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