More kidney related stuff

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More kidney related stuff

• Chris Dudley
• Renal Unit
• North Bristol NHS Trust, Southmead Hospital
• Bristol
• chris.dudley_at_nbt.nhs.uk

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• Joint Consensus Statement on the Initial
  Assessment of Haematuria
• Renal Association BAUS
• July 2008

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63 yr old man

• Hypertension for 10 years
• Smoker
• TIA in 2004
• BP 168/86
• Cholesterol 5.6
• HDL cholesterol 0.9
• Rx atenolol 50 mg, felodipine 5 mg, aspirin
  75mg, simvastatin 10mg,

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Should he be offered testing for CKD?

• diabetes
• hypertension
• cardiovascular disease (ischaemic heart disease,
  chronic heart failure, peripheral vascular
  disease and cerebral vascular disease)
• structural renal tract disease, renal calculi or
  prostatic hypertrophy
• multisystem diseases with potential kidney
  involvement for example, systemic lupus
  erythematosus
• family history of stage 5 CKD or hereditary
  kidney disease
• opportunistic detection of haematuria or
  proteinuria

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What tests should be performed?

• Creatinine
• eGFR
• Urine ACR
• Use urine ACR instead of PCR to detect
  proteinuria (especially in diabetics) NICE 2008

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• Creatinine 155 umol/l
• eGFR 42 mls/min/1.73m2
• Urine ACR 10 mmol/mg

• Hypertension for 10 years
• Smoker
• TIA in 2004
• BP 168/86
• Cholesterol 5.6
• HDL cholesterol 0.9
• Rx atenolol 50 mg, felodipine 5 mg, aspirin
  75mg, simvastatin 10mg

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CKD stages

• What stage of CKD is this?
• (eGFR 42)
• What stage would it be if UACR 85 mg/mmol?

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Use suffix (p) to denote presence of proteinuria
when staging
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How do you know if this is acute or chronic?

• Clinical setting
• Previous values
• Repeat the eGFR within 2 weeks
• (U/S)

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• Creatinine 155 umol/l
• eGFR 42 mls/min/1.73m2
• Urine ACR 10 mmol/mg

• Hypertension for 10 years
• Smoker
• TIA in 2004
• BP 168/86
• Cholesterol 5.6
• HDL cholesterol 0.9
• Rx atenolol 50 mg, felodipine 5 mg, aspirin
  75mg, simvastatin 10mg

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Should he be on an ACEI/ARB?

• Not because of his CKD

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Should he be referred to a nephrologist?

• Stage 4 or 5
• Significant proteinuria
• ACR gt 70, PCR gt 100 or 24 hr Uprot gt 1g unless
  diabetic on Rx
• Proteinuria haematuria
• ACRgt30 PCRgt50

• Rapidly declining eGFR
• gt5ml/min/1.73m2 within 1 yr or
• gt10ml/min within 5yr
• Difficult BP
• gt4 agents
• Rare or genetic causes of CKD
• Suspected RAS

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How do you identify progressive CKD?

• Exclude AKI
• Obtain a minimum of 3 eGFRs over a period not
  less than 90 days
• Define progression as before
• Focus on those whose extrapolated GFR shows that
  RRT will be required within their life-time

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What other opportunities are there here?

• Creatinine 155 umol/l
• eGFR 42 mls/min/1.73m2
• Urine ACR 10 mmol/mg

• Hypertension for 10 years
• Smoker
• TIA in 2004
• BP 168/86
• Cholesterol 5.6
• HDL cholesterol 0.9
• Rx atenolol 50 mg, felodipine 5 mg, aspirin
  75mg, simvastatin 10mg

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Assuming stable CKD when should he be
re-evaluated?

• Every 6 months

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Frequency of testing
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Frequency of testing

• Annually in all at risk groups
• During intercurrent illness perioperatively
• Within 2 weeks of introducing ACEI/ARB or dose
  increase
• Common sense

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Elderly patients to refer or not to refer?

• eGFR 28
• age 85
• congestive cardiac failure, unable to manage
  stairs
• no proteinuria

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Elderly patients to refer or not to refer?

• This patient is likely to have a cardio-renal
  syndrome
• Evidence of progression?
• if not, conservative management as per guidance
• if so, is there any prospect of reversibility (in
  this case probably not) or would the patient
  tolerate/ benefit from renal replacement therapy
  (in this case probably not)
• Palliative care pathway ? ESA

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Threshold eGFR below which risk of ESRD exceeds
risk of death
J Am Soc Nephrol 2007182758-2765
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NICE CKD guidelines 2008

• Who to test for CKD?
• Subcategorise CKD 3 (3A and 3B)
• Use urine ACR instead of PCR to detect
  proteinuria (especially in diabetics)
• Suffix (p) for proteinuria
• Who to refer?
• When to re-evaluate?

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Haematuria

• Which of the following statements are correct?
• Haematuria should be confirmed by microscopy
• Urine dipstix of 1 can be ignored
• Urine dipstix of 1 should be further evaluated
• Tests for haemolytic anaemia should be initiated
  if urine dipstix shows 2 haemolysed blood
• Visible haematuria should be urgently referred
  for urological investigation only in patients gt
  40 yrs

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Haematuria Consensus Guidelines RA BAUS July
2008

• Reagent strip testing only
• 1 considered positive
• 2 out of 3 persistent
• Visible and non-visible haematuria
• Symptomatic or asymptomatic

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What is significant haematuria?

• Any episode of VH
• Any episode of s-NVH (excluding UTI etc)
• Persistent a-NVH (excluding UTI etc)

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The following patients should be referred to
urology

• All patients with visible haematuria (VH)
  irrespective of symptoms
• Only symptomatic patients with VH
• All patients with s-NVH
• All patients with a-NVH
• Patients with s-NVH gt 55 yrs
• Patients with a-NVH gt 40 yrs

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Initial investigations of patient with s-NVH or
persistent a-NVH

• Urine microscopy
• MSU
• Urine cytology
• BP
• eGFR
• ACR
• C3/C4
• U/S
• ANA

?
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Who to refer to a nephrologist?

• As in CKD guidelines after ive urological
  investigations
• Significant proteinuria ACR gt 30
• lt 40 yrs with hypertension
• Unexplained systemic symptoms
• VH coinciding with intercurrent infection

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Follow up for all

• Regular assessment of
• LUTS
• VH
• ACR
• eGFR
• BP

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• 68 yr old female with stable CKD stage 3B
• eGFR 34
• UTI
• Rx trimethoprim
• 1 week later eGFR 28
• What would you do?

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Top tips to managing..

• Gout in CKD
• Colchicine but no more than 500 ug bd
• Prednisolone 20 mg od for 5 days
• Osteoporosis prophylaxis (biphosphonate) in CKD
• Never unopposed with out Ca2 Vit D supplement
• In CKD gt stage 3 measure PTH consider
  alfacalcidol (activated D3) in place of CaD3
• Monitor calcium

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Top tips to managing..

• ACEI/ARBs in elderly with concurrent illness esp.
  vol. depletion (hypotension)
• STOP THEM to avoid AKI

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