Kidney....the forgotten organ!

I have attended the international thal conference in Egypt and one of the very interesting lectures was about the kidneys and how they are rarely taken care of in thal.

Renal dysfunction is a threat that affects both transfusion dependent and independent patients.

In transfusion independent patients, they are exposed to oxidative stress. In addition to a low flow of oxygen to the cells of the kidneys. This will lead to tubular Ischemia which is a kidney disease. Therefore,  Acute tubular necrosis (ATN) is caused by lack of oxygen to the kidney tissues (ischemia of the kidney)

While in transfusion dependent patients, sometimes the side effects of the chelators lead to Interstitial Nephritis. Interstitial nephritis reduces the kidneys’ ability to filter properly.

In both situations this could lead to kidney dysfunction and kidney failure. The problem is tha
t most of us used to check the kidney functions by doing serum creatinine, uric acid and urea. The study
showed that these are not early markers to detect any change in the kidney.

Not only this, but the study showed that in many patients serum creatinine was in the normal range while other markers showed renal dysfunction.

The doctor said that renal dysfunction is not correlated with older age, duration of the disease or type of chelation. There are other markers that should be done at least once a year to make sure that the kidney is normally functioning.

These kidney markers are:
Albumiuria by A/C ratio ( albumin and creatinine ratio)
Glomerular filtration rate by creatinine clearance
Serum level of Cystatin C

The study showed that glomerular filtration rate (GFR) done by creatinine clearance was more accurate than than the one done with the Schwartz formula.

Also the good thing is that if these markers were found to be out of range, the patient is in an irreversible state where the situation can be improved and avoid renal failure, so we can say that these are EARLY markers, before it is too late

Also these markers should be investigated with patients who are diabetic too

Manal

Copied from the abstract...
The study was done on sixty beta thal patients (43 thal major and 17 thal intermedia) in addition to 20 age and sex matched healthy children as a control group.

The results:
47% of thal patients have moderate protienuria, 40% of thal patients have higher than normal serum cystatine C level and 13.3% of them had low eGFR.
Thal major patients have showed higher A/C ratio than thal intermedia patients, the A/C ratio correlated with serum ferritin levels. However none of the renal changes correlated with age of patients, duration of disease or type of chelation.

Conclusion:
Glomerular dysfunction in beta thal is not a rare complication even in young age. Therefore early attention to such changes and studying a large number of patients for better understanding of pathogenesis of these complications and it's relation to different chelators is highly recommended

I did these three markers to my son, but the cystatin C result will come in seven days

The results were as follows:
A/C ratio (microalbumin)  11 mg/g creat    (0-30)

Creatinine clearance:
Serum creatinine in blood.   0.5 mg/dl     (0.3 - 0.7)
Serum creatine in urine.       62 mg/dl
Urine volume.                         840 ml/24 h
Creatinine clearance.            80 ml/min.    (97 - 137)

So as you can see the creatinine clearance is low and I will be waiting for the result of the cystatine C then go a check with a doctor for the kidney

Andy,
Do you think the low results could be due to the usage of hydrea as it can affect the kidneys or the shortage of oxygen due to the low hb is the main reason

Manal,

I don't know the significance of these numbers but please keep us posted.  Did your doctor discuss these results with you?

Sharmin

Not yet Sharmin, I will met her next tuesday and will wait for the serum cystatine C result before I go to a specialist. Definetly will keep you updated

Just got the result now, it came early
Cystatine C.   0.73mg/L.          (0.59 - 1.04)

So it all markers are normal except for the creatinine clearance

Manal,

As with many tests, the reference range varies from source to source. "Normal" creatinine clearance can be seen in a range that goes as low as 60.

http://www.clinlabnavigator.com/Test-Interpretations/creatinine-clearance.html?letter=C

Renal failure causes reduced creatinine clearance. Creatinine clearance values of 30 to 40 mL/min/1.73 M2 suggest moderate renal impairment, while values < 28 suggest severe impairment.

Reference range is 60 180 mL/min/1.73M2

As you can see, his clearance is far higher than what is seen in moderate kidney impairment. Please keep in mind that "normal" clearance rises with age, so you cannot expect it to be normally as high as an adult. I would suggest making sure he stays well hydrated, especially when testing is coming up. It isn't easy with active kids to always keep them well hydrated, as this means stopping play for a moment, but always make sure that hydration is kept in mind when a routine testing is coming.

One thing I want to shout out about this whole kidney topic is this.

HYDRATE PROPERLY ALWAYS!

I can say nothing as important as this often overlooked therapy. Do not allow yourself to dehydrate at all when taking medications, including chelators. And please remember, if you are going for a test, make sure you are well hydrated in advance. This affects so many tests and will result in what appears to be worse scores when dehydrated to any extent. The one test where the opposite is observed is hemoglobin. Dehydration masks low hemoglobin and makes the Hb look higher. Conversely, if you are well hydrated, your Hb may appear to be lower than it really is. Encourage your kids to be water drinkers from an early age and do not allow their main hydration to come from sweetened drinks.

Thank you so much Andy for your reply and your advice too. I believe too that water is the only thing that can wash out all the body toxins and I try as much as I can to keep him hydrated too

Andy, in the lecture that I attended the professor said that the GFR was done for the same patients once by the creatinine clearance and another by the Schwartz formula and they found that using this formula did NOT give accurate results compared the creatinine clearance readings. That is why they advised not to use the Schwartz because it was not accurate.

The above quote is referring to this formula, isn't it ? If yes should I still compare to it's normal references?
Manal

Manal,

My point is that 80 isn't significantly low, and that for his age and physical development, you can expect lower readings than what you will see for an adult. In the chart I posted at http://www.thalassemiapatientsandfriends.com/index.php/topic,4017.msg40109.html#msg40109 you can see that for his age group, creatinine levels are only .6 compared to .9 in the over 10 age group. These ages are not hard and fast rules. They also depend on the physical development of the child. This also means there is less creatinine to excrete. The amount is based on muscle mass and size, so as one grows, so does creatinine levels and clearance.

My reading of how the tests are done shows there is some subjectivity involved in young children because of their size. There are also two ways to measure clearance and one requires 24 hour observation. This may be more accurate but is not often done due to the 24 hour requirement. As always with tests I say wait until you get the next scheduled test done and make sure hydration is planned a day in advance.

Andy,
You words are really so comfortable to me and makes a lot of sense

Although I used the 24 hour observation and urine collection( which is supposed to be more accurate), but I didn't pay much attention to hydration, just our normal day, which won't be the same the next test. Definetly I will make sure about this before the next test

Wow there it go
I had my GFR  94  with a question mark besides however my doctor never had any conversation about it ,once I read online about it it was said it shouldn't be above 60 ,so it's just one more thing to approach  my doc and see....

Ok ... 
I was confuse with the numbers I'm fine 
My numbers are fine I believe.
Danny

Dear All,

During one of my liver/spleen ultrasound examinations, the doctor pointed out that my kidneys seem to have some " strange shades/clouds ". Addtionally, I shared with him that sometimes I have a weird feeling such as weight in the lower back that appears mainly when I need to go to the toilet really badly.

I was advised to visit an nephrologist and do a series of blood and urine tests. All results except Cystatin C were in the norm ( details below).


Cystatin С   1.04   mg/l     (0.53 - 0.95)   High
eGFR   77.0   мл/мин      (90-120)           Low

Please note that every time I go for a transfusion, they check my creatinin level. The results are always fine. However, it's the first time I do a Cystatin C test. I am really worried what might cause this problem. Could it be because of the Exjade, or the emolysis or just a separate non-thalassemia issue I have to now face.

Your comments would be hugely appreciated. Please share with me if you have any observations about your Cystatin C level or if you have read any useful information regarding this. Many thanks!!!


Creatinin: 47.8 mmol/L    (34-134)
Urea: 4.74 mmol/L          (2.5-7.2)
Potassiom: 4.47 mmol/L   (3.5-5.6)
UA: 201.7 mmol/L           (100-350)
Sodium: 138.40 mmol/L   (134-145)

Manal,

My point is that 80 isn't significantly low, and that for his age and physical development, you can expect lower readings than what you will see for an adult. In the chart I posted at http://www.thalassemiapatientsandfriends.com/index.php/topic,4017.msg40109.html#msg40109 you can see that for his age group, creatinine levels are only .6 compared to .9 in the over 10 age group. These ages are not hard and fast rules. They also depend on the physical development of the child. This also means there is less creatinine to excrete. The amount is based on muscle mass and size, so as one grows, so does creatinine levels and clearance.

My reading of how the tests are done shows there is some subjectivity involved in young children because of their size. There are also two ways to measure clearance and one requires 24 hour observation. This may be more accurate but is not often done due to the 24 hour requirement. As always with tests I say wait until you get the next scheduled test done and make sure hydration is planned a day in advance.

yes Dr Andy is absolutely right,
one herbal suggestion...
1 teaspoon full coriander power + 1 glass of water , put it in night
boil it in morning up to half , let it cool , take empty stomach
it helps in cleansing of kidney and improves its functioning
if green leaves of coriander are available then it will best to use its juice.

Andy Sir
                I read lot of posts from you where you said keep well hydrated all the time while chelation or during HU therapy .
I want to know how much water should a thals drink as per body weight  ?
I drink 3-4 litre in winter and 4-5 litre in summer season. My weight is 46 kg. Am I drink enough water  ? Or I should increase the quantity  ?

Please advice  .