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Chronic Renal Insufficiency

Stages and Symptoms of Renal Insufficiency


Your nephrologist may use a classification system to describe what stage of chronic kidney disease you are at (such as Stage I, Stage II, etc.). Although these are not universally-used, a common example of this is given below. It is based on clinical practice guidelines on chronic kidney disease published in 2002 by the National Kidney Foundation (NKF) in the U.S., as part of its Kidney Disease Outcome Quality Initiative (K/DOQI).



Stages of Chronic Kidney Disease

These guidelines are adapted from the National Kidney Foundation's
Kidney Disease Outcomes Quality Initiative (KDOQI)
Stage
Description
GFR*
1
Signs of mild kidney disease but with normal or better GFR
greater than 90%
2
Mild kidney disease with reduced GFR
60-89%
3
Moderate chronic renal insufficiency
30-59%
4
Severe chronic renal insufficiency
15-29%
5
End-stage renal failure
less than 15%

*GFR is given in ml/min/1.73 m2





Because there is considerable unpredictability and overlap as to when various symptoms of chronic renal insufficiency might start appearing, rather than limiting ourselves to these specific stages, we will instead look at 3 broad categories as follows. Please note that if you happen to have heavy proteinuria, even if your IgAN is at a very mild stage in terms of chronic renal insufficiency, you may begin to experience symptoms of what is called nephrotic syndrome. These symptoms are due to the heavy loss of protein, and are not strictly-speaking symptoms of "renal failure".





Early chronic renal insufficiency (Stages 1 to 2)

  • Physical symptoms. Usually few or no physical symptoms that you can feel (other than those you may experience if you have heavy proteinuria).
  • Blood work. Blood work results will show abnormalities - mainly a slightly elevated serum creatinine. Note that there is often a time lag between elevations of serum creatinine, and some progression of the IgAN. By the time serum creatinine is elevated, the person may already have lost 50% of kidney function.
  • Urinalysis. Urine will show abnormalities. Urine can be checked by dipstick in the doctor's office (as an initial check), and followed up with a more complete urinalysis. The main urine abnormality that will suggest a kidney disease is the presence of protein and/or blood. Either will usually trigger further investigation. However, blood and/or protein in the urine doesn't say anything about actual kidney function.
  • Treatment. Treatment may involve some mild dietary changes (a lower protein diet may in some cases be recommended), and a blood pressure medication  may be prescribed (usually of the ACE inhibitor class, the angiotensin II receptor class, or both, even if blood pressure is not really elevated much).
  • Blood pressure. Some people start having high blood pressure even in early chronic renal failure. IgAN is one kidney disease that can do this.
  • Anemia.  Anemia may rarely occur at this stage. In this case, it is most often caused by having heavy proteinuria rather than actual chronic renal insufficiency.




Advanced chronic renal insufficiency (Stages 3 to 4)

  • Physical symptoms
You may still feel completely normal at this stage, or you may begin to experience one or more of the following symptoms:
  • Serum creatinine. Serum creatinine will be higher (indicating less than 30% kidney function)
  • Tiredness or fatigue
  • Puffiness or swelling (obvious in the hands or feet and ankles, but the puffiness will often first be seen around the eyes). 
  • Back pain. Usually felt as a dull ache anywhere in the mid-to-lower portion of the back, on one side or the other - this is sometimes referred to as flank pain, or loin pain)
  • Appetite. Changes in appetite or eating pattern. Foods may start tasting "funny".
  • Urine. Changes in urination (amount, colour, frequency). Urine may in fact look exceptionally clear at this point, rather than abnormal. This is because little is actually being filtered into it by your kidneys. Previously high proteinuria and/or hematuria may actually improve.
  • Blood pressure. High blood pressure (also referred to as hypertension)
  • Digestion. Poor digestion (varying degrees of gastroparesis, which means that digestion is slowed).
  • Treatment
  • Diet. Dietary changes may be ordered (renal diet: low protein, low potassium, low phosphorus, low sodium, higher calorie)
  • Medication
  • High blood pressure medications. It's common to need more than one at this stage, and often 3 or more.
  • Other drugs/supplements. May be prescribed if needed, such as vitamin D analog (calcitriol is a common one), renal vitamins (not a regular multi-vitamin, as these contain too much vitamin A for the typical advanced renal insufficiency patient).  Drugs for controlling heavy proteinuria if necessary (note that heavier proteinuria does not automatically follow with more advanced chronic renal insufficiency).
  • Phosphorus binder. You may be asked to begin taking a calcium supplement with meals as a phosphorus binder (or a medication may be prescribed instead of or in addition to calcium).






End-stage renal failure (or late chronic renal insufficiency)

The terms end-stage renal failure and end-stage renal disease are used interchangeably, and the abbreviation ESRD is commonly used. Typically, patients will have kidney function in the area of 10-15% or so. These are the common symptoms you may experience at this stage (and some people may start experiencing some of these earlier):
  • Symptoms
  • anemia (may begin earlier than this)
  • easy bleeding and bruising
  • headache
  • fatigue and drowsy feeling (more than normal or usual for you)
  • weakness
  • mental symptoms such as lowered mental alertness, trouble concentrating, confusion, seizures
  • nausea, vomiting, and generally less desire to eat
  • thirst
  • muscle cramps, muscle twitching
  • nocturia (night-time urination)
  • numb sensation in the extremities
  • diarrhea
  • itchy skin, itchy eyes
  • skin colour changes (grayish complexion, sometimes yellowish-brownish tone)
  • swelling and puffiness (more than you had while in advanced renal failure, and most likely in the feet and/or ankles)
  • difficulty breathing (due to fluid in the lungs, anemia)
  • high blood pressure (with IgAN, you may already have had this since the early stages)
  • decreased sexual interest
  • changes in menstrual cycle (and difficulty getting pregnant)
  • decreased urine output (however, you should be aware that some people with ESRD will continue to get rid of water as urine, but not wastes - therefore, the urine may be very clear and normal-looking, and some may have increased urine output rather than decreased).
  • poor digestion (varying degrees of gastroparesis).
  • Treatment
The exact time that dialysis starts will vary slightly depending on various factors. Consult your nephrologist.
  • Dialysis
  • Kidney transplant






© 2002-2006 Foundation for IgA Nephropathy

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