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Asymptomatic patients with severe renal impairment not always detected: Local study 

14 Feb 2022

  • Male farmers especially unwilling to participate in CKD screening programme unless symptomatic 
BY Ruwan Laknath Jayakody  Even though comprehensive community-based awareness and screening programmes for chronic kidney disease (CKD) are in place in the regions where the disease is endemic, asymptomatic patients with severe renal impairment, particularly male farmers, are not always discovered, as they are apparently unwilling to participate in the screening programme unless they are symptomatic, a local study found.  However, since the majority of these patients frequently seek medical care for common diseases at the primary care level, primary care physicians practicing in CKD of unknown origin (CKDu)-high endemic regions should be more vigilant and should engage in active case detection through opportunistic screening, even in the absence of common risk factors for CKD. The latter can be achieved through the screening of serum (an amber-coloured, protein-rich liquid which separates out when blood coagulates), creatinine (an increased level of creatinine – a chemical compound left over from energy producing processes in the muscles – may be a sign of poor kidney function), and urine albumin (a protein made by the liver which helps keep fluid in the bloodstream so it does not leak into other tissues and which carries various substances throughout the body – a low level of which could potentially indicate a problem with the liver or the kidneys) to creatinine ratio, per V.A. Moyer and the US Preventive Services Task Force’s “Screening for CKD: U.S. Preventive Services Task Force recommendation statement”.  Moreover, individuals showing abnormal results during such screenings will require referral to the nearest CKD clinic in the relevant endemic region for a nephrologist’s opinion and further evaluation.  These observations and recommendations were made by B.T.B. Wijerathne and S.B. Agampodi (attached to the Rajarata University’s Medicine and Allied Sciences Faculty, with the former being attached to the Community Medicine Department), R.J. Meier (attached to the Indiana University in the US), L.S.S. Salgado (attached to the Kelaniya University’s Medical Faculty), G.K. Rathnayake (attached to the Bankstown-Lidcombe Hospital, Australia), and S.S. Kumara (attached to the Thammannawa Divisional Hospital) in a letter to the Ceylon Journal of Medical Science Editor on “CKDu: The tip of the iceberg?”, which was published in the Ceylon Journal of Medical Science 55 (2) in December 2018.  CKDu is a leading public health concern. According to “CKDu: Prevalence and causative factors in a developing country” by N. Jayatilake, S. Mendis, P. Maheepala and F.R. Mehta, it is not attributable to any common risk factor such as diabetes, hypertension or glomerular (the tiny network of blood vessels that are the cleaning units of the kidneys which filter waste and remove extra fluids from the blood) diseases.  Moreover, according to studies (“Endemic CKDu in Sri Lanka: Correlation of pathology with clinical stages” by S. Wijetunge, N.V.I. Ratnatunga, T.D.J. Abeysekera, A.W.M. Wazil and M. Selvarajah, “Retrospective analysis of renal histology in asymptomatic patients with probable CKDu in Sri Lanka” by S. Wijetunge, N.V.I. Ratnatunga, D.T.D.J. Abeysekera, A.W.M. Wazil, M. Selvarajah and C.N. Ratnatunga, and “Chronic interstitial (relating to or situated in the small, narrow spaces between tissues or parts of an organ) nephritis ( a condition where the nephrons – the functional units of the kidneys – become inflamed, which can, in turn, adversely affect kidney function) in agricultural communities: A worldwide epidemic with social, occupational and environmental determinants” by C. Jayasumana, C. Orantes, R. Herrera, M. Almaguer, L. Lopez, L.C. Silva, P. Ordunez, S. Siribaddana, S. Gunatilake and M.E.D. Broe), despite being in an advanced stage of CKD, a significant number of patients remain asymptomatic; thus, the primary care physician may encounter patients with an advanced stage of CKDu who are seeking medical care for other health concerns. Hence, Wijerathne et al. performed a study for the screening of healthy individuals from a CKDu endemic region in Sri Lanka. “Healthy” individuals without a history or symptoms of kidney disease, hypertension, diabetes, and snakebite envenoming were invited to participate as “healthy controls”, where all participants were screened to exclude CKD before being recruited into the study.  Out of the 194 screened individuals, five patients fulfilled the criteria for diagnosing CKDu based on the definition used in the study conducted by the World Health Organisation and the Health Ministry, per Jayatilake et al.  The five patients were male farmers and included a 60-year-old with no family history of CKD and no signs and symptoms of CKD, a 58-year-old with two brothers who had CKD and who himself had headaches as the only sign and symptom of CKD, a 41-year-old whose mother had CKD but he himself had no signs and symptoms of CKD, a 46-year-old who had a brother who had CKD and who himself had no signs and symptoms of CKD, and a 44-year-old who had no family history of CKD and no signs and symptoms of CKD. All five patients had never been screened for CKD, despite three of them having had CKD affected family members. Three were in their 40s.  The designated patient was the 58-year-old with two brothers who had CKD and who himself had headaches as the only sign and symptom of CKD. He was detected to have high blood pressure (BP) as well as a history of headaches for four years. He was immediately referred to the Thammannawa Divisional Hospital. He reported that two weeks prior to participating in the screening programme conducted by the researchers, he had sought medical care for an upper respiratory tract infection from a general practitioner, but noted that his BP had not been measured at the time. However, a year earlier, during a primary care consultation for a respiratory condition, his BP was found to be normal. Wijerathne et al. opined that because there was a lack of previous BP measurement records, the cause of the CKD could have been undiagnosed hypertension.  The remaining four patients were referred to a tertiary care nephrology unit and were subjected to repeated renal function tests at the renal clinic over a period of three months, after which the diagnosis of CKD was confirmed. Importantly, except for the designated patient, none of the patients had reported clinical symptoms.  In conclusion, Wijerathne et al. also recommended that health education and health promotion regarding CKD be strengthened among the members of the public living in regions where CKD is endemic.


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