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Welcome to this episode of KD Go
Conversations and Nephrology. 

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This episode, titled CKD 
Evaluation and Measurement, is 

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provided by KD Go and is 
supported by an independent 

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educational grant from 
AstraZeneca. 

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Here's your host, Doctor Peter 
Lynn. 

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Hello and welcome to KD Go 
Conversations and Nephrology. 

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I'm Doctor Peter Lynn, director 
of the K Heart Research Center. 

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And family physician in Toronto,
Canada and joining me today to 

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discuss the importance of CKD 
evaluation and measurement is 

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Doctor Madelina Madeiro. 
Dr. Madeiro is the Head of 

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Nephrology Division at the 
National Heart Institute in 

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Mexico City and her clinical and
research interests include CKD 

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Progression, chronic 
chemodialysis and CKD of unknown

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origin. 
Welcome Doctor Madeiro to the 

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program. 
Thank you, Doctor Lane, and 

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thank you, Katie. 
Go. 

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It's an honor for me to be here 
today with you. 

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It's really good to have you 
here and I think the CKD of 

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unknown origin makes you sound 
like a UFO hunter. 

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So it's kind of interesting to 
hear that term. 

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But today I guess we're going to
focus in on trying to detect 

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kidney disease. 
I must admit our kidneys work 

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very hard for us and they never 
complain and by the time they 

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complain, they are quite 
damaged. 

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So therefore we have to go 
looking for this damage. 

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So can you just go over what are
the tools that we can use to 

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look for chronic kidney disease?
Thank you, Doctor Lynn, that's a

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great question and you are 
absolutely right. 

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Kidneys do not hurt until very 
late stage. 

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So we have some tools to assess 
kidney function in the earlier 

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stages and these tools are EGFR.
So this is estimated glomerular 

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filtration rate and albuminuria 
and these both are critical to 

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detect and to risk stratify 
chronic kidney disease. 

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We know that lower estimated GFR
and higher albuminuria are both 

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strongly associated with risk of
cardiovascular events, kidney 

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failure and mortality. 
So their measurement is crucial 

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for effective risk 
stratification of persons with 

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chronic kidney disease. 
The presence and severity of 

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algumineuria also guides the use
and dosage of treatments that we

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know delay chronic kidney cyst 
progression, so such as ACE 

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inhibitors, ARB and SGLT 2 
inhibitors. 

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So the ideal screening and 
diagnosis approach would consist

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of a triple marker panel with 
serum creatinine serum cystatin 

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C. 
And urine albumin to creatinine 

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ratio. 
We usually prefer albumin uria 

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over proteinuria. 
However, we know that in 

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resource limited settings we can
also use proteinuria for 

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detection of a protein or 
albumin in the urine. 

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There are now equations such as 
CKD EPI that are used to 

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estimate GFR from markers such 
as creatinine and sistatin C and

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the combination of both 
creatinine and sistatin C. 

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And the latest equation is 
without inclusion of a 

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coefficient for black rays. 
So we have these very useful 

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equations that can either use 
the statin C creating or both. 

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And you know the fact that rays 
was removed. 

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It's a very important. 
Event in the nephrology 

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practice. 
This was all done due to the 

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concerns about continuing use of
race in GFR and led to the 

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removal of the race coefficient.
So a big rationale for CKD 

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screening is the availability of
many effective interventions to 

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delay CKD progression and that 
reduce cardiovascular risk. 

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Yeah, that's actually very 
interesting, The fact that 

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you're talking about renal risk 
as well as cardiovascular risks.

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Really having these measurements
would be helpful for us to 

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manage our patients. 
And as you were saying, you 

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know, serum creatinine, we can 
get and with the equations, then

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we can estimate the glomerical 
for attrition rate. 

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And so that tells us about how 
to use other medications, how 

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well the kidneys are 
functioning. 

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And often times I, you know, for
simplicity sake, I tell my 

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patients that's the speed of 
your kidneys that it's working 

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at. 
And I usually tell them we want 

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at least 60 miles an hour or 
higher. 

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And you're only at 30 miles an 
hour and they seem to understand

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that concept of speed. 
And as you were putting it, the 

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urine, albumin, creatinine ratio
is very important as well 

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because I tell patients it's a 
quality of your kidneys. 

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In other words, we want to keep 
the good stuff in which in our 

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case, we've had that as albumin 
as being good things to keep in 

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your body. 
And creatinine, which is waste 

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product as you were mentioning, 
we want to get rid of that. 

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And so therefore we want to make
sure that the kidney is getting 

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rid of garbage and keeping in 
the good stuff. 

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So that measures the quality. 
Of the kidney. 

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So I think that part maybe we 
haven't explained that so well 

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to patients. 
Do you find that people may be 

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doing serum creatinines and and 
maybe not the albumin creatinine

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ratio? 
Yeah, that's that's a very good 

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analogy, Doctor Lynn. 
And you're right. 

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I mean, people do measure 
creatinine for the most part, 

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and many labs have automated 
each GFRS, but I find that a lot

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of people and are not having 
their urine albumines checked. 

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And you know this is very 
important because it is a big 

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risk factor for outcomes such as
kidney disease progression and 

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cardiovascular events. 
And we know that our patients 

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with kidney disease have an even
higher risk of dying from 

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cardiovascular causes and 
reaching to kidney failure. 

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So both markers are very 
important in the evaluation of 

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chronic kidney disease. 
And that makes a lot of sense, 

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so I must admit. 
In the beginning we only focused

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on creatinine and then we had 
the lesions, so we only focused 

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on that. 
But the album and creatinine 

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ratio together gives extra 
information, so we need both 

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pieces. 
So let's say we now have an 

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abnormal test. 
You've identified a patient. 

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How do we go about finding out 
the cause of the CKD? 

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Cuz I think a lot of us just 
assume it's diabetes or 

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hypertension, but how do you go 
about thinking about the 

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different causes that would put 
a patient in a CKD position? 

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Thank you, Doctor Lynn. 
That's a very important 

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question. 
It's not everything diabetes or 

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hypertension. 
So when we evaluate a patient 

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with known or suspected chronic 
kidney disease, clinicians 

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should inquire about additional 
symptoms that might suggest a 

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systemic cause. 
For instance, if a patient has 

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hemoptysis or a rash or 
lymphadenopathy or hearing loss 

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or neuropathy, this may Orient 
us towards something either 

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genetic or towards Glumerlar 
disease. 

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If a patient has for instance, 
urinary hesitancy, urgency or 

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frequency or incomplete bladder 
emptying, then this may guide us

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towards urinary obstruction. 
Moreover, patients should be 

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assessed for risk factors of 
kidney disease and this include 

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potential nephrotoxins such as 
non steroidal and inflammatory 

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medications, phosphate based 
bowel preparations, herbal 

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remedies such as those 
containing aristologic acid. 

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Antibiotic therapies such as 
gentamizing and chemotherapies. 

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Also a history of kidney stones 
or recurrent urinary tract 

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infections may guide us towards 
the cause. 

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Of course, as we mentioned 
earlier, presence of 

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comorbidities such as 
hypertension, diabetes or 

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autoimmune diseases may lead us 
towards the cause of the kidney 

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disease. 
And family history of kidney 

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disease is important. 
There are times where we need to

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do genetic testing, for instance
in younger people with 

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polycystic kidney disease where 
they still do not have cysts, or

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with inherited forms of focal 
segmental glomerular sclerosis 

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as this may allow an earlier 
treatment or make us take 

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decisions such as a big decision
on a family member that may be a

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kidney donor, for instance. 
Finally, imaging. 

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Studies such as an ultrasound 
give us an idea of the 

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chronicity of the disease and 
helps us to rule out 

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obstruction. 
And then when we have done all 

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these, a lot of the times we 
still do not know the cause and 

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we need to perform a kidney 
biopsy, for instance, in a 

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patient that has albuminuria or 
hematuria and we are not 100% 

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sure of the cause, then it is 
important. 

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To have a kidney biopsy as with 
the histologic diagnosis, we're 

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going to have a more precise 
diagnosis and a better 

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management. 
A fundamental justification for 

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the early detection of CKD is 
that we now have a lot of 

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available evidence based 
interventions to slow chronic 

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kidney disease progression as I 
mentioned earlier and this would

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help us reduce its complication 
accurate diagnosis and staging 

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of CKD impact the choice of the 
treatments. 

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And this is one of the most 
important causes to establish 

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what's really generating or 
causing the kidney disease in 

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our patients. 
For those just tuning in, you're

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listening to KD Co Conversations
in Nephrology. 

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I'm Doctor Peter Lynn. 
And speaking with me today is 

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Doctor Magdalena Madero. 
We're discussing the importance 

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of CKD evaluation and 
measurement. 

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Yeah, you make a very good 
point. 

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So now that we've identified a 
patient with CKD, finding the 

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cause will then direct our 
therapies and also risk stratify

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the patient. 
So finding the cause is actually

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as important as detecting the 
disease in the 1st place of 

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course. 
And and yet many of us may just 

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say, oh, the EGFR is a little 
bit low and then we stop there. 

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So all of these lists of 
diseases that you just mentioned

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reminds us that there are many 
causes that can bring a patient 

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to that state of chronic kidney 
disease. 

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So let's say we have these tests
now. 

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And let's say we've got a cause 
as well. 

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So we know which cause is 
causing the CKD. 

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Then when do we consider it as 
CKD progression? 

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Because a lot of times a 
nephrologist and the referral 

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centers would say if the CKD 
progresses, then please refer to

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us. 
So what does that mean in terms 

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of CKD progression? 
Yeah. 

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So that's a very good question, 
Dr. Lean. 

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And this is something we have 
debated as nephrologist over 

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years. 
Progression can be defined in 

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many ways. 
It can be defined as a sustained

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drop in e.g. 
Fr for longer than three months 

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and a 25% or greater decrease in
e.g. 

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Fr from baseline. 
Rapid progression, for instance,

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is usually defined as more than 
5ML minute loss. 

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In 12 months, there are also 
slopes of EGFR decline that have

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been accepted as a definition, 
such as 30 or 40% decline in 

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EGFR, let's say at two years. 
Because, you know, I have to 

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admit that in the past we used 
to define progression as 

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doubling of the creatinine or 
kidney failure, but these events

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are very. 
Drastic and you don't want to 

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wait until this happens to 
define progression, and that's 

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why we have been establishing 
other definitions of CKD 

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progression. 
There's also regression and 

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regression can be defined as a 
sustained higher e.g. 

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Fr category for longer than 
three months and a 25% or 

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greater increase in the e.g. 
Fr from baseline. 

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So this means that not 
everything is progression. 

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Patients can actually get better
from the disease. 

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And this would be considered as 
a regression. 

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Progression is important because
it can help us guide the 

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frequency of monitoring or 
assess a treatment progress, and

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This is why we need to establish
a progression. 

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Yeah, that's actually a very 
good point. 

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In other words, the direction, 
the speed at which it's 

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dropping, those are all very 
useful information. 

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And to your point is that it 
changes how quickly we refer, 

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how often we assess them and 
review their testing. 

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So these are all important 
things for us to do. 

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Now you had mentioned something 
about systatin C and that caught

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my attention because I'm not 
sure if everybody is aware of 

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systatin C So when would 
systatin C be appropriate 

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testing? 
So in other words, when would 

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our traditional creatinine egfr 
estimates sort of not be as 

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accurate and what kind of 
scenarios would we say that a 

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systatin C would probably do 
better in assessing real 

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function? 
Thank you. 

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That's a great question. 
Ideally, cystatin C should be 

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used for the initial diagnosis. 
The use of cystatin C alone or 

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in combination with creatinine 
strengthens the association 

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between the EGFR and the risk of
death and kidney failure across.

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Diverse population. 
So number one, it better 

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categorizes risk #2. 
It should be used when the 

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diagnosis of CKD is uncertain. 
For instance, patient that has 

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G3AA1, so patient with mild CKD 
and no albuminuria #3 when 

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muscle mass is low, such as in 
the case of amputations, or the 

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opposite when there's a large 
muscle mass, such as observing 

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football players or 
bodybuilders. 

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Where creatinine may be under or
over express and this would over

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or underestimate estimated GFR. 
And finally, a more accurate 

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estimation of e.g. 
Fr is required a lot of the 

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times for dosing on certain 
antibiotics such as chemotherapy

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assessment of kidney function in
kidney donors for instance. 

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So therefore there would be 
certain situations where 

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systatin C is better and I guess
as you were pointing out that 

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creatinine is muscle breakdown. 
So therefore if there's changes 

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in muscle mass, that might 
affect it as well. 

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And so there are situations 
where our creatinine friend may 

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not be as accurate. 
And that's why systatin C which 

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is sort of reduced at a regular 
rate in the cells and it's 

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mainly filtered out and there's 
no secretion of it in the renal 

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area that basically that might 
give a better measurement and 

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you listed some very important 
times. 

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Where we need a more accurate 
measurement and that's where the

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systatin C would be useful. 
And I think that's very useful 

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for us to know because many of 
us may not have heard of 

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systatin C as the new way of 
staying for real function. 

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So I think that brings us to a 
close for this particular 

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session. 
I want to thank you very much, 

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Dr. Maduro, for your insights 
into the importance of CKD 

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evaluation and measurement. 
You nicely told us about the 

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EGFR and how that sort of 
measures the speed of kidney 

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function. 
That's one component of it. 

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Albumin creatinine ratio is 
another important component. 

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Of assessing renal function. 
And so therefore both of them 

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together would tell us about the
speed of the kidney as well as 

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the quality as I sort of Simply 
put it for my patients. 

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And then you talked a little bit
about cyst and C and it's 

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important role in certain 
circumstances or maybe the 

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creatinine may not be estimating
the glomeris filtration rate as 

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well. 
And also to identify the causes 

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of CKD because you listed all 
these causes that would have 

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very different treatments and 
different trajectories. 

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And they would need different 
strategies to make sure that we 

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can prevent the kidney 
progression. 

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And then you nicely told us 
about kidney progression and 

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what we should be looking for 
deterioration, the e.g. 

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Fr changing classes of CKD and 
also this rapid drop of five 

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mils per minute over a 12 month 
period. 

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So we have things that we can 
look out for. 

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So that way we can make sure 
that the patient gets the care 

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in a timely fashion. 
And I think all of this, I'm 

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hoping with your knowledge and 
insight will help us all make 

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sure that we can detect CKD. 
And make sure that we manage 

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these patients as well as we can
so that we can avoid those 

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complications that you were 
saying used to be the only thing

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we measure which was doubling of
creatinine and end stage disease

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dialysis. 
Hopefully we will avoid those 

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horrible things for our patients
by diagnosing them earlier and 

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making sure that they do well. 
So thank you very much Doctor 

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Madeira for your insights and 
all your hard work in terms of 

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treating patients and sort of 
getting the benefits of all this

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knowledge make sure that the 
patients will benefit from this 

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new. 
Treatment strategy and 

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detection. 
Thank you, Dr. Lin, for all 

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these very important and 
interesting questions. 

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You just gave a very nice 
summary of what we have 

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discussed and it has been an 
honor to share this forum with 

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you. 
Great pleasure with you. 

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And it's so easy to summarize 
when you put things beautifully.

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So thanks very much again. 
Thank you. 

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You've been listening to KD Co 
Conversations and Nephrology. 

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00:15:54,030 --> 00:15:57,150
You can find 
more@kdco.org/podcast. 

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Thanks for listening.