Malaysian Society of NephrologyMinistry of Health Malaysia

Early Detection Of

Renal Disease

Asymptomatic urine abnormalities : proteinuria/ haematuria

Nephritic/Nephrotic syndrome

Hypertension

Unexplained anaemia

Incidental finding of elevated serum Creatinine

Uraemic emergencies

Common clinical presentations of kidney disease

Serum creatinine

Estimated glomerular filtration rate (GFR)

Urine testing :

Screening method

Urine dipstickUrine microscopic examinationUrine microalbuminuria

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

Screening method Serum Creatinine

Relationship between serum creatinine and GFR

1.23 x (140-Age) x BWSr Cr (umol/l)

1.04 x (140-Age) x BWSr Cr (umol/l)

Estimated Glomerular Filtration rate

Man

Woman

Screening method Estimated GFR

Urine for proteinDipstick24 hour urinary protein

Urine microscopic examinationFor RBC / Pus Cell / Cast

Urine for microalbuminuriaOn morning urine sampleusing strip for microalbumin

Screening methods Urine testing

Screening methods Microalbuminuria testing

Mass population screening is not cost effective

Screening of high risk groups to develop renal disease/failure

Target groups for screening

Hypertensive patientsDiabetic patientsCardiovascular diseaseProteinuriaHematuriaThose on regular NSAID/Herbs

Renal calculiAnemia of unknown aetiologyFirst and second degree relatives of ESRDAutoimmune disease (SLE/RA)Reduction of kidney mass(Nephrectomy)

Screening renal diseaseThe High Risk Groups

UFEMEBUSE/CrUSS KUBOther test

Young hypertensive

YearlyYearly

UFEMEBUSE/Cr

All hypertensive

FrequencyScreening tests

Screening of renal disease : Hypertensive patients

Type 1

Type 2

DM

5 years after diagnosis (age >12)Or earlier if CV risk

yearlyAt diagnosis

FrequencyFirst screening

BP

Urine Protein

Urine Microalbuminuria

BUSE/Creatinine yearly if normal

When to screen Methods

Screening of renal disease Diabetic Patients

Urine dipstick for protein

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

Overt NephropathyQuantify excretion rate24HUP

Negative

Screen forMicroalbuminuria(on early morning spot urine)

Negative

Yearly test

Positive

Retest twice in 3-6/12Exclude other cause

If 2 of test are positiveDiagnosis of microalbuminuriaIs established

3-6 monthly follow-up of microalbuminuria

Optimise glycaemic controlStrict Bp controlACE/ARBStop smokingLifestyle modificationTreat hyperlipidaemiaAvoid excessive protein intakeMonitor renal functionMonitor other endorgandamage

Algorithm: Screening for proteinuria/microalbuminuria in DM

<20<30Normoalbuminuria

>35 women>25 men

>200>200>300Overt Proteinuria

3.5-35 women2.5-25 men

20-20020-20030-300Microalbuminuria

Urine Albumin:creatinineratio (mg/mmol)

Urine AlbuminConcentration(mg/l)

<3.5 women<2.5 men

<20

First voided morning specimenTimedCollection(ug/min)

24 hrCollection(mg/24h)

Specimen collectedAlbuminExcretion

Proteinuria is a major manifestation of renal disease

Screening of renal diseaseProteinuria

Urinary Tract Infection

Sepsis

Heart Failure

Strenous exercise

Heavy protein intake

Menses

Causes of false positive 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 1984;310:310-60)

Significance of Proteinuria

HistoryPhysical ExaminationUrine Examination of

Urinary sediment

Abnormal

refer to a nephrologist

Normal

Repeat visit for a Qualitative proteinuria test

PositiveDo Renal profileQuantitate urinary proteinRefer to nephrologist

NegativeTransient proteinuriaReassure

Evaluation of persistent proteinuria

Definition:> 3-5 rbc/hpf on urinary sediment examination

In clinical practice can be diagnosed by urine dipstick test

False positivepovidone-iodine oxidising agents

False negativevit C excretionair-exposed dipsticks

Screening of renal diseaseHematuria

Evaluation of asymptomatic hematuriaDetection of Microscopic hematuria>5RBC/hpf or +ve dipstik test

Primary care investigationHistoryExaminationRenal functionUrine microscopy and culture

Consider Urological referral

Exclude benign causes :Menstruating womenWomen with UTIFalse +ve result Recent strenous exerciseSexual activity, viral illness,trauma etc

ProteinuriaRed cell cast/dysmorphic red blood cellsRenal Impairment

Nephrological referral

Isolated microscopic

haematuria and age>40 years

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

Benefits of early detection

a) specific disease treatment e.g. immunosuppression

b) future transplant –timing, risk of recurrent disease etc

c) counselling and screening of relatives

2. Allows measures to retard disease progression to be instituted and maximised

3. Complications associated with failing renal function can be addressed:

Benefits of early detection

anaemiarenal bone disease, malnutrition

4. Enables timely referral to nephrologists

Benefits of early detection

Adequate time for preparation of patients for renal replacement therapy

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

education regarding optionstimely creation of AVFplacement of Tenckhoff catheters