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Assesment of renal function in case of near normal creatinine (<1.5 )

Assesment of renal function in case of near normal creatinine (<1.5 ). Naseer Khan MD . Burden of CKD Stage II in USA. According to the NHANES III-study the prevalence of stage 2 chronic kidney disease is 3% in the American population i.e. about 9000000 persons are afflicted.

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Assesment of renal function in case of near normal creatinine (<1.5 )

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  1. Assesment of renal function in case of near normal creatinine (<1.5 ) Naseer Khan MD

  2. Burden of CKD Stage II in USA • According to the NHANES III-study the prevalence of stage 2 chronic kidney disease is 3% in the American population i.e. about 9000000 persons are afflicted

  3. Prevalence of CKD by GFR in the USA(There is a lot of CKD!) Coresh, et al, Am J Kidney Dis. 2003; 41: 1-12

  4. What is GFR ? • It is the volume of glomerular filtrate produced per unit of time, e.g. mL/min • GFR Quality means the composition of GFR in a patient relative to normal person • Real GFR not measurable except in lab. • 80,000 nephrons make it less easy • Surrogate markers with limitations in use

  5. Gold Standard Methods • Plasma clearance of inulin, iohexol, 51Cr-EDTA, 125I-iothalamate, 99mTc-diethylenetriaminepentaacetic acid • GFR markers are creatinine and Cystatin C which are now clinically used • GFR equations are based on either S.Creatinine and Cystatin C

  6. Problems with S.Creatinine • Varies with age , sex , muscle mass • Also varied results with exercise and protein intake • Does not show or predict quality of GFR like in cases of pre-eclempsia • One equation alone cannot predict accurate GFR • Both secreted and excreted

  7. Cystatin C • All nuclear human cells produce this protein • 120 amino acid ( small Mol.weight) • Removed from blood stream by filtration by kidneys; fully reabsorbed ( no urine excretion) • Decline in GFR results in rise of Cystatin C • Cross sectional studies show superiority to creatinine

  8. Emerging role of Cystatin C • Demonstrates the early, potentially reversible, decrease of GFR in the “creatinine-blind” area • Independent of muscle mass and diet • Independent of sex and age for children above 1 year • Demonstrates the decrease of GFR in old persons • No tubular secretion ; CV mortality data

  9. Creatinine limitation with age

  10. Age related Cystatin C levels

  11. Creatinine blind area

  12. GFR-markers for patients with muscle atrophy Non-parametric ROC plots for serum cystatin C (solid line) AUC = 0.912 and serum creatinine (dotted line) AUC = 0.507 AUC = 0.50 equals the diagnostic efficiency of tossing a coin

  13. Why use equations? • Equations estimate GFR taking into account creatinine; age ; gender; body surface area ; race • Adults : Cockcroft-gault equation • MDRD equation • Children :Schwartz & Counahan-Barratt equations

  14. Any value of 24 hours urine collection • 24 hr collection does not improve GFR estimation ( equations are better) • Helpful in persons with exceptional dietary variation ( vegetarians; protein diet) • Amputees • Muscle wasting /atrophy/ malnourished patients • Criteria for starting dialysis

  15. GFR equations • MDRD: GFR = 186.3 x (creatinine/88.4)-1.154 x age-0.203 • x 0.742 (if female) x 1.212 (if African American) • GFR(CC-estimate)= 84.69 x cystatin C-1.680 x 1.384 (if child<14years)

  16. Is GFR always the best marker for kidney disease/function? • Qualitative and quantitative measurement of urine proteins more important in paraproteinemia • Erythropoiten is a better marker for hormonal function of kidney • GFR quality is altered in Pre-eclempsia which is not detected by creatinine but is better outline by Cystatin C

  17. Cystatin C in Pre-eclempsia

  18. Creatinine in pre-eclempsia

  19. What do we do now ? • Use History and Physical as Gold Standard • Keep in mind limitations of serum creatinine measurement • Use more than one GFR marker • Use more than one equation while using S.Cr ( Lund University online equation) • Cystatin C seems promising esp. for qualitative analysis

  20. Identify High Risk Groups • Diabetes • Hypertension • Heart Disease • Family History • High Risk Ethnic Group • Age > 60 years • Screening : eGFR • Urinalysis • Albumin / Creatinine Ratio

  21. PCP Must be Engaged • 7.7 million people with GFR 30-60 mL/min/1.73 m2 • About 5,000 full-time nephrologists • Nearly 1,500 new patients per nephrologist Therefore, 7 new patients per day per nephrologist. Obviously not possible.

  22. Prevention Of Renal Failure Who should take the lead? The primary care physician and the nephrologists PRIMARY CARE PHYSICIAN NEPHROLOGISTS Screening Diagnosis Treatment Diagnosis Management Pre Dialysis care

  23. Old Chinese saying……. Gooddoctorrelieve disease Betterdoctorcure disease Superiordoctorpreventdisease

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