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.

Keywords: acute kidney injury (AKI); chronic kidney disease (CKD); creatinine; end stage renal disease (ESRD); national kidney foundation kidney disease outcomes quality initiative (NKF KDOQI); renoprevention; serum creatinine trajectory; syndrome of late onset renal failure from angiotensin blockade (LORFFAB); syndrome of rapid onset end stage renal disease (SORO-ESRD).

Figure 1

Serum creatinine trajectory in an obese hypertensive with glucose intolerance showing rapid and full recovery of renal function following AKI on CKD from MRSA bacteremia.

Figure 2

Serum creatinine trajectory demonstrating rapid-onset, acute yet irreversible ESRD requiring RRT following pneumonia in an obese, hypertensive, diabetic male Caucasian with III CKD in March 2010.

Figure 3

eGFR trajectory in the renal transplant recipient with a pancreas allograft following AKI-on-CKD from pyelonephritis and dehydration precipitating rapid onset yet irreversible ESRD.

Figure 4

Serum creatinine trajectory in a now-79-year-old Caucasian hypertensive, diabetic male with stable CKD V between 2006 and 2014, serum creatinine of 4.5–5.5 mg/dL, eGFR 8–11 mL/min per 1.73 m² BSA.

Figure 5

Serum creatinine trajectory in a now-56-year-old Caucasian hypertensive, diabetic male who developed predictable linear and progressive time-dependent CKD to ESRD, between 2007 and 2010, and has remained on maintenance hemodialysis from 2010–2014.

Figure 6

Serum creatinine trajectory, 2007–2014, with AKI in March 2012 in a 73-year-old morbidly obese, diabetic, hypertensive, CKD III Caucasian male following minimally invasive AVR for symptomatic aortic stenosis.

Figure 7

Serum creatinine trajectory, 2007–2014, with AKI in March 2012 in a 73-year-old morbidly obese, diabetic, hypertensive, CKD III Caucasian male following minimally invasive AVR for symptomatic aortic stenosis.

Figure 8

eGFR trajectory in the diabetic, hypertensive Caucasian male patient with features of LORFFAB.

Figure 9

Serum creatinine trajectory in the diabetic, hypertensive Caucasian male patient with features of LORFFAB following initial recovery of renal function and hemodialysis independence before the second post-operative hemodialysis-requiring AKI-ESRD in January 2007.

Figure 10

Serum creatinine trajectory on first post-operative day after elective ablation procedure for symptomatic atrial fibrillation.

Figure 11

Intra-operative systolic blood pressure translations after induction of anesthesia during elective ablation procedure for symptomatic atrial fibrillation.

Figure 12

Intra-operative mean blood pressure translations after induction of anesthesia during elective ablation procedure for symptomatic atrial fibrillation.

Figure 13

Serum creatinine trajectory two weeks after elective ablation procedure for symptomatic atrial fibrillation demonstrating complete recovery from the AKI.