Chronic Kidney Disease Workshop

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Chronic Kidney Disease Workshop

• Maarten Taal
• Department of Renal Medicine
• Derby City General Hospital

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Case 1

• 76 year male
• No previous illnesses
• Smoker 10/day
• PC tiredness, some dyspnoea
• Examination BP144/92 urine- protein
• Serum creatinine 116?mol/l Hb 10.5g/dL

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Case 1 - Questions

• What would you do next?
• What is his eGFR?
• Should he be referred to Nephrology?

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Case 1 - Answers

• What would you do next?
• Urine proteincreatinine (1.8mg/mg)
• eGFR
• What is his eGFR?
• 56ml/min/1.73m2 (CKD stage 3)
• Should he be referred to Nephrology?
• Yes

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Case 2

• 23 year female
• No previous illnesses
• PC tiredness arthralgia in hands for 2 months
• Examination BP132/78 urine protein
• Serum creatinine 63?mol/l Hb11.1g/dl

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Case 2 - Questions

• What would you do next?
• What is her eGFR?
• Should she be referred to Nephrology?

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Case 2 - Answers

• What would you do next?
• Urine proteincreatinine (0.9mg/mg)
• Lupus serology
• What is her eGFR?
• gt60ml/min/1.73m2 (CKD stage 1-2)
• Should she be referred to Nephrology?
• Yes

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Case 3

• 81 year male
• Past Hx Asthma non-smoker
• Well mans clinic
• BP128/76 urine protein
• Serum creatinine 114 ?mol/l eGFR 57 Hb11.1g/dl

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Case 3 - Questions

• What would you do next?
• Should he be referred to Nephrology?

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Case 3 - Answers

• What would you do next?
• Urine proteincreatinine (0.1mg/mg)
• Previous creatinine value? (112 in 2001)
• Should he be referred to Nephrology?
• No
• Recheck eGFR and urine in 6 months, annually if
  stable

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Case 4

• 64 year female
• Past Hx hypertension for 15y smokes 15/day
• Annual health check urine 2 blood
• Rx trimethoprim
• BP 132/74 urine 2 blood
• Serum creatinine 83 ?mol/l eGFRgt60

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Case 4 - Questions

• What would you do next?
• Should he be referred to Nephrology?

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Case 4 - Answers

• What would you do next?
• Send MSU for MCS (negative)
• Should he be referred to Nephrology?
• No
• Refer Urology

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Case 5

• 76 year female
• Type 2 diabetes for 17 years
• Hypertension and diabetic nephropathy for 10
  years
• Rx Irbesartan 300mg/day
• Annual review
• Serum creatinine 221 ?mol/l
• Urine 2 protein

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Case 5 - Questions

• What would you do next?
• What is her eGFR?
• Should she be referred to Nephrology?

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Case 5 - Answers

• What would you do next?
• Estimated GFR
• Urine proteincreatinine (2.3mg/mg)
• What is her eGFR?
• 20ml/min/1.73m2 (CKD stage 4)
• Should she be referred to Nephrology?
• Yes, immediately

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Case 6

• 57y male
• Type 2 diabetes x 15 years
• Diabetic nephropathy, hypertension, OA
• Rx
• Metformin 500mg tds
• Lisinopril 40mg od
• Aspirin 75mg od
• Simvastatin 40mg nocte

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Case 6 - Data

• Creatinine 245 ?mol/l eGFR 28ml/min
• Corr calcium 2.24mmol/l
• Phosphate 2.16mmol/l
• Hb 9.8mg/dl
• Ferritin 47 (normalgt30)
• B12 and folate normal

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Case 6 - Questions

• What changes to medication?
• What interventions for high phosphate and PTH?
• What investigations and treatment for anaemia?

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Case 6 - Answers

• What changes to medication?
• Stop Metformin
• What interventions for high phosphate and PTH?
• Phosphate binder
• 1-alfacalcidol once phosphate lt1.6mmol/l
• What investigations and treatment for anaemia?
• Clinical assessment to exclude GI bleeding
• Intravenous iron
• Erythropoeitin

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A 55y male type 2 diabetic patient is started on
Irbesartan 150mg/d for hypertension and
proteinuria. The serum creatinine increases from
145 to 171 ?mol/l after 1 week. The most
appropriate response is
Case 7

• No action required
• Discontinue the Irbesartan
• Reduce the dose of Irbesartan
• Repeat the creatinine measurement in 1 week
• Refer to a Nephrologist

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A 55y male type 2 diabetic patient is started on
Irbesartan 150mg/d for hypertension and
proteinuria. The serum creatinine increases from
145 to 171 ?mol/l after 1 week. The most
appropriate response is
Case 7 - Answer

• No action required
• Discontinue the Irbesartan
• Reduce the dose of Irbesartan
• Repeat the creatinine measurement in 1 week
• Refer to a Nephrologist

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Case 8

• 56y male
• Type 2 diabetes for 9 years
• Hypertensive and obese
• Rx amlodipine
• Annual screening
• BP143/90
• creatinine 103 ?mol/l eGFR gt60
• Urine ACR 4.7 mg/ ?mol

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Case 8 - Questions

• What would you do next?
• Should he be referred to Nephrology?

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Case 8 - Answers

• What would you do next?
• Repeat urine ACR (6.3 mg/ ?mol)
• Start treatment with ACEI or ARB titrate to
  maximum dose
• Control BP to lt130/80
• Minimise cardiovascular risk
• Weight loss
• Should he be referred to Nephrology?
• No
• Review annually once optimised