15% av inneliggande patienter på svenska sjukhus är intagna på grund av felmedicinering ofta orsakad av ej identifierad njurfunktionsnedsättning dvs nedsatt.

En presentation över ämnet: "15% av inneliggande patienter på svenska sjukhus är intagna på grund av felmedicinering ofta orsakad av ej identifierad njurfunktionsnedsättning dvs nedsatt."— Presentationens avskrift:

1 15% av inneliggande patienter på svenska sjukhus är intagna på grund av felmedicinering ofta orsakad av ej identifierad njurfunktionsnedsättning dvs nedsatt GFR

2 According to the NHANES III-study the prevalence of stage 2 chronic kidney disease is 3% in the American population i.e. about persons are afflicted

3 What is GFR? It is the volume of glomerular filtrate produced per unit of time, e.g. mL/min

4 Can GFR in humans be measured?
No, because it is not feasible to measure the filtration flow in the 800,000 human glomeruli

5 “Gold standard” methods to estimate GFR
Plasma clearance of inulin, iohexol, 51Cr-EDTA, 125I-iothalamate, 99mTc-diethylenetriaminepentaacetic acid

6 GFR markers Plasma creatinine Plasma cystatin C Creatinine clearance
Creatinine-based GFR prediction equations Cystatin C-based GFR prediction equations

7 Advantages of cystatin C as a GFR-marker
Demonstrates the early, potentially reversible, decrease of GFR in the “creatinine-blind” area Independent of muscle mass and diet Independent of sex and age for children above 1 year Demonstrates the decrease of GFR in old persons No tubular secretion

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10 Creatinine-blind area

11 GFR-markers for patients with muscle atrophy
Non-parametric ROC plots for serum cystatin C (solid line) AUC = and serum creatinine (dotted line) AUC = 0.507 AUC = 0.50 equals the diagnostic efficiency of tossing a coin

12 Concensus recommendation of the National Kidney Foundation (US)
“The serum creatinine concentration alone should not be used to assess the level of kidney function” Page 76, Am J Kidney Dis 2002;39Suppl.1

13 For Adults (MDRD) or

14 GFR-prediction equations Relative GFR in mL/min/1.73m2
MDRD: GFR = x (creatinine/88.4) x age-0.203 x (if female) x (if African American) GFR(CC-estimate)= x cystatin C x (if child<14years)

15 Diagnostic performance of a cystatin C-based GFR prediction equation

16 Diagnostic performance of a creatinine-based GFR prediction equation (MDRD)

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19 GFR (CC-estimat): 89 ml/min/1,73kvm
Grubb, Anders P-Cystatin C: 0,99 mg/L (ref. värde: 0,84 – 1,25 mg/L) GFR (CC-estimat): 89 ml/min/1,73kvm (ref.värde: 60 – 110 ml/min/1,73kvm)

20 “För dosering av njurutsöndrade läkemedel, speciellt hos barn, är det viktigt att känna till patientens absoluta (dvs ej kroppsyte-normaliserade) GFR i mL/min. Detta kan räknas ut från patientens estimerade, eller uppmätta, relativa GFR (i mL/min/1,73 kvm kroppsyta), vikt (kg) och längd (cm). På sajten finns ett hjälpmedel för snabb sådan uträkning.”

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22 Is GFR always the best marker for kidney disease/function?
No, for example: U-Protein HC is much better to demonstrate tubular damage P-Erythropoietin is much better to demonstrate renal anemia Altered glomerular filtration quality is much better to demonstrate preeclampsia

23 What does glomerular filtration quality mean?
It describes the composition of the glomerular filtrate in a patient in relation to the composition of a “normal” glomerular filtrate

24 Hemodialysis (small pores)

25 Hemofiltration (large pores)

26 Difference in plasma clearance of marker molecules

27 How can glomerular filtration quality be assessed in the clinical practise?
By the use of several GFR-markers differing in size and/or charge, e.g. Creatinine Cystatin C 2-microglobulin -trace 2-macroglobulin

28 S-Cystatin C in preeclampsia and normal pregnancy

29 S-Creatinine in preeclampsia and normal pregnancy

30 ROC-curves for demonstration of preeclampsia

31 Concluding suggestions
Use more than one GFR-marker e.g. cystatin C, creatinine and -trace with cystatin C as the basic one Use GFR-prediction equations Use assessment of glomerular filtration quality for diagnostic purposes

32 Penning som föreställer Erik Emune, utropad till kung över Skånelanden och Danmark på Libers hög i Lund 1134 Visas på anmodan.

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