Accuracy of Laboratory Parameters in Management of CKD and NCD
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New model for Health care delivery is suggesting to replace traditional health care organisational structure in Sri Lanka. This type of innovation is essential for "Non Patient" type healthcare receivers, such as "Healthy healthcare receivers" and "Risk Groups". This topic is inspired by Secretary, CMLS.SL at the Annual Academic Sessions of DiASL on April 22, 2017. CMLS.SL - College of Medical Laboratory Science, Sri Lanka DiASL - Dietetic Association of Sri Lanka
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Accuracy of Laboratory Parameters in Management of CKD and NCD
- 1. Accuracy of Laboratory Parameters in Management of CKD. College of Medical Laboratory Science, Sri LankaCollege 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 ModifiableModifiable •DiabetesDiabetes •HypertensionHypertension •History of AKIHistory of AKI •Frequent NSAID useFrequent 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 ofStatic assays: measures the actual level of the component in the specimen (serumthe component in the specimen (serum iron, Serum electrolytes)iron, Serum electrolytes) • Functional Assays: measure aFunctional Assays: measure a biochemical or physiological activity thatbiochemical or physiological activity that depends on the component of interest (eg:depends on the component of interest (eg: Glycated haemoglobin, Creatinine)Glycated haemoglobin, Creatinine) • Functional assays are not always specificFunctional assays are not always specific to the componentto the component CMLS.SL 4
- 5. Target • AccuracyAccuracy • PrecisionPrecision • AccuracyAccuracy CMLS.SL 5
- 6. • Detect renalDetect renal damagedamage • Monitor functionalMonitor functional damagedamage • Help determineHelp determine etiologyetiology Categories of renal function tests CMLS.SL 6
- 7. • glomerular filtrationglomerular filtration rate=GFRrate=GFR • plasma creatinine= Pplasma creatinine= Pcrcr • plasma urea-Pplasma urea-Pureaurea • urine volume= Vurine volume= V • urine urea- Uurine urea- Uureaurea • cystatin C in plasma?cystatin C in plasma? • urine proteinurine protein • urine glucoseurine glucose • hematuriahematuria • OsmolalityOsmolality • ElectrolytesElectrolytes Tests of renal function CMLS.SL 7
- 8. Tests of Glomerular Filtration Rate • UreaUrea • CreatinineCreatinine • Creatinine ClearanceCreatinine Clearance • eGFReGFR • Cystatin CCystatin C CMLS.SL 8
- 9. GFR & Creatinine • Ideal MarkerIdeal Marker • Produced normally by the bodyProduced normally by the body • Produced at a constant rateProduced at a constant rate • Filtered across glomerular membraneFiltered across glomerular membrane • Removed from the body only by theRemoved from the body only by the kidney filtered only, not reabsorbed orkidney filtered only, not reabsorbed or secretedsecreted CMLS.SL 9
- 10. Interference • Pre Analytical phasePre Analytical phase • Analytical PhaseAnalytical Phase • Post Analytical PhasePost Analytical Phase CMLS.SL 10
- 11. Interfering factors for elevated S. Creatinine • Destruction of muscleDestruction of muscle • High dietary intake of meatHigh dietary intake of meat • HypothyroidismHypothyroidism • higher average muscle masshigher average muscle mass (Eg Afro-Caribbean)(Eg Afro-Caribbean) • increase in musculatureincrease in musculature (Eg. Bodybuilding(Eg. Bodybuilding • DrugsDrugs • Some CephalosporinsSome Cephalosporins Interference with alkaline picrate assayInterference with alkaline picrate assay • Corticosteroids and vitamin D metabolitesCorticosteroids and vitamin D metabolites Modify the production rate & the release of creatinineModify the production rate & the release of creatinine • Artifactual (Artifactual (Eg. Diabetic Ketoacidosis)Eg. Diabetic Ketoacidosis) CMLS.SL 11
- 12. Interfering factors for Reduced S. Creatinine • Increasing ageIncreasing age Age-related decline in muscle massAge-related decline in muscle mass • Females - reduced muscle massFemales - reduced muscle mass • Malnutrition/ muscle wasting / amputationMalnutrition/ muscle wasting / amputation Reduced muscle mass ± reduced protein intakeReduced muscle mass ± reduced protein intake • Vegetarian dietVegetarian diet • DehydrationDehydration • HyperthyroidismHyperthyroidism • Icteric Serum SpecimensIcteric Serum Specimens Eg: Due to elevated BilirubinEg: Due to elevated Bilirubin • Drugs -Drugs - Testosterone therapyTestosterone therapy Eg: Cimetidine, Trimethoprim, Sulphamethoxazole, Fibric acid DEg: Cimetidine, Trimethoprim, Sulphamethoxazole, Fibric acid D CMLS.SL 12
- 13. Patient Preparation for S. Creatinine • No Specific patient preparationNo Specific patient preparation • Dose adjustment or stop taking some interferingDose adjustment or stop taking some interfering drugs on clinicians advicedrugs on clinicians advice • Nonsteroidal anti-inflammatory drugsNonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen(NSAIDs), such as aspirin or ibuprofen • Chemotherapy drugsChemotherapy drugs • CephalosporinCephalosporin • CimetidineCimetidine • Interpret results with related to drug historyInterpret results with related to drug history
- 14. Reference Range – S. Creatinine CMLS.SL 14
- 15. Serum Creatinine Concentration • Normally 0.7-1.4 mg/dl, depending onNormally 0.7-1.4 mg/dl, depending on muscle massmuscle mass • Inversely proportional to GFRInversely proportional to GFR • Good way to followGood way to follow changeschanges in GFRin GFR • BUT also elevated byBUT also elevated by ↑↑ muscle mass,muscle mass, ↓↓ tubular secretiontubular secretion CMLS.SL 15
- 16. Tests that predict kidney disease • eGFReGFR • Albumin Creatinine RatioAlbumin Creatinine Ratio (ACR or Microalbumin)(ACR or Microalbumin) CMLS.SL 16
- 17. Kidney damage and normal or ↑ GFR Kidney damage and 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. CMLS.SL 20 Diversity of Health Care Receivers
- 21. CMLS.SL 21 Traditional Health care Flow
- 22. CMLS.SL 22 Model for CKD/NCD control
- 24. Future Approach • Can serum creatinine be made moreCan serum creatinine be made more sensitive by adding more information?sensitive by adding more information? • Does it required an easy test to screen riskDoes it required an easy test to screen risk group in GFR that can apply at riskgroup in GFR that can apply at risk populationspopulations • Can we assure patient centered health careCan we assure patient centered health care service with novel collaborative coservice with novel collaborative co management modelmanagement model CMLS.SL 24
Editor's Notes
- From a clinical perspective it is important to have test which would have these characteristics. No such test exists. An early test to detect renal damage, for instance a simple strip test for haematuria is important in screening for heavy metal poisoning. There is a clinical need to monitor a patient with renal disease and this is achieved by serial plasma measurements. We need to know when to start dialysis in renal failure and laboratory tests assist the clinical decision making. There are about a million nephrons in each kidney and this represents a considerable functional reserve. In renal disease about half the nephrons have to lose their functioning before the abnormality can be detected by conventional laboratory tests.
- I shall review the tests in the left column today. The measurement of urine protein is important in certain conditions, e.g.diabetes. The detection of substances such as red cells or glucose could be an early indicator of renal damage.