Prevalence of normoalbuminuric chronic kidney disease among individuals with type 2 diabetes mellitus from India

Background & objectives: A subset of diabetic individuals are known to develop progressive renal insufficiency without albuminuria, referred to as normoalbuminuric chronic kidney disease (NACKD). There is, however, a paucity of studies regarding this condition in India. So, this study, aimed to find the prevalence of normoalbuminuric renal dysfunction and its clinical associations in diabetic Indian population. Methods: Medical record search of patients with type 2 diabetes mellitus at a tertiary care centre was done. Based on the urinary albumin:creatinine ratio (>30 mg/g creatinine) and estimated glomerular filtration rate (e-GFR) (<60 ml/min/1.73m2), individuals were classified as having, (i) no kidney disease (NKD), (ii) chronic kidney disease (CKD), (iii) albuminuria alone (ALB), (iv) normoalbuminuric low e-GFR (NACKD) and (v) albuminuria with low e-GFR albuminuric CKD (ACKD). Furthermore, the clinical and biochemical parameters of these groups were also compared. Results: Data from 3534 diabetes patients with a mean age of 53.8±10.9 yr and mean duration of diabetes of 10.3±7.5 yr were available for the analysis. NACKD constituted 39.1 per cent of the patients with reduced e-GFR, NACKD was found in 2.1 per cent and ACKD in 3.4 per cent of all diabetic patients. Compared to NKD patients, was found an independent association between NACKD and higher age, male sex, lower body weight and statin intake but not with glycated haemoglobin, fasting and postprandial plasma glucose. Patients with NACKD were found to be older than those with ACKD. Retinopathy was found to be more prevalent in the ACKD patients, whereas the rates of macrovascular complications were found to be similar between the groups. The prevalence of NACKD relative to ACKD decreased in CKD stages 3b, 4 and 5. Interpretation & conclusions: The results of this study suggest that NACKD constituted greater than one third of patients with diabetes and decreased e-GFR, which showed a strong association with age but not with duration or severity of hyperglycaemia or the presence of retinopathy. Both NACKD and ACKD showed similar associations with macrovascular disease

Awareness and Application of Creatinine Clearance/eGFR in Non-Nephrology Doctors

Introduction: We conducted this study to determine the awareness of usage of estimated GFR/creatinine clearance formulas while dealing with patients in various wards and outpatient departments of different tertiary hospitals in Lahore in doctors who are not working or trained in nephrology, it was done by using a questionnaire in between January 2019 to May 2019. It was found that good percentage of doctor is not using basic formulas and need education by fellow nephrology colleagues for basic patient management, drug dosing, and referral. Objective: To study the awareness and usage of creatinine clearance calculations in doctors not trained in nephrology. Study design: Descriptive, cross-sectional study. Methodology: The cross-sectional observational study was conducted. A questionnaire was designed which included questions about knowledge of estimated GFR/creatinine clearance, calculation methods, use of these formulas while dealing with patients for defining and diagnosing AKI and CKD, medicine dosage adjustment according to creatinine clearance and referral to nephrologists. Results: A total of 170 doctors working in different specialties were contacted and all of them filled questionnaire. 56 (32.9%) doctors answered that they know and calculate eGFR in routine practice while 114 (67.1%) were not performing eGFR while encountering patients. 80 (47.1%) were confident in staging chronic kidney disease and 90 (52.9%) were unable to stage chronic kidney disease on basis of eGFR. In routine patients dose and adjustment according to GFR was documented by 39 (22.9%) doctors and 131 (77.1%) doctors were not practicing dose adjustments for different medicines after calculating GFR. Referral to nephrologist was being done 99 (58.2%) doctors and 71 (41.8%) were not referring patients to nephrologists. Conclusion: Several considerable challenges remain regarding CKD and AKI early diagnosis and management and referral in Pakistan including inadequate knowledge and training systems, and needs education in this regard.

Serum fibroblast growth factor 23 levels in chronic kidney disease and its correlation with bio-chemical parameters in chronic kidney disease: a cross sectional comparative study

Background: Globally, chronic kidney disease (CKD) is a major public health problem. Fibroblast growth factor (FGF)-23 is a newly recognized phosphatonin secreted by the osteocytes which acts as a key regulator of serum phosphate levels in CKD. In the present study, we aimed to estimate the levels of serum FGF-23 in patients with CKD and to compare them with healthy controls. Also, we aimed to compare the levels of FGF-23 levels with creatinine clearance and kidney size in various stages of CKD.Methods: A cross sectional comparative study was conducted at Thiruvarur Government Medical College hospital in Tamil Nadu. Patients aged between 20 and 65 years with an established diagnosis of CKD and healthy controls were included in the study. Enzyme Immuno-Assay method was followed for the estimation of FGF-23. Spot Urine sample was collected to determine the presence of albumin. Serum levels of glucose, Urea, Creatinine, Electrolytes (Sodium, Potassium), Albumin, Calcium, Phosphorus and Alkaline Phosphatase were measured. Information on kidney size, cortical echogenicity, parenchymal thickness and cortico-medullary differentiation were assessed based on ultrasound abdomen.Results: A total of 45 CKD cases and 45 healthy controls were studied. Mean (SD) age of CKD cases was 54(11) years and that of controls was 46(9.6) years. The mean value of FGF23 in cases was 730.7±492.7 pg/ml and this was higher than that of the control group whose mean value was 39.49±12.47 pg/ml (P<0.05). Mean GFR levels in cases and controls were 23.8 and 113.8 and this difference was statistically significant (P value<0.0001). Among cases, Pearson correlation between serum FGF-23 levels and eGFR, serum albumin was statistically significant and had a negative inverse correlation.Conclusions: The present study demonstrated that serum FGF23 levels were significantly increased in patients with CKD. This increase in serum FGF23 levels were progressive from the early stages to the late stages of CKD.

Role Of Nigella Sativa In Renoprotection

Objective:To evaluate the role of Nigella sativa in renoprotectionMaterial and Methods:This prospective, comparative study was completed in a tertiary care centre of north India in patients of Chronic Kidney Disease (CKD). Group I (Control) received conservative management of CKD and while Group II (Test) received conservative management along with Nigella sativa oil (2.5 mL, orally, once daily) for 12 weeks. Renal function tests were done at 0, 6 and 12 weeks of treatment.Results:There was more progressive improvement in biochemical values and clinical signs and symptoms in test group. There was decrement in blood urea, serum creatinine and 24-hour total urine protein (TUP). There was rise in glomerular filtration rate (GFR) and 24-hour total urine volume (TUV). Conclusion:Nigella sativa oil supplementation is effective and safe in prevention of progression of nephropathy.

Impact of percutaneous nephrolithotomy operation on non-operated kidney: a single center based study

Background: Effects of percutaneous nephrolithotomy (PCNL) operation on ipsilateral renal function are widely known but functional changes in opposite kidney are limited. Authors have conducted this study to evaluate the impact of PCNL operation on the contralateral side during early post-operative period.Methods: From 1st November 2016 to 30th September 2018, those patients presented with unilateral renal stone disease were enrolled. After exclusion they were subjected to PCNL operation under general anaesthesia. Along with preoperative period, 99 m Tc DTPA renal scan is repeated at 3rd and 14th post-operative period.Results: Out of 121 patients enrolled we included 96 patients after exclusion. They are divided into 3 age groups, 19-32, 33-47 and 48-60 years. The mean GFR at pre-operative, post-operative day-3 and 14 of normal kidney in these 3 age groups are 47.32, 47.63 and 42.32 ml/min, 44.29, 45.78 and 40.63 ml/min and 47.10, 48.47 and 41.01 ml/min respectively. At post op day-3 there are reduction of mean GFR in all age groups but statistically not significant (p >0.05). At post-operative day-14 GFR improved towards the pre-op value but the change is also not significant (p >0.05).Conclusions: There are reduction of GFR of contralateral normal kidney following PCNL operation in early post-operative period. So, along with operated kidney normal kidney also showed decrease GFR. It is better to avoid further trauma in post PCNL patient like avoidance of using nephrotoxic medication, contrast agents, ESWL, etc. This study can guide us to avoid further trauma of any kidney.

Study of C-Reactive Protein Significance in Chronic Kidney Disease

Introduction: Chronic kidney disease (CKD) is a worldwide major disease, both for the number of patients and cost of treatment involved. Screening for CKD at an early stage helps to initiate specific therapy to reduce the progression of renal disease and burden of end stage renal disease (ESRD). Patients with CKD and ESRD show elevated acute phase C-reactive protein (CRP) levels as a consequence of chronic inflammatory states. The aim of this research was to study the significance of CRP with objective of finding an association between the CRP and parameters of other co-morbidities. Material and methods: The study was conducted in the Department of General Medicine, Civil Hospital, Aizawl. Chronic kidney disease patients admitted in the General Medicine ward were included in the study. 140 CKD patients fulfilling the inclusion and exclusion criteria were included to study the significance of CRP in CKD. CKD is defined as kidney damage or GFR < 60 ml/min/1.73 m2 for 3 months or more. All the patients selected for the study was investigated for serum CRP, Albumin, Creatinine, eGFR and ankle brachial index. Results: Most common past history of CKD patients was hypertension (29.3%) and diabetes mellitus (21.4%). >10 mg/L CRP patients serum albumin range (3.43±0.982 gm/dl) was significantly lower than <10 mg/L CRP patients (5.40±1.169 gm/dl). >10 mg/L CRP group eGFR range (35.74±7.54 ml/ min/1.73 m2 ) was significantly lower than <10 mg/L CRP group (42.39±11.47 ml/min/1.73 m2 ). Conclusion: This study shows a high rate of inflammation in CKD patients as seen by high CRP levels. High CRP levels are associated with lower eGFR and lower serum albumin levels

A Prospective Tertiary Care Hospital Based Study on Prevalence of Anemia in Non-Dialysis Chronic Kidney Cases

Background: A decrease in the glomerular filtration rate (GFR) shows chronic kidney disease (CKD). It may develop any structural or functional renal abnormalities. Methods: 140 total number of cases were included. This study was conducted in the Department of Pathology in Krishna Mohan Medical College & Hospital, Mathura, U.P, India. Result: The mean fasting blood sugar was 133.29 ± 12.63; the mean Post prandial blood sugar was 155.82 ± 12.56. The mean Hb1Ac were 6.16 ± 1.36 and serum creatinine was 3.76 ± 1.36 mg/dl. Finally, the mean hemoglobin for the whole sample was 10.74 ± 2.17 gm%. Conclusion: This study concludes that in future one could carried out research on large sample size along with a matched control group, simultaneous assessment of other biochemical parameters, and burden of various other metabolic for better results.

Relationship between glomerular filtration rate and acute ischemic stroke in middle-aged and elderly population / 上海交通大学学报（医学版）

Objective: To explore the occurrence risk and clinical significance of glomerular filtration rate (GFR) level and acute ischemic stroke in middle-aged and elderly population. Methods: The clinical data of 292 hospitalized patients in the Department of Neurology at the No.908 Hospital of the People's Liberation Army Joint Logistics Support Force from Jan. 2016 to Jun. 2018 were retrospectively analyzed, including gender, age, diastolic blood pressure, body mass index, smoking and drinking history, erythrocyte count, brain images, and the level of blood glucose, low density lipoproteincholesterol, high density lipoprotein-cholesterol, total cholesterol, GFR, blood urea nitrogen, blood uric acid, serum creatinine, glutamic-oxaloacetic transaminase, homocysteine. According to the GFR level, patients were divided into normal GFR group and low GFR group. The clinical characteristics were compared between two groups. Multivariate Logistic regression analysis was used to investigate the relationship between GFR level and the occurrence of acute ischemic stroke. Results: The number of patients in normal GFR group and low GFR group was 154 (52.74%) and 138 (47.26%), respectively. Chi-square test or t test analysis showed that there was no significant difference in gender, body mass index, smoking history, drinking history, erythrocyte count, blood glucose, low density lipoprotein-cholesterol, high density lipoprotein-cholesterol, total cholesterol, glutamic-oxaloacetic transaminase and homocysteine between two groups, and significant difference in age, diastolic blood pressure, GFR, blood urea nitrogen, blood uric acid, serum creatinine (all P<0.05). The incidence rate of acute ischemic stroke in normal GFR group and low GFR group was 41.56% (64/154) and 59.42% (82/138), respectively (χ2=9.291, P=0.002). Compared with the normal GFR group, the occurrence risk OR (95% CI) of acute ischemic stroke in lower GFR group was 2.06 (1.29-3.29) (P=0.002) and 2.04 (1.01-4.12) (P=0.047) before and after adjusted the related risk factors. Conclusion: The low GFR levels are associated with the occurrence of acute ischemic stroke in middle-aged and elderly population.

A study on FGF23 among chronic renal failure patients in Perambluar District

Background: Fibroblast growth factor 23 (FGF23) is a phosphate-regulating hormone primarily secreted by osteocytes. Levels of FGF23 increase as kidney function declines as a physiologic response to maintain normal serum phosphate levels and neutral phosphate balance. Although FGF23 helps to prevent hyperphosphatemia, elevated circulating levels are independently associated with vascular dysfunction, left ventricular hypertrophy, increased risk for ESRD, and death in patients with CKD. Aim of the study: To evaluate the FGF23 and eGFR levels in chronic kidney disease patients to compare them with healthy controls. Materials and methods: Totally 100 patients were included in the study. The study was conducted from June 2018 – November 2018 over a period of 6 months at Nephrology department of DSMCH, Perambalur. Group – I (50) who were in CKD stage - IV. Group - II (50) healthy controls were included in the study. Fibroblast growth factor 23 (FGF23) was estimated by standard techniques and results are analyzed accordingly. Results: The mean value of FGF23 in Group – I was 730.7 ± 492.72 pg/ml was higher than that of the Group – II whose mean value was 39.49 ± 12.47 pg/ml and this difference was statistically significant( p<0.05). Group – I had very low mean eGFR levels than Group - II and this difference was statistically significant. Conclusion: Higher FGF23 levels are independently associated with higher levels of inflammatory markers in patients with CKD and with significantly greater odds of severe inflammation. Future studies should evaluate whether inflammation modifies the association between FGF23 and adverse outcomes in CKD.

Cistatina C: marcador de laboratorio precoz de enfermedad renal en pacientes con depranocitosis / Cystatin C: early laboratory marker of renal disease In sickle cell disease

La enfermedad renal en el paciente con drepanocitosis es una consecuencia de su complejo proceso fisiopatológico, por lo que es importante disponer de un grupo de parámetros de laboratorio que, junto a la evaluación clínica, permita determinar de forma precoz la presencia de esta complicación. La cistatina C ha demostrado ser uno de los parámetros que con mayor exactitud aporta evidencia temprana de daño renal en este grupo de pacientes y al mismo tiempo constituye un posible indicador de pronóstico de gran importancia(AU)

Renal disease in patients with sickle cell disease is a consequence of its complex pathophysiological process, so it is important to have a set of laboratory parameters that, together with the clinical evaluation, allow the early detection of this complication. Cystatin C has been shown to be one of the parameters that provides, with greater accuracy, early evidence of kidney damage in this group of patients and at the same time constitutes a possible indicator of prognosis of great importance(AU)

Comparative Study Of Pulmonary Function Tests With Microvascular Complications, Retinopathy And Nephropathy In Type 2 Diabetes Mellitus And Correlation With Duration Of Diabetes

Background:Themajorintype2diabetesThough lung has been widely acknowledged to be a target organ in diabetes mellitus, its se-verity of involvement and correlation with other microvascular complications has not been studied. Aim:To study pulmonary function tests in type 2 diabetes mellitus and evaluate association of PFTs with microvascular complica-tions, retinopathy and nephropathy and further assess the relationship of retinopathy, nephropathy and lungs with duration of diabetes. Methods:A cross sectional study was carried out in 100 male type 2 diabetic patients attend-ing diabetic clinic in tertiary hospital. 100 non-diabetic subjects were selected as control from general population. PFTs tests were performed. Results were interpreted by one way ANOVA test. Association of PFT parameters FVC, FEV1, FEV1%in type 2 diabetic patients with nephropathy and retinopathy was analysed by Pearson’s correlation co-efficient. The patient population was subdivided according to the duration of diabetes into 2 groups; less than 10 years of illness and more than 10 years. Relationship of retinopathy, nephropathy and pulmonary function tests with duration of diabetes was assessed by one-way ANOVA test. Results:There was a significant decrease in PFT parame-ters as compared to non-diabetic controls. The PFTs in type 2 diabetic subjects with nephropathy showed decline in FVC, FEV1,FEV1%, however association of these parameters with Glomerular filtration rate (GFR) and microalbuminu-ria was not significant. Also, a similar decline of PFT parameters was observed with increasing grade of retinopathy, though not significant. There was a significant positive correlation of retinopathy with microalbuminuria and GFR (nephropathy) in type 2 diabetic subjects. Also, there was significant association of microalbuminuria, GFR and reti-nopathy with increase in duration of diabetes. On the contrary the decline in FVC, FEV1, FEV1%with duration of diabe-tes was not statistically significant. Conclusion:Type 2 diabetic patients with poor glycaemic control and longer du-ration of diabetes history had significant correlation with microvascular complications, nephropathy and retinopathy as compared to pulmonary complications (PFT parameters). It is highly suggestive that diabetic patients with reti-nopathy must be screened for nephropathy.

Risk factors of renal function after radical nephroureterectomy for upper tract urothelial carcinoma / 中华泌尿外科杂志

Objective To investigate the risk factors which can lead to chronic kidney disease (CKD) after radical nephroureterectomy and guide adjuvant chemotherapy for the patients with upper tract urothelial carcinoma (UTUC).Methods 239 patients with UTUC,who were treated at our hospital from October 2010 to February 2015 was analyzed retrospectively.Serum creatinine levels were measured preoperatively and 1 month (range:21days to 35 days) after radical nephroureterectomy.129 males and 110 females patients were enrolled.Ages were from 41 to 94,and mean age was 66 years.All patients underwent radical surgery.The pathological stages included Ta/T1/T2/T3/T4,and grades included G1/G2/G3.We calculated GFR using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in consideration of age,sex,and serum creatinine level.The new-onset CKD after RNU was defined as when the calculated CKD-EPI GFR decreased to less than 60 ml/(min · 1.73 m2).These patients were divided into 2 groups which depended on whether they got CKD after RNU.Cohorts were stratified by gender,age,smoking,BMI,hypertension,diabetes mellitus (DM),tumor location,tumor size,multifocality,pathologic stage,grade,hydronephrosis and preoperative CKD-EPI GFR.The chi-square test was used to examine the relationship among the various cohorts and the CKD after RNU.The Kaplan-Meier method was adopted to identify the relationship between Overall survival (OS).Cancer-specific survival (CSS) and CKD.Univariate and multivariate analyses were performed to study the relationship between clinical factors and CKD after RNU using the Cox proportional hazards regression model and chi-square test.Results In our study,the median follow-up time was 41.3 (range from 2-82) months for 239 patients.Median CKD-EPI GFR for all patients before and after surgery was 71.4 (65.2-108.7) ml/(min · 1.73 m2) and 54.7 (37.6-93.8) ml/(min · 1.73 m2),meanwhile 105 cases became new-onset CKD.There was no significant difference in overall or cancer specific survival between CKD + and CKD-(P =0.137,P =0.190).However age (HR =1.825,95％ CI 1.203-2.768,P =0.017),hydronephrosis (HR =0.243,95 ％ CI 0.106-0.613,P =0.034) and preoperative CKD-EPI GFR (HR =0.237,95 ％ CI 0.109-0.524,P =0.021) were significantly correlative with postoperative new-onset CKD.Conclusion Age,absence of hydronephrosis and preoperative CKD-EPI GFR were independent risk factors predicting new-onset CKD.They can be the predictor of new-onset CKD.

Risk factors of renal function after radical nephroureterectomy for upper tract urothelial carcinoma / 中华泌尿外科杂志

Objective To investigate the risk factors which can lead to chronic kidney disease (CKD) after radical nephroureterectomy and guide adjuvant chemotherapy for the patients with upper tract urothelial carcinoma (UTUC).Methods 239 patients with UTUC,who were treated at our hospital from October 2010 to February 2015 was analyzed retrospectively.Serum creatinine levels were measured preoperatively and 1 month (range:21days to 35 days) after radical nephroureterectomy.129 males and 110 females patients were enrolled.Ages were from 41 to 94,and mean age was 66 years.All patients underwent radical surgery.The pathological stages included Ta/T1/T2/T3/T4,and grades included G1/G2/G3.We calculated GFR using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in consideration of age,sex,and serum creatinine level.The new-onset CKD after RNU was defined as when the calculated CKD-EPI GFR decreased to less than 60 ml/(min · 1.73 m2).These patients were divided into 2 groups which depended on whether they got CKD after RNU.Cohorts were stratified by gender,age,smoking,BMI,hypertension,diabetes mellitus (DM),tumor location,tumor size,multifocality,pathologic stage,grade,hydronephrosis and preoperative CKD-EPI GFR.The chi-square test was used to examine the relationship among the various cohorts and the CKD after RNU.The Kaplan-Meier method was adopted to identify the relationship between Overall survival (OS).Cancer-specific survival (CSS) and CKD.Univariate and multivariate analyses were performed to study the relationship between clinical factors and CKD after RNU using the Cox proportional hazards regression model and chi-square test.Results In our study,the median follow-up time was 41.3 (range from 2-82) months for 239 patients.Median CKD-EPI GFR for all patients before and after surgery was 71.4 (65.2-108.7) ml/(min · 1.73 m2) and 54.7 (37.6-93.8) ml/(min · 1.73 m2),meanwhile 105 cases became new-onset CKD.There was no significant difference in overall or cancer specific survival between CKD + and CKD-(P =0.137,P =0.190).However age (HR =1.825,95％ CI 1.203-2.768,P =0.017),hydronephrosis (HR =0.243,95 ％ CI 0.106-0.613,P =0.034) and preoperative CKD-EPI GFR (HR =0.237,95 ％ CI 0.109-0.524,P =0.021) were significantly correlative with postoperative new-onset CKD.Conclusion Age,absence of hydronephrosis and preoperative CKD-EPI GFR were independent risk factors predicting new-onset CKD.They can be the predictor of new-onset CKD.

Importancia del examen médico preventivo para el diagnóstico precoz de enfermedad renal en Uruguay.: Programa Nacional de Salud Renal / Importance of preventive medical examination for early diagnosis of renal disease in Uruguay.: The National Renal Health Program

Introducción: El Programa Nacional de Salud Renal (PNSR) mostró que la enfermedad renal crónica (ERC) puede estabilizarse en la evolución. Objetivo: evaluar el tamizaje de Enfermedad Renal Crónica presuntiva (ERCp) en población ambulatoria de una Clínica Preventiva con tirilla reactiva para proteinuria (TPu) y determinación de creatinina. Método. Estudio observacional, descriptivo, de corte transversal, entre 1/1/2008 y 31/12/2012 en 83.912 personas que se realizaron Carné de Salud (edad media =34.4años). Se consideró proteinuria positiva (Pu+) si TPu ≥1+ o ≥ 0.3 g/l. Se realizó TPu a todos y dosificación de creatinina para estimación Filtrado Glomerular (TFGe) en subpoblación con factores de riesgo (FR) como hipertensión o diabetes. Se evaluó proteinuria según edad y presencia o no de FR. En 11.161 individuos con determinación de creatinina se estimó el TFGe por fórmula CKD-EPI, (edad media=44.7años) se estimó prevalencia de ERCp mediante Pu+ TFGe<60 ml/min aisladas o en conjunto según grupos con FR, en base de datos no identificados de la Clínica Preventiva. Se utilizó el software estadístico SPSS 15.0 y regresión logística para análisis multivariado. Resultados: La prevalencia total de Pu+ fue de 6% (5.5% en grupo sin FR, 6.7% en hipertensión-sin-diabetes, 9.2% en diabetes-sin-hipertensión y 13.6% con ambos FR). Se desconocen falsos positivos. La prevalencia de TFGe<60 ml/min fue de 1.8%, siendo edad e hipertensión FR independientes para TFGe descendido. Considerados en conjunto Pu+ y TFGe<60 ml/min la prevalencia de ERCp alcanza 9.2%. Los FR aumentan la frecuencia de ERCp (p<0.05). Con Pu+ aislada se detecta ERCp entre el 85-90% según tengan o no FR; por grupos etarios la Pu+ aislada detecta el 100% de individuos con ERCp <20 años, es >90% en <50 años y cae a 30% en >70 años, donde cobra importancia la TFGe: 21.9% en con FR. Conclusiones: La población del Carné de Salud es útil para el tamizaje de ERCp temprana. Este estudio permitió identificar los mejores marcadores de ERCp para segmentos diferentes de población: la Pu+ aislada detecta ERCp en más del 90% de las personas <50 años y la TFGe adquiere importancia en añosos.

Introduction: The National Renal Health Program showed that chronic kidney disease (CKD) can be stabilized in the outcome. Objective: To assess screening Chronic Kidney Disease presumptive (pCKD) in an outpatient population of a Preventive Clinic with dipstick proteinuria (TPu) and/or eGFR <60 ml/min. Method: It is an observational, descriptive and cross sectional study. Between 1/1/2008 and 12/31/2012 was performed medical check to 83.912 individual (average age=34.4 years) from a Preventive Clinic with a proteinuria by TPu. In a selective population with predominant hypertension and diabetes (n 11.161 individuals, age 44.7 years odl) was performed determination of creatina and eGFR was estimated by CKD-EPI formula. pCKD prevalence was assessed by Pu + and/or eGFR<60 ml/min/1.73m2 alone or combined. We analyzed the risk factors (RF) for pCKD with SPSS 15.0 statistical software and logistic regression was used for multivariate analysis. Results: The prevalence of Pu + in total population was 6% (5.5% in the reference group, 6.7% in hypertension-without-diabetes, 9.2% in diabetes-without-hypertension and 13.6% in both RF group); the risk of Pu+ was increased in the previous groups (p < 0.05). Pu + false positives were unknown. The prevalence of eGFR< 60 ml/min was 1.8%, and age and hypertension were independent risk factors. When Pu + and/or eGFR<60 ml/min are considered together, the prevalence of pCKD reaches 9.2%. RF increases the frequency of pCKD (p < 0.05). With isolated Pu +, pCKD is detected between 85-90% according to whether or not they have RF; by age groups the isolated Pu + detects 100% of individuals with pCKD <20 years, is > 90% in those with <50 years and drop to 30% at 70 years or more, where is relevant the eGFR: 21.9% in RF group. Conclusions: The Preventive Clinic population is a useful place for screening early pCKD. This study identified renal markers of pCKD for different population segments: isolated Pu + detects pCKD in more than 90% of people < 50 years and the eGFR makes it in aged people.

Measurement of Glomerular Filtration Rate by Exogenous and Endogenous Filtration Markers.

The National Kidney Foundation (NKF), through its Kidney Disease Outcomes Quality Initiative (K/DOQI), and other National institutions proposed glomerular filtration rate (GFR) to describe, classify, screen and examine chronic kidney disease (CKD). GFR is the standard measure of renal function but cannot be practically measured for clinical and research purposes, so serum creatinine (Scr) is used to calculate estimated GFR (eGFR) which is affected by age, weight, muscle mass, race, various medications and extra-glomerular elimination. To overcome this Cystatin C (CysC) is new and reliable marker for renal function due to its low molecular weight it is freely filtered through glomerulus, completely reabsorbed and catabolized, but not secreted, by tubular cells. Various equations used for GFR estimation such as the Modification of Diet in Renal Disease (MDRD) Study equation, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft–Gault (CG) equation based on Scr , Grubb and Hoek equation based on CysC and Stevens equation based on both SCr and CysC are used. CKD–EPI is preferred for identifying patients with CKD and for staging the disease. The risk of underestimation of kidney function with MDRD is highest when the GFR is 30 mL/minute/1.73 m2 so GFR is calculated by CKD–EPI equation for these persons. CKD–EPI is recommended for diagnosis and staging when the addition of appropriate prophylactic drugs or avoidance of certain nephrotoxic drugs should occur. The aim of this review is to evaluate from recent literature available different exogenous and endogenous markers used for the determination of GFR and which marker found suitable for the determination of GFR according to literature available on PubMed and determine their reliability in the detection and monitoring of CKD and its stages. Key words: Glomerular filtration rate, chronic kidney disease, Creatinine, Cystatin C, Measurement of GFR Abbreviations - Glomerular filtration rate (GFR), chronic kidney disease (CKD), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft–Gault (CG), Serum creatinine (Scr), serum cystatin C (CysC), National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI), Cardiovascular disease (CVD), Food and drug administration (FDA), Diethylene triamine pentaacetic acid (DTPA), Ethylene diamine tetra acetic acid (EDTA)

Assessment of Renal Function and Predictive Performances of GFR Estimating Equations among Nigerian Diabetic Patients.

Aims: To assess the renal functions in Nigerian diabetic patients and to examine the predictive performances of Glomerular Filtration Rate (GFR) estimating equations. Study Design: A case-control study. Place and Duration of Study: Department of Physiology and University College Hospital, University of Ibadan, Ibadan, Nigeria. May-August, 2009. Methodology: One hundred and nine volunteers comprising 58 diabetic patients receiving treatments and 51 healthy individuals. Measured GFR (mGFR) was by creatinine clearance and the equations includes Cockcroft and Gault, CG; Modification of Diet in Renal Disease, MDRD study equation; Chronic Kidney Disease and Epidemiological study group, CKD-EPI and Mayo Clinic Quadratic, Q equation. Ethnicity factor was administered as appropriate. Performances were determined by mean bias, precision and accuracy. Results: mGFR was significantly (P=.05) reduced among the diabetic when compared with the non-diabetic though within the recommended range for normal renal function. Among the diabetics, CG equation has the least bias when compared with the mGFR but overestimated the GFR by 2.42ml/min/1.73m2 while Q has the highest bias. When the bias of other equations where compared with that of CG, the CKD/EPI formula significantly underestimated the GFR (P=.05) and the Q significantly overestimated GFR (P=.05). The highest precision was by CG and the least was found in the CKD/EPI though not significantly. The highest accuracy in this group was by CKD/EPI. In the nondiabetics, the least bias was recorded in the MDRD when compared with the mGFR while the highest was recorded in the CKD/EPI, the bias when compared with that of CG, the CKD significantly underestimated GFR by up to 7.54ml/min/1.73m2 (P=.001). Precision was highest in the Q though, not significant while its accuracy was significantly lower (P=.05) when compared with the CG. Adjustment for the ethnicity factor significantly overestimated GFR in our two study groups. Conclusion: Creatinine-based predictive equations are useful in estimating renal functions but the CG as well as the MDRD equations are more superior in their predictive ability among Nigerians and the use of the ethnicity factor is not recommended in Nigerian African as there is overestimation when used with the relevant equations.

Prevalence of systemic co-morbidities in patients with various grades of diabetic retinopathy.

Background & objectives: Though diabetes affects multiple organs, most studies highlight the occurence of only one complication in isolation. We conducted a hospital-based study to estimate the co-existence of significant systemic co-morbid conditions in patients with varying grades of diabetic retinopathy. Methods: A total of 170 consecutive patients with diabetic retinopathy were prospectively recruited for the study between June 2009 to June 2010 at a tertiary care eye centre in north India. Retinopathy was graded by fundus biomicroscopy and fundus photography and classified into three categories (mild-moderate nonproliferative retinopathy, proliferative retinopathy requiring only laser and proliferative retinopathy requiring surgery). Nephropathy was classified by calculating the six variable estimated glomerular filtration rate (eGFR) for all patients. Nerve conduction studies and clinical assessment were used to determine presence of neuropathy. Co-existence of macrovascular disease and peripheral vascular disease was also ascertained. Results: The percentages of patients with overt nephropathy in the three groups were 19.2, 38.0 and 41.2, respectively. Significant linear trends were observed for serum creatinine (P=0.004), albumin (P=0.017) and eGFR (P=0.030). A higher per cent had abnormal nerve conduction on electrophysiology than that diagnosed clinically (65.4 vs. 44.2, 76.0 vs. 40.0 and 64.8 vs. 48.6, respectively). The odds ratio (95% CI) for co-existence of nephropathy, neuropathy, CVA (cerebrovascular accidents) and PVD (peripheral vascular disease) was 2.9, 0.9, 4.8 and 3.5, respectively. Independent of retinopathy severity, patients with clinically significant macular oedema (CSME) had a higher percentage of nephropathy (pP < 0.005). Interpretation & conclusions: The co-existence of overt nephropathy, nerve conduction based neuropathy and macrovascular co-morbidity in patients with early grades of diabetic retinopathy was significant. Screening for overt nephropathy by eGFR should be considered in all patients with clinically significant macular oedema.

Cystatin C: A Marker of Renal Function.

The most widely used investigation of renal function and GFR is the measurement of serum creatinine and creatinine clearance rate. This has been extremely popular in clinical medicine despite formidable difficulties associated with its quantification and interpretation. The main pathophysiological difficulties include variations in the rates of creatinine generation and its secretion by the renal tubules. Concentration of serum creatinine is now recognized as an unreliable measure of kidney function as it is affected by age, body weight, muscle mass, race and various medications. Several equations have been developed to improve the accuracy of serum creatinine level as a measure of GFR. The most widely used in adult populations are the Cockroft-Gault equation and the abbreviated Modification of Diet in Renal Disease (MDRD) equation. Even with these equations, measurement of GFR is difficult because the equations are less accurate with higher levels of kidney function and are affected by interlaboratory variation in measuring creatinine level. In the above perspective, cystatin C concentration has become a promising marker for kidney function in both native and transplanted kidneys. Because of the possible potentiality of cystatin C to be an emerging endogenous marker for quick and accurate assessment of renal function, we have decided to review elaborately on cystatin C as a marker of renal function and to review the sensitivity and specificity of cystatin C as an endogenous marker compared to serum creatinine. Results of our review study suggest that cystatin C is a better marker of renal function compared to serum creatinine and other endogenous markers irrespective of age, sex and clinical condition.

Management of Chronic Kidney Disease- an Update.

Chronic kidney disease (CKD) is a global public health issue demanding continuous improvement in its management. Different international groups and organizations have now achieved a good progress in its definition, classification (staging), treatment and referral criteria to nephrologists. In definition of CKD, "CKD is defined as abnormalities of kidney structure or function, present for at least three months with implications for health", the phrase "with implications for health" has been added at the end of the previous definition, which reflects the concept that there may be certain abnormalities of kidney structure or function that do not have prognostic consequences (for example, a simple renal cyst). At staging of CKD, grade 3 has been subdivided into G3a and G3b, according to whether the glomerular filtration rate (GFR) is (59 - 45) or (44 - 30) ml/min/1.73m2, respectively. Furthermore, albuminuria has been classified in any GFR grade, in to A1, A2 or A3 according to the albumin-creatinine ratio (ACR) in an isolated urine sample for values <3, 3-30 or >30mg/mmol, respectively. The term "microalbuminuria" has now been replaced by the term "moderately increased albuminuria". For GFR measurement Chronic Kidney Disease Epidemiology Collaboration (CKD- EPI) equation has been preferred than the Modification of Diet in Renal Disease (MDRD) study equation and new 2012 KDIGO guidelines consider the use of alternative formulas to be acceptable if they have been shown to improve accuracy when compared with the CKD-EPI formula. For detection of albuminuria ACR is preferred rather than conventional 24 hours urine albumin. The recommended BP control target is <_140/90mmHg (both diabetic and non-diabetic) if ACR <3mg/mmol and a stricter target is suggested, with BP <_130/80mmHg, (both in diabetic and non-diabetic) if the ACR is >_ 3mg/mmol. Use of erythropoisis-stimulating agent (ESA) in anemia of CKD should be rational; to avoid its adverse effects like stroke, thrombosis or hypertension acceleration and hemoglobin goals should not exceed 11 g per dl. Treating dyslipidaemia in CKD with statins for all adults >50 years of age, irrespective of low density lipoprotien (LDL) cholesterol levels is recommended. Referral to nephrologist should be rational according to guidelines and at least one year prior to the start of renal replacement therapy (RRT).

Effect of Enalapril on Glomerular Filtration Rate and Proteinuria in Children with Chronic Kidney Disease: A Randomized Controlled Trial.

Objective: To evaluate the efficacy of enalapril treatment on decline in glomerular filtration rate and reduction in proteinuria in children with chronic kidney disease (CKD). Design: Open-label, randomized controlled trial. Setting: Pediatric nephrology clinic at a tertiary-care referral hospital. Intervention: Children with GFR between 15-60 mL/min/1.73 m2 were randomized to receive either enalapril at 0.4 mg/kg /day or no enalapril for 1 year. Outcome measures: Change in GFR using 99mTc-DTPA and urine protein to creatinine ratio. Secondary outcomes included occurrence of composite outcome (30% decline in GFR or end stage renal disease) and systolic and diastolic blood pressure SDS during the study period. Results: 41 children were randomized into two groups; 20 received enalapril while 21 did not receive enalapril. During 1 year, GFR decline was not different in the two groups (regression coefficient (r) 0.40, 95% CI -4.29 to 5.09, P=0.86). The mean proteinuria reduction was 65% in the enalapril group, significantly higher than control group. The difference was significant even after adjustment for blood pressure was 198.5 (CI 97.5, 299.3; P<0.001). 3 (17.6%) patients in enalapril and 7 (36.8%) in nonenalapril group attained the composite outcome. Conclusions: Enalapril is effective in reducing proteinuria in children with CKD and might be renoprotective in proteinuric CKD.