Discuss about the Patient Health Evaluation for Urea and Electrolyte Test.
The case study is that of Mrs Y who is an 80 year old senior citizen with a 20 year history of diabetes (Type II), as well as hypertension. She has been experiencing difficulties in managing the diabetes over the last several years and has even had a few hypoglycaemic episodes. The doctor reduced her medication for diabetes 6 months ago with no other reported incidences of hypoglycaemia. The last recorded BGL was 7.0mmol/L which is within normal range. She is also on medication namely: Metformin for DM2; Gliclazide for DM2; and Ramipril for hypertension
According to AIHW[1], chronic disease is categorized into four major groups: diabetes, chronic obstructive pulmonary disease, cancers, and cardiovascular diseases. There are also four common behaviour risks that predispose persons to the aforementioned chronic diseases namely: alcohol use, poor nutrition, physical inactivity, and smoking. Between them, the chronic diseases account for 3/4 of all deaths related to chronic diseases. Diabetes has been classified as the 21st century epidemic and the leading challenge that combats the health system in Australia[2]. Without proper medical care and lifestyle changes, Mrs. Y who is diabetic, will predispose herself to untimely death due to her diabetic condition.
Urea and Electrolyte (Serum) test: patient recorded U&E-creatinine 65 micromol/L. The normal range is 45-90micromol/L[3]. Hence, the patient is within normal range. The creatinine waste product is what is referred to as creatinine and which leaks from muscle tissue at a fairly constant rate. A diet high in meat will cause leaking of exogenous creatinine[4]. On a diet that is free of creatinine, excretion of the latter is constant and is in proportion to the muscle mass. Therefore, 24 hour urine creatinine as well as Serum creatinine is dependent largely on the subject’s muscle mass with reference ranges pegged on this fact[5].
The patient results were: eGFR 77 mL/min/m2. This figure is within the stage 1 of kidney damage which is set at GFR = 90 ml/min/1.73m2[6]. This means that the patient is already experiencing the first stage of kidney damage with the probability of reversing the situation at nil.
Liver Function Test results: LFT- ALT 72 U/L (RR<31). The normal range in blood is 7-55IU/L.[7] This means the patient is way above the normal range and hence implies that her liver functioning is impaired. This essentially means that the liver cells of the patient are damaged (hepatocellular injury).
Diabetic nephropathy: Diabetic nephropathy is often described with reference to excretion rate of urinary albumin (UAER): (1)the normal rates of albuminuria is where the UAER is lower than 20 µg/min, while the rate of albumin to creatinine (ACR) is lower than 2.5 mg/mmol and 3.5 mg/mmol in men and women respectively; (2) microalbuminuria is also referred to as incipient nephropathy where the UAER levels is between 20-200 µg/min and ACR levels lower than 2.5 to 30 mg/mmol and 3.5-30 mg/mmol in men and women respectively; and (3) clinical proteinuria also referred to overt or clinical nephropathy where the UAER is more than 200 µg/min, the levels of ACR is more than 30 mg/mmol. The patient’s record was urine ACR (Albumin: Creatinine Ratio) -10.7 mg/mmol (RR<3.5)[8]. This means that the patient has developed microalbuminuria.
HbA1c Test: The normal range for diabetics with regard to HbA1c is 48 mmol/mol (6.5%)[9]. The recorded level of Mrs. Y was 7.8 which mean that she has superseded the normal range. The blood glucose levels are high and need to be controlled.
Chronic Kidney Disease: Removal of Creatinine from the blood is via the kidneys through the process of glomerula filtration as well as through secretion by the proximal tubes. There is little to none absorption of creatinine in the proximal tubes. Where there is deficiency in kidney filtration, the blood levels of creatinine will increase[10]. Hence, levels of creatinine on the urine or blood can be used in measuring the creatinine clearance (CrCl). Therefore, CrCl directly correlates to the ratio of glomerula filtration (GFR). Levels of creatinine in the blood can also be used in calculating the estimated GFR[11]
Chronic Kidney Disease (CKD) is usually as a result of pre-existing medical conditions such as hypertension, diabetes, urological or hereditary disease, or glomerulonephritis[12].CKD refers to damage to the kidneys or reduced functionality of kidneys that occurs continually over a 3 month period. To measure kidney function, the GFR is used which puts into account the gender, race, age, and levels of serum creatinine to measure the functionality of kidneys[13].
When a person has a GFR which is lower than 60 ml/min/1.73 m2over a period of 3 months and more, they are diagnosed with CKD. The disease progresses with the diminishing of amount of nephrons. However, slowing this progression is possible in the various stages of the disease but total elimination is not possible. The goal of slowing down the process is to prevent kidney failure from developing which requires kidney transplantation or kidney failure[14].
A liver function test checks the liver for several factors including: functioning of the liver which will indicate whether sufficient protein is being manufactured for normal functioning of the body; amount of blood bile pigment which is elevated in the event of a bile duct blockage or liver enzyme deficiency responsible for processing bile; liver enzymes level where elevation of the same means that the liver cells are slightly damaged or inflamed due to a number of causes[15].
ALT is the marker for hepatocellualr injury where damage to the liver cells results in sippage of ALT into the blood[16]. Elevated levels of ALT in the blood are not indicated in bile duct obstructive diseases or in cases of cholestasis.
Most patient who are diabetic will have normal UAER however, 1-2% of the few will develop micoalbuminuria that is persistent every year. Once the level of UAER reaches 200µg/min and above, proteinuria increases relentlessly and may lead to the nephrotic level with GFR declining progressively with the rate dependent on control of blood pressure.
The term HbA1c is in reference to glycated hemoglobin. This occurs when the red blood cells protein hemoglobin carrying oxygen combines with blood glucose to become glycated[17]. By taking measurements of glycated hemoglobin (HbA1c), it becomes possible to identify the amount of circulating glucose in the blood over the past weeks or months. This test is necessary for diabetics as a high level of glycated blood is potentially catastrophic[18]. By improving the HbA1c levels by as little as 1% (which is equivalent to 11 mmol/mol) for persons with either type 1 or type 2 diabetes, reduces their risk of complications (micro vascular) by 25% [19]. These micovascular complications include: Retinopathy, Neuropathy, and Diabetic nephropathy (kidney disease)[20]
Utilization: The test is done when symptoms of liver disorder manifest or when one is exposed to substances that can potentially damage the liver for example an overdose of paracetamol
Current indications: Blood sample is tested for levels of ALT, AST, total bilirubin, ALP, Albumin, and total protein. High levels of ALT and AST indicates liver disease or liver cell damage. High levels of bilirubin means bile duct blockage which in turn increases levels of ALP. Low levels of Albumin and consequent high levels of total protein means extensive loss of tissue from the liver
Accuracy: abnormal results can be due to burns, shock, muscle trauma, severe infection, pregnancy, or severs muscle damage from exercises[21]
Limitations: the tests do not give the exact cause of the liver disease. In addition, medication can interfere with eh final results[22].
HbA1c Test
Utilization: Used in testing persons with diabetes and form basis of treatment options. It also used to diagnose T2DM.
Current indications. Blood sample is tested to find the amount of glucose that is combined to Hemoglobin for the last weeks or months. When blood glucose levels are high in diabetics, the HbA1c levels will also be high[23]
Accuracy: accuracy is dependent on the age of the red blood cells of the person being tested. The longer the red blood cell life the higher the levels of blood glucose readings[24].
Limitations: there is a variation in the cut-off values ranges among patients with FPG proving to be more effective at accurately diagnosing dysglycaemia[25].
AIHW (2014). Leading Types of ill health. https://www.aihw.gov.au/australias-health/2014/ill-health/
Bidani, A. K., Griffin, K. A., & Epstein, M. (2012). Hypertension and Chronic Kidney Disease Progression: Why the Suboptimal Outcomes? The American Journal of Medicine, 125(11), 1057–1062. https://doi.org/10.1016/j.amjmed.2012.04.008
D’Antona G, Nabavi SM, Micheletti P, et al. Creatine, L-Carnitine, and ω3 Polyunsaturated Fatty Acid Supplementation from Healthy to Diseased Skeletal Muscle. BioMed Research International. 2014;2014:613890. doi:10.1155/2014/613890.
Dabla, P. K. (2010). Renal function in diabetic nephropathy. World Journal of Diabetes, 1(2), 48–56. https://doi.org/10.4239/wjd.v1.i2.48
Diabetes UK. (2017). Blood Sugar Level Ranges. https://www.diabetes.co.uk/diabetes_care/blood-sugar-level-ranges.html
Dousdampanis, P., Trigka, K., & Fourtounas, C. (2012). Diagnosis and Management of Chronic Kidney Disease in the Elderly: a Field of Ongoing Debate. Aging and Disease, 3(5), 360–372.
Gowda, S., Desai, P. B., Hull, V. V., Math, A. A. K., Vernekar, S. N., & Kulkarni, S. S. (2009). A review on laboratory liver function tests . The Pan African Medical Journal, 3, 17.
Gowda, S., Desai, P. B., Kulkarni, S. S., Hull, V. V., Math, A. A. K., & Vernekar, S. N. (2010). Markers of renal function tests. North American Journal of Medical Sciences, 2(4), 170–173.
Green, Hanna FW, Green J, Issa BG, Tahrani AA, Fryer AA. Limitations of glycosylated haemoglobin (HbA1c) in diabetes screening. Practical Diabetes. 2012 Jan 1;29(1):29-31
Jäger R, Purpura M, Shao A, Inoue T, Kreider RB.(2011) Analysis of the efficacy, safety, and regulatory status of novel forms of creatine. Amino Acids. 2011;40(5):1369-1383. doi:10.1007/s00726-011-0874-6.
Higgins, C. (2016). Urea and the clinical value of measuring blood urea concentration. https://acutecaretesting.org/en/articles/urea-and-the-clinical-value-of-measuring-blood-urea-concentration
Kang, K.-S. (2013). Abnormality on Liver Function Test. Pediatric Gastroenterology, Hepatology & Nutrition, 16(4), 225–232. https://doi.org/10.5223/pghn.2013.16.4.225
Koroshi, A. (2007). Microalbuminuria, is it so important? Hippokratia, 11(3), 105–107.
Lab Tests Online (2017). HbA1c Test. https://labtestsonline.org.uk/understanding/analytes/a1c/tab/sample/
Lab Tests Online (2017). Liver Function Test https://labtestsonline.org.uk/understanding/analytes/liver-panel/tab/faq/
National Kidney Foundation (2017). Tests to Measure Kidney Function, Damage and Detect Abnormalities. https://www.kidney.org/atoz/content/kidneytests
Nicholas, J., Charlton, J., Dregan, A., & Gulliford, M. C. (2013). Recent HbA1c Values and Mortality Risk in Type 2 Diabetes. Population-Based Case-Control Study. PLoS ONE, 8(7), e68008. https://doi.org/10.1371/journal.pone.0068008
Patient (2014) Chronic Kidney Disease. https://patient.info/doctor/chronic-kidney-disease-pro
Phillips, Q (2016). HbA1c Test accuracy. https://www.diabetesselfmanagement.com/blog/hba1c-test-accuracy/
Sherwani, S. I., Khan, H. A., Ekhzaimy, A., Masood, A., & Sakharkar, M. K. (2016). Significance of HbA1c Test in Diagnosis and Prognosis of Diabetic Patients. Biomarker Insights, 11, 95–104. https://doi.org/10.4137/BMI.S38440
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