Chronic Kidney Disease Workshop Maarten Taal Department of Renal Medicine Derby City General Hospital Derby Nephrology Research.

Chronic Kidney Disease WorkshopChronic Kidney Disease Workshop

Maarten TaalMaarten Taal

Department of Renal MedicineDepartment of Renal Medicine

Derby City General HospitalDerby City General Hospital

Derby Nephrology Research

Case #1

• 76 year male

• No previous illnesses

• Smoker 10/day

• PC: tiredness, some dyspnoea

• Examination: BP144/92; urine- + protein

• Serum creatinine 116mol/l; Hb 10.5g/dL

Case #1 - Questions

1. What would you do next?

2. What is his eGFR?

3. Should he be referred to Nephrology?

Case #1 - Answers

1. What would you do next?– Urine protein:creatinine (1.8mg/mg)– eGFR

2. What is his eGFR?– 56ml/min/1.73m2 (CKD stage 3)

3. Should he be referred to Nephrology?– Yes

Case #2

• 23 year female

• No previous illnesses

• PC: tiredness; arthralgia in hands for 2 months

• Examination: BP132/78; urine: + protein

• Serum creatinine 63mol/l ; Hb11.1g/dl

Case #2 - Questions

1. What would you do next?

2. What is her eGFR?

3. Should she be referred to Nephrology?

Case #2 - Answers

1. What would you do next?– Urine protein:creatinine (0.9mg/mg)– Lupus serology

2. What is her eGFR?– >60ml/min/1.73m2 (CKD stage 1-2)

3. Should she be referred to Nephrology?

– Yes

Case #3

• 81 year male

• Past Hx: Asthma; non-smoker

• “Well man’s clinic”

• BP128/76; urine: + protein

• Serum creatinine 114 mol/l ; eGFR 57; Hb11.1g/dl

Case #3 - Questions

1. What would you do next?

2. Should he be referred to Nephrology?

Case #3 - Answers

1. What would you do next?– Urine protein:creatinine (0.1mg/mg)– Previous creatinine value? (112 in 2001)

2. Should he be referred to Nephrology?– No– Recheck eGFR and urine in 6 months,

annually if stable

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; eGFR>60

Case #4 - Questions

1. What would you do next?

2. Should he be referred to Nephrology?

Case #4 - Answers

1. What would you do next?– Send MSU for MC&S (negative)

2. Should he be referred to Nephrology?– No– Refer Urology

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

Case #5 - Questions

1. What would you do next?

2. What is her eGFR?

3. Should she be referred to Nephrology?

Case #5 - Answers

1. What would you do next?– Estimated GFR– Urine protein:creatinine (2.3mg/mg)

2. What is her eGFR?– 20ml/min/1.73m2 (CKD stage 4)

3. Should she be referred to Nephrology?

– Yes, immediately

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

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 (normal>30)

• B12 and folate normal

Case #6 - Questions

• What changes to medication?

• What interventions for high phosphate and PTH?

• What investigations and treatment for anaemia?

Case #6 - Answers• What changes to medication?

– Stop Metformin

• What interventions for high phosphate and PTH?– Phosphate binder– 1-alfacalcidol once phosphate <1.6mmol/l

• What investigations and treatment for anaemia? – Clinical assessment to exclude GI bleeding– Intravenous iron– Erythropoeitin

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:

a. No action requiredb. Discontinue the Irbesartanc. Reduce the dose of Irbesartand. Repeat the creatinine measurement in 1 weeke. Refer to a Nephrologist

Case #7

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:

a. No action requiredb. Discontinue the Irbesartanc. Reduce the dose of Irbesartand. Repeat the creatinine measurement in 1 weeke. Refer to a Nephrologist

Case #7 - Answer

Case #8• 56y male• Type 2 diabetes for 9 years• Hypertensive and obese• Rx: amlodipine• Annual screening:

– BP143/90– creatinine 103 mol/l ; eGFR >60– Urine ACR 4.7 mg/ mol

Case #8 - Questions

1. What would you do next?

2. Should he be referred to Nephrology?

Case #8 - Answers

1. 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 <130/80– Minimise cardiovascular risk– Weight loss

2. Should he be referred to Nephrology?– No– Review annually once optimised