2. بِسْمِ اللَّهِ الرَّحْمَنِ الرَّحِيمِ صدق الله العظيم

4. SCREENING FOR OCCULT CHRONIC KIDNEY DISEASE IN PATIENTS ATTENDING THE OUTPATIENT CLINICS IN SOHAG UNIVERSITY HOSPITAL

5. . ESRD is usually the result of slowly progressive kidney damage. Due to the asymptomatic nature of renal disease, kidney damage frequently remains undetected until late in the course, at which stage therapeutic interventions are often ineffective. In contrast, early detection and intervention may slow the decline toward ESRD

6. Fortunately, the large burden of CKD does not appear to be inevitable; it can be reduced substantially. A key will be the early identification of individuals who are at risk. There is evidence that earlier stages of CKD can be detected and treated and that adverse outcomes of CKD can be prevented or delayed

7. The (NKF- K/DOQI) defines CKD as kidney damage for 3 months or longer defined by structural or functional abnormalities of the kidney, with or without decreased (GFR) manifested by: Markers of kidney damage, including abnormalities in the composition of the blood, urine or abnormalities in imaging tests. Or GFR of less than 60 ml/min/1.73 m 2 for 3 months or longer with or without kidney damage.

8. Diabetes mellitus Glomerulonephritis Genetic diseases Drugs: penicillin, (NSAIDs), proton pump inhibitors, ACEis and diuretics. Urological conditions : as Reflux nephropathy, Urinary tract obstruction. Infections: streptococcal infection, HIV, hepatitis B and C, tuberculosis and malaria.

9. SCREENING FOR OCCULT CHRONIC KIDNEY DISEASE IN PATIENTS ATTENDING THE OUTPATIENT CLINICS IN SOHAG UNIVERSITY HOSPITAL

10. To screen for chronic kidney disease stages 1 to 4 in patients attending Sohag University Hospital outpatient clinics. OBJECTIVES 1.To detect the prevalence of stages of CKD among patients attending outpatient clinics in Sohag University Hospital. 2.Compare between prevalence of CKD in Diabetic, non Diabetic patients and patients with recurrent urinary tract infection ( RUTI).

11. SCREENING FOR OCCULT CHRONIC KIDNEY DISEASE IN PATIENTS ATTENDING THE OUTPATIENT CLINICS IN SOHAG UNIVERSITY HOSPITAL

12. This study is a screening program carried out among patients at high risk for CKD including participants with a personal history of diabetes mellitus, hypertension, RUTI, CVD, compared to a control group, attending the internal medicine outpatient clinics in Sohag University Hospital. It is a cross sectional descriptive epidemiologic study done to screen for CKD in these population groups.

13. Subjects selected (n=150), were ≥40 years, were divided into 3 groups: Group I: They were 50 patients, having type II DM, chosen on basis of personal history of type 2 DM, oral anti- diabetic treatment, or file record of diabetes. Group II: 50 non diabetic patients having personal history of (RUTI) (more than three UTIs per year). Group III: (the control group): 50 healthy subjects without DM, hypertension and without UTI.

14. Subjects who satisfied the following inclusion criteria were enrolled in the study: 1.Age ≥ 40 years. 2.Type 2 DM (only in group I), RUTI (only in group II).

15. Subjects excluded had the following criteria: 1.Type 1 DM. 2.Age ≥70 years. 3.Patient on corticosteroids. 4.Recent surgery. 5.Patient with cardiac failure. 6.Patient with malignancy. 7.Patient with liver cirrhosis. 8.Patients known to have ESKD, or on regular hemodialysis. 9. Pregnant patients

16. Each subject was subjected to the following: 1.History : A Subjective history was obtained by the researcher from each subject, using a Questionnaire which included questions about: Socio-demographic (age, gender and educational status), area of residence (rural or urban), employment status, smoking, personal health (diabetes, hypertension, CVD, CKD, UTI, drug intake and other health related criteria). 2.Clinical examination: General and abdominal examination 3.Measuring of weight and height: To calculate BMI.

17. 4.Measuring blood pressure. 5.Laboratory investigations; including a)Blood sugar. b)S.Cr used to calculate eGFR by the MDRD method. c)HbA1c: Done for diabetic patients only d)urine analysis: to check for Proteinuria, Pyuria, and Hematuria. e)Albumin creatinine ratio: Done for diabetic patients only using spot urine collection. 6.Radiological investigations: Abdominal ultrasound is done for any person having serum creatinine >1.5 mg/dl.

18. All participants provided informed Verbal consent. This study was approved by the Ethics committee of the Public Health of Cairo University. Consent was obtained from each subject after explanation of the aim of the study and investigations that will be done for each subject.

19. SCREENING FOR OCCULT CHRONIC KIDNEY DISEASE IN PATIENTS ATTENDING THE OUTPATIENT CLINICS IN SOHAG UNIVERSITY HOSPITAL

20. Mean of S. Cr is highest in group Ι (1.1 mg/dl), with significant difference in comparison with other groups (p=0.003). Stages 3 and 4 CKD patients had S.Cr ranging from 1.2 mg/dl to 3.5mg/dl with 83% of cases having S.Cr > 1.5 mg/dl, this means that 17% of CKD patients stages 3 and 4 will be missed if S.Cr only was used for screening and this demonstrates the value of eGFR as a screening tool.

21. Figure (1): Showing mean of serum creatinine among the 3 groups

22. The prevalence of dipstick Proteinuria in the total subjects, was 18%, with the highest prevalence in group ΙΙ (26% of the group), while group Ι had a prevalence of (20%), and a statistically significant difference was found between the3 groups (p value = 0.025).

23. HbA 1c measured in group Ι subjects, ranged from 5-11 with a mean of 7.7±1.3. (38%) of the group have controlled blood sugar (HbA 1c ≤7), while 62% have uncontrolled blood sugar (HbA1c>7).

24. The prevalence of CKD in total population of the study depending on the MDRD method equals 16%, represented in the 3 groups in the following figure. Prevalence of CKD among the 3 groups as a percent of the group

25. Frequency of CKD % of group % of CKD patients P value Group I 1326%54 % P1 =0.23 P2 =0.002 P 3 =0.026 P=0.010 Group II 918%38 % Group III 24%8 % Total 2416%

26. Prevalence of CKD stages among the 3 groups as a percent of the total CKD patients

27. Variables Group ІGroup ІІ Group ІІІ Total P value CKD stage Stage16(14%)4(9%)1(2.3%)11 (25%) 0.95 Stage25(11%)3(7%)1(2.3%)9 (20.5%) Stage37(16%) 1(2.3%)15 (34%) Stage46(14%)2(4%)1(2.3%)9 (20.5%) Total 24(55%)16(36%)4(9%) 44 (29.3%) **

28. Age, Diabetes, hypertension, CVD, smoking and illiteracy have a statistically significant relation to CKD, and so the subjects with CKD were more elderly, hypertensive and had a higher prevalence of illiteracy and personal history of CVD and diabetes.

29. our study showed significant relation between glycemic control and prevalence of CKD in Group Ι, as none of the subjects with controlled blood sugar (HbA1c ≤7) had CKD while 42% of subjects with uncontrolled blood sugar had CKD. This finding indicates the importance of glycemic control in the prevention of CKD and is concomitant with other studies which correlate between CKD and hyperglycemia.

30. More than half (53%) of the hypertensive patients have uncontrolled blood pressure (>140/90 mm Hg), this means bad blood pressure control in our population and is considered as a contributing factor in establishing CKD. A significant relation was present between hypertension and CKD with a positive correlation (p= 0.000, r =0.33).

31. CVD was present in 14% of the population. It is most prevalent in group Ι (26% of the group, 62% of the CVD patients). A significant relation was present between CVD and CKD (p= 0.000) and 50% of CKD patients had CVD.

32. It was found that CKD shows high prevalence in patients attending Sohag University Hospital outpatient clinics, the prevalence of CKD (defined as eGFR< 60) depending on the (MDRD) equation equals 16%, Group I (diabetic patients) have the highest prevalence of CKD. The prevalence of dipstick Proteinuria in the total subjects (n=150) was 18%.

33. Diabetics and patients with RUTI are high risk groups in need for regular screening program, also a significant relation was found between old age, glycemic control, hypertension, smoking, nephrotoxic drugs intake, Low level of education and CKD. It was found that 17% of CKD patients of stages 3 and 4 will be missed if serum creatinine only was used for screening and this demonstrates the importance of using the eGFR as a screening tool for CKD.

34. SCREENING FOR OCCULT CHRONIC KIDNEY DISEASE IN PATIENTS ATTENDING THE OUTPATIENT CLINICS IN SOHAG UNIVERSITY HOSPITAL

35. The high prevalence and low awareness of CKD in Sohag governorate in Upper Egypt further emphasizes the need for sustained, integrated, population-based programs to prevent, delay the progression of, and treat CKD. We recommend organizing educational activities, campaigns and days to provide education to the general public and primary care providers about CKD in cooperation with social and political organizations.

36. The high prevalence of uncontrolled blood pressure and blood sugar raises our attention for performing health programs and activities for controlling these chronic diseases and their complications including kidney diseases. We also recommend a similar study to measure awareness of people at high risk for CKD (e.g. Patients with Hypertension, Diabetes mellitus, low educational state, obese, etc.) and more efforts should be done by health providers to deliver health education to these groups so as to reduce new cases, disability and economic costs.

37. Educational program for nephrologists and practitioners should be strengthened with special emphasis on etiological factors leading to ESRD, blood pressure and diabetes mellitus control appears to be an important strategy to improve outcomes. Finally, the role of media in our community should be increased and health educational programs should be done through it aiming at increasing awareness of the general population about CKD, risk factors and methods of primary and secondary prevention.