Chronic Kidney Disease Derby Nephrology Research Chronic Kidney Disease

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Chronic Kidney Disease Derby Nephrology Research Chronic Kidney Disease Powered By Docstoc
					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
•   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/1.73m2 (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 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/1.73m2 (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
                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
 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 #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

				
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