This 78 year old man has a medical history complicated by previous alcoholic dependence, alcoholic cardiomyopathy, recurrent bouts of atrial fibrillation and flutter. He also suffers from hypertension, Vit.B12 deficiency and hypothyroidism.
Up to now his kidney function has remained quite stable with his last normal blood result in 8 months ago. On routine kidney screening last month there was a marked deterioration in his kidney function with eGFR dropping to 39 and ACR 7.5. There was no obvious cause for this but the patient did admit to drinking most of a bottle of wine per day and described slight dehydration and mild metallic taste in his mouth.
On discussion he agreed to cut alcohol out, drink more fluids, and we stopped his Bendroflumethiazide and reduced his Enalapril to 10mgs. Repeat U&E shows little change in his function and I would appreciate your advice as to his further assessment.
I am unsure whether he needs referral to yourselves in view of his sudden deterioration without obvious cause, or whether it would be worthwhile monitoring this further and arranging an USS in the community?
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It’s a little bit difficult to know with this one; he’s complicated with quite a few things going on. In the first instance, I’d give him time. If he was dehydrated on a full dose of enalapril plus a diuretic he may have some tubular necrosis that may take time to heal; he may also have done some irreversible damage.
I don’t think there’s anything else to do at the moment. I’d be tempted to maximise his enalapril back up again if reducing it hasn’t had any effect – he needs it for his cardiomyopathy. Repeat his bloods in another month or so – if better, great, and if stable, then he’s got enough renal function to survive on. If he’s worse then perhaps we should see him, given everything that’s going on with him.
I wouldn’t rush to scan unless you’ve get any other reason to – haematuria, suprapubic mass, urinary symptoms etc; we do many scans and get back little in the way of positive results. If he’s worse again then that becomes more important.
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Things to read:
- Edinburgh Renal Unit – GP Referral criteria
- Edinburgh Renal Unit – CKD 1-3
- Edinburgh Renal Unit – Management of CKD
- SIGN Guideline on Management of Diabetes – SIGN CKD
- NICE CKD Guidelines – NICE CKD