0.09 mmol/l for women and 0.11 mmol/L for men is a sign of possible kidney disease.
• Blood urea nitrogen (BUN): The is a test to check for waste products in your blood; specifically, it measures the amount of nitrogen in the blood. Nitrogen is a product of the breakdown of the waste product urea, which is excreted through the kidneys in the urine.
  However, raised BUN levels do not always indicate kidney disease. Common medications, including large doses of aspirin and some types of antibiotics, can also increase your BUN. Therefore, it is important to tell your doctor about any medications or supplements that you may take that could increase your BUN levels.
  A normal BUN level is between 2.5-7.1 mmol/l.
• Estimated GFR: This test is the most accurate estimate of how well your kidneys are filtering waste products out of your blood and into the urine. The test determines this rate by looking at test results, specifically creatinine levels, compared to your age, gender and BMI (Body Mass Index, as determined by your weight and height).
  Any result lower than 60 ml/min/1.73m2 may be a warning sign of kidney disease. However, an abnormal GFR result is not always a sign of kidney disease but can occur if you are underweight or anorexic or if you are particularly muscular or pregnant. GFR may also not a very reliable measure of kidney function in very young people, less than 18 years old.

What causes chronic kidney disease?

The South African Medical Journal estimates that 10 % of people worldwide suffer from some degree of CKD, meaning that it is likely some 5 million South Africans over 20 years old may be affected by CKD.

Chronic kidney disease occurs when a disease process damages your kidneys, impairing one or both or their function. The damage worsens over several months or years.

Diseases and conditions that can cause kidney damage that can lead to CKD include:

• Uncontrolled diabetes: Diabetic kidney disease, or diabetic nephropathy, is the most common cause of CKD, along with hypertension. About 25 % people with diabetes will develop CKD.
  Uncontrolled diabetes (continuously high blood glucose levels) causes damage to the cluster of blood vessels that make up the glomeruli, or filtering units of the kidney. The damage worsens over time, until the kidneys can no longer filter blood properly.
• Uncontrolled hypertension: Continuous high blood pressure levels cause the arteries supplying blood to the kidneys to eventually weaken, narrow and harden, impairing blood flow to the kidneys.
• Chronic inflammation of the filtering units (glomeruli) in the kidney (glomerulonephritis) or of the tubules or surrounding structures (interstitial nephritis): Common causes of these conditions include: autoimmune diseases like systemic lupus erythematous, certain cancers such as myeloma or leukaemia, and exposure to certain toxins in drugs (lithium and cyclosporin, for example) and heavy metals (like lead).
• Polycystic kidney disease: This is an inherited condition where cysts develop on the kidneys, causing them to become enlarged and damaged until they cannot function anymore.
• Prolonged obstruction of the urinary tract: This is usually caused by an enlarged prostate in men or kidney stones more generally. These masses can block the flow of urine out of the urinary system (which starts at the kidneys) and as a result, pressure builds up in the kidneys, eventually damaging the glomeruli.
• Vesicoureteral reflux: This is a condition that is usually diagnosed in infants or children who are born with the disorder where urine is allowed to flow back into the kidneys from the ureters that lead to the bladder. This predisposes the kidney to infection, and if left untreated, can cause CKD. Sometimes children grow out of the condition, while other times they may require medication or surgery to prevent CKD.
• Recurrent kidney infection (pyelonephritis): This is caused by a lower urinary tract infection in the urethra (channel for urine out of the body) or higher up in the bladder. The infection then spreads up the ureters from the bladder to one or both of the kidneys.

These factors also increase your risk of CKD:

• Coronary artery disease
• Smoking
• Obesity
• Having a close family history of kidney disease
• Older age.

Living and managing

Knowing your risk factors and reducing them can significantly reduce your chance of developing CKD and stop kidney damage from worsening.

By working closely with your doctor, you can reduce your risk of CKD by focusing on the following healthy lifestyle measures:

1. Manage your diabetes
   Eating a healthy low-fat and low-sugar diet, exercising regularly and maintaining a healthy weight will all help you successfully manage your blood sugar levels.
   If your blood sugar levels are still above normal, even with a healthy diet and exercise, then speak to your doctor as you may need to take medication to manage your blood sugar levels.
2. Manage your blood pressure
   Keep your blood pressure within normal levels. Click here to read more about how to better manage your blood pressure. This includes limiting the salt intake in your diet.
3. Eat a healthy diet low in salt and potassium
   Click here to read about a healthy low-salt diet.
   You can also access your own Cooking from the Heart Low Salt booklet, containing listed salt contents of South Africa’s most popular foods and nutrition brands. You’ll never be tricked again and might save yourself a headache trying to understand complicated, and often misleading, food labels. Download it now for healthier cooking, shopping and snacking!
   Potassium can build up in the body and cause heart problems as the kidneys may not be able to filter it out of the blood if they are damaged. If you have CKD, it best you try to limit your intake in foods high in potassium. Potassium is found in high amounts in certain fruits and vegetables, as well as dairy and meats. Potassium-rich foods include: melons (such as cantaloupe, although not watermelon), bananas, orange and orange juice, tomatoes, prunes, dried beans (all kinds), pumpkins, winter squash and cooked green leafy vegetables like spinach and kale. Bran cereals, molasses, potatoes and sweet potatoes should also only be eaten in small amounts if you suffer from CKD.
4. Exercise regularly and try to maintain a healthy weight
   Try to keep as active as possible. You don’t have to join a gym do this; instead, just take regular walks, ride a bike or dance along to the music on your radio.
   Your goal should be 30 minutes of moderate activity (makes you sweat and your heart beat a little faster) most days of the week.
   Regular physical activity helps you manage your blood pressure and glucose levels and helps you lose weight.
5. Manage stress
   When you’re stressed, your heart rate and blood pressure go up – this is not good for your heart or blood vessels, and, as a result, is not good for your kidneys either. You may also not manage your blood pressure or other chronic conditions and forget to exercise, eat right or take your medicines when you are anxious.
   Therefore, find ways to relieve stress like practising mindfulness, yoga or deep breathing.
6. Stop smoking
   Talk to your doctor about ways to quit smoking, as tobacco smoke significantly increases your risk of cardiovascular disease and kidney disease.
7. Limit your alcohol consumption
   You will need to speak to your doctor or healthcare provider about what amount of alcohol is appropriate for you to consume. Generally, to stay healthy, it is recommended that women not exceed one glass of alcohol per day, while men should have no more than two glasses per day.

What treatment can be used for the complications of CKD?

• Diuretics, like amlodipine, can be used to treat and reduce the symptoms of fluid retention. These medications can also be used to reduce your blood pressure levels if they are high; other medications like ACE inhibitors may also be prescribed if you have high blood pressure.
• Limit dietary potassium intake: You may be prescribed medications called phosphate binders to reduce the amount of phosphate in your blood.
• Anaemia may be treated with medications that stimulate red blood cell production (erythropoiesis).
• Calcium supplements may be necessary to maintain bone health; alternatively, the hormone, calcitonin, may be prescribed to you.
• Children with kidney disease may be treated with growth hormone to reduce growth restriction.
• If kidney failure occurs, you will probably need dialysis to filter your blood for you: There are two types of dialysis haemodialysis or peritoneal dialysis.
  Haemodialysis, which uses a machine to filter your blood, is also sometimes called an ‘artificial kidney’; for this type of dialysis you will usually have to go to a special clinic for treatments several times a week.
  Peritoneal dialysis, on the other hand, uses the lining of your abdomen, called the peritoneal membrane, to filter your blood.
• In some cases of kidney failure, you may need a kidney transplant: This will require an operation to transplant a healthy, donor kidney into your body to replace one or both of your kidneys that are not working. The donor kidney may come from a donor that has died and donated their kidney(s) or otherwise, commonly from a living family member.

What are the complications associated with CKD?

When CKD progresses to a point where dangerous levels of fluid and waste products accumulate in the body, you may experience one or more of the following complications:

• Pulmonary oedema (fluid in the lungs) which can lead to pulmonary hypertension.
• Too much potassium in the blood (hyperkaliemia) which can cause life-threatening arrhythmias.
• Anaemia, or too few red blood cells or too little oxygen-carrying haemoglobin, that can cause fatigue, arrhythmias and heart failure.
• Too little calcium (hypocalcaemia) in the blood which can lead to weak bones and an increased risk of falls and fractures.
• Increase in blood pressure levels and other heart disease.
• A weakened immune system which could increase your risk of suffering common infections like colds and the flu.
• Gout.
• Metabolic acidosis which can cause confusion, seizures or coma.
• Stunted growth in children.
• Kidney failure.

What is kidney failure?

Kidney failure, also called end-stage renal disease, is the last stage of chronic kidney disease and it means your kidneys no longer work well enough for you to survive without dialysis to filter your blood or a kidney transplant to replace the non-functioning kidney(s).

However, there are some causes of acute kidney failure when the kidneys may stop working all of a sudden; such causes include a lack of blood supply to the kidneys from suffering a heart attack or dehydration, as well as blood clots in the renal artery or some acute infections and sepsis.

All of the symptoms of CKD can occur with kidney failure, but tend to be more severe or pronounced, including significant oedema (swelling) and reduction in urine output or not urinating at all (oliguria), sharp chest pain from pulmonary hypertension, as well as extreme drowsiness, confusion, seizures or coma.
If you have any of these symptoms, especially if you suffer from chronic kidney disease, contact your doctor or healthcare provider immediately.