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Annals of African Medicine
Annals of African Medicine Society
ISSN: 1596-3519
Vol. 6, Num. 3, 2007, pp. 130-136
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Annals of African Medicine, Vol. 6, No. 2, 2007, pp. 130-136
Recommendations for Early Diagnosis of Chronic
Kidney Disease
I. B. Bosan
Department of Medicine, Ahmadu Bello University Teaching Hospital,
Zaria, Nigeria
Reprint requests to: Dr. I. Bosan, Nephrology Unit, Department of Medicine,
Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
Code Number: am07033
Abstract
Background: Chronic kidney disease is an important component
of chronic non – communicable diseases that are now of pandemic proportions
and are the major cause of morbidity and mortality worldwide. Patients with
reduced renal function represent a population not only at risk for progression
of kidney disease and development of end stage renal disease (ESRD), but also
at a greater risk of cardiovascular disease and mortality. Unfortunately, chronic
kidney disease is under diagnosed and undetected resulting in lost opportunities
for improving the clinical outcome. Early diagnosis with appropriate interventions
will improve the quality of care of patients and prevent or delay progression
to end stage renal disease. Our objective is to review existing recommendations
and examine their adaptation to improving the quality of care for patients
with chronic kidney disease in our environment.
Method: Hand searches of published articles and electronic data
were the primary sources. Only articles published in the English language were
consulted excluding case reports, letters and conference abstracts. Articles
of original data were searched from 1980 while review articles and expert committee
reports were from 2000.
Results: Early diagnosis of chronic kidney disease is crucial
to improving the clinical outcome and reducing the incidence of end stage renal
disease. Certain individuals with specific socio demographic and clinical factors
are at increased risk of chronic renal disease. All individuals should be assessed
as part of routine health encounter, to determine whether they are at increased
risk of developing chronic kidney disease based on clinical and socio demographic
factors. Individuals at increased risk of developing chronic kidney disease
should undergo testing for markers of kidney damage, and to estimate the level
of GFR.Individuals found to have chronic kidney disease should be evaluated
and treated appropriately. A clinical action plan should be developed for each
patient based on the type and stage of renal disease, co-morbid conditions,
complications of the disease and risk factors for progression of renal disease
or development of cardiovascular disease.
Conclusion: Individuals at increased risk, but found not to have
chronic kidney disease, should be advised to follow of risk factor reduction,
if appropriate, and undergo repeat periodic evaluation.
Key words: Chronic kidney disease, risk factors, screening,
early diagnosis, prevention
Résumé
Introduction: Maladie du rein chronique est un composant important
des maladies chroniques non transmissibles qui sont actuellement d’une
proportion pandémique et sont des causes majeur de la morbidité et mortalité dans
le monde entier. Des patients atteints des fonctions d’une diminution
rénale constitue une poplation pas seulement à risque pour une progression
de la maladie du rein et du dévelopment de la maladie rénale de la dernière étape
(MRDE) mais aussi à un plus grand risque de la maladie cardiovasculaire et
mortalité. Malheuresement, la maladie du rein chronique est sous diagnostiquée
et sans détecter ce qui mène à la perte des occasions d’améliorer le
résultat clinique. Un diagnostique précoce avec des interventions adéquates
vont améliorer la qualité des soins pour des patients et éviter une progression
tardive pour la maladie rénale de la dernière étape. L’objet de cette étude
est de faire une rétrospective des récommendations actuelles et étudier leur
adaptation pour pouvoir améliorer la qualité des soins pour des patients atteints
de la maladie du rein dans notre milieu.
Méthodes: Recherches des articles publiées et des données électroniques
sont des sources de base. Des articles publiées en anglais ont été consultées
sans compter des rapports des cas, lettres et des résumés de la conférence. Des
articles des données originales ont été cherchées de 1980 tandis que bilan
des articles et des rapports du comité des spécialistes étaient de l’an
2000.
Résultats: Diagnostique précoce pour la maladie du rein chronique
est très important afin d’améliorer le résultat clinique et de réduire
la fréquence de la maladie rénale de la dernière étaple. Certains individus
avec des facteurs clniniques et socio-démographiques spécifiques ont une augmentation
du risque de la maladie du rein chronique. Tout le monde devrait être examiner
comme étant la démarche de la routine sanitaire, pour pouvoir décider s’ils
sont à un augmentation de risque d’atteindre la maladie chronique de
rein base sur des facteurs cliniques et socio-démographiques Des individus
qui sont à risque d’atteindre la maladie du rein chronique devraient
suivre un test qui va indiquer le dégats du rein, et déterminer le niveau du
GFR. Des individus trouvés d’être atteint de la maladie du rein chronique
devraient être étudiés et traités convenablement. On devrait établir un plan
d’action clinique pour chaque patient d’après le type d’étape
de la maladie rénale, conditions co-morbide, complication de la maladie et
des facteurs de risque pour progression de la maladie rénale ou développement
de la maladie cardiovasculaire.
Conclusion:Des individus avec augmentation, mais trouvés de
ne pas atteindre de la maladie du rein chronique, devraient être conseillés
de suivre une réduction du facteur du risque, si c’est nécéssaire, suivre
une évaluation périodique répétée.
Mots-clés: Maladie du rein chroniqu, facteurs du risque, test
du dépistage, diagnostique précoce, prévention
Introduction
Chronic non-communicable diseases are now of pandemic proportions and are
the major cause of morbidity and mortality worldwide. Chronic kidney disease
(CKD), diabetes mellitus, hypertension and cardiovascular disease all contribute
to the burden of chronic diseases which are replacing acute and communicable
diseases as the dominant public health problem even in the developing world. 1-4 These
diseases appear to have an unholy alliance increasing morbidity and mortality
and are expected to increase rapidly in the next two decades.
Chronic kidney disease plays a central role and represents a key element within
the network of major chronic diseases. For instance, chronic kidney disease
is a major risk factor for cardiovascular morbidity and mortality and is also
a major complication of diabetes mellitus and hypertension. 5 Patients
with reduced renal function represent a population not only at risk for progression
of kidney disease and development of end stage renal disease (ESRD), but also
at a greater risk of cardiovascular disease and mortality. Unfortunately, chronic
kidney disease is under diagnosed and undetected resulting in lost opportunities
for prevention. 6 There is paucity of programs for detection, management
and prevention of chronic kidney disease globally.
Chronic kidney disease has a prolonged latent period during which the disease
is present but asymptomatic with progressive renal damage. There is wide variability
in the rate of progression among individuals even when similar risk factors
are present. 7 This suggests the existence of biologically relevant
characteristics that influence the occurrence and course of renal disease.
This position is clearly illustrated among individuals with autosomal dominant
polycystic kidney disease (ADPKD). Family members who inherit the same mutation
of the polycystic gene may demonstrate highly variable rate of progression
to end stage renal disease. 7 Combinations of several factors that
result in rapid progression to end stage renal disease define the course of
the disease. 7, 8 Some of these factors may be causal while others
may be associated with but enhance other factors. 7, 9 Some of these
factors are modifiable while others are not. Early diagnosis with appropriate
interventions will improve the quality of care of patients and prevent or delay
progression to end stage renal disease. 8
Objective
The objective is to review existing expert recommendations and examine their
adaptation for improving the quality of care and outcomes of individuals with
chronic kidney disease in a poor economic environment.
Method
Hand searches of published literature and searches of electronic data bases
were the primary sources. Full journal articles of original data, review articles,
meta-analysis and editorials were considered. Case reports, letters and abstracts
were excluded. No systematic process was followed to obtain the articles. Only
articles published in English language were included in the search. Articles
of original data were searched from 1980 while review articles and expert committee
reports were searched from 2000.
Definition and Classification of Chronic Kidney Disease
Chronic kidney disease is defined either as kidney damage, evidenced by structural
or functional abnormalities, for not less than 3 months or a persistent decline
in glomerular filtration rate (GFR) to less than 60ml/min/1.73m2 for
not less than 3 months (Table 1). This definition has provided a basis for
the development of the kidney disease outcome quality initiative (K/DOQI) clinical
practice guidelines for chronic kidney disease evaluation, classification and
stratification. 10 Chronic
kidney disease is now uniformly defined 11 and risk factors for
initiation and progression identified (Tables 2, 3). Risk factors are also
classified based on response to appropriate intervention programmes and used
in cardiovascular disease epidemiology 10 (Table 4).
Chronic kidney disease can be diagnosed early by evaluating individuals with
risk factors for initiation and/or progression of kidney disease 12, 13 and
instituting appropriate interventions could either, reverse the disease process,
stop or slow down the progression of disease. 14
Table 1: Definition of chronic kidney disease
a. Kidney damage for not less
than three months, defined by structural or functional abnormalities
of the kidney with or without decrease in GFR, manifested by either: |
Pathological abnormalities, or
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Markers of kidney damage including abnormalities in composition of blood,
urine or imaging tests
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b. GFR less than 60mls/min./1.73m2 for
not less than three months with or without kidney damage
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GFR: Glomerular filtration rate
Table 2: Stages of chronic kidney disease
Stage
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Description
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GFR (mls/min./1.73m2
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1
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Kidney damage with normal or increased GFR
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90 or more
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2
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Kidney damage with mild decreased GFR
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60-89
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3
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Moderate decrease in GFR
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30-59
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4
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Severe decrease in GFR
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15-29
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5
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Kidney failure
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Less than 15 or requires dialysis
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GFR: Glomerular filtration rate
Table 3: Potential risk factors for susceptibility to and the initiation of
chronic kidney disease
Hypertension
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Renal stones
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Diabetes
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Autoimmune disease
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Age >60years
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Smoking
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Recovery from acute renal failure
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Illicit drugs use
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Male gender
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Neoplasm
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Low birth weight
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Reduced renal mass
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Low socio economic status
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Access to health care facility
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Recurrent or chronic urinary tract infection
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Oxidative stress/carbonyl stress
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Systemic infections
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Insulin resistance syndrome
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Obstructive uropathy
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Hyperlipidaemia
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Obesity
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Proteinuria
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Familial aggregation
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Genetic markers
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Lead and other heavy metals
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Poverty
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Analgesic abuse
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Dietary phytooestrogens
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Table 4: Classification of risk factors based on response to interventions
Classification
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Risk factor group
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Category I
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Factors for which interventions have been proven to lower risk
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Category II
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Factors for which interventions are likely to lower risk
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Category III
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Factors for which modification may lower risk
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Category IV
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Factors for which interventions have been proven to lower risk
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Early Diagnosis of Chronic Kidney Disease
The K/DOQI clinical practice guidelines for chronic kidney disease evaluation,
classification and stratification, recognize individuals with certain clinical
and socio demographic characteristics to have increased risk of developing
chronic kidney disease. 10 In guideline 3 of the clinical practice
guidelines, 10 some individuals without kidney damage and with normal
or elevated GFR are recognized to be at increased risk for developing chronic
kidney disease and recommend as follows:
a. All individuals should be assessed
as part of routine health encounter to determine whether they are at increased
risk of developing chronic kidney disease based on clinical and socio demographic
factors.
b. Individuals at increased risk of developing
chronic kidney disease should undergo testing for markers of kidney damage,
and to estimate GFR.
c. Individuals found to have chronic
kidney disease should be evaluated and treated as specified in guideline 2.
Evaluate to determine:
i. Diagnosis (type of disease)
ii. Comorbid conditions
iii. Severity of kidney disease
iv. Complications
v. Risk of disease progression
vi. Risk of cardiovascular disease
A clinical action plan should be developed for each patient based on the type
and stage of renal disease, comorbid conditions, complications of the disease
and risk factors for progression of renal disease or development of cardiovascular
disease.
d. Individuals at increased risk, but
found not to have chronic kidney disease, should be advised to follow of risk
factor reduction, if appropriate, and undergo repeat periodic evaluation.
Table 5: Recommended steps in screening for chronic kidney disease
Who to screen
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Patients at increased risk
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Arterial hypertension/cardiovascular disease
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Diabetes mellitus and other systemic diseases
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Age >60 years
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Family history of kidney disease
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Recurrent urinary tract infections
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How to screen
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Dipstick (spot urine) for proteinuria, WBC, RBC
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If positive for proteinuria, measure the total protein to creatinine
ratio in spot urine sample
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If negative for proteinuria, perform specific search for microalbuminuria
in patients with diabetes and/or hypertension
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If WBC or RBC positive, perform sediment analysis in spot urine sample
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Estimate GFR using Cockroft and Gault formula
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Evaluation
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If screening is negative, check again every 1-3 years depending on the
risk factors
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If abnormality is detected on screening, perform diagnostic and therapeutic
work up
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WBC: White blood cells; RBC: Red blood cells; GFR: Glomerular filtration rate
Table 6: Specific equations for estimating glomerular filtration rate
Adults
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MDRD study group equation
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GFR (ml/min/1.73m2) = 186 x (Scr in mg/dl) -1.154 x
(Age in years) -0.203 x (0.742 if female) x (1.210 if African-American)
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Cockcroft-Gault equation
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Ccr (ml/min) = (140 – Age in years) x weight x (0.85 if
female)
72 x Scr(mg/dl)
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Children
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Schwartz equation
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Ccr (ml/min) = 0.55 x length
Scr
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Counahan-Barratt equation
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GFR (ml/min/1.73m2) = 0.43 x length
Scr
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GFR: Glomerular filtration rate; MDRD: Modification of diet in renal disease;
Ccr: Creatinine clearance; Scr: Serum creatinine
Screening for Chronic Kidney Disease
Chronic kidney disease (CKD) detected early can be managed to prevent or slow
down the rate of progression to ESRD. 8, 10, 12 Failure to recognize
CKD early is a missed opportunity to improve patient outcome. While blood pressure
is checked at almost every visit to the doctor, dipstick urinalysis is seldom
considered even though it is cheap, available even in the rural areas and very
valuable. 12
Whole population based programs to promote screening for CKD should increase
the rate that persons with previously undetected renal injury are identified
and linked to further evaluation and disease modifying interventions. 7,
8, 10 Whole population surveys provide an opportunity for health education
and counseling by health care providers to promote awareness about the risk
of CKD and the benefits of early diagnosis and treatment. Despite the appeal
and potential benefits of whole population based screening programs, it is
clear from cost effective analysis that high risk population screening is more
practicable, more cost effective and more readily acceptable to policy makers. 9
The international society of nephrology (ISN) consensus workshopon the prevention
of progression of renal disease held in Hong Kong in June 2004 came out with
a consensus on screening for chronic kidney disease; who to screen, how to
screen and how to evaluate the result (Table 5).
Persons with increased risk of developing chronic kidney disease should be
tested for markers of kidney damage and estimate the GFR. A risk factor is
an attribute that is associated with increased risk of an outcome. The relationship
may be causal, determining the out come or may be non causal. Interventions
that reduce exposure to causal factors would improve outcome. Non causal factors
are associated with outcome through confounding relationship and intervention
to reduce exposure may not necessarily improve outcome.
The risk of occurrence or progression of CKD can be predicted from the existence
of certain risk factors (Table 3) and this enables the clinician to identify
individuals who may benefit from a limited screening program which is cost
effective. Such individuals will benefit from a more closely supervised care
and follow up and more intensive disease modifying interventions. Some of the
risk factors have been tested in randomized clinical trials and found to be
suitable targets for intervention. 7, 8, 10
If health care providers integrate the needed CKD screening within the existing
health care system, the population at high risk will be identified and targeted
for screening and intervention. The K/DOQI guidelines identify certain demographic
groups characterized by high incidence or prevalence of CKD as populations
that should be targeted for screening and prevention. 10 The progression
of CKD is affected by interplay of multiple risk factors with wide variability
in the rate of progression among individuals even when similar risk factors
are identified. 8, 10
Who should be screened?
If everyone were to be screened, hardly will anyone with chronic kidney go
undetected. Whole population screening is desirable but not practicable because
of logistics and huge financial burden. Representative sampling of the community
is recommended for establishing the burden of disease in the community. Screening
for chronic kidney disease should be part of routine examination for all persons
presenting to any health facility for any kind of service. Special attention
should be paid on persons at high risk of chronic kidney disease (Tables 3
and 4) if found negative, should be re screened at regular intervals every
one to three years depending on the underlying risk factors.
What to look for
1. Urine abnormalities
Proteinuria
Dipstick urine test on spot urine sample is a very valuable screening test.
It is simple, quick, cheap and easy to perform. 15 - 18 Abnormal
urinary excretion of albumin is a highly sensitive indicator of glomerular
disease. 8, 10, 19, 20 Normal individuals excrete small amounts
of albumin less than 30mg/day or proteins 80±24mg/day. Standard urine dipsticks
are acceptable for detecting increased total urine protein while albumin specific
dipsticks are acceptable for detecting albuminuria and will detect albumin
levels in urine when excretion is 300mg/day or more. Excretion between 30mg
and 299mg/day are detected as microalbuminuria. The dipstick test does not
detect paraproteins and is recommended for detecting CKD in adults and post
pubertal children because of its high sensitivity as a marker of CKD in hypertension,
diabetes and glomerular disease. 10 These are the three leading
causes of CKD in Nigeria. 21, 22
The National Kidney foundation K/DOQI clinical practice guidelines the following
for the assessment of proteinuria: 10
a. Under most circumstances, untimed
(spot) urine samples should be used to detect and monitor proteinuria in children
and adults.
b. It is usually not necessary to obtain
a timed urine collection (24 hours or overnight) for these evaluations in either
children or adults.
c. First morning specimens are preferred,
but random specimens are acceptable if first morning specimens are not available.
d. In most cases, screening with the urine
dipsticks is acceptable for detecting proteinuria:
i. Standard
urine dipsticks are acceptable for detecting increased total urine protein.
ii. Albumin
specific dipsticks are acceptable for detecting albuminuria
e. Patients with a positive dipstick
test (≥1+) should undergo confirmation of proteinuria by a
quantitative measurement (protein-to-creatinine ratio or albumin-to-creatinine
ratio) within 3 months.
f. Patients with two or more
positive quantitative tests temporarily spaced by 1 to 2 weeks should be diagnosed
as having persistent proteinuria and undergo further
g. Monitoring proteinuria in patients
with chronic kidney disease should be performed using quantitative measurements.
Patients with diabetes and/or hypertension, who have negative dipstick test for proteinuria, should be tested for microalbuminuria
as it predicts the later occurrence of overt proteinuria and also a marker
of increased cardiovascular complications in diabetes and hypertension. 10,
23-26 Orthostatic proteinuria must be excluded especially in children
by repeat measurements on first morning specimen if the initial proteinuia
was obtained on a random specimen.
2. Other urine abnormalities
The presence of red blood cells and or white blood cells in the urine may
indicate renal damage. Microscopic analysis of the urine sediment is recommended
in patients with chronic kidney disease and those at increased risk of developing
chronic kidney disease. 10 A significant number of cellular casts
highly suggest significant renal damage.
Imaging studies of the kidney should be performed in patients with chronic
kidney disease and those at increased risk of developing the disease.
Estimate glomerular filtration rate
The glomerular filtration rate should be the parameter used to evaluate the
level of kidney function because it is the best overall index of renal function. 10,
27-28 This should be estimated from prediction equations that take into
account serum creatinine concentration and some or all of the following variables:
age, gender, race and body size. 29-31 The following equations provide
useful estimates of GFR (Table 6):
i. The MDRD
(Modification of diet in renal disease) study group and Cockroft-Gault equations
for adults
ii. Schwartz
and Counahan-Barratt equations for children
The Cockroft-Gault equation estimates the creatinine clearance which over
estimates GFR in the obese, however it is a simple useful tool in estimating
the level of renal function and very valuable in adjusting drug dosages. 29-32 It
has been validated in adult Africans and shown to be reliable in screening
for CKD in the African adults. 33-34 The MDRD study equation estimates
the glomerular filtration rate more accurately and reflects the level of renal
function better especially in the obese and those with glomerular filtration
rate less than 90mls/min, 30 but it is more cumbersome to calculate.
The prediction equations are less reliable in screening for CKD in the African
children 35 and should be applied with caution while more reliable
methods are being sought. The serum creatinine alone should not be used to
assess the level of renal function because it is affected by factors such as
the muscle mass of the individual, diet, secretion, generation and extra renal
excretion. 36-38
References
- Harris MI, Flegal KM, Cowie
CC, Elerhardt MS, Goldstein DE, Little RR. Prevalence of diabetes impaired
fasting
glucose and impaired glucose tolerance in US adults. The third national health
and nutrition examination survey 1988-1994. Diabetes Care 1998; 21:518-524
- Burt VL, Whelton P, Rocella
EJ, Brown C, Cutter JA, Higgins M. Prevalence of hypertension in US adult
population.
Result from the third national health and nutrition examination survey 1988-1994.
Hypertension 1995; 25:305-313
- Chobanian AV, Bakris GL, Black
HR, Cushman WC, Green LA, Izzo JL. The seventh report of the joint national
committee on prevention, detection, evaluation and treatment of high blood
pressure. JNC VII report. JAMA 2003; 289:2560-2571
- United States renal data system.
Excerpts from the 2000 U.S. renal data system. Annual data report: atlas
of end stage renal disease in the United States. Am J Kidney Dis 2000; 36:S1-S279
- Weiner DE, Tighiouart H, Amin
MG, et al. Chronic Kidney disease as a risk factor for cardiovascular disease
and all-cause mortality: a pooled analysis of community based studies. J
Am Soc Nephrol 2004; 15:1307-1315
- Levey AS, Coresh J, Balk E,
et al. National kidney foundation practice guidelines for chronic kidney
disease;
evaluation, classification and stratification. Ann Intern Med 2003;139: 137-147
- McClellan WM, Flanders WD.
Risk factors for progression of chronic kidney disease. J Am Soc Nephrol
2003; 14:S65-S70
- Rossert JA, Wauters J-P. Recommendations
for screening and management of patients with chronic kidney disease. Nephrol
Dial Transplant 2002; 17(suppl 1):19-28
- McClellan W, Ramirez SPV,
Jurkovitz C. Screening for chronic kidney disease: unresolved issues. J Am
Soc Nephrol
2003; 14: S81-S87
- National kidney foundation (NKF) K/DOQI clinical
practice guidelines for chronic kidney disease; evaluation, classification,
and stratification. Kidney disease outcome initiative. Am J Kidney Dis 2002;
39: S1-S246
- Hsu CY, Chertow GM. Chronic renal confusion:
insufficiency, failure, dysfunction or disease. Am J Kidney Dis 2000; 36:415-418
- Bosan IB. Chronic kidney disease in Nigeria:
primary care physicians must intervene earlier. Nigerian Medical Practitioner
2006;
49: 18-23
- Hsu CY, Chertow GM, Gurhan GC. Methodological
issues in studying the epidemiology of mild to moderate chronic renal insufficiency.
Kidney Int 2002; 61: 1567-1576
- Nisienson AR, Collins AJ, Hurley J, Petersen
H, Periera BJ, Steinberg EP. Opportunities for improving the care of patients
with chronic renal insufficiency. Current practice patterns. J Am Soc Nephrol
2001; 12:1713-1720
- Zelmanovitz T, Gross JL, Oliveira JR, Paggi
A, Tatsch M, Azevedo MJ. The receiver operating characteristics curve in
the evaluation
of random urine specimen as a screening test for diabetic nephropathy. Diabetic
Care 1997; 20:516-519
- Schwab SJ, Christensen RL, Dougharty K, Klahr
S. Quantitation of proteinuria by use of protein
to creatinine ratio in single urine samples. Arch Intern Med 1987;
147:943-944
- Ginsberg JM, Chang BS, Matarese RA, Garella
S. Use of ingle voided urine samples to estimate quantitative proteinuria.
N Engl
J Med 1983; 309:1543-1546
- Nathan DM, Rosenbaum C, Protasowicki VD. Single
void urine samples can be used to estimate quantitative microalbuminuria.
Diabetes Care 1987; 10: 414-418
- Keane WF, Eknoyan G. Proteinuria, albuminuria,
risk assessment, detection, elimination (PARADE): position paper of the national
kidney foundation. Am J Kidney Dis 1999; 33:1004-1010
- Ruggeneti P, Gaspari F, Perna A, Remuzzi G.
Cross-sectional longitudinal study of spot morning urine protein/creatinine
ratio, 24 hours
urine protein excretion rate, glomerular filtration rate and end stage renal
failure in chronic renal disease without diabetes. BMJ 1998; 316:504-509
- Adelakun TA, Akinsola A. Hypertension induced
renal failure, clinical features, management and prognosis. West Afr Med
J 1998; 17:104-108
- Akinsola A, Odesanmi WO, Ogunniyi JO, Ladipo
GOA. Diseases causing renal failure in Nigeria: a prospective study of 100
consecutive
cases. Afr J Med med Sci 1989; 18: 131-137
- Mogensen CE. Microalbuminuria predicts clinical
proteinuria and early mortality in maturity onset diabetes. N Engl J Med
1984; 310:356-360
- Bigazzi R, Bianchi S, Baldari D, Sgherri G,
Baldari G, Campese VM. Microalbuminuria in salt sensitive patients. A marker
for renal
and cardiovascular risk factors. Hypertension 1994; 23:195-199
- Yudkin JS, Forrest RD, Jackson CA. Microalbuminuria
as predictor of vascular disease in non diabetic subjects. Lancet 1998; 2:
530-533
- Scheid DC, McCarthy LH, Lawler FH, Hamm RM,
Reilly KE. Screening for microalbuminuria to prevent nephropathy in patients
with
diabetes. A systemic review of the evidence. J Fam Pract 2001; 50:661-668
- Lindeman RD, Robin J, Shock NW. Longitudinal studies on the rate of decline in
renal functionwith age. J Am Geriatr Soc 1985; 33:278-285
- Manjunath G, Tighiouart H, Coresh J, Macleod
B, Salem DN, Griffith JL. Level of kidney function as a risk factor for cardiovascular
outcomes in the elderly. Kidney Int 2003; 63:1121-1129
- Cockroft DW, Gault MH. Prediction of creatinine
clearance from serum creatinine. Nephron 1976; 16:31-41
- Levey AS, Bosch JP, Breyer LJ, Greene T, RogersN,
Roth D. A more accurate method to estimate glomerular filtration rate from
serum creatinine: a new prediction equation. Ann Intern Med 1999; 130:461-470
- Levey AS, Green T, Kusek JW, Beck GJ, Group
MS. A simplified equation to predict glomerular filtration rate from serum
creatinine.
J Am Soc Nephrol 2000; 11:0828
- Cochran M, St. John A. A comparison between
estimation of GFR using 99TcDTPA clearance and the approximation
of Cockroft and Gault. Aust NZ J Med 1993; 23:494-497
- MCligeyo SO, Shoji T, Hayashi T, Kitamura E.
Calculation of creatinine clearance from plasma creatinine. East Afr Med
J 1993; 70:3-5
- Sanusi AA, Akinsola A, Ajayi AA. Creatinine
clearance estimation from serum creatinine values: evaluation and comparison
of five
prediction formulae in Nigerian patients. Afr J Med med Sci 2000; 29:7-11
- Gbadegesin RA, Asinobi AO, Osinusi K. Inaccuracy
of the Schwartz formula in estimating glomerular filtration in Nigerian children.
Ann Trop Paediatr 1997; 17:179-185
- Perrone RD, Madias NE, Levey AS. Serum creatinine
as an index of renal function: new insights into old concepts. Clin Chem
1992; 38:1933-1953
- Toto RD. Conventional measurements of renal
function utilizing serum creatinine, creatinine clearance, inulin and aminohippuric
acid clearance. Current Opin Nephrol Hypertension 1995; 4:505-509
- Shemesh O, Golbetz H, Kriss JP, Myers BD. Limitations
of creatinine as a filtration marker in glomerulopathic patients. Kidney
Int 1985; 28:830-838
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