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RENAL DISEASE – A GENERAL PRACTICE PERSPECTIVE Dr Shareen Hallas

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  • RENAL DISEASE A GENERAL PRACTICE PERSPECTIVEDr Shareen Hallas

  • REMEMBER THE KIDNEYS?

  • ..AND THE NEPHRON?

  • AND WHAT GOES ON THERE?

  • WHATS IN THE NEWS?Apple Shape linked to higher risk of kidney disease. (BBC News 12th April 2013)

  • RECENT RESEARCHBMJ2013;346:f324 Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysisOver 2 million participantsCohort studyConclusionsBoth sexes face increased risk of all-cause mortality, cardiovascular mortality, and end stage renal disease with lower estimated glomerular filtration rates (30). These findings were robust across a large global consortium

  • WHAT DO WE SEE IN PRIMARY CARE?

  • SCENARIO 1A 60 year old man presents with urinary frequency and urgency. He is a smoker. He has hypertension and takes amlodipine 5mg. Urinalysis shows blood++. No nitrites or leucocytesWhat will you do next?

  • HAEMATURIAVisible haematuriaREFER at any age to Urology2 week rule if painless at any ageRemember with renal stones up to 20% are negative for haematuria

  • NON VISIBLE HAEMATURIAIs it blood? (beetroot, rifampacin etc)Exclude UTI, menstruation, exercise)Refer symptomatic non visible haematuria at any age

  • SYMPTOMATIC NON VISIBLE HAEMATURIACheck U&E, creat, eGFR, bp, ACR.Refer if over 40 to UROLOGY 2 weeksLikely needs referral to urology if symptomatic at any age

  • ASYMPTOMATIC NON VISIBLE HAEMATURIACheck 3 urinalysis over a 2/52 period. If 2/3 positive this is a positive resultIf over 40 refer to UROLGYIf under 40 refer NEPHROLOGY if:ACR>30eGFR140/90If these referral criteria are not met, annual follow up as likelihood of serious pathology is 8% and malignancy in 1.5%

  • REMEMBERProteinuria is the best indicator of glomerular diseaseApproximately 10% people with non visible haematuria have a urological malignancy. The most common is bladder cancerCheck a urinalysis when looking for causes of iron deficiency anaemia

  • SCENARIO 2A 46 year old woman presents for follow up urinalysis after a recent UTI. No urinary symptoms. NoHx hypertension, diabetes. Not pregnant. No FH renal disease. Meds nil reg, intermittent NSAID for dysmennorhoea.O/E bp 140/80 no oedema.Urinalysis protein++. Nil else.What will you do next?

  • NSAIDSMost common cause of drug induced renal damage in general practiceIf on long term nsaids monitor renal function 2-3 times per year.

  • PROTEINURIAPositive urinalysis in 2 or more urine samples over a 1-2 week period. UTI can cause false positiveRemember ACR has a greater sensitivity than PCRIf ACR >70mg/mmol (PCR >100mg/mmol) REFER NEPHROLOGYIf ACR >30mg/mmol (PCR > 50mg/mmol) WITH NON VISIBLE HAEMATURIA. REFER NEPHROLOGY

  • OTHER INVESTIGATIONSU&E, eGFR, BP, Hba1cThen select ix depending on potential causeMay include; C3, C4, Igs, electrophoresis, RF, ASOT, ANCA, ANA, dsDNA, cholesterol (raised in nephrotic synd)..What about renal ultrasound?

  • LOTS OF CAUSES OF PROTEINURIA!Transient proteinuriaEmotional stress.Exercise.Fever.Urinary tract infection.Orthostatic (postural) proteinuria*.Seizures.Persistent proteinuria.Primary glomerular causesFocal segmentalglomerulonephritis.IgA nephropathy(ie Berger's disease).IgM nephropathy.Membranoproliferative glomerulonephritis.Membranous nephropathy.Minimal change disease.Secondary glomerular causesAlport's syndrome.Amyloidosis.Sarcoidosis.Drugs (egnon-steroidal anti-inflammatory drugs(NSAIDs),penicillamine, gold,angiotensin-converting enzyme (ACE) inhibitors).Anderson-Fabry disease.Sickle cell disease.Malignancies (eglymphoma, solid tumours).Infections (egHIV,syphilis,hepatitis, post-streptococcal infection).Tubular causesAminoaciduria.Drugs (eg NSAIDs, antibiotics).Fanconi's syndrome.Heavy metal ingestion.Overflow causesHaemoglobinuria.Multiple myeloma.Myoglobinuria.Other important causes (likely to have multiple pathologies)Pre-eclampsia/eclampsia.

  • NEPHROTIC SYNDROMEHeavy proteinuria. PCR > 200mg/mmol Hypoalbuminaemia
  • MODERATE PROTEINURIA (100-200MG/MMOL)May be tubular disease eg drug induced interstitial nephritis.

  • PROTEINURIA WITH NVH MORE LIKELY TO BE:IgA nephropathy (most common cause of acute glomerulonephritis, 80% in age 16-35), polycystic kidneys, vasculitis, collagen multisystem disease, post infectious glomerulonephritis

  • WHAT ABOUT PRESCRIBING IN RENAL IMPAIRMENT?BNF - For many drugs with only minor or no dose-related side-effects very precise modification of the dose regimen is unnecessary and a simple scheme for dose reduction is sufficient. For more toxic drugs with a small safety margin, dose regimens based on GFR should be usedTake care with many antibiotics, histamine H2-receptor antagonists, digoxin, anticonvulsants and NSAIDs, potassium sparing drugs, vit D, antacids (high Na content), ACE (watch out for renal artery stenosis), diuretics.Care after iodine contrast If patient on dialysis ask a specialist.

  • SCENARIO 3A 55 year old woman presents after receiving a letter from the practice to come in to discuss he blood tests which show chronic kidney disease stage 3.She has hypertension controlled with amlodipine 5mg. Bp 140/90. eGFR 50ml/min/1.73m2What will you do?

  • WHAT IS CKD DEFINED AS?eGFR < 60ml/min/1.73m2 for 3 months

  • CKDStage 1 eGFR >90 with other evidence of kidney damageStage 2 eGFR 60-90 with other evidence of kidney damageStage 3A eGFR 45-59Stage 3B eGFR 30-44Stage 4 eGFR 15-29Stage5 EGFR
  • HOW OFTEN SHALL I MONITOR CKD?

    CKD 1 and 2 , yearly3A and 3B, 6 monthly4, 3 monthly5, 6 weeklyAccording to NICE CG 73NB CKD is a part of the QRISK 2 score

  • REMEMBERCorrect eGFR for ethnicity (African or Caribbean) X 1.21New low eGFR repeat within 2 weeksMeasure minimum 3 eGFRs over 90 day period - need at least 2 to diagnose CKDDO NOT EAT MEAT for 12 hour pre-test for eGFRMeasure ACRACE inhibitors can reduce creatinine by up to 20%. If creat inc by >20% or eGFR dec by >15% can be due to renal artery stenosis.Serum creatinine has limitations - can remain within the normal range despite the loss of over 50% of renal function

  • CKD 3

    All cause mortality (and CVD mortality) is increased in stage 3 CKD, increase is much greater in stage 3BProgression of renal disease is rare (4% with esrf in 10 years)Cholesterol lowering in this group can reduce CV events (SHARP study)Over 10 years a patient with CKD 3 has a 25% chance of dying from CVDNeed pneumococcal and annual flu immunisations

  • REMEMBERWill kidneys fail in your patients lifetime, or will they die of something else first?

  • TIPCSA CKD explained mattandhazelsmith video youtube

  • ACR IN DIABETESNormal is
  • ACE INHIBITORSCheck u&e 1-2 weeks after starting ACEIf creatanine rises by >20% or eGFR drops by >15% consider renal artery stenosisRepeat after dose increaseStop ACE in dehydrating illnessCounsel women of childbearing age

  • WHEN DO I DO A RENAL ULTRASOUND?Obstructive symptomsFH polycystic kidneysHaematuria, progressive CKDStage 4 or 5 CKD

  • WHEN DO I REFER A PATIENT WITH CKD?Stage 4 or 5 (check Hb and Ca/PO4)Proteinuria (ACR >70)ACR >30 AND haematuriaRapidly declining eGFR (>5ml/min in one year)Poorly controlled hypertension despite 4 drugs (aim bp
  • REMEMBER LIFESTYLEStop smokingReduce saltMen have bigger kidneys than womenAfter age 40 renal function decreases by 1ml/min/year

  • DIALYSISAround 40,000 people in the UK are having dialysis or have functioning kidney transplants

  • DIALYSISUsually starts when GFR 10 ml/min ( 15ml/min in diabetes)Indications:Presence of clinical features of uraemia (eg,pericarditis, gastritis,hypothermia, fits or encephalopathy).Fluid retention leading topulmonary oedema: inability to reduce excess volume with diuretics with urine volume under 200 mL in twelve hours.Severehyperkalaemia(potassium above 6.5 mmol/L) unresponsive to medical management.Serum sodium above 155 mmol/L or below 120 mmol/L.Severe acid-base disturbance (pH under 7.0) that cannot be controlled by sodium bicarbonate.Severe renal failure (urea greater than 30 mmol/L, creatinine greater than 500 mol/L.Toxicity with drugs that can be dialysed

  • HAEMODIALYSISArterio-venous fistula formed 3-6 months before starting dialysisDialysis 3 times a week, 4 hours each timeComplications:Access-related: local infection, endocarditis, osteomyelitis, creation of stenosis, thrombosis or aneurysm.Hypotension (common), cardiac arrhythmias, air embolism.Nausea and vomiting, headache, cramps.Fever: infected central lines.Dialyser reactions: anaphylactic reaction to sterilising agents.Heparin-induced thrombocytopenia, haemolysis.Disequilibration syndrome: restlessness, headache, tremors, fits and coma.Depression.

  • PERITONEAL DIALYSISCAPD involves 4 exchanges of 20 minutes through the dayCan do peritoneal dialysis at night tooGreater flexibilityContra-indications to peritoneal dialysisIntra-abdominal adhesions and abdominal wall stoma.Obesity, intestinal disease, respiratory disease and hernias are relative contra-indications.Complications of peritoneal dialysisPeritonitis, sclerosing peritonitis.Catheter problems: infection, blockage, kinking, leaks or slow drainage.Constipation, fluid retention, hyperglycaemia, weight gain.Hernias (incisional, inguinal, umbilical).Back pain.Malnutrition.Depression

  • RENAL TRANSPLANTGood survival rates1 year and 10 year graft survival rates are 89% and 67% for adult kidneys from 'brain death donors' and 96% and 78% for kidneys from live donors.

  • SCENARIO 4A 20 year old woman presents to you in tears a

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