Early Detection Of Renal Disease

Malaysian Society of Nephrology Ministry of Health Malaysia

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

Screening method
Serum creatinine Estimated glomerular filtration rate (GFR) Urine testing :
Urine dipstick Urine microscopic examination Urine microalbuminuria

Screening method Serum Creatinine

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

Relationship between serum creatinine and GFR

Screening method Estimated GFR

Estimated Glomerular Filtration rate
Man 1.23 x (140-Age) x BW Sr Cr (umol/l)

Woman

1.04 x (140-Age) x BW Sr Cr (umol/l)

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

Screening methods Microalbuminuria testing

Target groups for screening

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

Screening renal disease The 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)

Screening of renal disease : Hypertensive patients

Screening tests

Frequency

All hypertensive

UFEME BUSE/Cr UFEME BUSE/Cr USS KUB Other test

Yearly Yearly

Young hypertensive

Screening of renal disease Diabetic Patients

When to screen
DM Type 2 Type 1 First screening At diagnosis 5 years after diagnosis (age >12) Or earlier if CV risk Frequency yearly

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

Algorithm: Screening for proteinuria/microalbuminuria in DM

Urine dipstick for protein

Negative

Positive (Urine protein >300mg/l) On 2 separate occasions (exclude other causes)

Overt Nephropathy Quantify excretion rate 24HUP

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

Negative

Retest twice in 3-6/12 Exclude other cause

Yearly test

If 2 of test are positive Diagnosis of microalbuminuria Is established

Screening of renal disease Proteinuria

Proteinuria is a major manifestation of renal disease
Albumin Excretion Specimen collected 24 hr Collectio n (mg/24h) Timed Collection (ug/min) <20 20-200 First voided morning specimen Urine Albumin Concentration (mg/l) <20 20-200 Urine Albumin:creatinine ratio (mg/mmol) <3.5 women <2.5 men 3.5-35 women 2.5-25 men >35 women >25 men

Normoalbuminuria <30 Microalbuminuria 30-300

Overt Proteinuria

>300

>200

>200

Causes of false positive proteinuria

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

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 100150% increase in death rate
(Mogensen CE, New Eng. J. Med 1984;310:310-60)

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

Screening of renal disease Hematuria

Definition: > 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

Evaluation of asymptomatic hematuria

Detection of Microscopic hematuria >5RBC/hpf or +ve dipstik test

Exclude benign causes : Menstruating women Women with UTI False +ve result Recent strenous exercise Sexual activity, viral illness,trauma etc

Primary care investigation History Examination Renal function Urine microscopy and culture

Proteinuria Red cell cast/dysmorphic red blood cells Renal Impairment

Isolated microscopic haematuria and age >40 years

Nephrological referral Consider Urological referral

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

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

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