http://www.revistanefrologia.com © 2012 Revista Nefrología. Órgano Oficial de la Sociedad Española de Nefrología originales Early detection of chronic kidney disease: Collaboration of Belgrade nephrologists and primary care physicians Ljubica Djukanovi´c1, Visnja Lezai´c2, Nada Dimkovi´c2, Gordana Perunici´c Pekovi´c3, Danica Bukvi´c4, Sanja Bajceti´c5, Jelena Pavlovi´c6, Ana Bonti´c6, Nadezda Zec3, Danijela Momcilovi´c7, Marina Stojanovi´c Stanojevi´c8 1 Academy of Medical Science. Serbian Medical Society. Belgrade (Serbia) 2 Medical Faculty. Belgrade University. Belgrade (Serbia) 3 Department of Nephrology. Clinical Centre Zemun. Belgrade (Serbia) 4 Special Hospital for Endemic Nephropathy. Lazarevac (Serbia) 5 Department of Nephrology. Clinical Centre Zvezdara. Belgrade (Serbia) 6 Department of Nephrology. Clinical Centre of Serbia. Belgrade (Serbia) 7 Hemodialysis Center of Health. Obrenovac (Serbia) 8 Hemodialysis Center of General Hospital. Mladenovac (Serbia) Nefrologia 2012;32(1):59-66 doi:10.3265/Nefrologia.pre2011.Oct.11031 ABSTRACT Detección precoz de la enfermedad renal crónica: colaboración entre nefrólogos y especialistas de atención Background: Belgrade screening study was undertaken in primaria de Belgrado order to detect persons with CKD markers in at risk RESUMEN populations and to educate primary care physicians how to carry out CKD screening. Methods: The study was Antecedentes: El estudio de Belgrado se realizó para detec- tar personas con marcadores de ERC en poblaciones de ries- performed by primary care physicians from thirteen go y formar a los especialistas de atención primaria sobre Belgrade health centers in collaboration with nephrologists cómo realizar proyecciones de ERC. Métodos: El estudio fue from clinical centers. Subjects without previously known realizado por especialistas de atención primaria de trece kidney disease were enrolled: 1316 patients with centros de salud en colaboración con nefrólogos de centros hypertension without diabetes, 208 patients with type 2 clínicos. Se incluyó a personas sin enfermedad renal previa conocida: 1316 pacientes con hipertensión sin diabetes, 208 diabetes and 93 subjects older than 60 years without pacientes con diabetes tipo 2 y 93 pacientes de más de 60 hypertension or diabetes. The survey consisted of an años sin hipertensión ni diabetes. El estudio consistía en interview, estimation of glomerular filtration rate una entrevista, determinación de la tasa de filtración (eGFR–MDRD), single urine dipstick detection of proteinuria, glomerular estimada (TFGe-MDRD) y detección de protein- hematuria, glucosuria, microalbuminuria. Results: uria, hematuria, glucosuria y microalbuminuria con una única tira reactiva de orina. Resultados: Se detectó microal- Microalbuminuria with or without proteinuria in buminuria con o sin proteinuria en combinación con una combination with eGFR>60 ml/min/1.73m2 was detected in TFGe >60 ml/min/1,73m2 en el 17%, el 41% y el 24% de los 17% , 41% and 24% of patients with hypertension, diabetes pacientes con hipertensión, diabetes y mayores de 60 años, and those above 60 years, respectively. Reduced eGFR (< 60 respectivamente. Se encontró una TFGe reducida (<60 2 ml/min/1.73m2 ) was found in 23%, 12% and 22% of the ml/min/1,73m ) en el 23%, el 12% y el 22% de estos mis- mos grupos de pacientes. La prevalencia de los marcadores same patient groups. The prevalence of CKD markers de ERC aumentaba cuanto mayor era el número de factores increased with increasing number of risk factors. de riesgo. Conclusión: La elevada prevalencia de mar- Conclusion: High prevalence of CKD markers in at risk cadores de ERC en una población de riesgo detectada por population detected by primary care physicians in this los médicos de atención primaria en este estudio de colab- collaborative study seems to be the best way to encourage oración parece ser la mejor forma de motivar a estos espe- cialistas para que realicen cribados de ERC con regularidad. primary care physicians to carry out regular CKD screening. Keywords: Chronic kidney disease. Screening. Primary care. Palabras clave: Enfermedad renal crónica. Proyección. Atención Primaria. Correspondence: Ljubica Djukanovi´c INTRODUCTION Academy of Medical Science. Serbian Medical Society. Pasterova 2. 11000 Belgrade. Serbia. [email protected] The steady increase in the incidence of patients on renal [email protected] replacement therapy (RRT) was first noted in developed 59 originales Ljubica Djukanovi´c et al. Belgrade screening study countries and thereafter all around the globe1-3. Over the over a three month period. The patients were enrolled in same period diabetes and hypertension became the leading the study according to the following criteria: patients with causes of chronic kidney disease (CKD) and the number of hypertension for more than 5 years, patients with type 2 elderly patients in end-stage renal disease increased steadily3. diabetes mellitus for more than 5 years regardless of the It became obvious that more attention should be directed to presence or not of hypertension, and persons older than 60 prevention and early detection of CKD. Recent data years without hypertension or diabetes. Exclusion criteria indicated stabilization of incidence rates of RRT patients in involved: previously known kidney diseases, malignant many developed countries4-6. Although different factors disease, congestive heart disease, pregnancy, any acute might have led to this stabilization, greater emphasis on illness, as well as persons younger than 18 years. early detection and prevention of CKD is doubtless one of them. However, our country is among those European Informed consent was obtained from all patients and the countries where the incidence rate of patients on RRT is Ethics Committee of the Clinical Center of Serbia continuing to increase7,8. The experience of developed approved the study. countries in primary and secondary prevention of CKD has taught us that attention must be moved from treating The survey started with an interview in which the advanced stages of CKD towards treatment of the early participants answered a detailed questionnaire on stages. As early stage of CKD in most patients is demographic issues, personal medical and family history asymptomatic and undiagnosed, detection can be achieved with special attention to duration and treatment of only by active screening. It was proposed that prevention hypertension and diabetes and data on smoking. After the and early detection of CKD would be best managed in a interview the primary care physicians examined all partnership between primary and secondary care9. Therefore, selected subjects physically, including measurement of we undertook the first study for early detection of CKD in body weight, height and blood pressure. In addition, they Serbia in which primary care physicians from thirteen analyzed the medical records of each subject and Belgrade health centers collaborated with nephrologists from calculated the average systolic and diastolic blood Belgrade clinical centers. The aim was to detect persons with pressure as well as the average serum glucose level using CKD markers in populations at risk and also to educate all values registered in the year preceding the study. primary care physicians how to carry out screening for CKD These data were also noted in the questionnaire. and how to interpret the results and manage subsequent treatment alone or in collaboration with nephrologists. All participants were sent to the laboratory where serum creatinine level was measured by a kinetic Jaffé method and glomerular filtration rate (eGFR) estimated using the original SUBJECTS AND METHODS Modification of Diet in Renal Disease (MDRD) Study formula11. Proteinuria, hematuria, glycosuria and The present paper presents the results of screening for CKD carried microalbuminuria were assessed semiquantitatively in spot out in Belgrade under the leadership of the Academy of Medical urine samples using the urine dipstick test. Proteinuria, Science of the Serbian Medical Society. The study included three hematuria, glycosuria were defined when dipstick analysis steps: (1) Education. Educative meetings for primary care quantified them as 1+ or more. Microalbuminuria (MAU) physicians on prevention and early detection of CKD were was detected with Micral-test® strips (ACCU-CHEK organized by Academy in 2008. (2) Organization of study for product, Roche Diagnostics). These immunoassay reagent detection of persons with CKD markers. At the beginning of 2009 strips (monoclonal antibodies to human albumin) reveal a primary care physicians from all 13 Belgrade Health Centers were distinctive color corresponding to a scale on the vial label invited to participate in the screening study. After their positive giving a range of albumin concentrations as follows: response nephrologists from three clinical centers presented the negative, 20 mg/L, 50 mg/L and 100 mg/L. According to the study design to primary care physicians who carried out manufacturer’s instructions albumin concentrations detected investigations from April to June 2009. (3) Results presentation as _> 20 mg/L are consistent with microalbuminuria _> 30 and guideline distribution. In November 2009, the Academy mg/day. This was confirmed in 100 patients with MAU organized a meeting where the results from each health center were detected by the Micral-dipstick test during the screening and presented by general practitioners and the overall findings were subsequent determination of albumin