https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/249 Mon, 10 Jul 2017 11:07:54 +0000 Chronic kidney disease (CKD) with diabetes mellitus is one of the most common and major public health problems globally. In Bangladesh, several studies indicate an increasing prevalence of diabetes though very few studies are available on CKD. For CKD, diagnostic method, criteria or cutoffs still remained undecided. This study aimed to determine the prevalence of CKD among the hospitalized patients and to compare the diagnostic approach practiced in the hospital. Results: A total of 4172 patients got admitted in the study period of 90 days; and 442 patients (m / f = 256 / 186) were investigated. Of the total (n=4172), 241 (5.8%) had CKDcreat and 272 (6.5%) had CKDgfr. Of the investigated 442 patients, 241 (54.5%) had CKDcreat and 272 (61.5%) had CKDgfr. The differences of characteristics between CKDcreat and non-CKDcreat groups were almost similar to the differences between CKDgfr and non-CKDgfr groups. Higher age, higher social class and higher blood pressure showed significant (p<0.001) and similar associations with both CKDcreat and CKDgfr. Interestingly, if the cut-off of eGFR is taken at <90 ml/min/1.732, as suggested by K/DOQI, the prevalence of CKDgfr increases to 86.7%. This indicates a wide variation (32.2%) between the two criteria (CKDcreat: creat >1.2 mg/dl and CKDgfr: <90 ml/min/1.732). Thus, a large proportion remained either under- or over-diagnosed depending on the criterion used. Ibrahim Med. Coll. J. 2014; 8(2): 50-55   Chronic kidney disease (CKD) is a growing public health problem both in the developing and developed world.1 Prevalence is estimated to be 8-16% worldwide. The complications of CKD related to and resulted in increased all-cause and cardiovascular mortality.2 More striking is the fact that diabetes mellitus is the most common cause of chronic kidney disease, but in some regions other causes, such as herbal and environmental toxins, are more common.2 About 5% of the adult populations have some form of kidney damage and every year millions of people die prematurely of cardiovascular diseases linked to CKD. The recent literatures indicate that diabetes and hypertension are becoming the most common causes of CKD, especially in older people both in developed and developing nations,3,4 CKD is estimated to effect 19 million people of US population and greater than 50 million people worldwide.5,6 In Bangladesh, a survey among the disadvantaged community in Dhaka City revealed that 13.1% had CKD.7 This indicates that the prevalence of CKD is not negligible. Early diagnosis of CKD and intervention are the imperative measures to prevent or retard life-threatening complications. The intervention measures initiating low-protein dietary changes, close monitoring of blood pressure, control of blood glucose levels, health related education, exercise, and so on.9 The aim of this study was to estimate the burden of CKD in hospitalized patients and to compare the two diagnostic criteria practiced in the hospital setting with a view to accept a cheaper and simpler diagnostic method. Subjects and Methods Statistical analyses: Socio-demographic characteristics were given in percentages for qualitative and mean (SD) for quantitative variables. Independent t-tests were applied for comparisons of characteristics between CKDcreat and NCKDcreat group and between CKDgfr and NCKDgfr groups to see any difference observed between these two comparisons. The prevalence rates for CKDcreat and CKDgfr were givenin percentages. We also used c2-test to assess risk factors like sex, age, residence, social class, hypertension status, occupation and smoking for both types of CKD. The values for eGFR based on K/DOQI and the corresponding values for creatinine were shown in means with 95% confidence interval. A p< 0.05 was considered statistically significant. All statistical analyses were performed using SPSS 20.0. Results Of the study population (n = 442) the males were 256 and females were 186. Based on the two criteria (creat >1.2mg/dl) and eGFR (<60 ml/min/ 1.73m2), the prevalence of CKDcreat and CKDgfr was 5.8% and 6.5%, respectively, among the admitted (n=4172) patients. In other words, at any given period in a hospital, the prevalence of CKD ranges from 5 – 7%. In contrast, when only the investigated (n = 442) patients were considered the prevalence of CKDcreat was 54.5% and CKDgfr, was 61.5%. (table 1). If the cut-off of eGFR is taken at <90 ml/min/1.73m2, as suggested by K/DOQI, the prevalence of CKDgfr increased further to 86.7%. Thus, there was a wide variation (32.2%) between the two criteria (CKDcreat: creat >1.2 mg/dl and CKDgfr: <90 ml/min/1.732).   The socio-demographic characteristics are shown in Table 2. The mean (SD) age was 56.1 (13.9) and BMI was 23.3 (4.3). Forty years and above comprised   almost 90%. Table-2: Demographic characteristics of the study population (N=442).   Table-3: Comparison of characteristics between non-CKD (NCKD) and CKD based on serum creatinine and eGFR (cut-off: creat 1.2mg/dl and eGFR 60 ml/min/1.73m2).3       Table-4: Comparison of Prevalence of CKD (based on both criteria) according to sex, age, residence, social class, hypertension, occupation and smoking habit.     Discussion Then which criteria should we follow? The prevalence of CKDgfr (eGFR <90 ml/min/1.73 m2) was found 86.7%, based on K/DOQI (table 3). In contrast, the prevalence of CKDcreat was found 54.5%. based on creatinine level (>1.2mg/dl). This means that about 38.5% remained undiagnosed by CKDcreat or over-diagnosed by CKDgfr criteria. The controversy remained still unsettled as reported from Pakistan.12 Had we included other variables like micro-albuminuria, gross proteinuria, albumin-creatinine ratio or evidence of other micro-angiopathic (retinopathy or neuropathy) and macro-angiopathic lesions like coronary artery disease or cardiovascular morbidity then we could have better assessment of diagnosis or grading of CKD. The recent suggestion is that serum cystatin C alone or creatinine plus cystatin C may predict better CKD.13 But, this recommendation was challenged by others.14 Considering the above mentioned studies it remained unsettled issue to recommend an accurate diagnostic tool for CKD. This study concludes that the prevalence of CKD among the hospitalized patients is almost comparable to other studies and the prevalence was found much higher if K/DOQI is used. Older age, hypertension, rich class and urbanization were found significantly associated CKD. The study suggests that inclusion of serum creatinine with eGFR, micro-albuminuria, gross proteinuria, albumin-creatinine ratio and cystatin C in a prospective cohort may determine more reliable and acceptable method for the staging of CKD, which in turn may help screening of CKD. We also propose that any population, free from diseases, should have the reference values (mean, median, deviation percentile) of creatinine and body surface area (for eGFR), any value exceeding 95th percentile may be considered abnormal for staging of CKD. Acknowledgements   1.    The World Health Report 2003. Shaping the future. World Health Organization; 2003. 3.    Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Inter Med 2003; 139: 137-47. 5.    Coresh J, byrd-Holt D, Astor BC, Briggs JP, Eggers PW, Lacher DA, Hostetter TH: Chronic kidney disease awareness, prevalence, and trends among U.S adults, 1999 to 2000.  J Am Soc Nephrol 2005; 16: 180-88. 7.    Huda MN, Alam KS, Rashid HU, Alam MR, Rahman MH and Selim SI. Prevalence of Chronic Kidney Disease in adult Disadvantageous Population. Journal of Chittagong Medical College Teachers’ Association 2010; 21(2): 25-29. 9.    McClellan WM: Epidemiology and risk factors for chronic kidney disease. The Medical clinics of North America 2005; 89(3): 419-45. 11.  Valmadrid CT, Klein R, Moss SE, Klein BE: The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med 2000; 160: 1093–1100. 13.  Shlipak MG, Matsushita K, Ärnlöv J, Inker LA, Katz R, Polkinghorne KR, Rothenbacher D, Sarnak MJ, Astor BC, Coresh J, Levey AS, Gansevoort RT; CKD Prognosis Consortium. Cystatin C versus creatinine in determining risk based on kidney function. N Engl J Med. 2013; 369(10): 932-43. 15.  Mulder WJ, Hillen HFP. Renal function and renal disease in the elderly. Eur J Int Med 2001; 12: 86-97. 2026 Ibrahim Medical College. All rights reserved.