World Kidney Day (March 13)
Eminent Author, Medical Biochemist and Scientist, Technical Education consultant.
AGD Biomedicals (Pvt) LTD. Andheri East, Mumbai.
There are rising incidences of chronic kidney diseases (CKDs), which are likely to pose major global healthcare and socioeconomical problems in future years(1, 2). Routinely performed physical examination tests (including pulse rate and blood pressure), regular monitoring of hypertension and blood sugar with yearly performed IVD laboratory tests could be useful to prevent and also detect early kidney diseases(3) (refer to case study). Early detection of CKD with effective treatment can prevent complete kidney failure and will be able to avoid in future very expensive treatment options like dialysis or kidney transplantation(3). Opportunities for primary and secondary prevention of kidney disease are often missed due to lack of education on kidney care. Patients seek medical advice only when they are symptomatic, and usually late in the course of renal disease(4). The development and outcomes of CKD can be achieved by considering kidney risk factors related to sociodemographic variables(11) (Refer to answer of Q.10). The average annual out-of-pocket expenditure for CKD patients can be reduced effectively by planning for the preventive healthcare policies and provision of funds for simple routine laboratory methods based on advanced point of care tests(4).
Q1. What is the prevalence of CKD?
ANS: CKD affects more than 850 million people worldwide and will become the fifth largest cause of years of life lost by 2040. The World Health Organization ranked CKD as the 10th most common cause of death. The global all-age prevalence and mortality from CKD increased by 29.3 and 41.5%, respectively between the years 1990-2017. There was a 38% increase in the proportion of deaths attributable to kidney failure between the years 2001–13, in India(13).
Q2. What are the most common causes and other genetic related kidney diseases?
ANS: The most common causes of kidney diseases include: Prolonged uncontrolled diabetes mellitus, poorly-managed hypertension, and glomerular diseases. Other genetic related kidney diseases include: Polycystic kidney disease and autoimmune kidney disorders (including those having genetic predisposition)(10).
Q3. What are the routinely performed kidney profile tests and related clinical significance?
ANS: Routine urine examination and following Kidney Profile Tests(7,8):
| KIDNEY PROFILE TESTS | CHANGED VALUE | CLINICAL SIGNIFICANCE |
| (1) Blood urea nitrogen (BUN) | Increased | Indicates Renal disease |
| (2) Serum creatinine | Increased | Indicates Renal disease |
| (3) Blood glucose | Increase | Prolonged increase indicate Diabetic nephropathy |
| (4) Serum total cholesterol | Increase | Atherosclerosis, leading to decrease in blood supply to the kidneys |
| (5) Serum total proteins | Decrease | Proteinuria |
| (6) Serum albumin | Decrease | Albuminuria |
| (7) Serum sodium | Decrease | Affected tubular function |
| (8) Serum potassium | Increase | Affected tubular function |
| (9) Serum inorganic phosphorus | Increase | Affected tubular function |
| (10) Serum calcium | Decrease | Affected tubular function |
| (11) Serum bicarbonate | Decrease | Affected tubular function |
| (12) eGFR | Decrease | Kidney dysfunction. Affected Glomerular filtration rate. |
Q4. What is the importance of routine urine examination (as a part of kidney function test)?
ANS:
(1) Presence of albumin (glomerular damage), glucose, ketones (diabetes), significant number of pus cells, bacteria, occult blood (bacterial infection and glomerular damage) by dip-stick test(7).
(2) Presence of large numbers of pus cells, epithelial cells, casts, crystals, bacteria, yeast cells by microscopic examination indicate possibility of renal disease(7).
Q5. What is eGFR and its clinical significance?
ANS: eGFR is estimated glomerular filtration rate (in terms of ml). Normal average eGFR should be more than 90 ml. It is calculated by considering patient’s age, sex, weight, height (in meters), body surface area of the patient, normal average body surface area (1.73/A), serum creatinine and urine creatinine values by using the formula: eGFR= Estimated GFR in mL/min/1.73 m2. eGFR less than 60 ml indicate kidney dysfunction(7).
Note:
(1) Average 1 million nephrons (micro-functional units) are present in a normal adult kidney. eGFR is significantly decreased, when more than 70% of nephrons are damaged(7).
(2) The following hormones play very important roles in kidney functions: Rennin (Blood pressure maintenance), ADH (water reabsorption), mineralocorticoids (controlled sodium reabsorption and potassium excretion), parathyroid hormones (controlled calcium reabsorption and inorganic phosphorus excretion). Actions of these hormones on kidneys are disturbed in kidney disease (7).
(3) Acid-base balance and homeostasis are significantly affected in kidney disease(7).
Q6. What is the percentage of uncontrolled diabetic persons that may develop kidney disease in future?
ANS: About 35-40% of persons with diabetes may develop chronic kidney disease (CKD) in their lifetime(5).
Q7. What is the percentage of patients with poorly controlled high blood pressure that may develop kidney disease in future?
ANS: About 3-30% patients with poorly controlled high blood pressure are strongly associated with a higher risk of developing kidney disease(6).
Q8. What is the percentage of patients with genetic predisposition that may develop end stage kidney disease?
ANS: Autosomal dominant polycystic kidney disease is the most common hereditary kidney disease and accounts for 5–10% of end stage kidney disease.
Note: A genetic predisposition to kidney disease means that a person has inherited genes that increase possibility to develop the disease.
Q9. What are the recent innovations in IVD that have significantly impacted the management and monitoring of kidney functions?
ANS: Advancements in the fifth generation point of care test (POCT) methods for blood and urine can diagnose kidney risk factors by performing urine albumin, glucose occult blood (dipstick method), blood glucose (glucometer), urea, creatinine, serum cholesterol, urine microalbumin (Rapid immunochromatographic tests) in few minutes with accuracy and precision at patient’s bed side(7). Moreover, genetic predisposition to CKD could be detected by advanced DOT-BLOT molecular tests(7).
CASE STUDY
A 57-year-old man (BMI: 34) was admitted in the hospital with significant weight loss, lethargy, and generalized weakness. On examination, the patient was found to be anemic and had a blood pressure of 170/105 mmHg. Random urine examination showed the presence of proteins (+) and glucose (+). His laboratory test reports were as follows:
| PARAMETER | VALUE | REFERENCE RANGE (NORMAL VALUES) |
| Plasma glucose (Random) | 240 mg/dl | 70-180 mg/dl |
| Serum urea nitrogen | 85 mg/dl | 7–21 mg/dl |
| Serum creatinine | 5.4 mg/dl | 0.6–1.2 mg/dl |
| Serum total proteins | 5.8 g/dl | 6–8 g/dl |
| Serum albumin | 3.0 g/dl | 3.3-4.8 g/dl |
| Serum total globulins | 2.8 g/dl | 1.8–3.6 g/dl |
| Glomerular filtration rate (eGFR) | 80 ml | > 90 ml |
| Serum calcium | 7.8 mg/dl | 8.5-10.5 mg/dl |
| Serum inorganic phosphorus | 5.8 mg/dl | 2.5-4.5 mg/dl |
| Serum sodium | 130 mEq/l | 133-148 mEq/l |
| Serum potassium | 5.6 mEq/l | 3.8-5.6 mEq/l |
| Serum bicarbonate | 21 mEq/l | 21-28 mEq/l |
| Urine microalbumin | Present | Absent |
Evaluation of the laboratory report
Decreased eGFR, increased excretory substances such as urea and creatinine in blood, presence of protein in urine, decreased serum proteins, disturbed renal tubular absorption of calcium and sodium and excretion of inorganic phosphorus and potassium indicate that the patient was suffering from ‘Renal disease’.
Note
(1) Laboratory tests also indicate that the patient was suffering from uncontrolled type 2 diabetes mellitus and related hypercholesterolemia (obesity-related) .
(2) Due to prolonged uncontrolled diabetes, the patient probably suffered from diabetic nephropathy.
(3) Timely control of obesity and diabetes by appropriate medicines and life-style changes (diet and regular exercises) and routine medical examinations with body profile tests could prevent the patient from the episodes of severe renal disease.
Q10. How do early detection of CKD impact patient outcomes and overall healthcare costs?
ANS: The economic burden of CKD can range from Rs. 150.00 (Charitable clinics) to Rs 1,500 (Government hospitals) to Rs 2,000 (Private medical centers), leading to an annual average cost of about Rs 1.4 lakhs for only dialysis, which puts strain on patients due to the involved high out-of-pocket expenditure (with additional consultancy charges, supplements and medicines)(12,13).
Q11. What sociodemographic variables are responsible for increased incidences of CKD?
ANS:
(A) Sociodemographic variables such as education level, ethnicity, race, income, and geographic location can significantly impact the risk of developing chronic kidney disease (CKD)(12,13).
(B) Persons from lower socioeconomic backgrounds often experience higher incidences of CKD due to increased prevalence of related risk factors like hypertension, diabetes, and poor access to healthcare(12,13).
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References
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(2) Raghavan, Vasundhara; Anandh, Urmila. Journey of a Patient with CKD in India. Kidney 360 4(5):p 684-686, May 2023.
(3) Levin A, Stevens PE. Early detection of CKD: the benefits, limitations, and effects on prognosis. Nat Rev Nephrol. 2011;7(8):446-57. doi: 10.1038/nrneph.2011.86.
(4) Rajiv Ahlawat, MPharm, Pramil Tiwari, PhD, Sanjay D’Cruz. Direct Cost for Treating Chronic Kidney Disease at an outpatient setting of a tertiary hospital: evidence from a cross-sectional study. Value in health regional issues, 12c (2017) 36 – 40.
(5) Kumpatla S, Kothandan H, Tharkar S, et al. The costs of treating long-term diabetic complications in a developing country: a study from India. J Assoc Physicians India. 2013 Feb;61(2):102-9.
(6) George Thomas, Dawei Xie, Hsiang-Yu Chen, Amanda H Anderson, et al. Prevalence and Prognostic Significance of Apparent Treatment Resistant Hypertension in Chronic Kidney Disease: Report From the Chronic Renal Insufficiency Cohort Study. 2016 Feb;67(2):387-96. doi: 10.1161/HYPERTENSIONAHA.115.06487. Epub 2015 Dec 28.
(7) Godkar PB, Godkar DP. Text book of Medical laboratory technology (4th edition, 2024), Bhlani Publishers, Mumbai. India.
(8) Godkar PB, Godkar DP. Medical Biochemistry, Theory and Practicals (1st edition, 2024), CBS Publishers, New Delhi,India.
(9) Khanna U. The economics of dialysis in India. Indian J Nephrol 2009;19:1–4.
(10) Hanny Sawaf, Tariku T Gudura, Sylvester Dorobisz, Dianne Sandy, Xiangling Wang, Shane A Bobart. Genetic Susceptibility to Chronic Kidney Disease: Links, Risks and Management. Int J Nephrol Renovasc Dis. 2023 Jan 5;16:1–15. doi: 10.2147/IJNRD.S363041.
(11) Vivek Kumar, Ashok Kumar Yadav, Jasmine Sethi, Arpita Ghosh, et al. The Indian Chronic Kidney Disease (ICKD) study: baseline characteristics. Clin Kidney J. 2021 Aug 13;15(1):60–69. doi: 10.1093/ckj/sfab149.
(12) GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020; 395: 709–733.
(13) Dare AJ, Fu SH, Patra J et al. Million Death Study Collaborators. Renal failure deaths and their risk factors in India 2001–13: nationally representative estimates from the Million Death Study. Lancet Glob Health 2017; 5: e89–e95 [DOI]
