General medicine final year project: Evaluate glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022

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This study "Evaluate glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022" with two objectives: Describe clinical and subclinical features of living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022, evaluate the glomerular filtration rate of this specified group.

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Nội dung Text: General medicine final year project: Evaluate glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022

VIETNAM NATIONAL UNIVERSITY, HANOI UNIVERSITY OF MEDICINE AND PHARMACY TRUONG GIANG NGUYEN EVALUATING GLOMERULAR FILTRATION RATE IN LIVING KIDNEY DONORS IN VIET DUC HOSPITAL FROM 01/2022 TO 12/2022 GENERAL MEDICINE FINAL YEAR PROJECT Hanoi – 2023
VIETNAM NATIONAL UNIVERSITY, HANOI UNIVERSITY OF MEDICINE AND PHARMACY Submitted by student: TRUONG GIANG NGUYEN EVALUATING GLOMERULAR FILTRATION RATE IN LIVING KIDNEY DONORS IN VIET DUC HOSPITAL FROM 01/2022 TO 12/2022 GENERAL MEDICINE FINAL YEAR PROJECT Class: QH. 2017.Y – GENERAL MEDICINE Supervisor no.1: PHD. MD. NGUYEN VU LE Supervisor no.2: MS. MD. QUANG LONG LUU Hanoi – 2023
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Acknowledgments I would like to express my deepest appreciation to my dear instructors PhD. MD. Nguyen Vu Le and MS. MD. Quang Long Luu for providing me with the best opportunity and the best instruction I could ever ask for to complete this final year project. The two doctors wholeheartedly guide and impart to me knowledge, scientific research methods and valuable experiences. Under their guidance, I gained not only professional knowledge but also passion for science. I also wish to thank the board of directors of Viet Duc Hospital, the leaders, and the nurses of Organ Transplant Center-Viet Duc Hospital, especially Nursing Bachelor Ms. Thi Nga Nguyen, for their interests, useful knowledge and creating favorable conditions for me on this research. I am also grateful to the Board of Directors and teachers of the Center for Andrology and Sexual Medicine and Department of Surgery at the University of Medicine and Pharmacy, Vietnam National University, Hanoi for providing me with all the facilities that was required. Lastly, I would like to mention teachers in the thesis committee, patients in this research, my family, and friends for giving me much helpful knowledge, advice, and comment to complete this task. Hanoi, May the 23rd 2023 Truong Giang Nguyen
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Declaration I declare that this final year project has been composed solely by myself under the guidance of PhD. MD. Nguyen Vu Le and MS. MD. Quang Long Luu and that it has not been submitted, in whole or in part, in any previous application for a degree. Except where stated otherwise by reference or acknowledgment, the work presented is entirely my own. I declare that the data and information I collected in this study are completely accurate, objective, and honest. This data and information were verified and approved by the department where I conduct this research. Hanoi, May the 23rd 2023 Truong Giang Nguyen
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. List of Abbreviations Abbreviation Definition AER Albumin Excretion Rate AFP Alpha-fetoprotein ALP Alkaline Phosphatase ALT Alanine Transaminase APTT Activated Partial Thromboplastin Time AST Aspartate Aminotransferase BMI Body Mass Index BSA Body Surface Area BUN Blood Urea Nitrogen CA-199 Cancer Antigen-199 CEA Carcinoembryonic antigen CKD Chronic Kidney Disease CMV Cytomegalovirus CrCl 24h Creatinine Clearance 24-hour DBP Diastole Blood Pressure EBV Epstein-Barr Virus eCrClCG Estimated Creatinine Clearance by Cockcroft-Gault EF Ejection Fraction eGFR Estimated Glomerular Filtration Rate ESRD End Stage Renal Disease GERD Gastroesophageal Reflux Disease GGT Gamma Glutamyl Transferase GI Gastrointestinal HBsAg Hepatitis C Virus Antigen HBV Hepatitis B Virus HCT Hematocrit HCV Hepatitis C Virus HDL-Cho High Density Lipoprotein Cholesterol HGB Hemoglobin HIV Human Immunodeficiency Virus HLA Human Leukocyte Antigen IgA Immunoglobulin A
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. IgG Immunoglobulin G IgM Immunoglobulin M KDIGO Kidney Disease Improving Global Outcomes L Lumbar LDH Lactate Dehydrogenase LDL-Cho Low Density Lipoprotein Cholesterol MDRD Modification of Diet in Renal Disease MSCT Multi-slice Spiral Computed Tomography PLT# Platelet Count PSA Prostate Specific Antigen PT-INR Prothrombin Time-International Ratio RBC# Red Blood Cell Count SBP Systole Blood Pressure T Thoracic
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Table of Contents Acknowledgments .......................................................................................................1 Declaration ..................................................................................................................2 List of Abbreviations...................................................................................................3 Table of Contents ........................................................................................................5 List of tables ................................................................................................................8 List of charts ................................................................................................................9 List of figures ............................................................................................................10 INTRODUCTION .......................................................................................................1 Chapter 1: LITERATURE REVIEW .......................................................................2 1.1 Kidney anatomy ...............................................................................................2 1.1.1 External anatomy...........................................................................2 1.1.2 Kidney structure ............................................................................2 1.1.3 Size and weight of the kidney .......................................................3 1.1.4 Renal vasculature ..........................................................................3 1.2 Kidney physiology ...........................................................................................4 1.2.1 Physiological anatomy of the kidneys...........................................4 1.2.2 Urine formation results from glomerular filtration, tubular reabsorption, and tubular secretion ......................................................................5 1.2.3 Glomerular filtration process ........................................................6 1.2.4 Glomerular filtration rate evaluation theoretically ........................7 1.3 Classification, evaluation, examination of living kidney donors .....................7 1.3.1 Selection of the living organ donor ...............................................8 1.3.2 Checklist for the evaluation, examination of living kidney donors 8 1.3.3 Normal living kidney donors’ criteria .........................................16 Chapter 2: RESEARCH SUBJECTS AND METHODOLOGY ...........................18 2.1 Research population .......................................................................................18
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. 2.1.1 Inclusion criteria ..........................................................................18 2.1.2 Exclusion criteria.........................................................................18 2.2 Research methodology ...................................................................................18 2.2.1 Research method .........................................................................18 2.2.2 Study sample size ........................................................................18 2.2.3 Research facilities and procedures ..............................................19 2.2.4 Research variables .......................................................................20 2.3 Data collected, analyzed. ................................................................................22 2.4 Research ethics ...............................................................................................22 Chapter 3: RESULTS .............................................................................................23 3.1 Clinical and subclinical features of living kidney donors ..............................23 3.1.1 Preoperative evaluation ...............................................................23 3.1.2 Albuminuria evaluation ...............................................................25 3.1.3 Nephrology ultrasound and nephrolithiasis assessment ..............25 3.1.4 Hyperuricemia assessment ..........................................................26 3.1.5 Metabolic assessment ..................................................................27 3.1.6 Imaging........................................................................................28 3.2 Evaluating GFR in living kidney donors .......................................................28 Chapter 4: DISCUSSION .......................................................................................37 4.1 Clinical and subclinical features of living kidney donors ..............................37 4.1.1 Preoperative evaluation ...............................................................37 4.1.2 Albuminuria evaluation ...............................................................38 4.1.3 Nephrology ultrasound and nephrolithiasis assessment ..............38 4.1.4 Hyperuricemia .............................................................................39 4.1.5 Metabolic assessment ..................................................................39 4.1.6 Imaging........................................................................................40 4.2 Evaluating GFR in living kidney donors .......................................................40 CONCLUSION .........................................................................................................43
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. 1. Clinical features of living kidney donors. .............................................................43 2. Subclinical features of living kidney donors. ........................................................43 3. Evaluating GFR in living kidney donors ...............................................................43 References .................................................................................................................45 Appendix 01: Research medical record ....................................................................49 Appendix 02: List of research subjects .....................................................................52
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. List of tables Table 2.1: Research variables. ..................................................................................20 Table 3.1: General characteristics of the study population. ......................................23 Table 3.2: Age groups distribution of study population. ..........................................24 Table 3.3: Albuminuria evaluation of living kidney donors. ....................................25 Table 3.4: Kidney ultrasound results. .......................................................................25 Table 3.5: Nephrolithiasis assessment of living kidney donors. ...............................26 Table 3.6: Hyperuricemia assessment in living kidney donors. ...............................26 Table 3.7: Metabolic assessment of living kidney donors. .......................................27 Table 3.8: MSCT both kidneys size of living kidney donors. ..................................28 Table 3.9: CrCl 24h 1st time passing the threshold of living kidney donors. ...........28 Table 3.10: CrCl 24h and related tests in living kidney donors. ...............................29 Table 3.11: CrCl 24h in each age group of living kidney donors. ............................30 Table 3.12: CrCl 24h in each age groups distribution. .............................................30 Table 3.13: 24-hour CrCl by BMI groups.................................................................31 Table 3.14: 24-hour CrCl by height groups. .............................................................32 Table 3.15: 24-hour CrCl by weight groups. ............................................................33 Table 3.16: Comparison of evaluating GFR methods...............................................34
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. List of charts Chart 2.1: Research procedures.................................................................................19 Chart 3.1: Age groups distribution, and distribution of sex by each age groups. .....24 Chart 3.2: CrCl 24h distribution by age groups. .......................................................31 Chart 3.3: Correlation between CrCl 24h and eCrCl Cockcroft Gault (n = 138). ....35 Chart 3.4: Correlation between CrCl 24h and eGFR MDRD (n = 138). ..................36
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. List of figures Figure 1.1: Internal structure of the kidney [5]. ..........................................................3 Figure 1.2: Renal vasculature [5] ................................................................................4 Figure 1.3: Nephron anatomy .....................................................................................5 Figure 1.4: Urine formation [11]. ................................................................................6 Figure 1.5: Framework to accept or decline donor candidates based on a transplant program’s threshold of acceptable projected lifetime risk of kidney failure [13]. .....9 Figure 1.6: Stepwise approach in assessment of GFR and application to donor candidate selection facilitates efficiency [1]. ............................................................11 Figure 1.7: Sequential evaluation of microscopic hematuria in living kidney donor candidates. Hpf, high-power field [1]. ......................................................................12
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. INTRODUCTION Kidney transplant is a modern surgery treatment to replace the diseased kidney of end-stage renal disease (ESRD) patients. It is considered as one of the most major contributions to modern medicine. After the surgery, patients can almost fully go back to normal life, working almost as normal with just a little help from medicines, ESRD patients after transplantation do not have to dialysis, and just have to follow up once a month. Kidney transplants also provide a better life quality and a longer survival rate. Those are the major advantages of kidney replacement compared to other methods. In the present-day, the sources of kidneys vary from the brain-dead donors to donors whose hearts have stopped beating, especially those who have died of trauma to living donors. But there are too few deceased donors to meet the demand, and a living donor transplant, offers many advantages, including superior graft and patient survival, shorter wait times, and lower health care costs [1-3]. One of the most important goals of kidney transplantation from a living kidney donor is to ensure that the function of the transplanted kidney as well as to preserve the function of the kidney donor [4]. To achieve that, the evaluation of GFR in living kidney donors must be the most necessary and important steps in assessing suitable kidney donors. An ideal GFR test that ensures high accuracy, simplicity, safety, and economic efficiency is 24-hour Creatinine clearance in the assessment of living kidney donor. Despite there are much research conducted on deceased donors, still little evidence of GFR has been evaluated in this living kidney donors in Viet Duc Hospital. Therefore, with the goal of determining the GFR in living kidney donors, in order to ensure kidney function for both donors and the recipients in the future, I conduct this research to: “Evaluate glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022” with two objectives: - Describe clinical and subclinical features of living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. - Evaluate the glomerular filtration rate of this specified group. 1
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Chapter 1: LITERATURE REVIEW 1.1 Kidney anatomy 1.1.1 External anatomy In a healthy person, there lie two bean-shaped kidneys in the retroperitoneal of the posterior abdominal region. In the supine position, the kidneys extend from approximately vertebra TXII superiorly to vertebra LIII inferiorly, with the right kidney lower than the left because of its relationship with the liver [5]. The kidneys are enclosed in and associated with a unique arrangement of fascia and fat. Immediately outside the renal capsule, there is an accumulation of extraperitoneal fat – the perinephric fat (perirenal fat), which surrounds the kidney completely. Enclosing the perinephric fat is a membranous condensation of the extraperitoneal fascia (the renal fascia). There are two layers of the renal fascia, the anterior layer (or the Gerota’s fascia and posterior layers (or the Zuckerkandl’s fascia), these 2 layers fused together. Each fascial compartment doesn’t connect to each other [5]. 1.1.2 Kidney structure Internally, the renal parenchyma can be divided into two main areas – the outer cortex and inner medulla. The cortex extends into the medulla, dividing it into triangular shapes – called renal pyramids. The apex of a renal pyramid is called a renal papilla. Each renal papilla is associated with a structure known as the minor calyx, which collects urine from the pyramids. Several minor calices merge to form a major calyx. Urine passes through the major calices into the renal pelvis, a flattened and funnel-shaped structure. From the renal pelvis, urine drains into the ureter, which transports it to the bladder for storage. The medial margin of each kidney is marked by a deep fissure, known as the renal hilum. This acts as a gateway to the kidney – normally the renal vessels and ureter enter/exit the kidney via this structure [6]. 2
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Figure 1.1: Internal structure of the kidney [5]. 1.1.3 Size and weight of the kidney The kidney size is approximately: 12x6x3 centimeters, 12 centimeters on the height, 6 centimeters on the length, and have the width of 3 centimeters [7]. The kidney weight normally varies from 90 to 130 gram [7, 8]. 1.1.4 Renal vasculature 1.1.4.1 Renal artery Renal artery origin and end: renal artery originated from abdominal aorta. The vessel usually arises just inferior to the origin of the superior mesenteric artery between vertebrae LI and LII. It usually ends at the renal hilum and divides into anterior and posterior branches, which supply the renal parenchyma [5]. Renal artery quantities: mostly there is only 1 single large renal artery that supply the kidney (96.29%), however, the kidney arteries usually vary from 1 to 3 arteries per kidney [9]. 3
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Figure 1.2: Renal vasculature [5] Renal artery length: depend on the renal origin and its end, the right renal artery is longer and pas posterior to the inferior vena cava [5]. 1.1.4.2 Renal vein Renal vein origin and end: renal vein originates from the kidney outer cortex and inner medulla and then flows into arcuate veins and to interlobular veins, and finally end at inferior vena cava with 1 to 3 branches, thes veins are all connect to each others. Renal vein quantities: usually there are many veins, vary from 2-3 veins and they are all connnect to each others, so that they can be clamp without any serious problems, unlike the renal artery clamping, which can cause ischemia to the kidney, this is the most important anatomy note in renal transplant technique [10]. Renal vein length: the right renal vein is usually shorter than the left one. 1.2 Kidney physiology 1.2.1 Physiological anatomy of the kidneys Each human kidney contains about 800,000 to 1,000,000 nephrons, each of which is capable of forming urine. The kidney cannot regenerate new nephrons. 4
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. Therefore, with renal injury, disease, or normal aging, the number of nephrons gradually decreases and cannot reverse [11]. Each nephron contains a tuft of glomerular capillaries called the glomerulus, through which large amounts of fluid are filtered from the blood, and a long tubule, including Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, cortical collecting tubule and collecting duct, in which the filter fluid is converted into urine on its way to the pelvis of the kidney [11]. Figure 1.3: Nephron anatomy 1.2.2 Urine formation results from glomerular filtration, tubular reabsorption, and tubular secretion The rates at which different substances are excreted in the urine represent the sum of three renal processes, shown in figure 1.4: (1) glomerular filtration, (2) reabsorption of substances from the renal tubules into the blood, and (3) secretion of substances from the blood into the renal tubules. Urine formation begins when a large amount of fluid that is virtually free of protein is filtered from the glomerular capillaries into Bowman's capsule. Most 5
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. substances in plasma, except for proteins, are freely filtered, so their concentration in the glomerular filtrate in Bowman's capsule is almost the same as in plasma. As filtered fluid leaves Bowman's capsule and passes through the tubules, it is modified by reabsorption of water and specific solutes back into the blood or by secretion of other substances from the peritubular capillaries into the tubules [11]. Figure 1.4: Urine formation [11]. 1.2.3 Glomerular filtration process The first step in urine formation is the filtration of large amounts of fluid through the glomerular capillaries membrane of 3 layers into Bowman’s capsule – almost 180 liters each day of glomerular filtrate, most of which is reabsorbed and leaving only about 1 liter of fluid to be excreted each day. The GFR is determined by (1) the sum of the hydrostatic and colloid osmotic forces across the glomerular membrane, which gives the net filtration pressure, and (2) the glomerular Kf. Expressed mathematically, the GFR equals the product of Kf and the net filtration pressure: GFR = Kf x Net filtration pressure [11]. 6
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. 1.2.4 Glomerular filtration rate evaluation theoretically The rates at which difference substances are “cleared” from the plasma provide a useful way of quantitation the effectiveness of kidneys excrete various substances. Renal clearance of a substance is the volume of plasma that is completely cleared of the substance by the kidneys per unit of time. Clearance can be expressed as: Us × V Cs = Ps Where Cs is the clearance rate of the substance s, Ps is the plasma concentration of that substance, and V is the urine flow rate. If a substance is freely filtered and is not reabsorbed or secreted by the renal tubules, then the rate at which that substance is excreted in the urine (Us x V) is equal to the filtration rate of the substance by the kidneys (GFR x Ps). Therefore, the GFR can be calculated as the clearance of the substance as follows: Us × V GFR = = Cs Ps Theoretically, a substance that fits these criteria is inulin, a polysaccharide molecule with a molecular weight of about 5200. Inulin, which is not produced in the body, is found in the roots of certain plants and must be administered intravenously to a patient to measure GFR [11]. 1.3 Classification, evaluation, examination of living kidney donors It is very significant to evaluate the living kidney donor before any kidney donation process to minimize the risks of having post surgery complications, and to maintain the longevity of the kidney donor’s function. The assessment of living kidney donor pre-surgery based on KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors in 2017 to assure that the risks of having any complications post surgery are low. In any stage of the process, the living kidney donor must be considered as a legal patient as the kidney receiver. 7
Evaluating glomerular filtration rate in living kidney donors in Viet Duc Hospital from 01/2022 to 12/2022. 1.3.1 Selection of the living organ donor In Vietnam, according to “Law on donation, removal, and transplantation of human tissues and organs and donation and recovery of cadavers” pursuant to the 1992 Constitution of the Socialist Republic of Vietnam, which was amended and supplemented under Resolution No. 51/2001/QH10 of December 25th, 2001, of the Xth Nation Assembly, the 10th Session, article 5; person aged full 18 years (25 in Viet Duc Hospital) or older having full civil act capacity are entitled to donate tissues, organs when living and after dead in accordance with law [12]. 1.3.2 Checklist for the evaluation, examination of living kidney donors These are the main steps to evaluation, examination, and follow-up care for living kidney donors according to KDIGO [1]. 1.3.2.1 Evaluation goals, principle, framework, roles, and responsibilities In this step, living kidney donor should be provided and be evaluated with these main targets: - Provide the donor candidate with individualized estimates of short- and long-term risks. Evaluate medical risks to predetermined program acceptance thresholds [13]. - The donor candidate should be checked for the willingness to donate a kidney voluntarily without any visible pressure [13] - The decision to accept or exclude a donor candidate should follow transplant program policies and each circumstance must be provided with each individual plan to follow-up care whether a donor be accepted or not [14]. A transplant program can use various methods to establish thresholds for acceptable risk. If the donor candidate's estimated risk is below the threshold for acceptable risk, the donor candidate should be permitted to make an autonomous decision whether to proceed with donation after being informed of the risks. Donor candidate autonomy does not overrule medical judgment, and transplant professionals are ethically justified to decline a donor candidate when they believe the risk of poor postdonation outcomes is too high [13]. 8