Section 2: Detection of CKD. What Tests Are Available? Direct GFR measurement –Inulin clearance –Radionuclides –Iohexol clearance 3 hr CrCl with Cimetidine.

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Presentation transcript:

Section 2: Detection of CKD

What Tests Are Available? Direct GFR measurement –Inulin clearance –Radionuclides –Iohexol clearance 3 hr CrCl with Cimetidine Prediction equations Cystatin C 24 hr urine CrCl Serum creatinine Accurate Inaccurate

Gold Standards Inulin clearance –Tedious, time consuming & unavailable Radionuclides – 125 Iodine-iothalamate, technetium DTPA, 51 Chromium-EDTA clearance –Time consuming and expensive –Research, accurate drug dosing

Serum Creatinine: Problems Non-renal influences Gender, ethnicity, age and muscle mass Nutrition/diet Drugs (e.g. cimetidine) Clinical utility Poor sensitivity for CKD Not useful in ARF Muscle wasting disorders and amputees Analytical problems Non-specificity (protein, ketones, ascorbic acid) No international standardization Spectral interferences (icterus/lipaemia/haemolysis)

Serum Creatinine Hides Early Renal Damage Serum creatinine (µmol/L) GFR (mL/min/1.73m 2 ) CKD stage Reproduction from the late David Newman Proportion misdiagnosis

Glomerular Filtration Rate Sum of all nephron filtration rates Best index of overall function Reduction implies a problem Translatable concept Equates to percentage Kidney function

GFR Prediction Equations Cockcroft-Gault formula C cr (ml/min) = 1.23 x (140-age) x weight/P cr (x 0.85 if female) MDRD Study equation GFR (ml/min/1.73 m 2 ) = 186 x [(P cr )/88.4] x (age) x (0.742 if female) x (1.210 if African American) Cockcroft & Gault. Nephron 1976; 16: Levey AS, et al. Ann Intern Med 1999;130:

MDRD equation vs serum creatinine Males Females eGFR (ml/min/1.73m 2 ) Middleton et al 2004 eGFR (ml/min/1.73m 2 ) sCr (µmol/L) sCr (µmol/L) 79.4% 27.7% 98.4% 81%

Scatter Increases as GFR Approaches Physiological Levels Froissart et al JASN 2005;16:

MDRD Formula: validation

What is Microalbuminuria? Definitions and prevalence Microalbuminuria is found in: –5-7% of the ‘healthy’ population 1,2 –12-30% of the hypertensive population 1,3,4 –25%-40% of people with diabetes 1,5 Comparison of tests uACR (mg/mmol) uPCR (mg/mmol) Dipstick Normal <2.5 (males) < 3.5 (females) <15- Microalbuminuria < (males) < (females) /trace Macroalbuminuria (clinical proteinuria) > /++ 1.Yuyun et al. Current Opinion in Nephrology and Hypertension 2005;14(3): Hillege et al. J Internal Medicine : (PREVEND) 3. Garg et al. Kidney International (NHANES-III) Atkins et al. Kidney International Supplement (AUSDIAB) Wachtell et al. Am Heart J. (LIFE) RA/RCP Joint CKD Guidelines 2006

NICE 2008: Diagnosis of CKD Proteinuria=ACR>30 or PCR>50 (NOT dipstick) 3 eGFR estimations <60 over a period not less than 90 days Progressive decline defined as eGFR falling by >5mls/min/year Focus on those whose observed rate of decline would necessitate RRT ‘within their lifetime’

NICE: 2008 Classification of CKD waking up to the impact of proteinuria Stage 1:GFR>90 + abnormal urinalysis Stage 2:GFR abnormal urinalysis Stage 3A:GFR Stage 3B:GFR Stage 4:GFR Stage 5: GFR <15 or dialysis dependent Suffix P denotes presence of proteinuria (ACR>30 or PCR>50)