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Welcome to the “Stage”: GFR and Albuminuria

Reviewing CKD Classification!

• Kidney Disease: Improving Global Outcomes (KDIGO) introduced a for chronic kidney disease (CKD)
  • (G-Stage)
    • eGFR between 60 - 120 ml/min/1.73 m2
      • NOT clinically significant CKD
    • Stage G3
      • Stage G3a
        • 45 < eGFR < 59
      • Stage G3b
        • 30 < eGFR < 44
    • Stage G4
      • 15 < eGFR < 29
    • Stage G5
      • eGFR < 15
  • (A-Stage)
    • Measured by albumin-to-creatinine ratio (ACR) in mg/g
      • Stage A1
        • 0 < ACR < 30 mg/g
      • Stage A2
        • 30 < ACR < 300 mg/g
        • Moderately elevated (previously “microalbuminuria”)
      • Stage A3
        • > 300 mg/g  ACR
        • Severely elevated (previously “macroalbuminuria”)
• Both the G-stage and A-stage are for cardiovascular and renal events! 

What’s WRONG with how we estimate GFR?

• The ideal molecule to estimate GFR does NOT exist!
  • :
    • Exact serum quantity is known
    • Freely filtered at glomerulus
    • Neither secreted NOR reabsorbed in the tubules 
    • Ex: Insulin used historically
      • but cumbersome since requires injection
• Why is creatinine flawed as an estimator of GFR? 
  • Creatinine is used as an endogenous estimator
  • • Differs between patients based on:
      • Sex
      • Age 
    • Low muscle mass → lower levels of creatinine
      • Result: Cr will overestimate eGFR measurements & give false reassurance!
        • Example: Cr of 1 mg/dl in a 90-year-old frail female
    • Higher muscle mass → higher levels of creatinine
      • Result: Cr will underestimate eGFR measurements
        • Ex. Serum Cr of 1.8 mg/dL in Arnold Schwarzenegger or Shaq

• • • nfluenced by medications!
      • Bactrim

• • Race-adjusted eGFR formula
    • African Americans were systematically under-staged (i.e., for a given creatinine, higher eGFR would be reported → undiagnosed CKD)
• Enter a NEW Contender: Cystatin C! 
  • Advantages  
    •  
  • Disadvantages
    •  Affected by sex and age
      • • But, you can correct for these!
    • • • Diabetes
        • Cigarette smoking
        • Thyroid disease
        • Cancer
        • HIV
        • Steroid use
  • Which patient should I order Cystatin C for?!
    • Patients with low muscle mass
      • • Who may be under staged by creatinine measurements alone
          1. Erroneously reporting higher eGFR 
    • Patients with high muscle mass
      • • Who may be falsely labeled with CKD
          1. From a creatinine derived eGFR
• Which marker of eGFR is the best?
  • On a populational level,

Assessing Qualitative Renal Function using A-Stage! (Albuminuria)

• A Dive into the Endothelium!
  • Endothelial dysfunction → Albuminuria
    • Urine = Direct pathway to observe endothelial dysfunction
    •  
• A-Stage
  • Helps identify patients who (1) are in early stages of renal dysfunction and (2) who can respond well to more aggressive interventions!
    • Potential treatments:
      • • • Otherwise are just like other BP meds
      • SGLT2i
        • Shown to decrease decline in GFR, ESRD, and death
          • • Pro tip! If proteinuria is still > 500 mg/g with RAASi and SGLT2i, can consider adding finerenone!
    • You can trend A-Stage to assess the effectiveness of treatment interventions!
    • Make sure to measure :
      • Diabetes AND known CKD
• Confounding Factors for albuminuria
  • The following activities can lead to transient albuminuria
    • Exercise
    • Standing upright
    • Inflammation
• How do we measure A-Stage? 
  • • Most commonly used!
      • Influenced by denominator (creatinine)
        • Note: Urine albumin WITHOUT reporting urine creatinine is NOT meaningful!
      • But this is affected by all the aforementioned flaws of creatinine measurement
  • • • Can be quite cumbersome to collect/perform, especially in outpatient settings

Contributors

Shreya Trivedi, MD, ACP Member – Editor
Gregory Katz, MD – Host, Editor
Cary Blum, MD – Host, Editor
Yichi Zhang, MD, MBA – Editor, MOC Questions

Reviewers

Tomas Guerrero, MD
Tejas Patel, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  November 8, 2023

Expiration Date: November 7, 2026

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the �ܼ�����ˮ��̳ and Core IM.  The �ܼ�����ˮ��̳ is accredited by the ACCME to provide continuing medical education for physicians.

The �ܼ�����ˮ��̳ designates this enduring material (podcast) for .5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to .5 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.