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Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Renal Failure, Chronic


Text Only Home | Graphic-Rich Site | Overview | Risk and Causation | Diagnosis | Treatment | Prognosis | Differential Diagnosis | Specialists | Comorbid Conditions | Complications | Factors Influencing Duration | Length of Disability | Ability to Work | Maximum Medical Improvement | Failure to Recover | Medical Codes | References

Medical Codes

ICD-9-CM:
585.6 - Chronic Kidney Disease (CKD), End Stage Renal Disease, Requiring Chronic Dialysis
585.9 - Chronic Kidney Disease, Unspecified; Chronic Renal Disease; Chronic Renal Failure NOS; Chronic Renal Insufficiency

Related Terms

  • Chronic Kidney Disease
  • Chronic Kidney Failure
  • Chronic Renal Disease
  • End-Stage Renal Disease (ESRD)

Overview

Chronic renal failure (CRF) refers to gradually reduced functioning of the kidneys that causes eventual kidney atrophy and scarring; it is irreversible and progressive. Often, symptoms may not occur until more than 70% of kidney function is lost ("Chronic Renal Failure").

CRF results in the accumulation of fluid and waste products in the blood (uremia). Healthy kidneys filter the nitrogen end-products of protein and amino acid metabolism in the blood and change the fluid waste into urine for excretion. Impaired kidneys, however, will not handle this task efficiently, and the waste will accumulate in the blood (azotemia). CRF that requires for survival renal replacement therapy (dialysis or a kidney transplant) is called end-stage renal disease (ESRD).

CRF may result from any disease that causes progressive damage to and destruction of the internal structures of the kidneys. Diabetes, glomerulonephritis and high blood pressure (hypertension) are the leading causes of CRF and subsequent ESRD.

Kidney damage may occur as a result of conditions directly affecting the kidney, including damage to the filtration units (glomerulonephritis); inflammation and infection of the renal pelvis where urine is collected in the kidney (pyelonephritis); underdevelopment of the kidney (congenital hypoplasia); cysts scattered throughout both kidneys (polycystic kidney disease); kidney scarring from chronic reflux (reflux nephropathy); and urinary tract obstruction, such as that produced by bladder outlet obstruction or kidney stones, that results in backup of urine and pressure within the kidneys (obstructive uropathy).

Kidney damage can also occur as a result of abnormal conditions elsewhere in the body (secondary renal failure). In addition to diabetes and hypertension, secondary causes can include a type of metabolic abnormality in which deposits occur in organs and tissues (amyloidosis), chronic inflammatory diseases (e.g., systemic lupus erythematosus), HIV infection, impaired cardiac function, chronic liver failure, a form of bone marrow cancer that is characterized by myeloma cells that form multiple tumors within bone (multiple myeloma), and other cancers. CRF can also result from ingesting substances that are toxic to the kidneys or other highly toxic reactions such as poison ivy or snakebite.

Chronic renal failure (CRF) staging is based on the estimated glomerular filtration rate (GFR); normal GFR is 100-130 mL/min/1.73 m2 for both sexes. Stages of CRF are as follows: 0 (> 90 mL/min/1.73 m2 without albuminuria); 1 (? 90 mL/min/1.73 m2 plus persistent albuminuria or structural or hereditary renal disease); 2 (60-89 mL/min/1.73 m2); 3 (30-59 mL/min/1.73 m2); 4 (15-29 mL/min/1.73 m2); and 5 (< 15 mL/min/1.73 m2).

Incidence and Prevalence: Kidney disease is the ninth leading cause of death in the US (Arora). CRF is present in 26 million individuals ("Chronic Kidney Disease"), approximately 11.5% of the adult population ("Kidney").

Approximately 485,000 people with ESRD are treated each year in the US (Arora). Of these, more than 350,000 individuals receive hemodialysis and more than 18,000 individuals receive a kidney transplant ("Kidney").

Source: Medical Disability Advisor



Causation and Known Risk Factors

In the US, those at highest risk for CRF are individuals with diabetes (causing 75% of all cases) or hypertension (Arora). Disease conditions or toxins that directly affect kidney function increase risk. Advancing age, family history, and smoking also increases the risk of CRF.

Men have a slightly higher risk of developing CRF and ESRD than women because they are more likely to have underlying conditions such as hypertension and cardiovascular disease (Arora). The incidence of ESRD is 3.6 times higher in blacks and 1.5 times higher in Hispanics than in whites (Krause).

Source: Medical Disability Advisor



Diagnosis

History: The progression of kidney disease may be so gradual that symptoms are not obvious until more than 70% of kidney function is lost ("Chronic Renal Failure"). Individuals may initially report nonspecific symptoms such as nausea and vomiting, fatigue, itching (pruritus), headaches, forgetfulness, unintentional weight loss, and malaise. They may also report symptoms that include loss of appetite (anorexia), decreased exercise tolerance, difficulty breathing, chest pain, problems with taste, mood changes, a tingling or restless feeling in the legs, and sleep disturbances. Some individuals may report a family history of kidney disease. Later symptoms include increased or decreased urinary output, increased nocturnal urination (nocturia), excessive thirst, easy bruising or bleeding, and blood in stool or vomit.

Physical exam: The exam may reveal dry, brittle, and pale yellow- or brown-toned skin (sallow complexion), an ammonia odor on the breath, hair loss, nail changes, loss of sensation in the hands or feet (peripheral neuropathy), altered mental status (drowsy and lethargic or agitated and confused), brownish discoloration of the tongue, muscle twitching or cramping, and hand flapping when the arms are extended (asterixis). It may also reveal accumulation of fluid in the tissues of extremities (edema), increased blood pressure (hypertension), fluid in the abdominal cavity (ascites), and pericardial effusion. A rapid heartbeat, heart murmur, or abnormal lung sounds may be heard with a stethoscope (auscultation). An eye examination may reveal abnormalities associated with hypertension, diabetes, or other metabolic conditions. A neurologic exam may show changes in several of the peripheral nerves (polyneuropathy).

Tests: Diagnostic tests typically include laboratory examination of blood and urine, diagnostic imaging, and a kidney biopsy if the cause of the CRF remains unclear. Blood urea nitrogen (BUN) and creatinine levels will typically be elevated. Electrolyte levels may be abnormal, showing an imbalance of potassium (hyperkalemia), sodium (hyponatremia), chlorides, calcium (hypocalcemia), phosphate (hyperphosphatemia), and magnesium. A complete blood count (CBC) may reveal anemia. Other blood chemistries and arterial blood gas testing may reveal reduced bicarbonate and metabolic acidosis. The parathyroid hormone (parathormone) level may be elevated. Routine urinalysis may reveal an abnormal pH indicative of acid concentration; a high specific gravity indicating an abnormal concentration of solids and water; and the presence of protein (albumin), glucose, ketones, or blood in the urine. All urine produced over a 24-hour period may be collected for testing. Additional diagnostic tests may include ultrasound, which may reveal structural abnormalities in the urinary tract or abnormalities in the size of the kidneys. Other imaging tests may include a renal or abdominal x-ray, CT scan, or MRI. A contrast scan (using injection of radiopaque dye or contrast material) may also be performed to evaluate kidney function. A renal biopsy may reveal cellular changes in kidney tissues that are associated with CRF.

Source: Medical Disability Advisor



Treatment

Chronic renal failure is irreversible, but lifelong treatment may control symptoms and delay progression of the disease. Treatment focuses on controlling the individual's particular symptoms, minimizing complications, and slowing disease progression. Aggravating factors (volume depletion, drugs or toxic substances, obstruction, infections, high blood pressure, diabetes, and metabolic abnormalities) are usually treated immediately to prevent further kidney damage. Infections and marked blood pressure elevations are treated with drug therapy.

Treatment is conservative until kidney function becomes severely affected. Initial treatment may involve a diet that is low in protein (protein wastes disposal increases the work of the kidneys), potassium, and phosphorus. Sodium intake is restricted to meet the needs of the individual. Bicarbonate may be given to control an increased acid level (metabolic acidosis). If anemia is severe, iron supplements may be given to increase hemoglobin, and blood transfusion or a medication that increases red blood cell production (erythropoietin) may be required to maintain adequate numbers of red blood cells as well as blood volume. Calcium and phosphorus levels in the blood are carefully monitored, and phosphate-binding antacids, calcium, and vitamin D may be given to maintain the proper balance. Fluid intake may be controlled to equal the amount of urine being excreted.

When kidney function decreases to the point of becoming life-threatening, dialysis will be done regularly to replace the work of the kidneys. One of two methods of dialysis will be used, either hemodialysis or peritoneal dialysis. In hemodialysis, a machine pumps blood through a dialysis membrane that filters excess fluids, electrolytes, and waste products from the blood. In peritoneal dialysis, fluid is infused into the membrane that lines the abdominopelvic walls (peritoneal cavity), where it filters the excess fluid, electrolytes, and waste products from the body. Individuals who undergo hemodialysis must have a surgical connection made between an artery and a vein (arteriovenous fistula or graft) that will be used for blood exchange during hemodialysis. By the end of 2009, the number of ESRD patients receiving either form of dialysis was 398,861. More than 10 times as many ESRD patients receive hemodialysis at a clinic as those who receive peritoneal dialysis and home hemodialysis combined. ("Kidney").

A kidney transplant may eventually be necessary.

Source: Medical Disability Advisor



Prognosis

End-stage renal disease is the usual outcome. The rate of progression to end-stage disease depends on the underlying cause and the clinical characteristics of the kidney disease, the level of kidney function, the individual's age and sex, the presence of complications, any underlying medical conditions, the type of treatment, and the individual's response. Individuals with ESRD over the age of 65 have a mortality rate six times higher than younger individuals (Arora). When ESRD is treated by dialysis, the five-year survival rate is 35% (Arora). Individuals with poorly controlled potassium levels (hyperkalemia) or those who miss scheduled dialysis treatments are prone to sudden death from cardiac malfunction.

Some individuals become permanently disabled due to the presence of comorbid conditions and complications associated with CRF or treatment. A successful kidney transplant improves the prognosis, with a survival of 90% to 95% after 1 year and 70% to 80% after 5 years. The outcome of CRF without dialysis or transplantation is death.

Source: Medical Disability Advisor



Differential Diagnosis

Source: Medical Disability Advisor



Specialists

  • Internal Medicine Physician
  • Nephrologist
  • Urologist

Source: Medical Disability Advisor



Comorbid Conditions

  • Anemia
  • Bacterial infection, especially urinary tract
  • Cardiac conditions that involve fluid retention
  • Diabetes mellitus
  • Hypertension

Source: Medical Disability Advisor



Complications

Chronic renal failure results in a large number of complications. Electrolyte levels may either rise or fall to life-threatening levels. The electrolyte potassium must be balanced with sodium levels and kept within the normal range for proper functioning of the heart; abnormal potassium levels or sodium-potassium imbalance may result in abnormal heart rhythms. The ability to produce red blood cells is decreased, resulting in anemia. Bleeding abnormalities may develop, resulting in nosebleeds, excessive menstrual flow, and easy bruising. Skeletal changes (osteodystrophy) can occur as a result of an elevated phosphate level and an increase in the parathyroid hormone that helps regulate calcium and phosphorus. The parathyroid gland may become hyperactive, calcium blood levels may be decreased, and abnormalities of vitamin D metabolism can occur. Cardiovascular abnormalities include accelerated atherosclerosis, high blood pressure (hypertension), and inflammation of the membrane of the heart (pericarditis). Gastrointestinal problems include nausea and vomiting, problems with taste, and weight loss. Muscle weakness and muscle wasting are common. Individuals are also more susceptible to urinary tract infections (UTIs) and to developing kidney stones. Itching of the skin (pruritus) is present in up to 49% of individuals with CRF, and in nearly 90% of those receiving hemodialysis (Nunley).

Individuals with CRF requiring surgical general anesthesia are at risk for a reduction in blood flow to the kidneys by as much as 50%, worsening the disease (Krause). Undergoing surgery also increases the risk for fluid and electrolyte imbalances, cardiac arrhythmias, and cardiac depression that may lead to death.

Source: Medical Disability Advisor



Factors Influencing Duration

Factors influencing length of disability include any underlying medical conditions such as high blood pressure (hypertension), diabetes, cardiac problems, the amount of kidney function remaining, dialysis, age, sex, and the development of complications. Although some amount of disability is permanent, dialysis makes it possible for individuals who have chronic renal failure to maintain some degree of independence. Among diabetics and hypertensive patients, other complications, including gradual loss of vision, may increase the length of disability.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Possible work restrictions and accommodations include transferring the individual from duties that require heavy lifting or long periods of standing, increasing rest periods to accommodate fatigue, shortening the workday, or having the individual take a leave of absence. If undergoing dialysis, the individual generally needs treatment 3 days a week. Dialysis appointments are scheduled around work schedules, but flexibility is necessary. Heavy lifting cannot be done, and restrictive clothing cannot be worn over arms in which there is a surgical connection made between an artery and a vein (arteriovenous fistula or graft) used during hemodialysis. Medical appointments are needed for follow-up and evaluation of hemodialysis vascular access sites or for evaluation of the peritoneal catheter needed for peritoneal dialysis. Time off from work may be necessary for hospital procedures required to maintain vascular access for dialysis.

Individuals who undergo a kidney transplant may need several weeks off from work for surgery and recovery. For several months after the transplant, extra precautions to prevent infection are necessary because of the medications that must be taken to preserve the transplant.

Risk: Jobs that entail exposure to known toxins should be avoided. For more information, refer to "Disease and Injury Causation," pages 350-351.

Capacity: Blood testing should verify no obvious limit in returning to work.

Tolerance: Fatigue is a prominent symptom in renal failure and may limit work return.

Source: Medical Disability Advisor



Maximum Medical Improvement

When the creatinine is stable for 90 days duration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does individual have diabetes or hypertension? Glomerulonephritis or pyelonephritis? Congenital hypoplasia? Polycystic kidney disease? Reflux nephropathy? Obstructive uropathy? Kidney stones? Kidney infection? Amyloidosis?
  • Does individual have systemic lupus erythematosus? HIV? Multiple myeloma?
  • Has individual ingested any substances that are toxic to the kidneys?
  • Does individual report nausea and vomiting, fatigue, pruritus, headaches, forgetfulness, unintentional weight loss, or malaise?
  • Does individual also report anorexia, decreased exercise tolerance, dyspnea, chest pain, problems with taste, mood changes, or sleep disturbances? Family history of kidney disease?
  • Has individual noticed either an increase or a decrease in urinary output?
  • Does individual report excessive thirst? Easy bruising or bleeding? Blood in stool or vomit?
  • On exam, is skin dry, brittle, and pale yellow or brown-toned?
  • Is there an ammonia odor on the breath? Hair loss? Nail changes?
  • Does individual have a rapid heartbeat, heart murmur, or loss of sensations in the hands or feet?
  • Is individual's mental status altered? Are there changes in the peripheral nerves?
  • Is there brownish discoloration of the tongue?
  • Is there hand flapping when the arms are extended (asterixis)? Muscle twitching?
  • Is edema or hypertension present? Ascites? Congestive heart failure? Pericardial effusion?
  • Has individual had blood and urine testing? Did the blood tests include electrolytes, kidney function tests, and parathyroid hormone tests?
  • Was a 24-hour urine done? Intravenous pyelogram? Kidney biopsy?
  • Did individual have abdominal and kidney x-rays? Ultrasound? CT scan? MRI?
  • Have conditions with similar symptoms been ruled out?

Regarding treatment:

  • Have volume depletion, drug side effects, toxic substances, obstruction, infections, high blood pressure, and metabolic abnormalities been treated?
  • Is individual on a low protein diet? Is sodium intake balanced for individual?
  • Is metabolic acidosis being treated? Has fluid intake been restricted?
  • Is individual on iron supplements or erythropoietin? Have transfusions been necessary?
  • Does individual see physician frequently to monitor the disease?
  • Are phosphate-retaining antacids, calcium, and vitamin D being given?
  • Has dialysis become necessary? Is individual a candidate for a kidney transplant?

Regarding prognosis:

  • Is individual's employer able to accommodate any necessary restrictions?
  • Does individual have any conditions that may affect the ability to recover?
  • Has individual had any complications such as bleeding disorders? Electrolyte imbalance? Pericarditis? Skeletal changes?

Source: Medical Disability Advisor



References

Cited

"Chronic Kidney Disease (CKD)." National Kidney Foundation. 24 Apr. 2013 <http://www.kidney.org/kidneydisease/ckd/index.cfm>.

"Kidney and Urologic Diseases Statistics for the United States, NIH Publication No. 09-3895." National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK). 15 Nov. 2012. National Institutes of Health (NIH). 24 Apr. 2013 <http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/>.

Arora, Pradeep , and Mauro Verrelli. "Chronic Renal Failure." eMedicine. Eds. Laura L. Mulloy, et al. 25 Mar. 2013. Medscape. 24 Apr. 2013 <http://emedicine.medscape.com/article/238798-overview>.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Nunley, Julia R. "Dermatologic Manifestations of Renal Disease." eMedicine. Eds. Daniel J. Hogan, et al. 11 Apr. 2012. Medscape. 24 Apr. 2013 <http://emedicine.medscape.com/article/1094846-overview>.

Source: Medical Disability Advisor