Renal Medicine for Primary Care in 90 minutes
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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?
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Chronic Kidney disease or not?
Urinalysis?
Historical blood tests
Symptoms?
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
Case 1
• Urinalysis protein trace, blood ‘non-hemolysed
trace’
• eGFR was 39 last year
• No symptoms
• BP 146/86
• Refer to nephrology??
Age and eGFR?
Follow up of CKD in primary care
NICE CG73
Follow up of CKD in primary care
Follow up of CKD in primary care
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
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BMI 20-25
Salt
Exercise
alcohol
Kidney International 2012; Suppl 2: 337-414
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)
Blood Pressure targets in CKD
• Diabetes or proteinuria 130/80
• Neither diabetes nor proteinuria 140/90
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, comorbidities, careful escalation of treatment, side
effects and tolerance of treatment
Additional primary care follow up
parameter
Stage 1-2
Stage 3
Creatinine and K annually
6/12
Hb
If clin indicated
6/12
Ca and Phos
No monitoring
12/12
PTH
No monitoring
Initial assess
CKD is a vascular risk factor so:
Smoking
Diet
Exercise
Lipid-lowering? (SHARP)
USS if LUTS or difficult hypertension
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
Case 2
• 76 year old male
• Hx of PVD (angioplasty two years ago),
hypertension, osteoarthritis
• Bilateral swollen legs
• eGFR 55
• What next?
Case 2
• 76 year old male
• Hx of PVD (angioplasty two years ago),
hypertension, osteoarthritis
• Bilateral swollen legs
• eGFR 55
• Urinalysis- protein ++++
• What next?
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 ?
Nephrotic Syndrome
• Specific definition
– Proteinuria (>3g) + hypoalbuminemia + oedema
• Can we deduce the diagnosis?
Nephrotic syndrome
• Specific definition
– Proteinuria (>3g) + hypoalbuminemia + oedema
• Can we deduce the diagnosis?
• No
• Needs a renal biopsy except……….
Nephrotic syndrome in adults
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Minimal Change
Focal and Segmental Sclerosis
Membranous Glomerulonephritis
Diabetes
Amyloid
SLE
Other long names
Management of Nephrotic Syndrome
• Specific therapy
– Steroids +/- immunosuppression
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Prednisolone
Cyclophosphamide
Mycophenolate Mofetil
Tacrolimus
– Underlying disease
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
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?
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
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
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
Assessment of haematuria
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Exclude UTI
Blood pressure
eGFR
proteinuria
Haematuria referral
• Urology
– All visible haematuria
• (possible exception cola urine in <40 with resp
symptoms)
– All s-NVH
– All a-NVH > 40
Nephrology Referral
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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
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
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
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
Renal Bone Disease
• High phosphate plus
low calcium drives
hyperparathyroidism
• Vitamin D deficiency
• Age
• Steroid and other
therapies
Management of renal bone disease
• Dietary phosphate restriction
• Phosphate binders
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Aluminium hydroxide
Calcium carbonate or acetate
Sevelamer (renagel/renvela)
Lanthanum (fosrenol)
Osvaren (calcium acetate/magnesium carbonate)
– Need to be taken correctly and avoid hypercalcemia
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
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
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
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
Case 6
• 64 year old known CKD
• eGFR 19 at last renal clinic appointment
• Complains of difficulty moving legs and feels
awful
• Next steps?
Hyperkalaemia is life threatening
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?
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
Case 7
• 64 year old, known CKD
• On darbepoetin, ramipril, aspirin, calcichew,
alfacalcidol, simvastatin
• eGFR 14 (18 4 months ago, 22 1 year ago)
• What next?
JL recip creat plot
Predicted ERF
Case 7
• 64 year old, known CKD
• On darbepoetin, ramipril, aspirin, calcichew,
alfacalcidol, simvastatin
• eGFR 14 (18 4 months ago, 22 1 year ago)
• What next?
• Refer if not already known to nephrology
• Low Clearance Clinic (Advanced Kidney Care
Clinic)
The Low Clearance Clinic
• Preparation for dialysis or decision not to have
dialysis
• Who should not have dialysis?
• What type of dialysis?
Dialysis Options
or
Preparation for dialysis
• Need to allow 2 attempts at fistula surgery
• Better (and financial incentive!) to start
dialysis with a fistula
• Peritoneal dialysis catheter also needs a short
‘lead in time’
• Hepatitis B vaccination
• Pre-emptive transplantation if suitable
Preparation for haemodialysis
or
Dialysis for GPs!
• Haemodialysis
– Usually 3 x weekly for approx 4 hours
– Fistula needs protecting
– Fluid restriction
• High BP is fluid until proven otherwise
– Pre-dialysis blood tests are the only ones of value
– Can have medicines! (please discuss or consult renal
drug handbook)
– Can have CT scans
– 24/7 advice from renal unit
http://nww.bradfordhospitals.int:2234/SiteAssets/Pages/Renal/Renal%20Drug%20Handbook.pdf
Dialysis for GPs!
• Peritoneal dialysis
– Home based therapy
– Continual and therefore more ‘gentle’
– Abdominal pain/fever is peritonitis until proven
otherwise
– Peritonitis needs intra-peritoneal antibiotics
– Assisted PD is available
Conservative care instead of dialysis
• Patient choice
• Joint care with nephrology, primary care,
palliative care
• Gold Standard Framework
• EPO, dietician support etc
• Often these patients do remarkably well for a
surprising length of time
• The creatinine will go up!
Transplantation in one slide
• Cadaveric or live donor
– Not all donors are equal
– T1/2 10-15 years
• Gradual reduction in follow up frequency
– National guidelines
• Plan to repatriate immunosuppression prescribing (NHS England)
• Other ‘funny drugs’
– Valganciclovir
– Anti-TB
– Cotrimoxazole/nystatin
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Immunosuppressed patients get sick quickly
Please always think about drug interactions esp ciclosporin/tacrolimus
Fertility restored
Bone health
Failing transplant = CKD
Case 8
• 76 year old male
• Hx of PVD (angioplasty two years ago),
hypertension, osteoarthritis
• Aspirin, simvastatin, ramipril,
bendroflumethiazide
• D&V
• Creatinine 560 (212 2 months ago)
• Acute on chronic kidney disease
Case 8
• Discharged from hospital 5 days later (on a
Friday!)
• What do you want to know from the discharge
summary?
Case 8
• Discharged from hospital 5 days later (on a
Friday!)
• What do you want to know from the discharge
summary?
– Diagnosis (AKI + cause)
– Are drugs stopped or suspended and when should
they restart
– Discharge renal function and plans for further checks
or OPA
– He is at risk of ACUTE KIDNEY INJURY in the future
Acute Kidney Injury
What do we want Primary Care to do about AKI?
Case 9 AS
AKI patient pathway at www.aki.org.uk
RCP Consensus Statement 2012: no non-elective admission should receive
ACE/ARB or NSAID until there has been a senior review.
This will only work if AKI is entered in the patient record