Diabetic Nephropathy and CKD—Analysis of Individual Patient Serum Creatinine Trajectories: A Forgotten Diagnostic Methodology for Diabetic CKD Prognostication and Prediction

Abstract

Creatinine is produced in muscle metabolism as the end-product of creatine phosphate and is subsequently excreted principally by way of the kidneys, predominantly by glomerular filtration. Blood creatinine assays constitute the most common clinically relevant measure of renal function. The use of individual patient-level real-time serum creatinine trajectories provides a very attractive and tantalizing methodology in nephrology practice. Topics covered in this review include acute kidney injury (AKI) with its multifarious rainbow spectrum of renal outcomes; the stimulating vicissitudes of the diverse patterns of chronic kidney disease (CKD) to end-stage renal disease (ESRD) progression, including the syndrome of rapid onset end stage renal disease (SORO-ESRD); the syndrome of late onset renal failure from angiotensin blockade (LORFFAB); and post-operative AKI linked with the role of intra-operative hypotension in patients with diabetes mellitus and suspected diabetic nephropathy with CKD. We conclude that the study of individual patient-level serum creatinine trajectories, albeit a neglected and forgotten diagnostic methodology for diabetic CKD prognostication and prediction, is a most useful diagnostic tool, both in the short-term and in the long-term practice of nephrology. The analysis of serum creatinine trajectories, both in real time and retrospectively, indeed provides supplementary superior diagnostic and prognostic insights in the management of the nephrology patient.

Patterns of Estimated Glomerular Filtration Rate Decline Leading to End-Stage Renal Disease in Type 1 Diabetes

“…Furthermore, acceleration or deceleration was observed in a small minority of trajectories. There was no evidence that acute kidney injury or series of it, as suggested by others (6,7), leads to onset of ESRD in a significant proportion of patients with type 1 diabetes.…”

“…The decline trajectory and underlying mechanisms are not well understood. Theoretically, the decline may be abrupt, as in acute renal failure (6), episodic with plateaus or periods of improvement (7), or inexorably progressive (8). Each pattern points to a different pathophysiology.…”

The relationship between estimated glomerular filtration rate trajectory and all-cause mortality in type 2 diabetes: the Fremantle Diabetes Study

“…clinical interpretation of patterns in serial eGFR measures remains an important part of case management (46). This study found that the degree of albuminuria was a predictor of all-cause mortality independent of eGFR categories both in the full FDS1 cohort and in the subset in whom trajectories were determined.…”

Hospital-acquired nephrotoxic exposures in the precipitation of acute kidney injury – A case series analysis and a call for more preventative nephrology practices

“…Moreover, the application of logic and other decision support systems in the electronic health record (EHR) could be leveraged to enhance biochemical surveillance and monitoring paradigms to improve renal outcomes in hospitals (31,32). We have demonstrated that the utility of serum creatinine trajectories in the real-time management of AKI in hospitalized patients cannot be over-emphasized (33). Chaumont et al have suggested that appropriate renal dosing of ACE inhibitors could lead to significantly reduced nephrotoxicity associated with this class of drugs (34).…”