|Year : 2020 | Volume
| Issue : 1 | Page : 13-16
Kidney disease screening among a low-income group of hospital staffs who have less opportunity
MA Kashem1, Rajat Sanker Roy Biswas2, Shaikh Md Hasan Mamun2
1 Department of Nephrology, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
2 Department of Medicine, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong, Bangladesh
|Date of Submission||08-Jan-2020|
|Date of Acceptance||30-Jan-2020|
|Date of Web Publication||23-Jun-2020|
Dr. Rajat Sanker Roy Biswas
Department of Medicine, Chattagram Maa-O-Shishu Hospital Medical College, Chittagong
Source of Support: None, Conflict of Interest: None
Background: The prevalence of chronic kidney disease (CKD) has been rapidly increasing worldwide, and its early screening is vital to prevent the development of end-stage renal failure. Population-based studies on detection at early stage of kidney disease and its prevalence are scanty in our country. Hence, taking advantage of the observance of the World Kidney Day 2019, we conducted a screening program for kidney disease organized at the Chattagram Maa-O-Shishu Hospital premises among a low-income group of hospital staffs. Methods: This was a cross-sectional observational study among a low-income group of hospital staffs, working at our hospital. Age, body weight, height, body mass index (BMI), and blood pressure were documented, and urinary protein and serum creatinine were measured at a single sitting. Kidney function was estimated by calculating the glomerular filtration rate (GFR) using the Modification of Diet in Renal Disease formula. Kidney function was classified according to the estimated GFR (eGFR) and Kidney Disease Outcomes Quality Initiative guidelines. Results: A total of 101 hospital staffs were studied. Majority of the participants (38%) were in the age group of 30–39 years. Among all, 24% of the participants had proteinuria (trace to ≥1 plus). The distribution of eGFR was symmetrical, with the majority (79%) of participants in the 60–89 ml/min category, 6.9% in the 30–59 ml/min category, and only 13.9% of the study population had eGFR >90 ml/min. An inverse relation between eGFR and age and a direct relation between eGFR and BMI were observed. Conclusion: Proteinuria, low GFR levels, and consequently the possibility of high burden of CKD are prevailing in the studied participants, and further targeted population-based studies are warranted to clarify these issues.
Keywords: Body mass index, estimated glomerular filtration rate, hospital staffs, Modified Diet in Renal Disease Formula, proteinuria, serum creatinine
|How to cite this article:|
Kashem M A, Biswas RS, Mamun SM. Kidney disease screening among a low-income group of hospital staffs who have less opportunity. J Sci Soc 2020;47:13-6
|How to cite this URL:|
Kashem M A, Biswas RS, Mamun SM. Kidney disease screening among a low-income group of hospital staffs who have less opportunity. J Sci Soc [serial online] 2020 [cited 2020 Sep 24];47:13-6. Available from: http://www.jscisociety.com/text.asp?2020/47/1/13/287486
| Introduction|| |
Chronic kidney disease (CKD) is emerging as a health issue of significance across the globe and is one of the top 20 causes of death worldwide. Much of the rise in CKD-attributable deaths has occurred in low-income and middle-income countries (LMICs). Few data exist to inform screening strategies for early detection and management of CKD in LMICs, where risk factors for CKD may differ from those in high-income countries. Kidney disease usually progresses silently, often destroying most of the kidney function before causing any symptoms. The early detection of failing kidney function and its complications may delay or prevent the development of end-stage renal disease. The study showed that most CKD patients who report to the tertiary care hospitals in our country are already in the state of end stages when renal replacement therapy is the only answer, which is largely unaffordable and unavailable in our country. Early identification and appropriate nephrological management of patients with mild renal disease has been increasingly recognized as an important opportunity to delay the progression of renal disease. Although some debate exist about how to most effectively evaluate persons with CKD in general population, a previous follow-up study showed that participants in the Kidney Early Evaluation Program were more likely to seek and receive renal care and experience less mortality and morbidity compared with nonparticipants. In view of this, renal status in a group of hospital staffs was assessed by measuring proteinuria, serum creatinine, and estimating glomerular filtration rate (GFR) in a kidney screening program, organized on March 14 to coincide with the observance of the “World Kidney Day 2019.”
| Methods|| |
At the campus of Chattogram Maa-O-Shishu Hospital, Agrabad, Chittagong, Bangladesh, the Department of Nephrology organized a free kidney screening program among a low-income group of hospital staffs with prior permission from the Institutional Ethical Committee. A total of 101 hospital staffs (ward boys, patient attendants, security guards, and laboratory assistants) were included in the study on first-come and first-served basis and whose monthly income is around Bangladeshi currency, taka 8000/(equivalent to < 100 USD). All participants completed a questionnaire, documenting their sociodemographic status (e.g., age and sex) and personal and family health history (e.g., hypertension, diabetes, and kidney disease) with the assistance of trained volunteers. Participants having a history of urinary tract infection or CKD were excluded from the study. Each participant underwent weight and height measurements using a calibrated scale, and the body mass index (BMI) was calculated as weight (in kilograms) divided by height in square meters and categorized as per the cutoff value for the Asian population. Blood pressure (BP) was measured according to the guidelines presented in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNC VII). Participants were asked to collect a spot urine sample, which was then used to detect proteins with urinary strips. Five milliliter venous blood was collected for the measurement of serum creatinine, which was done by an enzymatic method on an autoanalyzer (DADE Behring Limited, Deerfield, Illinois, USA) in the college laboratory. Hypertension was defined as systolic BP (SBP) ≥140 mmHg or diastolic BP DBP ≥90 mmHg. The GFR, calculated by using the simplified Modification of Diet in Renal Disease (MDRD) formula, detects CKD more accurately than does the serum creatinine level alone and was used for renal function staging. Using these estimated GFRs (eGFRs) and the Kidney Disease Outcomes Quality Initiative (K/DOQI), kidney functioning was classified for each participant. According to the K/DOQI guidelines to define CKD, we should have at least 3-month history or three positive test results. As we conducted a screening program and tested only once, we used the term “likely CKD” instead of classical CKD. The participants were divided into four groups according to their BMI based on the WHO international classification: <18.5 kg/m2 (underweight), 18.5–24.99 kg/m2 (normal), 25–29.99 kg/m2 (overweight), and ≥30 kg/m2 (obese). Data were analyzed by using SPSS 20 (IBM, Armonk, NY, USA). Results were presented as numbers, percentages, mean, standard deviation (SD), and range. Student's t-test and Chi-square test were used for comparison of means and proportions where appropriate. The crude (unadjusted) relationship between the exposure variables (age, BP, and BMI) and eGFR was examined by univariate logistic regression analysis. A multiple linear regression model was used to determine the independent association between the reduction of eGFR and continuous variables such as age, SBP, DBP, and BMI.
| Results|| |
Regarding different demographic data of the participants where the mean (± SD) age of the population was 35.17 (±08.82) years, 30% were 20–29 years, 38% were 30–39 years, 27% were 40–49 years, and 6% were >50 years old. The mean BMI was 24.38 ± 3.64 kg/m2. The mean SBP and DBP pressure were 121 ± 11 mmHg and 81 ± 8.5 mmHg and the mean (±SD) of blood urea, serum creatinine, and eGFR (MDRD) was 24.07 ± 4.97 (mg/dl), 1.05 ± 0.16 (mg/dl), and 76.50 ± 12.26 (ml/min), respectively [Table 1]. Proteinuria was detected among 24 participants in the range of trace (22%) to 1+ (2%), as shown in [Table 2]. The age-wise distribution of eGFR is shown in [Table 3]. Only 14 (13.94%) participants had eGFR >90 mL/min. Majority (80 [79.90%]) had eGFR at 60–89 mL/min and 7 (06.90%) had eGFR <60 ml/min [Table 4]. There was a tendency of gradual increase in eGFR up to 40-year-old group and then a gradual decline with increasing age. Association of eGFR with age [Figure 1] shows the relation between age and eGFR, and there was an inverse relation between the two. eGFR showed a positive correlation with BMI [Figure 2].
|Table 3: Age-wise distribution of estimated glomerular filtration rate calculated by the Modification of Diet in Renal Disease formula|
Click here to view
|Table 4: Stratification of the participants according to the estimated glomerular filtration rate (n=101)|
Click here to view
|Figure 2: Relationship between body mass index and estimated glomerular filtration rate|
Click here to view
| Discussion|| |
We observed that proteinuria and low eGFR are frequently detected among the participants in our community-based screening program that was carried out on the World Kidney Day observance. An average GFR level was 76.58 ± 12.36 ml/min, which is on the lower side of the generally accepted normal values. Nearly 79% of our study participants had GFR 60–89 ml/min and nearly 7.0% of the participants had GFR 30–59 ml/min, leading to the observation of poor or low GFR profiles in our hospital staffs. We do not know the average GFR level in our community, especially among the low-income group of hospital staffs, and hence, it is difficult to make any conclusions on these results. Our previous study showed the same trend of lower GFR profile among the female hospital staffs. An observation of a low profile of eGFR indicates that the general level of GFR in our community itself might be low for lower muscle mass in comparison to African and Caucasians and hence a lower serum creatinine. However, this needs to be confirmed or contradicted by more community-based studies.
As per the K/DOQI definition of CKD, we observed 7% of likely CKD in Stage 3, 80% in Stage 2, and only 14.0% in Stage 1, that is, eGFR >90 ml/min in our study. The apparently lower level of eGFR results in problems of staging due to fixed cutoff values in the K/DOQI classification of CKD stages. In fact, it is not known if the K/DOQI classification can be applied to our population or not. Whether the lower level of GFR in the population indicates a greater susceptibility to developing ESRD or proportionately lower cutoff values at each stage are required is not known. Besides, another contributing factor may be related to the issue of measurement methodology and calibration of serum creatinine. On the whole, the burden of CKD in this small population was much higher compared to the available prevalence/incidence data on the Indian population. The difference may be partly due to the fact that the earlier studies did not depend on GFR/eGFR but on serum creatinine and clinical judgment.
We observed a linear negative correlation between age and eGFR. The age-wise distribution of GFR indicated that the peak was in the age group of 30–39 years. The proportion of variation in GFR explained by age was 32.0%. Age is a determinant of renal function, and GFR is believed to decline by 1 ml/min/1.73 m2/year after the age of 30 years in healthy persons. Our data are in agreement with other reports based on cross-sectional data, but slightly more than the decline based on longitudinal data.
The correspondence between eGFR and serum creatinine values among the various stages of CKD led to the interesting observation that serum creatinine levels were not elevated even in CKD Stage 3, although the GFR indicated derangement or presence of disease. Only in CKD Stages 4 and 5, could elevated levels of serum creatinine be seen. Thus, if we depend on serum creatinine alone, there is a possibility of missing the diagnosis of the disease when it is in its earlier stages, and similar views have also been reported previously. Only one-time measurements of serum creatinine and a lack of calibration of the measurement of serum creatinine are some of the limitations of the study.
We found proteinuria among 24 participants in the range of trace (22 participants) to 1+ (2 participants). Although majority of the participants had proteinuria in trace in amount, the significance of this finding cannot be overlooked, as proteinuria signifies the underlying renal disease and hence it demands further evaluation. On the contrary, the urine sample was not a first morning sample which does bring up a question of false-positive and false-negative results. Moreover, there is also the potential of transient proteinuria on a one-time dipstick test. We also observed a prevalence of hypertension (SBP ≥140 and DBP ≥90 mmHg) among 10% of the participants. However, more community-based studies with longitudinal follow-up are mandatory to resolve the issues.
| Conclusion|| |
As the prevalence of proteinuria, hypertension, obesity, and reduced GFR is frequently detected in the community and early detection of which is vital for early intervention, larger community-based, multicentric studies are warranted to abate the potential epidemic of CKD in our country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1736-88.
Liyanage T, Ninomiya T, Jha V, Neal B, Patrice HM, Okpechi I, et al
. Worldwide access to treatment for end-stage kidney disease: A systematic review. Lancet 2015;385:1975-82.
Anand S, Zheng Y, Montez-Rath ME, Wei WJ, Perico N, Carminati S, et al
. Do attributes of persons with chronic kidney disease differ in low-income and middle-income countries compared with high-income countries? Evidence from population-based data in six countries. BMJ Glob Health 2017;2:e000453.
McClellan WM, Ramirez SP, Jurkovitz C. Screening for chronic kidney disease: Unresolved issues. J Am Soc Nephrol 2003;14:S81-7.
Kashem A, Dutta PK, Huda MN, Das S, Yunus EB, Chowdhury D. Clinical profiles of chronic kidney disease patients at the time of maiden presentation: An experience at the nephrology ward, Chittagong Medical College Hospital. J Chittagong Med Coll Teach Association 2010;2:7-10.
Jungers P. Screening for renal insufficiency: Is it worth while? Is it feasible? Nephrol Dial Transplant 1999;14:2082-4.
Kurella Tamura M, Li S, Chen SC, Cavanaugh KL, Whaley-Connell AT, McCullough PA, et al
. Educational programs improve the preparation for dialysis and survival of patients with chronic kidney disease. Kidney Int 2014;85:686-92.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al
. The Seventh Report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA 2003;289:2560-72.
Yamagata K, Iseki K, Nitta K, Imai H, Iino Y, Matsuo S, et al
. Chronic kidney disease perspectives in Japan and the importance of urinalysis screening. Clin Exp Nephrol 2008;12:1-8.
Levey AS, Greene T, Kusek JW, Beck GJ. Simplified equation to predict glomerular filtration rate from serum creatinine. J Am Soc Nephrol 2000;11:828.
Kashem MA, Biswas RS, Jewel KH. Kidney disease screening in a group of female health personnel: Who are often missing? J Integrat Nephrol Androl 2019. [Ahead of print].
Duncan L, Heathcote J, Djurdjev O, Levin A. Screening for renal disease using serum creatinine: Who are we missing? Nephrol Dial Transplant 2001;16:1042-6.
Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third national health and nutrition examination survey. Am J Kidney Dis 2003;41:1-2.
Agarwal SK, Dash SC, Irshad M, Raju S, Singh R, Pandey RM. Prevalence of chronic renal failure in adults in Delhi, India. Nephrol Dial Transplant 2005;20:1638-42.
Lindeman RD, Tobin JD, Shock NW. Association between blood pressure and the rate of decline in renal function with age. Kidney Int 1984;26:861-8.
Kawamoto R, Kohara K, Tabara Y, Miki T, Ohtsuka N, Kusunoki T, et al
. An association between body mass index and estimated glomerular filtration rate. Hypertens Res 2008;31:1559-64.
Lindeman RD, Tobin J, Shock NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 1985;33:278-85.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]