Accuracy of Laboratory Parameters in Management of CKD.
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This document discusses laboratory parameters for managing chronic kidney disease (CKD). It covers direct and indirect methods of nutritional assessment, modifiable and non-modifiable risk factors for CKD, types of assays including static and functional, targets for assay accuracy and precision, categories and specific tests of renal function including glomerular filtration rate (GFR) tests. It addresses factors that can interfere with creatinine levels, patient preparation, reference ranges, and interpretation of creatinine concentrations. Stages of CKD and roles in patient safety are outlined. Alternative ways to identify early CKD and approaches for the future are proposed.
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Accuracy of Laboratory Parameters in Management of CKD.
- 1. Accuracy of Laboratory Parameters in Management of CKD. College of Medical Laboratory Science, Sri Lanka
- 2. Direct Methods of Nutritional Assessment • Anthropometric methods • Medical Laboratory methods • Clinical methods • Dietary evaluation methods CMLS.SL 2
- 3. CKD Risk Factors Modifiable • Diabetes • Hypertension • History of AKI • Frequent NSAID use Non-Modifiable • Family history of kidney disease, diabetes, or hypertension • Age 60 or older (GFR declines normally with age) • Race/U.S. ethnic minority status CMLS.SL 3
- 4. Types of Assays • Static assays: measures the actual level of the component in the specimen (serum iron, Serum electrolytes) • Functional Assays: measure a biochemical or physiological activity that depends on the component of interest (eg: Glycated haemoglobin, Creatinine) • Functional assays are not always specific to the component CMLS.SL 4
- 5. Target • Accuracy • Precision • Accuracy CMLS.SL 5
- 6. • Detect renal damage • Monitor functional damage • Help determine etiology Categories of renal function tests CMLS.SL 6
- 7. • glomerular filtration rate=GFR • plasma creatinine= Pcr • plasma urea-Purea • urine volume= V • urine urea- Uurea • cystatin C in plasma? • urine protein • urine glucose • hematuria • Osmolality • Electrolytes Tests of renal function CMLS.SL 7
- 8. Tests of Glomerular Filtration Rate • Urea • Creatinine • Creatinine Clearance • eGFR • Cystatin C CMLS.SL 8
- 9. GFR & Creatinine • Ideal Marker • Produced normally by the body • Produced at a constant rate • Filtered across glomerular membrane • Removed from the body only by the kidney filtered only, not reabsorbed or secreted CMLS.SL 9
- 10. Interference • Pre Analytical phase • Analytical Phase • Post Analytical Phase CMLS.SL 10
- 11. Interfering factors for elevated S. Creatinine • Destruction of muscle • High dietary intake of meat • Hypothyroidism • higher average muscle mass (Eg Afro-Caribbean) • increase in musculature (Eg. Bodybuilding • Drugs • Some Cephalosporins Interference with alkaline picrate assay • Corticosteroids and vitamin D metabolites Modify the production rate & the release of creatinine • Artifactual (Eg. Diabetic Ketoacidosis) CMLS.SL 11
- 12. Interfering factors for Reduced S. Creatinine • Increasing age Age-related decline in muscle mass • Females - reduced muscle mass • Malnutrition/ muscle wasting / amputation Reduced muscle mass ± reduced protein intake • Vegetarian diet • Dehydration • Hyperthyroidism • Icteric Serum Specimens Eg: Due to elevated Bilirubin • Drugs - Testosterone therapy Eg: Cimetidine, Trimethoprim, Sulphamethoxazole, Fibric acid D CMLS.SL 12
- 13. Patient Preparation for S. Creatinine • No Specific patient preparation • Dose adjustment or stop taking some interfering drugs on clinicians advice • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen • Chemotherapy drugs • Cephalosporin • Cimetidine • Interpret results with related to drug history
- 14. Reference Range – S. Creatinine Male Infant - Not established Age 1-2 years - 0.1–0.4 mg/dL Age 3-4 years - 0.1–0.5 mg/dL Age 5-9 years - 0.2-0.6 mg/dL Age 10-11 years - 0.3-0.7 mg/dL Age 12-13 years - 0.4-0.8 mg/dL Age 14-15 years - 0.5-0.9 mg/dL Age 16 years or older - 0.8-1.3 mg/dL Female Infant - Not established Age 1-3 years - 0.1–0.4 mg/dL Age 4-5 years - 0.2–0.5 mg/dL Age 6-8 years - 0.3-0.6 mg/dL Age 9-15 years - 0.4-0.7 mg/dL Age 16 years or older - 0.6-1.1 mg/dL CMLS.SL 14
- 15. Serum Creatinine Concentration • Normally 0.7-1.4 mg/dl, depending on muscle mass • Inversely proportional to GFR • Good way to follow changes in GFR • BUT also elevated by muscle mass, tubular secretion CMLS.SL 15
- 16. Tests that predict kidney disease • eGFR • Albumin Creatinine Ratio (ACR or Microalbumin) CMLS.SL 16
- 17. Kidney damageand normalor GFR Kidney damageand mild GFR Severe GFR Kidney failure Moderate GFR Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 NephrologistPrimary Care Practitioner GFR 90 60 30 15 Who Should be Involved in the Patient Safety Approach to CKD? Patient safety Consult? CMLS.SL 17
- 18. Alternatives of identifying CKD Stage 1 • Higher than normal levels of creatinine or urea in the blood • Blood or protein in the urine • Evidence of kidney damage in an MRI, CT scan, ultrasound or contrast X-ray • A family history of polycystic kidney disease (PKD) CMLS.SL 18
- 19. Assessment of component of interest CMLS.SL 19
- 20. Patients Client Healthy Risk GroupPatient CMLS.SL 20 Diversity of Health Care Receivers
- 21. Clinicians Lab Professionals Clinicians Nutritionists Clinicians CMLS.SL 21 Traditional Health care Flow
- 22. Clinicians Lab Professionals Nutritionist CMLS.SL 22 Model for CKD/NCD control
- 24. Future Approach • Can serum creatinine be made more sensitive by adding more information? • Does it required an easy test to screen risk group in GFR that can apply at risk populations • Can we assure patient centered health care service with novel collaborative co management model CMLS.SL 24