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Lahore College for Women University

Department: Home Economics

Class: BS-IV
Semester: VII
Session: 2017-2021
Instructor: Miss Ayesha Nawaz
Submission Date:
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Group Members

• Amna Khan 1725121003

• Aneeqa Saleem 1725121004
• Aniqa Anwer 1725121006
• Raima Aziz 1725121046
• Rija Sehar 1725121048
• Sumayya Tariq 1725121062
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TABLE OF CONTENT

1. INTRODUCTION

1.1. Minor kidney disease

1.2. Major kidney diseases

1.3. Nutritional status of body in CKD

1.4. Hormonal imbalance in CKD

1.5. Metabolic dysfunction in CKD

1.6. Altered bowel flora in CKD

1.7. Anorexia

2. LITERATURE REVIEW
3. SCREENING

3.1. Evaluation of Nutrition

3.2. Monitoring of nutrition

4. METHODOLOGY

4.1. Urinary proteomics using capillary electrophoresis

4.2. Lifestyle modification

4.3. Water retention

4.4. Dialysis

4.5. Kidney Transplant

5. STATISTICAL DATA

5.1. Change in diet of Renal Patient

5.2. Modification in diet of Renal Patient

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6. Epidemiology

6.1. Epidemiology of CKD in Pakistani population

7. CASE STUDIES
7.1.Case presentation & patient assessment
7.2.Diagnosis
7.3.Treatment
7.4.Discussion
7.5. Conclusion
8. REFRENCE
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INTRODUCTION
The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on
the left and right in the retroperitoneal space, and in adult humans are about 12cm (4 1⁄2 inches) in
length. Each kidney is attached to a ureter, a tube that carries excreted urine to the bladder.
The nephron is the structural and functional unit of the kidney. Each human adult kidney contains
around 1 million nephrons.

Renal diseases mean your kidneys are damaged and can't filter blood the way they should. Most
kidney diseases attack the nephrons, causing them to lose their filtering capacity. Damage to the
nephrons may happen quickly, often as the result of injury or poisoning. But most kidney diseases
destroy the nephrons slowly and silently.

MINOR KIDNEY DISEASES

Diabetic Nephropathy

Damage to the nephrons from unused glucose in the blood is called diabetic nephropathy. If you
keep your blood glucose levels down, you can delay or prevent diabetic nephropathy.

Glomerular Diseases

The most common primary glomerular diseases include membranous nephropathy, IgA
nephropathy and focal segmental glomerulosclerosis.

NEPHRITIS

Nephrotic syndrome is a kidney disorder where the body releases too much protein into the urine.

Inherited and Congenital Kidney Diseases

Some kidney diseases result from hereditary factors like:-

• Congenital obstruction of urinary tract

• Duplicated ureter occurs in approximately one in 100 live births

• Horseshoe kidney occurs in approximately one in 400 live births

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• Nephroblastoma (Syndromic Wilm's tumour)

• Renal dysplasia

• Unilateral small kidney

Polycystic kidney disease

Polycystic kidney disease (PKD) is a genetic disorder in which many cysts grow in the kidneys.
PKD cysts can slowly replace much of the mass of the kidneys, reducing kidney function and
leading to kidney failure.

MAJOR KIDNEY DISEASES

Chronic kidney disease describes the gradual loss of kidney function. Your kidneys filter wastes
and excess fluids from your blood, which are then excreted in your urine. When chronic kidney
disease reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can build up
in your body.

It may include several diseases like:-

• Glomerulonephritis
• End stage renal disease (ESRD)
• Polycystic kidney disease
• Peritoneal dialysis (Continuous ambulatory peritoneal dialysis, Continuous celiac
peritoneal dialysis, Intermittent peritoneal dialysis)
• Hemodialysis
• Tubular necrosis.
Chronic kidney disease can progress to end-stage kidney failure, which is fatal without artificial
filtering (dialysis) or a kidney transplant.
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NUTRITIONAL STATUS OF BODY

Nutritional status disorders (NSD) are considered now as one of the prognostic risk factors not
only for dialysis but also for pre-dialysis CKD stages. Since the publication of KDIGO 2012
guidelines for CKD patient’s management, there has been some significant advancement in our
understanding of main NSD mechanisms in CKD.

MICRONUTRIENT DEFICIENCY IN CHRONIC KIDNEY DISEASE

Chronic kidney disease predisposes patients to vitamin and mineral deficiencies, which may
contribute to comorbidities such as anemia, cardiovascular disease, and metabolic imbalances. The
overall decrease in nutritional intake, dietary restrictions, poor intestinal absorption, inflammatory
state, metabolic acidosis, and dialysate losses all put the CKD patient at risk for micronutrient
deficiencies. Studies in CKD patients including dialysis and non-dialysis patient shows decrease
in the intake of micronutrients such as vitamins, folate, iron, and pantothenic acid. Losses of zinc,
selenium, folic acid, pyridoxine and ascorbic acid during hemodialysis are well documented.

Excessive loss of micronutrients may occur in all stages of CKD. In earlier stages of the disease,
micronutrients are lost with urine due to the use of diuretics and insufficient reabsorption by
specific transporters. In end-stage-renal-disease (ESRD), vitamins or trace elements tend to be
removed by dialysis, as those low-molecular-weight substances are not routinely present in
Hemodialysis (HD) and Peritoneal dialysis (PD) dialysis fluids. On the other hand, even their
minute concentrations in dialysis fluid, sourced from water, could lead to increased blood levels,
and to accumulation in a patient’s body.

HORMONAL IMBALANCE AND APPRTITE REGULATION IN

CHRONIC KIDNEY DISEASE

The kidneys play a major role in the synthesis and regulation of a wide variety of hormones in the
body. As kidney function declines, hormonal imbalance becomes a characteristic feature and this
has been implicated in the suppression of appetite, muscle wasting and growth impairment in
CKD. Insulin resistance occurs early in CKD. Insulin resistance in these patients leads to increased
protein catabolism and muscle wasting. Additionally, insulin resistance has been implicated in the
progressive deterioration of kidney function in CKD.
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METABOLIC DYSFUNCTIONING IN CHRONIC KIDNEY DISEASE

The metabolic system in CKD is significantly altered due to the progressive accumulation of
metabolic by-products that are naturally cleared by the kidneys. Metabolic derangements such as
metabolic acidosis, hyperparathyroidism, insulin resistance, up regulation of the renin angiotensin
aldosterone system and dyslipidemia are common in CKD. Metabolic acidosis occurs early in
CKD because of reduced excretion of the acid load generated by metabolic activity. Multiple
studies have shown an association between metabolic acidosis and increased protein catabolism in
patients with CKD. Proteolysis induced by an up regulation of the ubiquitin-proteasome system,
also facilitates the degradation of whole-body protein. Metabolic acidosis, chronic inflammation,
insulin resistance and increased angiotensin II levels, all of which are seen in CKD, also stimulate
the ubiquitin-proteasome system of enzymes.

ALTERD BOWEL FLORA IN CHRONIC KIDNEY DISEASE

The intestinal microbial flora is significantly altered in patients with CKD and this has been
thought to play a pathogenic role in the chronic inflammatory state seen in CKD. These changes
lead to the generation and systemic accumulation of pro-inflammatory uremic toxins including
sulfate, amines, and ammonia. Moreover, disruption of the intestinal epithelial barrier in patients
with CKD facilitates the systemic absorption of these toxins. These uremic toxins induce
inflammation, endothelial injury, cardiovascular disease and protein energy wasting.
ANOREXIA

Anorexia is common in CKD patient, which worsens with deterioration of kidney function.
Anorexia leads to decreased nutritional intake, which predisposes to protein energy wasting and
micronutrient deficiency in patients with CKD. Decreased protein and energy intake due to
anorexia, increased protein catabolism, decreased anabolism, chronic inflammation, metabolic
acidosis and hormonal imbalances The mechanism of appetite suppression in these patients is
attributed to complex dysregulation of neuroendocrine pathways involving orexigenic (appetite
stimulating) and anorexigenic (appetite inhibiting) substances. Ghrelin is an appetite-stimulating
hormone secreted by the stomach. Its role in anorexia in CKD has been extensively investigated.
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It is typically released in response to fasting and has potent appetite stimulatory properties have
all been linked to protein energy wasting.

Other Causes of Kidney Disease

Poisons and trauma, such as a direct and forceful blow to your kidneys, can lead to kidney disease.
Some over-the-counter medicines can be poisonous to your kidneys if taken regularly over a long
period of time.

Risk Factors

• Low caloric intake

• Higher C-reactive protein levels
• The presence of edema
• Lower resistance measured during a bioelectrical impedance analysis
• Lower nitrogen balance
(SUMMIYA TARIQ)
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LITERATURE REVIEW

This study was conducted in 2010 although past research has examined self-management among
patients with end stage renal disease (ESRD), little is known about self-management in patients
with chronic kidney disease (CKD). In this cross-sectional survey, 174 patients with CKD
(serum creatinine ≥1.7 mg/dL) completed self-reported measures of self-efficacy, physical and
mental functioning, and self-management. The purpose of the study was to explore the association
between patients' perceived self-efficacy and their self-management behaviors. Five types of self-
management behaviors were measured: communication with caregivers, partnership in care, self-
care, self-advocacy, and medication adherence. Controlling for other relevant variables including
age, education, diabetic status, hypertension, serum creatinine, physical functioning, and mental
health functioning, higher perceived self-efficacy scores were associated with increased
communication, partnership, self-care, and medication-adherence behaviors.

In this study, patients' perceived self-efficacy was a more consistent correlate of self-management
behavior than were demographic or health characteristics. Because self-management has been
associated with positive patient outcomes, fostering self-management by supporting patient self-
efficacy may have long-term benefits.

CKD was evaluated at community level in few studies. The highest prevalence among Sindh is
(men 9.5%, women 10.3%) and lowest prevalence among Baluch is (men 2.4% and women 4.2%)
and the Pashtuns (men 2.5%, women 1.2%)

The prevalence of CKD was also evaluated in a community-based cross-sectional study

conducted in Karachi in 2014, the largest city of Pakistan. The study was not designed to measure
the prevalence of CKD; rather it was a secondary analysis of the study, which was performed to
promote intervention that can ensure blood pressure control at community level. The data were
collected through a factorial design cluster randomized controlled trial. The prevalence of CKD
and reduced eGFR was higher in women compared to men, and it increased with age. When the
CKD prevalence was standardized with age, it turned out to be 15.3% (13.7%–16.9%) while that
of reduced eGFR and albuminuria, was 7.4% (6.2%–8.6%) and 11.1% (9.8%–12.4%),
respectively. In another study, it is evaluated 262 subjects > 40 years of age, from a Pashtun
community of Karachi, to determine the prevalence of reduced GFR. They found an overall
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prevalence of reduced GFR of 29.9% (24.2% to 35.1%) in men and 32.5% (24.8%–41.3%) in
women.
In chronic kidney disease, nephropathy is typically reported from regions which are warm, located
in low altitude in coastal and tropical and subtropical regions. Characteristically, the disease is
prevalent in rural inhabitants of low socioeconomic status, especially in males working in
agricultural fields. Typically, all regional nephropathies have a histological appearance of chronic
tubulointerstitial nephritis and mostly, the clinical features have similarities, such as late
presentation, a long asymptomatic phase, non-glomerular proteinuria and an absence of HTN at
the beginning of the disease. Chronic tubulointerstitial nephritis is the biopsy finding in most of
the studies mentioned above. In Pakistan, despite massive urbanization, the population in rural
areas is >60% in all four provinces and most of them rely on agriculture as their occupation.

The climate is hot in these areas. In an analysis of kidney biopsy, pathological data of 1200 patients
performed at our center, it was shown that chronic tubulointerstitial nephropathy was found in
11% of the patients. In a further analysis of those who had been diagnosed to have tubulointerstitial
nephropathy (unpublished data), we found that most patients presented with similar clinical
features and were from rural areas. The exact cause of kidney injury, such as water deprivation
due to excessive sweating in warm humid climate, or drinking plenty of contaminated water.

In Pakistan, the status of drinking water contaminated with As and Cd is alarming. Contamination
of drinking water with heavy metals, such as Cadmium (Cd) and Arsenic (As) has been recognized
as nephropathic due to their oxidative stress. In a cross-sectional case–control study of more than
6000 individuals, which included 733 cases and 4044 controls from endemic and non-endemic
areas, found significantly higher urinary excretion of Cd in individuals with CKD compared with
controls in endemic areas. They also found a dose-effect relationship between urinary Cd
concentration and CKD stages.

The Pakistan Council of Research in Water resources evaluated the status of arsenic level regularly
in major cities of Pakistan. Due to persistent and increasing contamination of arsenic, a national
action plan to mitigate the as effect was introduced between 2007 and 2011.
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Cadmium is also a great concern due to its renal and other toxicities. The safe standard for Cd
concentration in drinking water by WHO is 0.0003 mg/L. In Pakistan, high Cd concentration in
drinking water was found from effluent discharges of marbles, steel, mining, metal, planting, and
aluminum industry. High concentration of Cd was found from many samples collected from
different parts of the country. The concentration of Cd in groundwater samples collected from
various sites of Pakistan ranged from 0.001 to 0.2 μg/L.
A research conducted in 2018, this study aimed to systematically review the existing data from
population-based studies in this region to bridge this gap. Chronic kidney disease (CKD) is
becoming a major public health problem around the world. But the prevalence has not been
reported in South Asian region as a whole. Methods Articles published and reported prevalence of
CKD according to K/DOQI practice guideline in eight South Asian countries between December
1955 and April 2017 were searched, screened and evaluated from seven electronic databases using
the PRISMA checklist. CKD was defined as creatinine clearance (CrCl) or GFR less than 60
ml/min/1.73 m².

Results Sixteen population-based studies were found from four South Asian countries (India,
Bangladesh, Pakistan and Nepal) that used eGFR to measure CKD. No study was available from
Sri Lanka, Maldives, Bhutan and Afghanistan. Number of participants ranged from 301 in Pakistan
to 12,271 in India. Majority of the studies focused solely on urban population. Different studies
used different equations for measuring eGFR. The prevalence of CKD ranged from 10.6% in Nepal
to 23.3% in Pakistan using MDRD equation. This prevalence was higher among older age group
people. Equal number of studies reported high prevalence among male and female each. This
systematic review reported high prevalence of CKD in South Asian countries.

Chronic kidney disease (CKD) is being increasingly recognized as a leading public health problem.
However, there are limited data available with respect to prevalence of CKD in Pakistan, a
developing South Asian country. The study presents the baseline findings of prevalence and risk
factors for adult kidney disease in a Pakistani community cohort. A total of 667 households were
enrolled between March 2010 and August 2011 including 461 adults, aged 15 and older. Mild
kidney disease was defined as estimated Glomerular Filtration Rate (eGFR) ≥60
ml/min with micro albuminuria ≥ 30 mg/dl and moderate kidney disease was defined as eGFR
<60 ml/min (with or without micro albuminuria).
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The overall prevalence of kidney disease was 16.6% with 8.6% participants having mild kidney
disease and 8% having moderate kidney disease. Age was significantly associated with kidney
disease (p < 0.0001). The frequency of diabetes, hypertension and smoking differed significantly
among the three groups, i.e., no kidney disease, mild kidney disease and moderate kidney disease.

A research that has been done in 2018 stated, both the incidence and prevalence of chronic kidney
disease (CKD) are rising with immense pace worldwide. People living in developing countries are
speculated to suffer the consequences due to economic deprivation and high cost of treatment. The
prevalence of CKD is highly variable in different parts of the world, due to various environmental,
ethnic, socio-economical, and rural-urban differences. We reviewed all studies along with the
global as well as regional data to have better insight into the problem. The epidemiology of CKD
and its risk factors are not well studied in Pakistan, and very few hospital-based studies have been
performed in the past.

These studies have shown that DM and HTN are the major causes of CKD in urban areas while
CKD of unknown etiology, glomerulonephritis and kidney stones were prevalent in the rural areas.
In a biopsy series of 212 diabetic patients, 91 (42.9%) were having non-diabetic kidney disease,
while 45 (21.2%) had non-diabetic lesions with the background of diabetic kidney disease. In
another study from the same city, in a renal biopsy series of 62 diabetic patients, 34 patients (52%)
had non-diabetic kidney disease. The causes of CKD are different and some of the regions have
shown a high prevalence of CKD caused by glomerulonephritis and obstructive nephropathy and
those of unknown etiology.

This demographic study conducted in 2015 which states chronic Kidney Disease in a Pakistani
Population. Chronic kidney disease (CKD) is progressively increasing in south Asian countries
like Pakistan, and the reason for this spread is multi-factorial. Most of the people have inadequate
health-care provision due to either lack of health education, lack of primary health-care most
importantly, the increasing prevalence of risk factors for CKD such as diabetes and hypertension.
Lack of a central registry makes epidemiological assessment extremely difficult and in-adequate
in Pakistan. Most of the data regarding disease burden estimates are mostly center-based. The
average population served by this center is large and the catchment area includes a vast area of
Punjab, Khyber and Kashmir (the three provinces). A case record form was used to record
demographic details, stage of renal disease and possible etiology of patients with established CKD.
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The data was obtained from patient interviews, diagnosis charts and case records, ultrasounds can
report and renal biopsy findings. A diagnosis of diabetic nephropathy was established based on
the presence of confirmed diabetes mellitus and one of the following criteria: Long-standing
diabetes preceding CKD (minimum of 10 years), normal-sized kidneys on ultra-sound or presence
of established diabetic retinopathy by fundoscopy. CKD due to hypertension was established
based on history of hypertension (minimum of five years) preceding renal dysfunction, evidence
of hypertension related end organ damage and exclusion of other renal diseases. A diagnosis of
chronic tubule interstitial disease was made based on history of polyuria, nocturia with low-
specific gravity of urine and low or normal blood pressure associated with small kidneys on
ultrasound.

A research that has been done in 2012 stated, Among CDs, chronic kidney disease (CKD) is of
particular significance and contributes heavily to the global CVD and end-stage renal disease
(ESRD). CKD ultimately progresses to ESRD, the rate of which is dependent on coexisting
pathologies and risk factors. The prevalence of CVD in ESRD and end-stage CKD patients
increases to 74%. CKD is a burden not just for renal replacement therapy (RRT) demands but also
for overall population health. Currently, CKD is the 12th highest cause of death and 17th highest
cause of disability worldwide. However, the rapid surge in diabetes and hypertension (HT), both
of which are predicted to drive epidemics in CKD and CVD, will dramatically escalate this burden.
CKD is expected to be a profound 21st century medical challenge. As the global health paradigm
shifts towards CDs, the current development aid for health focus on infectious diseases is no longer
a sustainable approach in developing countries.

The impact of CDs is overwhelming and there is a dire need for a greater alignment of funding
with the burden of CDs. Coordinated and integrated action to target the growing prevalence of
CDs will become essential in 21st century global public health policy.

Chronic diseases present a significant challenge to 21st century global health policy. In developing
nations, the growing prevalence of chronic diseases such as chronic kidney disease has severe
implications on health and economic output. The rapid rise of common risk factors such as
diabetes, hypertension, and obesity, especially among the poor, will result in even greater and more
profound burdens that developing nations are not equipped to handle. Attention to chronic
diseases, chronic kidney disease in particular, has been lacking, largely due to the global health
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community’s focus on infectious diseases and lack of awareness. There is a critical need for
funding in and to developing countries to implement more comprehensive, cost-effective, and
preventative interventions against chronic diseases. However, in many of the poorest nations, the
epidemiological shift to CDs as the major cause of morbidity and mortality is increasingly evident
in spite of low overall indicators of development. Sixty percent of the 58 million deaths in 2005
were attributed to CDs, with 4 out of 5 deaths globally occurring in low- and middle-income
countries (LMICs). By 2030, it is expected that out of the 4 leading causes of death will be due to
chronic conditions, indicating an alarming health burden.

Due to the escalating prevalence of CD risk factors, many developing countries now
simultaneously bear the burden of both chronic and infectious diseases. Another research
conducted in 2014 shows In Pakistan the exact magnitude of the burden of chronic kidney
disease or end-stage kidney disease is not known. A population-based study calculated the end-
stage renal disease (ESRD) incidence at 152 per million populations.

(ANIQA ANWER)

Screening of Renal Patients

Evaluation of Nutrients

Patients with chronic kidney failure undergoing dialysis have high prevalence of protein-energy
malnutrition. There is still no uniform method for assessing these patients' nutritional status. It is
recommended that a set of subjective and objective methods should be applied so that an adequate
nutritional diagnosis can be reached.

Examining the quality and quantity of food intake by appropriate methods is critical in the
management of patients with chronic kidney disease (CKD). The four commonly used dietary
assessment methods in CKD patients include short term dietary recalls, several days of food
records with or without dietary interviews, urea kinetic based estimates such as protein nitrogen
appearance calculation, and food histories including food screeners and food frequency
questionnaires (FFQ). There are a number of strengths and limitations of these dietary assessment
methods. Accordingly, none of the four methods is suitable in and of itself to give sufficiently
accurate dietary information for all purposes. FFQ, which is the preferred method for
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epidemiological studies, should be used for dietary comparisons of patients within a given
population rather than individual assessment. Food histories including FFQ and dietary recalls may
underestimate important nutrients, especially in CKD patients. Given the large and increasing
number of dialysis patients and work responsibilities of renal dietitians, routine analysis of dietary
records and recalls is becoming less feasible. Ongoing and future studies will ascertain additional
strengths and limitations of dietary assessment methods in CKD populations including the
assessment of food intake during an actual hem dialysis treatment.

In the presence of CKD, a constellation of factors can influence not only the nutritional status but
also the susceptibility of the methods used. We can highlight hydration, inflammation, dialysis
procedure, the limitations of dietary surveys, as well as observers’ variations, among others. Also,
as the cut-off points for adequacy established for the general population are not always appropriate
for these patients, the comparison of individuals over time takes a central role. Therefore, it is
essential to establish a routine to monitor the nutritional status of CKD patients.

Monitoring of Nutrients

Dietary management of chronic kidney disease (CKD) focuses on limiting the intake of substances
that might accumulate to toxic levels (such as potassium, phosphorus or salt) and, although still a
matter of debate for some, restricting dietary protein to retard kidney damage.

Evidence exists that nutritional therapy induces favorable metabolic changes, prevents signs and
symptoms of renal insufficiency, and is able to delay the need of dialysis. Currently, the main
concern of the renal diets has turned from the efficacy to the feasibility in the daily clinical practice.

Herewith we describe some different dietary approaches, developed in Italy in the last decades and
applied in the actual clinical practice for the nutritional management of CKD patients.

A step-wise approach or simplified dietary regimens are usually prescribed while taking into
account not only the residual renal function and progression rate but also socio-economic,
psychological and functional aspects.
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The application of the principles of the Mediterranean diet that covers the recommended daily
allowances for nutrients and protein (0.8 g/Kg/day) exert a favorable effect at least in the early
stages of CKD. Low protein (0.6 g/kg/day) regimens that include vegan diet and very low-protein
(0.3-0.4 g/Kg/day) diet supplemented with essential amino acids and ketoacids, represent more
opportunities that should be tailored on the single patient’s needs.

Rather than a structured dietary plan, a list of basic recommendations to improve compliance with
a low-sodium diet in CKD may allow patients to reach the desired salt target in the daily eating.

Another approach consists of low protein diets as part of an integrated menu, in which patients can
choose the “diet” that best suits their preferences and clinical needs.

Lastly, in order to allow efficacy and safety, the importance of monitoring and follow up of a
proper nutritional treatment in CKD patients is emphasized.

(RAIMA AZIZ)
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METHODOLOGY

Urine is the most useful of body fluids for biomarker research. Therefore, we have focused on
urinary proteomics, using capillary electrophoresis coupled to mass spectrometry (CE-MS), to
investigate kidney disease in recent years.

Urinary proteomics using capillary electrophoresis

Urinary proteomics has been used in several studies, in order to identify and validate biomarkers
associated with different kidney diseases. These biomarkers, with improved sensitivity and
specificity when compared to the current standards, provide a significant alternative for diagnosis
and prognosis, as well as improving clinic decision making.

CKD (chronic kidney disease)

DN is caused by diabetes mellitus, a chronic metabolic disease, associated with cardiovascular and
renal complications. CKD diagnosis is currently obtained by the detection of alterations in
estimated glomerular filtration rate (eGFR) and/or albuminuria as indicators of renal dysfunction.
However eGFR has limited value in predicting risk of CKD progression unless substantially
reduced. Instead (or together with eGFR) albuminuria is often used even though, in a non-
negligible number of patients, renal disease progresses despite the absence of albuminuria
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Over the last five years CE-MS has been a frequently used proteomics approach to discover urinary
biomarkers for the diagnosis and prognosis of CKD

Using CE-MS, Good et al. were able to define 273 urinary peptide markers for CKD (named the
“CKD273-classifier”) in a cohort of 379 healthy controls and 230 patients with CKD derived from
different etiologies. These peptide markers were mostly different fragments of various collagens,
blood proteins (e.g. serum albumin, α-1-antitrypsin) and specific kidney-derived proteins (e.g.
uromodulin). In order to validate the defined biomarkers, Good et al. applied the CKD273-
classifier to a set of 144 samples consisting of 34 controls and 110 patients with CKD, showing a
sensitivity of 85% and specificity of 100% (AUC=0.96).

(RIJA SEHAR)

Lifestyle changes

The following lifestyle measures are usually recommended for people with kidney disease:

• Stop smoking if one smoke

• Eat a healthy, balanced diet
• Restrict your salt intake to less than 6g a day – that's around 1 teaspoon
• Do regular exercise – aim to do at least 150 minutes a week
• Lose weight if you're overweight or obese
• Avoid over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen, except when advised to by a medical professional – these medicines can harm
one kidney if one has kidney disease

Water retention

One may get swelling in his/her ankles, feet and hands if one has kidney disease. This is because
one kidney is not as effective at removing fluid from one blood, causing it to build up in body
tissues (oedema). One may be advised to reduce one daily salt and fluid intake, including fluids in
food such as soups and yoghurts, to help reduce the swelling. In some cases, one may also be given
diuretics (tablets to help you pee more), such as furosemide. Side effects of diuretics can include
dehydration and reduced levels of sodium and potassium in the blood. (NHS Choices, 2019)
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Dialysis

For a small proportion of people with CKD, the kidneys will eventually stop working. This usually
happens gradually, so there should be time to plan the next stage of your treatment. One of the
options when CKD reaches this stage is dialysis. This is a method of removing waste products and
excess fluid from the blood.

There are 2 main types of dialysis:

• Hemodialysis – this involves diverting blood into an external machine, where it's filtered
before being returned to the body
• Peritoneal dialysis – this involves pumping dialysis fluid into a space inside your tummy
to draw out waste products from the blood as they pass through vessels lining the inside of
your tummy

Hemodialysis is usually done about 3 times a week, either at hospital or at home. Peritoneal dialysis
is normally done at home several times a day, or overnight. If one doesn’t have a kidney transplant,
treatment with dialysis will usually need to be lifelong. (NHS Choices, 2019)

Kidney transplant

An alternative to dialysis for people with severely reduced kidney function is a kidney transplant.
This is often the most effective treatment for advanced kidney disease, but it involves major
surgery and taking medicines (immunosuppressants) for the rest of one life to stop one body
attacking the donor organ. One can live with one kidney, which means donor kidneys can come
from living or recently deceased donors. But there's still a shortage of donors, and you could wait
months or years for a transplant. One may need to have dialysis while you wait for a transplant.
Survival rates for kidney transplants are very good. About 90% of transplants still function after 5
years and many works usefully after 10 years or more.

A kidney transplant is the transfer of a healthy kidney from one person into the body of a person
who has little or no kidney function. The main role of the kidneys is to filter waste products from
the blood and convert them to wee. If the kidneys lose this ability, waste products can build up,
which is potentially life-threatening. This loss of kidney function, known as end-stage chronic
kidney disease or kidney failure, is the most common reason for needing a kidney transplant.
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It's possible to partially replicate the functions of the kidney using a blood filtering procedure
known as dialysis. However, this can be inconvenient and time-consuming, so a kidney transplant
is the treatment of choice for kidney failure whenever possible. (NHS Choices, 2019)

(ANEEQA SALEEM)

Statistical data and its significance

A diagnosis of diabetic nephropathy was established based on the presence of confirmed diabetes
mellitus and one of the following criteria: Long-standing diabetes preceding CKD (minimum
of 10 years), normal-sized kidneys on ultra-sound or presence of established diabetic
retinopathy by fundoscopy. CKD due to hypertension was established based on history of
hypertension (minimum of five years) pre-ceding renal dysfunction, evidence of hyper-tension-
related end-organ damage and exclusion of other renal diseases .A diagnosis of chronic tubulo-
interstitial disease was made based on history of polyuria, nocturia with low-specific gravity of
urine and low or normal blood pressure associated with small kidneys on ultrasound. The other
etiologies of CKD were determined based on renal biopsy and ultrasound findings. The stage of
CKD was established by recording the most recent (within the last three months) eGFR according
to the (Modification of Diet in Renal Disease (MDRD) equation. Reports from Pakistan have
shown that eGFR than serum creatinine alone in the Pakistani population. CKD staging was
performed according to the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines.

A total of 520 patients were initially included in the study, with a male to female ratio of
1:1(100:100). A total of 500 patients were considered for final analysis based on data adequacy.
The mean age of the population was46.3 years, with the minimum age maximum being 83
years .Common causes of CKD identified in these patients included diabetic nephropathy
(140,28%), glomerulonephritis (110, 22%), hyper-tension (73, 14.6%), tubulo-interstitial
disease(67, 13.4%) and renal stone disease (40, 8%).The cause was unknown in a significant
percentage of patients (53, 10.6%). Other causes including post-partum renal failure, which
constituted 2% of the cases (Table 1).The majority of patients were in end-stage renal failure
at presentation (93%). Stages 3 and 4 constituted a minority (2% and 5%, res-pectively) (Table
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2). In 20% of the patients, a diagnosis of acute on CKD, mostly due to drugs, was made. A total
of 268 patients were below the age of 50 years. The common etiology of CKD in this age-group
included glomerulonephritis (33.2%),diabetic nephropathy (17.9%), tubulo-interstitial disease
(10%) and renal stone disease(13.8%). The patients who had CKD of un-known cause
comprised 12.31%.Among the 232 patients who were ≥50 years, the following causes of CKD
were identified: diabetic nephropathy (39.6%), hypertension (19.8%), renal stone disease (12.9%),
tubulo-interstitial disease (5.6%) and adult polycystic kidney disease (3%). Only 8.6% of patients
in this age-group had CKD of unknown etiology

It is estimated that the annual incidence of new cases of end-stage renal disease (ESRD) is >100
per million population in Pakistan. In this study, diabetes was the leading cause of CKD,
confirming previous results from Pakistan.

Changes in diet of a renal patient

A renal diet is one that is low in sodium, phosphorous, and protein. A renal diet also emphasizes
the importance of consuming high-quality protein and usually limiting fluids.

Among patients with moderate renal insufficiency, the slower decline in renal function that started
four months after the introduction of a low-protein diet suggests a small benefit of this dietary
intervention. Among patients with more severe renal insufficiency, a very-low-protein diet, as
compared with a low-protein diet, did not significantly slow the progression of renal disease.

Following a kidney diet may also help promote kidney function and slow the progression of
complete kidney failure.

Modification in diet of renal patients

In CKD, One needs to make changes in their diet. Diet modification in renal diseases depends on
two factors; Protein restriction and Control of blood pressure.

These modifications may include limiting fluids, eating a low-protein diet, limiting salt, potassium,
phosphorous, and other electrolytes, and getting enough calories if you are losing weight.

The purpose of this diet is to keep the levels of electrolytes, minerals, and fluid in your body
balanced when you have CKD or are on dialysis.
 P a g e | 23

People on dialysis need this special diet to limit the buildup of waste products in the body. Limiting
fluids between dialysis treatments is very important because most people on dialysis urinate very
little. Without urination, fluid will build up in the body and cause too much fluid in the heart and
lungs.

(AMNA KHAN)

Epidemiology

The study, assessment, and analysis of public health concerns in a given population; the tracking
of patterns and effects of diseases, environmental toxins, natural disasters, violence, terrorist
attacks, etc. (the definition of epidemiology, 2019)

Epidemiology of Chronic Kidney Disease in a Pakistani Population

Chronic kidney disease (CKD) is progressively increasing in south Asian countries like Pakistan,
and the reason for this spread is multi-factorial. Most of the people have inadequate health-care
provision due to either lack of health education, lack of primary health-care, inadequate funding
on the part of the government and, most importantly, the increasing prevalence of risk factors for
CKD such as diabetes and hypertension. In addition, other causes like glomerulonephritis and
renal stones are prevalent due to infections and dry weather conditions. Lack of a central registry
makes epidemiological assessment extremely difficult and in-adequate in Pakistan. Most of the
data regarding disease burden estimates are mostly center-based. Our nephrology unit, which is
part of a large tertiary care hospital, the Pakistan Institute of Medical Sciences, Islamabad caters
to a large population in the region. The average population served by this center is large and the
catchment area includes a vast area of Punjab, Khyber and Kashmir (the three provinces). We have
a separate dedicated CKD clinic.
(Kifayat Ullah et al., 2015)
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Category Number of subjects Percentage

Diabetic nephropathy 140 28%
Glomerulonephritis 110 22%
Hypertension 73 14.6%
Tubulo-intestinal nephritis 67 13.4%
Unknown cause 53 10.6%
Renal Stone disease 40 8%
Adult polycystic kidney 7 1.4%
disease
Other causes 10 2%
Total 500 100%

In our study, diabetes was the leading cause of CKD, confirming previous results from Pakistan.
These results are also consistent with those reported from Western countries. According to the
United States Renal Data System (USRDS), diabetes is the leading cause of ESRD (42.9%).

Glomerulonephritis remains the second leading cause of CKD, which probably reflects the high
prevalence of infections in our society. Studies from Karachi have reported chronic
glomerulonephritis as the leading cause of ESRD in dialysis patients, indicating the high
prevalence of infections in the community. Studies from India have shown that chronic glomerular
nephritis (37%) is the most common cause of ESRD in their population, followed by diabetic
nephropathy (14%) and chronic tubular interstitial disease.

Hypertension represents the third major cause. In our setup, hypertension largely remains
unrecognized and untreated due to the symptomatic nature of the disease and lack of regular health
checkup thus leading to com-plications like CKD.

Tubulo-interstitial disease remains one of the leading causes (13.4%) in our study, probably
reflecting misuse of analgesics and herbal drugs.

In a significant number of patients (10.6%), the cause of renal failure was not known. These
patients mostly included those who presented very late or those in who multiple disorders co-
existed and thus the cause could not be ascertained. (Kifayat Ullah et al., 2015)
 P a g e | 25

Etiology Age <50 years (total 26%) Age >50years (total 232)
Diabetic nephropathy 48(17.9%) 92(39.6%)
Hypertension 27(10.07%) 46(19.8%)
Glomerulonephritis 89(33.20%) 21(9.05%)
Adult polycystic kidney 0 7(3%)
disease
Renal stone Diseases 37(13.80%) 30(12.9%)
Tubulo-intestinal disease 27(10.07%) 13(5.60%)
Unknown cause 33(12.31%) 20(8.6%)
Others 7(2.6%) 3(1.2%)
(ANEEQA SALEEM)

Case Study

Sex and gender differences are of fundamental importance in most diseases, including chronic
kidney disease (CKD). Men and women with CKD differ with regard to the underlying
pathophysiology of the disease and its complications, present different symptoms and signs,
respond differently to therapy and tolerate/cope with the disease differently. Yet an approach using
gender in the prevention and treatment of CKD, implementation of clinical practice guidelines and
in research has been largely neglected. The present review highlights some sex- and gender-
specific evidence in the field of CKD, starting with a critical appraisal of the lack of inclusion of
women in randomized clinical trials in nephrology, and thereafter revisits sex/gender differences
in kidney pathophysiology, kidney disease progression, outcomes and management of
hemodialysis care. In each case we critically consider whether apparent discrepancies are likely to
be explained by biological or psycho-socioeconomic factors. In some cases (a few), these findings
have resulted in the discovery of disease pathways and/or therapeutic opportunities for
improvement. In most cases, they have been reported as merely anecdotal findings. The aim of the
present review is to expose some of the stimulating hypotheses arising from these observations as
a preamble for stricter approaches using gender for the prevention and treatment of CKD and its
complications. (Raima Aziz)
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