Chronic Kidney Disease Workshop Maarten Taal Department of Renal Medicine Derby City General Hospital Derby Nephrology Res...
Case #1 <ul><li>76 year male </li></ul><ul><li>No previous illnesses </li></ul><ul><li>Smoker 10/day </li></ul><ul><li>PC:...
Case #1 - Questions <ul><li>What would you do next? </li></ul><ul><li>What is his eGFR? </li></ul><ul><li>Should he be ref...
Case #1 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Urine protein:creatinine (1.8mg/mg) </li></ul></ul...
Case #2 <ul><li>23 year female </li></ul><ul><li>No previous illnesses </li></ul><ul><li>PC: tiredness; arthralgia in hand...
Case #2 - Questions <ul><li>What would you do next? </li></ul><ul><li>What is her eGFR? </li></ul><ul><li>Should she be re...
Case #2 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Urine protein:creatinine (0.9mg/mg) </li></ul></ul...
Case #3 <ul><li>81 year male </li></ul><ul><li>Past Hx: Asthma; non-smoker </li></ul><ul><li>“ Well man’s clinic” </li></u...
Case #3 - Questions <ul><li>What would you do next? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
Case #3 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Urine protein:creatinine (0.1mg/mg) </li></ul></ul...
Case #4 <ul><li>64 year female </li></ul><ul><li>Past Hx: hypertension for 15y; smokes 15/day </li></ul><ul><li>Annual hea...
Case #4 - Questions <ul><li>What would you do next? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
Case #4 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Send MSU for MC&S (negative) </li></ul></ul><ul><l...
Case #5 <ul><li>76 year female </li></ul><ul><li>Type 2 diabetes for 17 years </li></ul><ul><li>Hypertension and diabetic ...
Case #5 - Questions <ul><li>What would you do next? </li></ul><ul><li>What is her eGFR? </li></ul><ul><li>Should she be re...
Case #5 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Estimated GFR </li></ul></ul><ul><ul><li>Urine pro...
Case #6 <ul><li>57y male </li></ul><ul><li>Type 2 diabetes x 15 years </li></ul><ul><li>Diabetic nephropathy, hypertension...
Case #6 - Data <ul><li>Creatinine 245   mol/l; eGFR 28ml/min </li></ul><ul><li>Corr calcium 2.24mmol/l </li></ul><ul><li>...
Case #6 - Questions <ul><li>What changes to medication? </li></ul><ul><li>What interventions for high phosphate and PTH? <...
Case #6 - Answers <ul><li>What changes to medication? </li></ul><ul><ul><li>Stop Metformin </li></ul></ul><ul><li>What int...
A 55y male type 2 diabetic patient is started on Irbesartan 150mg/d for hypertension and proteinuria.   The serum creatini...
A 55y male type 2 diabetic patient is started on Irbesartan 150mg/d for hypertension and proteinuria.   The serum creatini...
Case #8 <ul><li>56y male </li></ul><ul><li>Type 2 diabetes for 9 years </li></ul><ul><li>Hypertensive and obese </li></ul>...
Case #8 - Questions <ul><li>What would you do next? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
Case #8 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Repeat urine ACR (6.3 mg/   mol)   </li></ul></ul...
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Chronic Kidney Disease Workshop

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Chronic Kidney Disease Workshop

  1. 1. Chronic Kidney Disease Workshop Maarten Taal Department of Renal Medicine Derby City General Hospital Derby Nephrology Research
  2. 2. Case #1 <ul><li>76 year male </li></ul><ul><li>No previous illnesses </li></ul><ul><li>Smoker 10/day </li></ul><ul><li>PC: tiredness, some dyspnoea </li></ul><ul><li>Examination: BP144/92; urine- + protein </li></ul><ul><li>Serum creatinine 116  mol/l; Hb 10.5g/dL </li></ul>
  3. 3. Case #1 - Questions <ul><li>What would you do next? </li></ul><ul><li>What is his eGFR? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
  4. 4. Case #1 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Urine protein:creatinine (1.8mg/mg) </li></ul></ul><ul><ul><li>eGFR </li></ul></ul><ul><li>What is his eGFR? </li></ul><ul><ul><li>56ml/min/1.73m 2 (CKD stage 3) </li></ul></ul><ul><li>Should he be referred to Nephrology? </li></ul><ul><ul><li>Yes </li></ul></ul>
  5. 5. Case #2 <ul><li>23 year female </li></ul><ul><li>No previous illnesses </li></ul><ul><li>PC: tiredness; arthralgia in hands for 2 months </li></ul><ul><li>Examination: BP132/78; urine: + protein </li></ul><ul><li>Serum creatinine 63  mol/l ; Hb11.1g/dl </li></ul>
  6. 6. Case #2 - Questions <ul><li>What would you do next? </li></ul><ul><li>What is her eGFR? </li></ul><ul><li>Should she be referred to Nephrology? </li></ul>
  7. 7. Case #2 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Urine protein:creatinine (0.9mg/mg) </li></ul></ul><ul><ul><li>Lupus serology </li></ul></ul><ul><li>What is her eGFR? </li></ul><ul><ul><li>>60ml/min/1.73m 2 (CKD stage 1-2) </li></ul></ul><ul><li>Should she be referred to Nephrology? </li></ul><ul><ul><li>Yes </li></ul></ul>
  8. 8. Case #3 <ul><li>81 year male </li></ul><ul><li>Past Hx: Asthma; non-smoker </li></ul><ul><li>“ Well man’s clinic” </li></ul><ul><li>BP128/76; urine: + protein </li></ul><ul><li>Serum creatinine 114  mol/l ; eGFR 57; Hb11.1g/dl </li></ul>
  9. 9. Case #3 - Questions <ul><li>What would you do next? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
  10. 10. Case #3 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Urine protein:creatinine (0.1mg/mg) </li></ul></ul><ul><ul><li>Previous creatinine value? (112 in 2001) </li></ul></ul><ul><li>Should he be referred to Nephrology? </li></ul><ul><ul><li>No </li></ul></ul><ul><ul><li>Recheck eGFR and urine in 6 months, annually if stable </li></ul></ul>
  11. 11. Case #4 <ul><li>64 year female </li></ul><ul><li>Past Hx: hypertension for 15y; smokes 15/day </li></ul><ul><li>Annual health check: urine 2+ blood </li></ul><ul><li>Rx trimethoprim </li></ul><ul><li>BP 132/74; urine 2+ blood </li></ul><ul><li>Serum creatinine 83  mol/l; eGFR>60 </li></ul>
  12. 12. Case #4 - Questions <ul><li>What would you do next? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
  13. 13. Case #4 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Send MSU for MC&S (negative) </li></ul></ul><ul><li>Should he be referred to Nephrology? </li></ul><ul><ul><li>No </li></ul></ul><ul><ul><li>Refer Urology </li></ul></ul>
  14. 14. Case #5 <ul><li>76 year female </li></ul><ul><li>Type 2 diabetes for 17 years </li></ul><ul><li>Hypertension and diabetic nephropathy for 10 years </li></ul><ul><li>Rx Irbesartan 300mg/day </li></ul><ul><li>Annual review </li></ul><ul><ul><li>Serum creatinine 221  mol/l </li></ul></ul><ul><ul><li>Urine: 2+ protein </li></ul></ul>
  15. 15. Case #5 - Questions <ul><li>What would you do next? </li></ul><ul><li>What is her eGFR? </li></ul><ul><li>Should she be referred to Nephrology? </li></ul>
  16. 16. Case #5 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Estimated GFR </li></ul></ul><ul><ul><li>Urine protein:creatinine (2.3mg/mg) </li></ul></ul><ul><li>What is her eGFR? </li></ul><ul><ul><li>20ml/min/1.73m 2 (CKD stage 4) </li></ul></ul><ul><li>Should she be referred to Nephrology? </li></ul><ul><ul><li>Yes, immediately </li></ul></ul>
  17. 17. Case #6 <ul><li>57y male </li></ul><ul><li>Type 2 diabetes x 15 years </li></ul><ul><li>Diabetic nephropathy, hypertension, OA </li></ul><ul><li>Rx </li></ul><ul><ul><li>Metformin 500mg tds </li></ul></ul><ul><ul><li>Lisinopril 40mg od </li></ul></ul><ul><ul><li>Aspirin 75mg od </li></ul></ul><ul><ul><li>Simvastatin 40mg nocte </li></ul></ul>
  18. 18. Case #6 - Data <ul><li>Creatinine 245  mol/l; eGFR 28ml/min </li></ul><ul><li>Corr calcium 2.24mmol/l </li></ul><ul><li>Phosphate 2.16mmol/l </li></ul><ul><li>Hb 9.8mg/dl </li></ul><ul><li>Ferritin 47 (normal>30) </li></ul><ul><li>B12 and folate normal </li></ul>
  19. 19. Case #6 - Questions <ul><li>What changes to medication? </li></ul><ul><li>What interventions for high phosphate and PTH? </li></ul><ul><li>What investigations and treatment for anaemia? </li></ul>
  20. 20. Case #6 - Answers <ul><li>What changes to medication? </li></ul><ul><ul><li>Stop Metformin </li></ul></ul><ul><li>What interventions for high phosphate and PTH? </li></ul><ul><ul><li>Phosphate binder </li></ul></ul><ul><ul><li>1-alfacalcidol once phosphate <1.6mmol/l </li></ul></ul><ul><li>What investigations and treatment for anaemia? </li></ul><ul><ul><li>Clinical assessment to exclude GI bleeding </li></ul></ul><ul><ul><li>Intravenous iron </li></ul></ul><ul><ul><li>Erythropoeitin </li></ul></ul>
  21. 21. 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: <ul><li>No action required </li></ul><ul><li>Discontinue the Irbesartan </li></ul><ul><li>Reduce the dose of Irbesartan </li></ul><ul><li>Repeat the creatinine measurement in 1 week </li></ul><ul><li>Refer to a Nephrologist </li></ul>Case #7
  22. 22. 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: <ul><li>No action required </li></ul><ul><li>Discontinue the Irbesartan </li></ul><ul><li>Reduce the dose of Irbesartan </li></ul><ul><li>Repeat the creatinine measurement in 1 week </li></ul><ul><li>Refer to a Nephrologist </li></ul>Case #7 - Answer
  23. 23. Case #8 <ul><li>56y male </li></ul><ul><li>Type 2 diabetes for 9 years </li></ul><ul><li>Hypertensive and obese </li></ul><ul><li>Rx: amlodipine </li></ul><ul><li>Annual screening: </li></ul><ul><ul><li>BP143/90 </li></ul></ul><ul><ul><li>creatinine 103  mol/l ; eGFR >60 </li></ul></ul><ul><ul><li>Urine ACR 4.7 mg/  mol </li></ul></ul>
  24. 24. Case #8 - Questions <ul><li>What would you do next? </li></ul><ul><li>Should he be referred to Nephrology? </li></ul>
  25. 25. Case #8 - Answers <ul><li>What would you do next? </li></ul><ul><ul><li>Repeat urine ACR (6.3 mg/  mol) </li></ul></ul><ul><ul><li>Start treatment with ACEI or ARB; titrate to maximum dose </li></ul></ul><ul><ul><li>Control BP to <130/80 </li></ul></ul><ul><ul><li>Minimise cardiovascular risk </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><li>Should he be referred to Nephrology? </li></ul><ul><ul><li>No </li></ul></ul><ul><ul><li>Review annually once optimised </li></ul></ul>

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