Chronic Kidney Disease Workshop Maarten Taal Department of Renal Medicine Derby 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 116  mol/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/1.73m 2 (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 63  mol/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/1.73m 2 (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/1.73m 2 (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 required b.Discontinue the Irbesartan c.Reduce the dose of Irbesartan d.Repeat the creatinine measurement in 1 week e.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 required b.Discontinue the Irbesartan c.Reduce the dose of Irbesartan d.Repeat the creatinine measurement in 1 week e.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