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Chronic Kidney Disease Workshop

Derby Nephrology Research. Chronic Kidney Disease Workshop. Maarten Taal Department of Renal Medicine Derby City General Hospital. Case #1. 76 year male No previous illnesses Smoker 10/day PC: tiredness, some dyspnoea Examination: BP144/92; urine- + protein

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Chronic Kidney Disease Workshop

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

  2. 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

  3. Case #1 - Questions • What would you do next? • What is his eGFR? • Should he be referred to Nephrology?

  4. Case #1 - Answers • What would you do next? • Urine protein:creatinine (1.8mg/mg) • eGFR • What is his eGFR? • 56ml/min/1.73m2 (CKD stage 3) • Should he be referred to Nephrology? • Yes

  5. 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

  6. Case #2 - Questions • What would you do next? • What is her eGFR? • Should she be referred to Nephrology?

  7. Case #2 - Answers • What would you do next? • Urine protein:creatinine (0.9mg/mg) • Lupus serology • What is her eGFR? • >60ml/min/1.73m2 (CKD stage 1-2) • Should she be referred to Nephrology? • Yes

  8. 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

  9. Case #3 - Questions • What would you do next? • Should he be referred to Nephrology?

  10. Case #3 - Answers • What would you do next? • Urine protein:creatinine (0.1mg/mg) • Previous creatinine value? (112 in 2001) • Should he be referred to Nephrology? • No • Recheck eGFR and urine in 6 months, annually if stable

  11. 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

  12. Case #4 - Questions • What would you do next? • Should he be referred to Nephrology?

  13. Case #4 - Answers • What would you do next? • Send MSU for MC&S (negative) • Should he be referred to Nephrology? • No • Refer Urology

  14. 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

  15. Case #5 - Questions • What would you do next? • What is her eGFR? • Should she be referred to Nephrology?

  16. Case #5 - Answers • What would you do next? • Estimated GFR • Urine protein:creatinine (2.3mg/mg) • What is her eGFR? • 20ml/min/1.73m2 (CKD stage 4) • Should she be referred to Nephrology? • Yes, immediately

  17. 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

  18. 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

  19. Case #6 - Questions • What changes to medication? • What interventions for high phosphate and PTH? • What investigations and treatment for anaemia?

  20. 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

  21. 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: • No action required • Discontinue the Irbesartan • Reduce the dose of Irbesartan • Repeat the creatinine measurement in 1 week • Refer to a Nephrologist

  22. Case #7 - Answer 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: • No action required • Discontinue the Irbesartan • Reduce the dose of Irbesartan • Repeat the creatinine measurement in 1 week • Refer to a Nephrologist

  23. 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

  24. Case #8 - Questions • What would you do next? • Should he be referred to Nephrology?

  25. Case #8 - Answers • 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 • Should he be referred to Nephrology? • No • Review annually once optimised

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