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Renal Medicine for Primary Care in 90 minutes

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This case study explores the management of chronic kidney disease (CKD) in a 76-year-old male patient with a history of peripheral vascular disease (PVD), hypertension, and osteoarthritis. The patient presents with an eGFR of 42, prompting questions regarding further investigation and referral. We evaluate the relevance of urinalysis, blood pressure management, and potential nephrology consultation based on current NICE guidelines and KDIGO recommendations. Various cases highlight the importance of individualized treatment and lifestyle modification in managing CKD effectively.

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Renal Medicine for Primary Care in 90 minutes

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  1. Renal Medicine for Primary Care in 90 minutes russell.roberts@bthft.nhs.uk

  2. Case 1 • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Aspirin, simvastatin, ramipril, bendroflumethiazide • Annual check up • eGFR 42 • What next?

  3. Chronic Kidney disease or not? • Urinalysis? • Historical blood tests • Symptoms?

  4. Chronic Kidney Disease • CKD-1 • normal GFR (>90) with other evidence of chronic kidney damage • CKD-2 • Mild impairment, GFR 60-89 with other evidence of chronic kidney damage • CKD-3 • Moderate impairment, GFR 30-59 • Divided into 3A 45-59 and 3B 30-44 • CKD-4 • Severe impairment, GFR 15-29 • CKD-5 • Established renal failure, GFR <15 or on dialysis • Note, a patient with GFR 60-89 without other markers does not have CKD and does not need further investigation unless other reasons • Use ‘p’ to indicate proteinuria

  5. Case 1 • Urinalysis protein trace, blood ‘non-hemolysed trace’ • eGFR was 39 last year • No symptoms • BP 146/86 • Refer to nephrology??

  6. Age and eGFR?

  7. Follow up of CKD in primary care NICE CG73

  8. Follow up of CKD in primary care

  9. Follow up of CKD in primary care

  10. Blood Pressure targets in CKD • KDIGO Clinical Practice Guidelines 2012 • General Statements • Individualize treatment considering age, co-morbidity, risk of progressive CKD, tolerance of treatment • Check for postural symptoms and postural hypotension • Lifestyle measures • BMI 20-25 • Salt • Exercise • alcohol Kidney International 2012; Suppl 2: 337-414

  11. Blood Pressure targets in CKD • CKD, no diabetes • <140/90 • CKD, no diabetes, ACR >30 • <130/80 • CKD plus diabetes, ACR <30 • <140/90 • CKD plus diabetes, ACR >30 • <130/80 • If drug treatment is indicated, use an ACE/ARB in the presence of proteinuria (ACR >30)

  12. Blood Pressure targets in CKD • Diabetes or proteinuria 130/80 • Neither diabetes nor proteinuria 140/90

  13. Blood Pressure targets in CKD • Special situations • Renal Transplants- target <130/80 regardless of ACR or diabetes status • Elderly- tailor the BP regimen considering age, co-morbidities, careful escalation of treatment, side effects and tolerance of treatment

  14. Additional primary care follow up CKD is a vascular risk factor so: Smoking Diet Exercise Lipid-lowering? (SHARP) USS if LUTS or difficult hypertension

  15. Case 1a • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Aspirin, simvastatin, ramipril, bendroflumethiazide • Comes to see you with acute swollen joint? • Pyrexial, BP 106/62, WCC 17 • Management

  16. Case 2 • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Bilateral swollen legs • eGFR 55 • What next?

  17. Case 2 • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Bilateral swollen legs • eGFR 55 • Urinalysis- protein ++++ • What next?

  18. Case 2 • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Bilateral swollen legs • eGFR 55 • Urinalysis- protein ++++ • PCI 5430 • [albumin] 22 • Diagnosis? • Referral ?

  19. Nephrotic Syndrome • Specific definition • Proteinuria (>3g) + hypoalbuminemia + oedema • Can we deduce the diagnosis?

  20. Nephrotic syndrome • Specific definition • Proteinuria (>3g) + hypoalbuminemia + oedema • Can we deduce the diagnosis? • No • Needs a renal biopsy except……….

  21. Nephrotic syndrome in adults • Minimal Change • Focal and Segmental Sclerosis • Membranous Glomerulonephritis • Diabetes • Amyloid • SLE • Other long names

  22. Management of Nephrotic Syndrome • Specific therapy • Steroids +/- immunosuppression • Prednisolone • Cyclophosphamide • MycophenolateMofetil • Tacrolimus • Underlying disease

  23. Management of Nephrotic Syndrome • General Measures • Diuretics • Guided by symptoms and weight, helped by salt and water restriction • BP control • ACE/ARB • Thromboprophylaxis • Lipid lowering? • Protection from specific therapies • Bone protection, antimicrobial prophylaxis, stomach protection

  24. Case 3 • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Aspirin, simvastatin, ramipril, bendroflumethiazide • Annual check up • eGFR 42 • Urinalysis protein trace, blood ++ • What next? • Are you going to refer and who to?

  25. What to you need to consider in Haematuria? • Does it matter if it is visible or not? • Presence of symptoms or not • Proteinuria, blood pressure, eGFR • Features of acute glomerulonephritis • Features of malignancy • Bladder or renal

  26. Joint British Haematuria Guidelines 2008 • Visible or Non-visible • Symptomatic or not • Dipstix based diagnosis, routine microscopy is not indicated from primary care • Haemolysed or non-haemolysed not relevant

  27. Joint British Haematuria Guidelines 2008 • Significant if: • Any episode of VH • Any episode of s-NVH if UTI or other cause excluded • Persistent a-NVH (2 out of 3) • Exclusions • UTI (but remember may need to investigate why) • Exercise-induced haematuria • Menstruation • WARFARIN (and anti-platelets) is IRRELEVANT

  28. Assessment of haematuria • Exclude UTI • Blood pressure • eGFR • proteinuria

  29. Haematuria referral • Urology • All visible haematuria • (possible exception cola urine in <40 with resp symptoms) • All s-NVH • All a-NVH > 40

  30. Nephrology Referral • Evidence of progressive fall in eGFR • Stage 4 or 5 CKD • Proteinuria (PCR >50) • Visible Haematuria with URTI • Isolated haematuria plus HT if <40 • If you don’t refer or if they are sent back • Monitor for LUTS, visible haematuria, proteinuria, eGFR and hypertension • Annual check if NVH persists • THEY HAVE CKD

  31. Case 4 • 76 year old male • Hx of PVD (angioplasty two years ago), hypertension, osteoarthritis • Aspirin, simvastatin, ramipril, bendroflumethiazide • Tired, breathless, poor appetite • eGFR 20, Hb 101, Ca 2-04, • BP 176/94 • Refer or not

  32. Anaemia of CKD • Consider investigation and management if Hb <110 or symptoms attributable to anaemia • MCV, haematinics, other causes of anaemia (CRP, PTH, myeloma) • Offer ESA treatment to people with anaemia of CKD who are likely to benefit in terms of quality of life and physical function NICE CG114

  33. Anaemia of CKD • Target ranges • Hb 100-120 • Do not try to achieve normal Hb • Ferritin 200-500 • And TSAT >20% • Or %hypochromic red cells <6% • Likely to need intravenous iron • Likely to need specialist input

  34. Renal Bone Disease • High phosphate plus low calcium drives hyperparathyroidism • Vitamin D deficiency • Age • Steroid and other therapies

  35. Management of renal bone disease • Dietary phosphate restriction • Phosphate binders • Aluminium hydroxide • Calcium carbonate or acetate • Sevelamer (renagel/renvela) • Lanthanum (fosrenol) • Osvaren (calcium acetate/magnesium carbonate) • Need to be taken correctly and avoid hypercalcemia

  36. Management of renal bone disease • Activated Vitamin D • Alfacalcidol • But dangers of calcification • Unresponsive Hyper-PTH • Surgery • Cinacalcit (mimpara) • Paricalcitol (zemplar) • Always check [Ca] in ‘bloods’ for CKD 4 or 5

  37. Acidosis • Low [bicarbonate] a risk factor for renal bone disease • Possible role in muscle catabolism • Emerging evidence that correction of acidosis delays progression of CKD

  38. Case 5 • 57 year old • MI x 3 previously, turned down for CABG as poor LV function • Ramipril, bumetanide, spironolactone • SOB on minimal exertion, peripheral oedema • Creatinine 243, urea 36 • Diagnosis/what next

  39. Cardiorenal syndrome • Remember the basics, BP, urinalysis, previous creatinines • But this is likely to reflect cardiorenal syndrome • Balancing act of diuretic benefit vs effect on kidney function • Kidneys will benefit if you improve cardiac function but may have to tolerate some oedema • Use the Heart Failure nurses

  40. Case 6 • 64 year old known CKD • eGFR 19 at last renal clinic appointment • Complains of difficulty moving legs and feels awful • Next steps?

  41. Hyperkalaemia is life threatening

  42. Case 6 • 64 year old known CKD • eGFR 19 at last renal clinic appointment • Complains of difficulty moving legs and feels awful • eGFR 9, K+ 7.2 • Treated with antibiotics for UTI last weekend • Which antibiotic?

  43. Case 6 • 64 year old known CKD • eGFR 19 at last renal clinic appointment • Complains of difficulty moving legs and feels awful • eGFR 9, K+ 7.2 • Treated with antibiotics for UTI last weekend • Trimethoprim

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