Annual Screening for Chronic Kidney Disease using Urinary Dipstick to Detect Proteinuria among Elderly Patients with Hypertension and Diabetes Mellitus Attending Agbeke Mercy Medical Clinic, Oluyole Cheshire Home, Ibadan, Nigeria

Background: Chronic kidney disease (CKD) is a highly prevalent medical condition throughout the world, with worsening indices in the developing countries. The economic burden with renal replacement therapy is something that most developing nations may find difficult to cope with. It is important for those at risk of CKD to be screened and identified early in order to prevent or slow progression to advanced stages. There are different screening methods for CKD, the acceptable minimum is an annual screening with the use of dipstick to detect urinary protein. Dr. Ibisola Babalola Adeniyi et al. Annual Screening for Chronic Kidney Disease using Urinary Dipstick to Detect Proteinuria among Elderly Patients with Hypertension and Diabetes Mellitus Attending Agbeke Mercy Medical Clinic, Oluyole Cheshire Home, Ibadan, Nigeria International Journal of Contemporary Research and Review, Vol. 9, Issue. 07, Page no: MS 20497-20530 DOI: https://doi.org/10.15520/ijcrr/2018/9/07/556 Page | 20499 Methodology: For the first cycle of the audit, medical records of the elderly hypertensive and diabetic patients attending Agbeke Mercy Medical Clinic were obtained for a retrospective assessment of their annual urinalysis uptake. A ninety percent standard was set for the second audit cycle. This was followed by a three months prospective dipstick (Medi-Test Combi 10 ® SGL) urinalysis screening, after health talks and a significant subsidization of the screening cost for all the participants were put in place. Results: The records showed that 37% (32) of the eligible 87 patients had a dipstick urinalysis screening done in the preceding one year. In the three months, 93% (79) were screened for urinary protein with dipstick. 12.6% results were positive for at least 1+ of proteinuria. Conclusion: Clinical audit is very important in improving clinical practice. It helps to identify areas of practice that may need improvement, as in this case annual screening for CKD with dipstick urinalysis, especially among patients who are at the risk of developing CKD. Despite financial constraints, efforts should be made to make CKD screening a routine in all at-risk patients.


Background:
The Agbeke Mercy Medical Clinic (AMMC) is a primary care facility that operates as a day care outpatient outpost of the Family Medicine Department, University College Hospital (UCH), Ibadan.
The services offered at AMMC cut across different age groups and disease conditions. All primary care services are provided at the clinic with the exception of ante-natal and obstetric care.
As part of the compulsory rural and remote postings stipulated in the West African College of Physicians (WACP) curriculum, resident doctors from the Family Medicine Department of University College hospital are sent to the clinic on rotation.
The AMMC is located within the Oluyole Cheshire Home Ibadan. There is a special clinic for the elderly patients attending the Agbeke Mercy Medical Clinic known as the Senior Citizens' Club (SCC). Their total population at the beginning of this audit in May 2017 was one hundred and twenty four (124). A monthly meeting holds for clinic follow-up and as a form of social gathering. Most of these elderly patients are retired and depend on their relatives and community for emotional, financial and instrumental support. Sixty years, the cut off point for the elderly as defined by the United Nations 1,2 is the generally accepted age for an individual to be entitled to pension or gratuity which is usually the case in our environment. This is not so for the majority of Senior Citizens' Club members, due to the fact that majority of our aged folks were never in any formal employment that will make them eligible for such stipend as they get older. The spirit behind the setting up of the Senior Citizens' Club amongst others is to minimize the cost incurred by this group of patients for their health care services.

The Need for Audit:
Chronic kidney disease is defined as decline in renal function evidenced by glomerular filtration rate (GFR) of less than 60 mL/min per 1.73m 2 , or markers of kidney damage, or both, of at least three months duration, regardless of the underlying cause. 3 There are different risk factors that have been identified to be associated with the development of chronic kidney disease. 4 These include hypertension, diabetes mellitus, advancing age, family history of chronic kidney disease, past history of acute kidney failure and obesity amongst others.
In addition to being above 60 years, members of the Senior Citizens' Club have one or more risk factors for chronic kidney disease as mentioned above. The most common of which are hypertension and diabetes mellitus. Some of them have the two conditions coexisting.
In a three year retrospective study on the admission pattern in the tropics, chronic kidney disease (CKD) was responsible for 6.5% of the admitted cases and those 60 years and above made up 29% of the admissions 5 In the few weeks preceding the conduct of this clinical audit, there has been an average of three patients among the SCC members per month who had clinical features suggestive of renal insufficiency or renal failure. The presentation ranged from facial puffiness to pedal oedema, reduced urinary output and or history of frothy urine.
A closer look at the previous documentations for these patients found that initial work up investigations (urinalysis, serum electrolytes, urea and creatinine, ECG and lipid profile) were requested as it is the standard practice in the main hospital, University College Hospital. The records showed that majority of the ordered urinalysis were not done. The few that were done that showed normal results were taken as a one off event without repeat testing in more than twelve months following the initial test.
In patients with type 2 diabetes mellitus (DM), the International Diabetes Federation (IDF) guideline recommends screening for chronic kidney disease at presentation and annually with serum creatinine for Glomerular Filtration Rate (GFR) estimation and urinalysis for proteinuria. In resource limited settings like Agbeke Mercy Medical Clinic, an annual test for proteinuria 6 with dipstick will suffice. The National Institute for Health and Clinical Excellence (NICE) guideline on chronic kidney disease in adults recommends an annual screening for chronic kidney disease in patients with risk factors such as hypertension and diabetes. 7 Instituting treatment in the early stages of the disease slows down the progression to End Stage Renal Disease (ESRD) 6,8 thereby reducing the associated financial burden necessary for the provision of renal replacement therapy. It has also been shown in a meta-analysis study titled; the association of kidney disease measures with mortality and end stage renal disease among those with diabetes and those without diabetes, that irrespective of the presence or absence of diabetes, a lower kidney function (estimated Glomerular Filtration Rate 15ml/min/1.73m 2 ) is associated with higher mortality 9 , as such early identification of Chronic Kidney Disease (CKD) is not only vital but also very cost effective. 10 It is on this premise that a decision was made to look through the records in the last one year to find out how many members of the Senior Citizens' Club had their urine checked with dipstick for proteinuria at least once per annum, and if they have not, to identify the reason and then proffer solutions within the reach of the management board of the Agbeke Mercy Medical Clinic.

Literature Review:
Chronic kidney disease (CKD), defined as the decline in renal function evidence by the decrease in estimated glomerular filtration rate from measured serum creatinine or the presence of persistent proteinuria indicating structural kidney damage and either of these two has been on for three months or more. 16,17 CKD is prevalent throughout the world despite poor awareness both among those affected and their carers. 18,19 According to the world kidney day 2006 -2017 report, chronic kidney disease is the third most rapidly increasing cause of mortality, with 2 million deaths out of 3.5 million ESRD cases among patients living in the low and middle income countries (LMIC). 20 In a systematic analysis of population health data, with aim of calculating the global burden of disease and risk factors for 2001 as well as examining the regional trends , CKD as an entity was not measured or reported among the disease burden in the world. 21 Also the World Health Organization (WHO), according to Kidney Disease Prevention Network (KDPN) in the time past did not attribute great importance to CKD on the overall burden of non-communicable diseases. 22 However, the prevalence of chronic kidney disease has been well documented in the following years as a global condition. According to a Nature Review article titled early chronic kidney disease: diagnosis, management and models of care, the prevalence of chronic kidney disease among non-institutionalized adults in the United States was 12% (95% CI, 10.4 -13.5%) from 1988 to 1994. This was followed by at least 2% increase in the 1999 -2004. 22 Another review study reported a prevalence of 13.1% in the US population. 23 Among the elderly participants in the Kidney Early Evaluation Programme (KEEP) and National Health and Nutrition Examination Survey (NHANES) studies, chronic kidney disease prevalence was as high as 44% between 1999 and 2006. 24 In a national representative health survey in Canada, the prevalence of CKD was 12.5% between 2007 and 2009. 25 According to a cross-sectional cohort study in six regions of the world, CKD prevalence in China was 29·9% (95% CI: 28·9% -31·0%), India was 16·8% (95% CI: 15·5% -18·1%), Moldova 25·5% (95% CI: 23·3% -27·9%), Bolivia 5·5% (95% CI: 4·7% -6·3%), Nigeria 23·0% (95% CI: 21·2% -25·0%) with an overall 14·3% (95% CI: 14·0-14·5) and 36·1% (95% CI: 34·7% -37·6%) in high-risk populations. 26 In sub-Saharan Africa according to a systematic review and meta-analysis study, an overall CKD prevalence of 13.9% was reported. 27 In a cross sectional study of over 500 at risk people from the Democratic Republic of Congo reviewed a 36% prevalence in different stages of chronic kidney disease was recorded. 19 A prevalence range of 20% in Ghana, Nigeria and Rwanda to 30.2% in Zimbabwe was reported in another study on chronic kidney disease in sub-Saharan Africa. 28 Local studies from Nigeria show different trends in the prevalence of CKD in the different regions of the country. In Sagamu in the Southwest, Alebiosu et al. reported a prevalence of 3.6% in a ten year retrospective study of Chronic Renal Failure (CRF) cases seen at the Olabisi Onabanjo University Teaching Hospital, Sagamu. 29 A 7.8% prevalence in the South-south region in a study; prevalence and correlates of chronic kidney disease among civil servants in Bayelsa state. 30 Afolabi et al. reported 12.4% and 10.4% CKD prevalence based on persistent albuminuria and low GFR respectively. 31 An aggregate of 11.7% prevalence was reported in a retrospective systematic review of 30 CKD screening exercises across different regions of the country. 32 Chronic kidney disease is fast assuming an epidemiologic dimension throughout the world 26 in part due to the increasing role of hypertension and diabetes in the global disease burden. 33,34 There is also an increase in the co-morbidity of the two conditions and the development of chronic kidney disease 35 thereby tipping the latter towards the top of the list of global disease burden across both the developed and the developing nations. 21,34,36 Type 2 diabetes mellitus has strong association with the development of chronic kidney disease. 23, 37 According to Adebamowo et al. type 2 DM patients are 13.4% (95% CI: 11.9 -14.7) p value < 0.001 more likely than non-diabetics, 4.8% (95% CI: 4.0 -5.6), to develop impaired renal function. 38 In Nigeria and other parts of Africa, the infective causes such as chronic glomerulonephritis, pyelonephritis, 39 schistosomiasis, 40 HIV and others 41 contribute significantly to the number of CKD. 27,41 The lifestyle related non-communicable diseases 27 such as diabetes mellitus, obesity and hypertension are already adding to the burden in most developing nations. 38,44,45 In a community-based study done in Southeastern Nigeria, a crude prevalence of 14.4% and 28% of chronic kidney disease was reported among the elderly population. A prevalence of 12% and 6.9% were observed among patients with hypertension and diabetes mellitus respectively. 46 Diabetic nephropathy and accelerated hypertension 43 are the two important factors contributing to the prevalence of chronic kidney disease in Nigeria and other developing nations. 47,48 In one systematic review study, prevalence of CKD was shown to increase with age, with 23.4 -35.8% among those age 64 years and above and a median of 7.2% among those age 30 49 . In the global context chronic kidney disease is more prevalent in the middle and low income countries (MLIC) when compare to the high income countries, and there is also a higher female to male gender ratio. 50,51 Diagnosing chronic kidney disease early has both clinical and economic significance. Cost of care for ESRD is over one trillion USD globally 22 and 35 billion USD for yearly management of ESRD in Medicare programme alone. 20 Resulting morbidity and mortality from late CKD diagnosis with subsequent progression to ESRD and development of cardiovascular complication is huge 33,36,52,53 and all of these underscore the importance of screening and early diagnosis of CKD especially among at risk population.
Who to screen, when to screen and what to screen for in establishing the presence of CKD are all as important as the end result. According to the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) guideline, Chronic Kidney Disease (CKD) should be assessed by testing for proteinuria (structural integrity of the glomerular filter), preferably using early morning urine sample to test for any of the following; urine albumin creatinine ratio (ACR) , urine protein creatinine ratio (PCR) or a dipstick test for proteinuria (either via automated or manual reading) in that order 54 , depending on availability and affordability.
According to the synopsis on Kidney Disease Improving Global Outcome (KDIGO) 2012 guideline spot urinary albumin estimation with albumin specific dipstick or albumin creatinine ratio are good monitoring options for adults with chronic disease. 17 The position of various international guidelines is that renal function should be determined by estimation of glomerular filtration rate (eGFR) using serum creatinine while kidney damage should be assessed by the use of urinary albumin creatinine ratio (ACR). 17, 55,56 Measurement of urinary albumin or albumin creatinine ratio determination especially over a period of time serves as a good screening tool for early detection of chronic kidney disease among at risk patients. 57,58 Alone, persistent proteinuria has been established as a good predictor of cardiovascular and renal disease. Low GFR and albuminuria are associated with bad cardiovascular outcome. 57,59 A systematic review and metaanalysis study on the epidemiology of chronic kidney disease in sub-Saharan Africa, showed that 69% of the reviewed studies measured urinary protein as a screening method for CKD. 27

The End Stage; meeting the renal replacement therapy:
The possibility of progression of CKD to End Stage Renal Disease (ESRD) is high among the Black population. 60  This assumes a greater importance considering the fact that most patients in sub-Saharan African present at the late stages of the disease 60 and there is also lack of adequate facility for renal replacement therapy across most developing countries. 64 Diabetes mellitus and hypertension are independently known as the leading causes of renal damage and has been ascribed amongst the blacks to be responsible for the increasing prevalence of chronic kidney disease as well as the progression to ESRD. [65][66][67] For individuals with GFR of 60ml/min/1.73m 2 and below, the rate of renal deterioration and progression to ESRD can be catastrophic, especially economically. 22 According to the Kidney Health Australia -Caring for Australian with Renal Impairment (KHA-CARI) Guidelines on early chronic kidney disease: detection, prevention and management, as many as 2300 Australians will have an annual decline in their renal function to require one form of renal replacement therapy or the other. 56 In the world today, the prevalence of ESRD is mounting. 68 Hypertension and diabetes combined are responsible for nearly 70% of ESRD cases. 69 In the developed world, where financial resources and manpower/skills are not in short supply, the burden of end stage renal disease (ESRD) is huge and attempts are being made to meet the demand. 68 Such financial resources are not readily available in most African nations. In Africa, the total health expenditure as a percentage of Gross Domestic Product (GDP) was 2.6% and 5.8% respectively for year 1995 and 2013. In the same period, Nigeria figure was 2.8% and 3.7% respectively. 70 In sub-Saharan Africa with countries largely categorized as Low and Middle Income Countries (LMIC), national or regional renal registries are lacking or very scant in number. One can only imagine at best, with gross poverty 71 , lack of education and other indices that define poor socioeconomic status, that the figures will be very worrisome.
Early stages of chronic kidney disease have been shown to be similar in many countries. [72][73][74] Progression to the advanced stages of CKD and ultimately to the ESRD are dependent on associated risk factors or co morbidities, rural or urban living and race. 24, 75,76 In terms of availability, the various renal replacement therapies for ESRD are not readily available in our settings. The few that are available are found mostly in the tertiary urban based health institutions with the problem of accessibility and affordability for the poor rural dwellers. 77 The development of chronic kidney disease can both be prevented and progression slowed by identifying early, the risk factors such as hypertension and diabetes mellitus and keeping them well controlled. 44, 78 The global burdens of the non-communicable diseases are rising so also is the sequel they leave on their wake as complications. [79][80][81] Screening for chronic kidney disease is important in at risk patients, especially among those who have hypertension or diabetes 16,82 but not necessary in the general population 83 without known risk factors. 84 It is important, especially among general practitioners that patients to be screened for chronic kidney disease be carefully selected against the backdrop of screening costs and the risk of developing advanced chronic kidney disease and its attending complications. 56  diabetes mellitus and hypertension and those at least age fifty-five years, with or without hypertension or diabetes mellitus has been found to be an effective means in identifying up to 93% of patients with chronic kidney disease. 85 A more superior screening tool to dipstick for proteinuria in detection of chronic kidney disease is the use of albumin-creatinine ratio. 86 However in resource poor countries like Nigeria, an ordinary proteinuria alone as screening tool is better than doing nothing. 6 Proteinuria is a recognized evidence of kidney damage 56 when factors such as fever, vigorous exercise and urinary tract infection have been ruled out.
The renal function declines with age at about 1ml/min/1.73m 2 /year from age 30 years and above as part of normal aging processes. 62 The fact that CKD can be asymptomatic in the elderly underscores the importance of screening among this group of people. 62,87 A simple urinalysis with dipstick is one of the recommended routine investigations in patients with hypertension. This is not target towards the level of control of hypertension itself but to guide in the choice of drugs to be used depending on the presence or not of end organ damage. [88][89][90] In patients with type 2 diabetes mellitus as it is for those with hypertension, detection of CKD in the early stage 6 is as important as the primary preventive measures. Across all age, development of ESRD is higher at lower GRF and high level of albuminuria. 91 In what is popularly known as the Abuja Declaration, the heads of government from the African Union unanimously agreed that 15% of the annual national appropriation bill for each country should be allocated for health. 92,93 However, this has not been the case in Nigeria as the nation is yet to meet this demand. The health budget for 2016 and 2017 are paltry 4.6% 94 and 3.5% 95,96 respectively. With all these realities in mind, to not screen for and aim to identify early the various stages of CKD may result in catastrophic spending for the any individual.

Estimated Glomerular Filtration Rate (eGFR):
This is important in the determination of the renal function of an individual. 97 An eGFR is more predictive of renal function 98 than ordinary serum creatinine 16 and so the appropriate formula should be employed when estimating the glomerular filtration rate (GRF).
There are different formulae, but the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPID) and the Modification of Diet in Renal Disease study (MDRD) equations are the ones favoured by most researchers. The CKD-Epid has however be found to have less bias with better prognostic value than the MDRD equation. 99 There can be serious and progressive structural renal damage without a commiserate decline in renal function, as the eGFR may remain unchanged over a long period of time. 16 According to Kidney Heart Australia-Caring for Australians with Renal Impairment(KHA-CARI) Guideline, both urinalysis to detect albuminuria and serum test for creatinine to estimate GFR should be done every one to two years in at risk patient. 56 The eGFR was once the accepted standard in making the diagnosis of chronic kidney disease in Australia 86 and in the United States. 100 The Australian Diabetic (AusDiab) Study however had 57% of the study population with albuminuria or proteinuria whose eGRF were greater than 60ml/min/1.73m 2 . 47 This implies that an individual can have proteinuria in the CKD range and not have a corresponding fall in the GFR value. At all times, the eGFR must be calculated when the serum creatinine is assayed as the eGFR is a better marker of kidney function that the serum creatinine. 58 outcomes. Urinary albumin detection in the form of microalbuminuria (3 -30mg/mmol) or sometimes macroalbuminuria (>30mg/mmol) is more sensitive and specific than total protein 86 at detecting chronic kidney disease at the early stages of the disease. 8 Using urinary albumin:creatinine ratio in combination with eGFR increases the chance of early chronic kidney disease detetection and prediction of ESRD. 101 High value of microalbuminuria can predict the risk of acute kidney injury, 98 chronic kidney disease and cardiovascular risk more accurately than proteinuria. 102 Proteinuria is however favoured over microalbumin in non-diabetic patients as it has wider usage for screening in other conditions like pregnancy related hypertension and more supporting evidence for chronic kidney disease screening than microalbuminuria. 103 When the consideration is between ACR and dipstick for albuminuria, the former is prefered for accurate prediction of poor quality of life. Poor sensitivity and high false positive screening result is seen more with dipstick for albuminuria compared to ACR.

The Choice of dipstick urinary protein estimation:
The use of twenty four hours urinary protein estimation though once the standard is now rarely employed as both the urinary albumin creatinine ratio and protein creatinine ratio 104 have been found to have similar results. It is a very cumbersome and laborious procedure with potentials for errors. 105 Collecting a timed overnight or random spot sample and testing for protein by estimating either albumin creatinine ratio 106 and albumin concentration has been shown by various studies to correlate well with the 24-hours urinary protein estimation and that ACR is superior in prognosticating both the renal and cardiovascular events. 85,104 According to a review article titled; how should proteinuria be detected and measured, a spot urine, preferably first early morning urine is good enough in determination of urinary albumin or protein concentration 82 since the value obtained for a 24 hours collection will be dependent on the concentration of the urine. 82,104 The choice of urinary strips as measuring tools has both pros and cons. Many will jettison its usage on account of the propensity for false positive or false negative results. At the albumin excretion cut-off rate of 30mg/24 both the semi-quantitative Clinitek strip and the quantitative DCA 2000+ have been shown to be reliable. Among eighty six chronic disease patients at Hope Hospital, Salford United Kingdom, the semi-quantitative Clinitek strip was found to be a -reliable test for ruling out increased urinary albumin excretion with LR-of < 0.05 above the 24hour urinary albumin excretion rate of 30mg/24 hours and less than 0.01 above the albumin excretion rate of 100mg/24 hours 108 and the DCA2000+ system demonstrated similar performance as a rule-out test,with likelihood ratios of less than 0.02 at 24-hour albumin excretion rates above 30mg/24 h‖. 108 It is true that detecting microalbuminuria is a more sensitive screening test for chronic kidney disease, dipstick urinalysis for proteinuria can also be very invaluable 82 . In the low and middle income countries(LMIC), where patients with chronic kidney disease present late, dipstick urinalysis for proteinuria is by far very useful than doing nothing. Additionally, the dipstick for proteinuria used in this audit (Medi-Test Combi 10 ® SGL) is readily available, affordable and makes better economic sense 109 than the reliance on clinical diagnosis which is synonymous with severe forms of chronic kidney disease.
The choice of dipstick urinalysis for proteinuria is putting into consideration the limited resources available in our setting to achieving the highest possible standard of care. This is to also assure a sustainable practice that is feasible and affordable. International Diabetes Federation recommends an annual check for proteinuria in an early morning or random urine sample using dipstick. Should the test be positive, UTI should be excluded by microscopy and culture. Serum creatinine should be measured and eGFR calculated on an annual basis. 6 Recommedations from different guidelines may have some variations, the scope is however consistent on how CKD should be evaluated and managed across different locations. 110

Criterion:
All the members of the Senior Citizen's Club who have attended the last three consecutive clinics must have an annual dipstick urinalysis for proteinuria done during their clinic visits.
This, according to the various international guidelines 6,16,83,105,111,113 is the minimum expected of standard practice among patients who are at the risk of chronic kidney disease. At risk patients include the elderly, 114 people with past history of acute kidney injury, patients with hypertension, diabetes mellitus, obesity and those with family history of chronic kidney disease. 111,114 The members of Senior Citizen's Club all aged 60 years and above, have one or more of hypertension, diabetes mellitus, family history of chronic kidney disease and obesity.
Amongst the important peculiarities of this group are; their low social status and their meager incomes. The most feasible, affordable, sustainable and evidence-based method of screening them for chronic kidney disease is the use of dipstick urinalysis for proteinuria and this is the minimum the Agbeke mercy Medical Clinic has to ensure they have annually.

Inclusion criteria:
All member of SCC who; 1. Have hypertension or diabetes mellitus or both. 2. Have been consistent with clinic attendance and follow up in the past three months. 3. Consented to participate in the audit.
Exclusion criteria: 1. Those who have attended less than three (3) consecutive clinics 2. Those who did not consent to participate in the audit

Setting standard:
Ninety percent (that is, 79 out of the 87) of the Senior Citizen's Club members should have their urine tested for proteinuria with the urinary dipstick by the end of July 2017. The set standard of 90% was arrived at following discussions among the healthcare team members (Nurses, Doctors, Medical record officer) at Agbeke Mercy Medical Clinic. We were convinced that this standard is achievable as the Senior Citizen's Club members attend their monthly clinic en mass, able to receive focused group talk/discussion as a unit and the decision to heavily subsidize the cost of the urinalysis as a good motivating factor for them to participate in the screening. Even though one would expect that a 100% should be the standard, considering the position of the various guidelines. However, in the time interval available for this audit, a 90% set standard is both realistic and achievable.

Preparation and Methods:
The The representative of the board of management of Agbeke Mercy Medical Clinic was informed of the need to carry out this clinical audit. The nursing staffs, who are already multitasking, being the ones who dispenses medication, takes vital signs and manages the side laboratory (essentially carrying out point of care testing like random or fasting plasma glucose and rapid diagnostic test for malaria) were specifically engaged in preparation and planning of this audit. The health talk was discussed with them and they agreed to keep giving the talk even beyond the SCC group on a continuous and regular basis. Their motivation and enthusiasm was heavily relied upon to meeting the standard that was set for this audit.
Enlisting the help of the record officer, the case files of all the members of the Senior Citizens' Club, one hundred and twenty four (124) were retrieved from the record office. Eighty seven (87) have been consistent with monthly clinic follow up in the three months preceding the review of the records, and these were the ones considered for this audit.
Sixty four (64) were altogether had hypertension, seven (7) had diabetes mellitus and 16 had both conditions. Twenty seven of those with hypertension and/or diabetes mellitus had either osteoarthritis or lumbar spondylosis and were on one type of Non-Steroidal Anti Inflammatory drugs (NSAIDs) or the other. This, with being 60 years and above made them all to be at the risk of developing chronic kidney disease. 46 The records of all the eighty seven were assessed retrospectively to see if they have had urinalysis for proteinuria done at least once in the last one year. In addition, the laboratory stock book was reviewed to see how regularly the dipstick urinalysis strips were purchased in the last one year.
The patients' clinical records showed values that were far below the set standard.
The laboratory record books showed that the strips were not purchased regularly and were in fact out of stock at the time of the first audit cycle.
These findings were discussed with the nursing staffs and the representative of the hospital board. We all agreed that the finding was below expectations and should be improved upon as a matter of urgency.
The plan on how to improve the urinalysis uptake for chronic kidney disease screening was shared with the team and the board. First step taken was to make the urinalysis strips available in the clinic with a proposition of at least fifty percent subsidy on the cost for the patients considering these elderly patients have to bear the cost otherwise. A two-third discount was finally obtained for every patient with the commitment of the hospital board to always include the money for the strips in the subvention to the clinic.
Following that, group talk/discussion; you and your kidney was set up with the group at their next Senior Citizens' meeting. They were given background information on the functions of the kidneys as the organs responsible for filtration of the blood and excretion of certain wastes from the body in the urine. They were informed that certain risks factors like increasing age, family history of chronic kidney disease and others can lead to reduced kidney function in the form of chronic kidney disease.
During this talk, emphasis was laid on the effects of hypertension and diabetes mellitus on the kidney functions. The reality of potential development of chronic kidney diseases from either of the two conditions was spelt out without ambiguity.
The other investigations available to monitor the renal functions, their order of importance, and the cost of each were provided to the patients during the talk. Letting them know the cost implications for the dipstick urinalysis and other test that may be required was necessary as their source of health care financing was out of pocket.
Without undermining the significance of the most important tests in chronic kidney disease screening, the spot urinalysis with dipstick for proteinuria was projected as a good way to start their renal Their consents were obtained to participate or not in the study and were reliably assured of their autonomy to pull out of the process. The benefits of the screening were made known to them as well and were also reassured that no harm will come to them from this screening.
All their questions were attended to as they were helped to understand the need for annual testing for proteinuria with the dipstick urinalysis strip and the possibility of further testing such as serum creatinine for glomerular filtration rate estimation and urinary albumin creatinine ratio, both of which were not available at the Agbeke Mercy Medical Clinic.
The dipstick for urinalysis were procured and made available in the clinic.
Screening began in the month of May 2017, for those who were ready after listening to the health talk. Random urine samples, produced in the clinic were screened for proteinuria.
The screening for the purpose of this audit was spread over the three months of May to July. The results of their dipstick urinalysis for proteinuria were recorded prospectively and the record updated each clinic day. Each test was defined as ‗absent proteinuria' to mean negative or trace and ‗present proteinuria' as 1+ or more. 102 By the third week in July, the members of the Senior Citizen's Club have had their third monthly meeting/clinic. The number of those who have had the urinalysis screening with dipstick done and the findings were noted for report. The result of the first audit revealed that 32 (37%) out of the eligible 87 (that is, those who have attended clinic for the last three consecutive months) to be included in the study had been screened for chronic kidney disease with urinary dipstick for proteinuria in the preceding one year. This was far below what was expected for all at risk patients for chronic kidney disease, of at least an annual screening, according to various guidelines reviewed. All the stakeholders or their representative were informed of this outcome. The need for significant improvement was discussed and the agreed modalities as outlined in the planning stage were followed. These include subsidy for screening cost by the board of AMMC, provision of health talks by the nurses, further enlightenment of the members of the SCC by their chairman and the secretary and the need for the rotating resident doctors to make the request for those who are eligible for the screening.

Second Cycle:
In the succeeding three months period, ninety three 93% (79 out of 87) were found to have had a dipstick urinalysis for proteinuria done. This meets and surpasses the standard of 90% set for this audit.
The table 1 and 2 showed the number of patients, their disease condition(s) and the outcome of the dipstick screening for proteinuria.     The first audit result of 37 percent was far below the standard set for this audit and the various guidelines with annual screening recommendation for all patients at the risk of chronic kidney disease.
One important factor worthy of note among this group of patients is the fact that majority of them have low earning powers, being at the twilight of life and never formally employed. It is true that they have been attending clinic, seen by the doctors, laboratory investigations requested and drugs prescribed. But the financial ability to carry out the dipstick urinalysis test for proteinuria at a rate of six hundred to one thousand two hundred naira (1.5 to 3.0 USD) was lacking among the majority of them. The usual cycle of doctors requesting for investigation and the patients not being able to carry it out, in this case urinalysis for proteinuria screening, showed in the pattern in which the urinary strips were being stocked in the clinic. It is only logical that we will opt for the most affordable means to improving our health care delivery as a country. A move to spend less on prevention and early identification of chronic medical conditions like hypertension, diabetes mellitus and chronic kidney disease will save us the pain of having to spend a large fortune on management of already complicated cases.
At the end of the second audit, 7% (6/87) of the patients were yet to have the dipstick urinalysis for proteinuria done. What is ideal and standard according to several guidelines on screening for chronic kidney disease is for all-at-risk patients for chronic kidney disease to have at least an annual screening. 6,111 So for this group of patients, we will keep monitoring their records over the next nine months in order to see when a hundred percent uptake has been achieved in the one year period. Consideration will also be made for other members of the groups who were not involved in this audit. That is, those not regular with clinic attendance for the three consecutive months prior the audit. The patient education is continuous and it is hoped that as they come for their appointments, they will be encouraged to have the urinalysis screening for chronic kidney disease.

Lessons learned
What one can readily infer from this audit report among many others is that the practice of giving proper information to patients may sometimes not be enough. Reinforcement is also very vital. Individualization of care is something that cannot be over emphasized in family medicine practice; as for this group of patients in this audit the consideration given for their earning power might have been responsible for the success rate recorded. The same may be the key in the sustenance of this routine screening and other important testing going forward.
In addition, with proper situational analysis and evaluation, other areas of practice in the hospital that has hitherto not received due attention can benefit from simple and non-expensive measures like this with resultant transformational outcomes.

Recommendations:
From this audit, the recommendation targets will be towards service improvement and adoption of basic standard clinical methods that is simple, measurable, achievable and reliable enough to be sustained for efficient clinical practice. The hope going forward is that this audit work in its simplicity would have opened the minds of my colleagues and other clinicians that will read the work, and who are practicing in this sort of settings, that a little testing of the waters, towards improving the quality of care and service we provide to our patients is always a worthy venture.
That the practice in Agbeke Mercy Medical Clinic, Cheshire Home Ibadan will always strive to live off of every new leaf turned in this era of evidencebased medicine, searching for the best available evidence, combine them with what is obtainable in our settings and judiciously apply them to the patient as an individual.
That all stakeholders in health, especially those who are concerned with primary health care, will realize that for our health system already stymied with underfunding, anticipatory steps towards early detection and management rather than waiting for early CKD stages to progress to ESRD in at risk patients is the best approach towards maximizing our scarce resources on health.
Importantly, the government and the policy makers must create a sustainable social support scheme, such as community health insurance in order to cater for the health of our emerging older population. This step will also help to minimize out of pocket health care expenditure which stood at 96% in 2013 across the African region. 70 Adopting the spirit of the WHO/AFRO, Nigeria government needs to design robust "health financing systems that are sustainable, equitable and able to support the provision of good quality health services" 116 for the citizens.

Agbeke Mercy Medical Clinic:
Attending the Agbeke Mercy Medical Clinic are other groups of patients who fall into the same category as the members of the Senior Citizen's Club by virtue of their age and disease profile but who are yet to be registered into the club.
The other group are patients, younger than sixty years who has one or more of the risk factors for chronic kidney disease; such as type 1 or type 2 diabetes mellitus, hypertension, obesity, family history of chronic kidney disease, heavy and chronic non-steroidal anti-inflammatory drug users, heavy consumers of local herbs rich in potential Considering the success with the relative ease of achieving it in this audit, it would be recommended to the board of Agbeke Mercy Medical Clinic to make provisions, by subsidizing the cost of conducting urinalysis for all the eligible patients. This will turn out to be the right step in the right direction as early identification of those with chronic kidney disease, their prompt treatment to prevent disease progression will not only reduce the economic burden on our underperforming health system, it will also help us with huge savings from the humongous renal replacement therapies.

Urine Microscopy and/or Culture:
For those with positive dipstick proteinuria, a further step must be taken to rule out urinary tract infection as a possible cause of the proteinuria. The side laboratory can be upgraded or equipped with a microscope to facilitate prompt urinary microscopy. This is a skill already possessed by the rotating resident doctors and will not require hiring of a laboratory scientist at an additional cost. Where there is a strong indication for culture, mid-stream urine sample should be sent to the main hospital, UCH, under special transport arrangement.

Serum Creatinine:
Once urinary tract infection has been ruled out by either urinary microscopy and culture, those who tested positive for proteinuria should have their serum creatinine level assay and their glomerular filtration rate estimated using the CKD-EPID equation.
This should be followed by appropriate staging of their chronic kidney disease.

Other steps:
Efforts should be made to achieve and maintain good blood pressure control and optimal glycaemic levels in those who are diabetic. Life style measures such as complete cessation of cigarette smoking, reduction in alcohol use, weight reduction, regular exercise for weight maintenance and healthy dietary practice must be encouraged. Judicious use of angiotensin converting enzyme inhibitors (ACEIs) or the angiotensin receptor blockers (ARBs), for those who will benefit from their use must always be considered.
The services of nephrologists are readily available at the University College Hospital, UCH and no hesitation should be entertained in referring those who will benefit from their services.

Conclusion:
In concluding, this audit work is the first step in what I hope will become standard procedure in the evaluation of patients attending Agbeke Mercy Medical Clinic for both the incidence and prevalence of chronic kidney disease. As we strive to sustain this initial simple and yet important step, it is my hope that the future resident doctors will make efforts to follow up on both the old and the new patients, build data and use the same to inform the local community and to add to the body of knowledge, the situation at Agbeke Mercy Medical Clinic and the community it serves.
Importantly, as resources hopefully improve in the future, either through increase in subventions to the clinic from the board or implementation of the social health insurance scheme, the use of both serum creatinine for glomerular filtration rate estimation and quantitative urinary albumin creatinine ratio to screen for chronic kidney disease annually should be considered.
Considering the various determinants of health, now spanning across both the social and economic status, integrative care strategies is the way to go. Preventive services, in the form of screening, vaccination, lifestyle changes and early treatment are all effective health management processes that have to be adopted across the three tiers of government in Nigeria.  Finally, my best friend and pillar of support, Folashademi, your patience and steadfastness saw me through this course from the start to the finish. God alone can fully reward you for the sacrifices, financially, emotionally and materially that you