Renal Medicine for GPs

in 1 hour
Dr Philippa Peto
Feb 2021
Kidneys!
Acute Kidney Injury
 Case 1
• 78 year old man attends for DM review
• PMH:
– Diabetes 2012
• Insulin dependent since 2016
– Hypertension 2004
– OA
• Bilateral hip replacements
– Obesity
 Case 1
• Results:
– HbA1c 64

– Urine A:CR 236

– Urine dip:
• Blood ++
• Protein +++
• Leu/nit –ve
• Glucose ++
 Case 1
• Why does he have proteinuria?

• Why does he have haematuria?

• Should you refer to the Renal team?

78 yr male Results:

PMH: HbA1c 64
Diabetes 2012
Insulin dependent since Urine A:CR 236
2016
Hypertension 2004 Urine dip:
OA Blood ++
Bilateral hip Protein +++
replacements Leu/nit –ve
Obesity Glucose ++
When to refer to the Renal team?
• Urgent referral for:
– Rapid progression+/- blood and proteinuria with
systemic symptoms

• Routine referral for:

– Diagnosis of intrinsic renal disease

– Monitoring for patients with progressive or

advanced chronic kidney disease
 Diagnosing CKD –NICE guidance
• Renal US

• Bloods:
– Take the following steps to identify the rate of progression of
CKD:
• Obtain a minimum of 3 GFR estimations over a period of not less than
90 days.
• In people with a new finding of reduced GFR, repeat the GFR within 2
weeks to exclude causes of acute deterioration of GFR
– for example, acute kidney injury or starting
renin–angiotensin system antagonist therapy. [2008, amended 2014]

• Urine Dip
 When to refer for monitoring of CKD?
• Refer to Renal if:
– GFR < 30ml/min/1.73 m OR falling rapidly
2

• (sustained decrease >15 ml/min/1.73 m2 or 25% in 1 year)

– ACR >70mg/mmol unless known to be caused by diabetes
• (PCR>100)

– ACR > 30 mg/mmol AND haematuria

• Monitor in community if:

– High risk developing CKD (previous AKI/DM/HT)

– Blood Pressure, Urine dip and Creatinine every 6-12 months

 What will happen in General Nephrology
clinic?
• Optimise
– BP/DM management
– Medication
• Stop all nephrotoxics!
• Ensure on ACEi/ARB
• SGLT2 (CREDENCE)
– Rule out other potential causes of AKI/CKD
– Imaging, myeloma, virology, autoimmune

• 4 monthly monitoring
– Creatinine
– Proteinuria
– HCO3

• Anaemia and bone health

• Refer to Advanced Kidney Care Clinic when GFR<20

– Transplant/Dialysis/Conservative Care
 Case 2
• 34 yr old man

• Background:
– Asthma
– ESRF secondary to IgA nephropathy
• Awaiting transplant
– Haemodialysis 3 x week (T/T/S)
• Right tunnelled line
• Started 4 months ago

• Presents for asthma review on Monday pm with severe SOB

 Case 2
• Why is he short of breath?

• What is the emergency management?

 Dialysis
• 3x week at a satellite unit

• First three months high mortality

• Urine output will fall over first year

• Fluid management will be an issue
• Dry weight may change
• BP and DM management will change

• All will be on EPO/IV iron/1-alfacalcidol

• All will have dietary restriction (fluid/K/PO4)

• Contact renal team if unsure

 EPO and iron
• Given and monitored by the Renal Anaemia
team

Target ferritin <800mcg/L

Side effects:
hypertension and thrombosis

Target Hb: 100-120

 Potassium
• Continue ACEi/ARB unless K>6.0 (titrate)

• Low potassium diet

– No bananas!
– No fruit juice/dried fruit
– No fizzy drinks
– No crisps!

• Consider Potassium binder with meals

– sodium zirconium silicate (Lokelma) or Patiromer (Valtassa)
– Resonium no longer used
Phosphate Binders
 Peritoneal Dialysis
• At home
– Usually overnight
• Less fluid shift

• Risk of peritoneal fibrosis after 5 years

• DGH may not be equipped to manage as inpt

 Case 3
• 62 yr old woman

• Background:
– End stage renal failure due to ANCA vaculitis
• Renal transplant 2019
• Tacrolimus, MMF
– Hypertension
– Lives alone, independent

• PC: Tremor, Diarrhoea

 Case 3
• Differential diagnosis for the tremor?

• Diarrhoea
– What is the main concern?
 Case 3
• Differential diagnosis for the tremor?

• Diarrhoea
– What is the main concern?
• AKI

• CMV??
 What happens in Renal transplant clinic?
• Monitor transplant function

• Monitor immunosuppression levels/compliance

– Tacrolimus
– MMF
– Prednisolone
– Azathioprine
– Cyclosporine

• Ensure patients are aware of potential side effects

• Monitor as per CKD

– EPO/PTH etc.
 Case 4
• 53 woman
– PC: bilateral leg swelling
– PMH: Nil

– Ix:
• Hb 102
• WCC 6.7
• Plt 349

• Na 137
• K 5.4
• Creat 274
• Albumin 19
 Case 4
• What is the diagnosis?!

• Should you refer to the Renal team?

Medication
 Medication
• Check in the BNF!!!

• GFR <30 should already be under renal review

• Usually just dose reduction

• Exceptions:
– 1-alfacalcidol instead of cholecalciferol
– Unfractionated Heparin instead of LMWH
– Linagliptin and Canagliflozin
– Apixaban not rivaroxaban
 Nephrotoxic Medication
STOP
– NSAID
– PPI

• Monitor everything else..

– Furosemide
– ACEi/ARB
– Antihypertensives
– Metformin (not nephrotoxic!)
– Sulphasalazine
– Long term abx

And consider referring to the renal team if rapidly falling GFR

• Nb. Trimethoprim causes short term fluctuation

 Patient information resources
• www.kidneycare.org
• https://www.thinkkidneys.nhs.uk
 Conclusion
• Refer to the Renal team for monitoring and
management of progressive CKD

• All CKD patients benefit from optimised

DM/BP control and stopping nephrotoxics

• Liaise with Renal team if uncertain

Questions?!