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In fact, low serum creatinine is associated with higher mortality. • Finally, creatinine generation rates decline with advancing renal failure. Other factors affecting serum creatinine include: • dietary meat intake • drugs inhibiting tubular creatinine secretion (cimetidine, trimethoprim, cobicistat among others, can increase serum creatinine by up to 50µmol/L) • interference with colorimetric creatinine assays (especially ketones, cefoxitin, and flucytosine) increases the reported value by up to 40µmol/L • women, children, the elderly, and those with reduced muscle bulk also have reduced creatinine generation rates, and hence will have a lower serum creatinine for a given GFR • protein and creatine supplements.

G. diet, ACEIs, transfusion, surgery, gastrointestinal (GI) bleed, potassium-sparing diuretics Bicarbonate Low Chloride Normal in renal tubular acidosis Urea Affected by protein intake, hydration, liver disease Creatinine Affected by muscle mass and increasing tubular secretion with advancing renal impairment Albumin Reflects urinary losses, protein intake and hepatic synthesis. Low levels (<40) at start of RRT strongly associated with poor prognosis Calcium May be normal, low, or high depending on parathyroid activity Phosphate Rises late in CKD.

3 Mechanisms underlying renal bone disease. Complications of renal failure: malnutrition Complications of renal failure: malnutrition Poor nutrition This is a predictor of poor outcome at the start of dialysis. It develops as patients become anorectic. Patients spontaneously reduce their protein intake as well as their overall calorie intake, and some become severely cachectic. There are various biochemical markers of nutrition, but the most easily measured is plasma albumin. Low albumin may also reflect ongoing inflammation rather than nutritional status.

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