Early Detection Of Renal Disease

1
Early Detection Of Renal Disease
2
Common clinical presentations of kidney disease

• Asymptomatic urine abnormalities
• proteinuria/ haematuria
• Nephritic/Nephrotic syndrome
• Hypertension
• Unexplained anaemia
• Incidental finding of elevated serum Creatinine
• Uraemic emergencies

3
Screening method

• Serum creatinine
• Estimated glomerular filtration rate (GFR)
• Urine testing

• Urine dipstick
• Urine microscopic examination
• Urine microalbuminuria

4
Screening method Serum Creatinine

• Sr creatinine is poor reflection of early renal
  disease/failure
• Damage lt 60 sr creatinine still normal
• Almost all early renal failure patients are
  asymptomatic
• SCREENING IS THEREFORE VERY IMPORTANT

5
Relationship between serum creatinine and GFR
6
Screening method Estimated GFR
Estimated Glomerular Filtration rate
1.23 x (140-Age) x BW Sr Cr (umol/l)
Man
1.04 x (140-Age) x BW Sr Cr (umol/l)
Woman
7
Screening methods Urine testing

• Urine for protein
• Dipstick
• 24 hour urinary protein
• Urine microscopic examination
• For RBC / Pus Cell / Cast
• Urine for microalbuminuria
• On morning urine sample
• using strip for microalbumin

8
Screening methods Microalbuminuria testing
9
Target groups for screening

• Mass population screening is not cost effective
• Screening of high risk groups to develop renal
  disease/failure

10
Screening renal diseaseThe High Risk Groups

• Hypertensive patients
• Diabetic patients
• Cardiovascular disease
• Proteinuria
• Hematuria
• Those on regular NSAID/Herbs

• Renal calculi
• Anemia of unknown aetiology
• First and second degree relatives of ESRD
• Autoimmune disease (SLE/RA)
• Reduction of kidney mass(Nephrectomy)

11
Screening of renal disease Hypertensive
patients
12
Screening of renal disease Diabetic Patients
When to screen
Methods

• BP
• Urine Protein
• Urine Microalbuminuria
• BUSE/Creatinine yearly if normal

13
Algorithm Screening for proteinuria/microalbuminu
ria in DM
Urine dipstick for protein
Positive (Urine protein gt300mg/l) On 2 separate
occasions (exclude other causes)
Overt Nephropathy Quantify excretion rate 24HUP
Negative
Screen for Microalbuminuria (on early morning
spot urine)
Positive
3-6 monthly follow-up of
microalbuminuria Optimise glycaemic
control Strict Bp control ACE/ARB Stop
smoking Lifestyle modification Treat
hyperlipidaemia Avoid excessive protein
intake Monitor renal function Monitor other
endorgan damage
Retest twice in 3-6/12 Exclude other cause
Negative
If 2 of test are positive Diagnosis of
microalbuminuria Is established
Yearly test
14
Screening of renal diseaseProteinuria
Proteinuria is a major manifestation of renal
disease
15
Causes of false positive proteinuria

• Urinary Tract Infection
• Sepsis
• Heart Failure
• Strenous exercise
• Heavy protein intake
• Menses

16
Significance of Proteinuria

• A dominant risk factor for deterioration of renal
  failure (besides HT)
• Marker of Increased Risk for CV mortality and
  morbidity (DM non-DM)
• e.g. Microalbuminuria is associated with a 100-
  150 increase in death rate
• (Mogensen CE, New Eng. J. Med 1984310310-60)

17
Evaluation of persistent proteinuria
History Physical Examination Urine Examination
of Urinary sediment
Abnormal
Normal
refer to a nephrologist
Repeat visit for a Qualitative proteinuria test
Positive Do Renal profile Quantitate urinary
protein Refer to nephrologist
Negative Transient proteinuria Reassure
18
Screening of renal diseaseHematuria

• Definition
• gt 3-5 rbc/hpf on urinary sediment examination
• In clinical practice can be diagnosed by urine
  dipstick test
• False positive
• povidone-iodine
• oxidising agents

• False negative
• vit C excretion
• air-exposed dipsticks

19
Evaluation of asymptomatic hematuria
ALGORITHM FOR INVESTIGATION OF HAEMATURIA
20
Benefits of early detection

• 1. Proper investigation and accurate diagnosis
• - definitive diagnosis relevant for

• a) specific disease treatment
• e.g. immunosuppression
• b) future transplant
• timing, risk of recurrent disease etc
• c) counselling and screening of relatives

21
Benefits of early detection

• 2. Allows measures to retard disease progression
  to be instituted and maximised
• 3. Complications associated with failing
• renal function can be addressed

• anaemia
• renal bone disease,
• malnutrition

22
Benefits of early detection

• 4. Enables timely referral to nephrologists

• Adequate time for preparation of patients for
  renal replacement therapy

• education regarding options
• timely creation of AVF
• placement of Tenckhoff catheters

• Avoids the increased mortality and morbidity
  associated with temporary dialysis catheters and
  IPD