Anaemia, heart failure and CKD (21)

This elderly man has multiple medical problems.  His main current problem is heart failure – he has moderate LV dysfunction, valvular heart disease and pulmonary hypertension.  He is seen by the Heart Failure Nurse and we have reached the point where we agree his treatment is palliative.  He gets recurrent peripheral oedema and ascites.  His renal function shows a urea of around 20 and creatinine of around 200.  At home he is able to walk with a frame from his bedroom to the living room but this makes him breathless.  He is a type 2 diabetic and also has mild memory impairment.

He has had a chronic long standing anaemia over a number of years.  This has seen his haemoglobin slide from the 10.3 down to 8.3 when last checked.   He had GI investigations and was found to have a number of polyps and an area of angiodysplasia.  He has had a couple of transfusions.  It was decided earlier this year that further investigation was not appropriate.  He is on iron so it is difficult to know how much of his anaemia is due to his renal problems.

When discharged last week it was suggested that we should contact you about erythropoietin treatment.  Improvement of his anaemia might help his heart failure a little though I suspect this would only be temporary.  He is very frail and clinic attendance might not be possible.  I would be grateful for your advice

What further information would you seek before giving your opinion?

See more of the history or available results?

Current medications include: bumetanide 5mg OD, metolazone 2.5mg once weekly and insulin.

 

 

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

There are 2 issues here:

1. Anaemia & EPO – the advice given to you is a bit misleading.  EPO is designed to bring haemoglobin up slowly, the recommended rise being 1gm/month.  In other words, he’s going to get decent haemoglobin in about 2-3 months time.  Furthermore, EPO is contraindicated in GI bleeding and his anaemia is probably mainly due to angiodysplasia rather than renal disease.  I would normally commit someone like this to regular transfusion.

2. Oedema – I would try and dry him out and ignore his U&Es.  Our ability to control heart failure is so often hampered by our worrying about the urea rising but I would ignore it.

 

 

 


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Anaemia and CKD III (20)

This diabetic lady has CKD3 with microalbuminuria of 14.8.  She was recently seen in the haematology clinic regarding her chronic anaemia (most recent haemoglobin was 100g/l).  She was in hospital at the end of last year when she was transfused and started on oral iron.  At that time endoscopy was normal but she has previously had angiodysplasia.  Haematology felt this is most likely anaemia of chronic disease rather than iron deficiency anaemia, and that it probably relates to her deteriorating renal function.  Her most recent eGFR was 52, creatinine 91 and urea 8.6.  They have suggested that she might be a candidate for EPO injections to boost her blood count.  I wonder if I should be referring her to renal clinic?

What further information would you seek before giving your opinion?

See more of the history or available results?

B12 and folate are normal.  Ferritin 85, Transferrin saturations 17%

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

Renal anaemia with a GFR above 30ml/min is extremely unusual indeed.  10% of anaemia in CKD 3 is explained by EPO-deficiency, but the patients involved are in the eGFR of 30-35 bracket, rather than 52 as in this case.  Given the history of previous angiodysplasia this is most likely the explanation for the recurrent anaemia.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Anaemia and CKD in the frail elderly (19)

This rather frail 85 year old man has recently become anaemic.  His haemoglobin has dropped down to around 9.0 having previously been around the 11 mark.  Haematinics are normal.  His latest renal function shows urea 15.6, creatinine 213, potassium 4.8 and eGFR 26.

His general health is poor.  He lives at home and is slowly mobile with a zimmer but has had falls and is awaiting a residential or nursing home placement.

Can we attribute his anaemia to his CKD and should he be considered for EPO?  Or should we refer him to haematology for further assessment of his anaemia?

What further information would you seek before giving your opinion?

See more of the history or available results?

Co-morbidities include: recent significant stroke, diabetes, angina, Parkinson’s disease, atrial fibrillation, hypertension and LVF.

 Currently: ACR 155, PCR 260, Ferritin 60.

12 months ago: Hb 10.5, urea 11.4, creatinine 168, ACR 120, PCR 185

3 years ago: ACR 35

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

This gentleman has evidence of progressive CKD – now Stage 4 – almost certainly secondary to diabetic nephropathy given the longstanding albuminuria and proteinuria.  His anaemia has been evident for some time.  His haematinics do indicate that he may be Fe deficient – his ferritin is only 60 (we would normally look for a minimum of 100). His iron saturation has not been done but should be >20%.   I would suggest in the first instance repeat of his iron stores specifically to include iron saturation and ferritin.  If they are below targets then I would suggest oral iron supplementation.

 I don’t think there is a good indication for a renal clinic referral, but he may be a candidate for erythropoietin therapy if he remains anaemic when iron stores are replete.

 

 


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Creatinine rise on losartan (18)

A 60 year old lady on losartan and simvastatin had bloods done 3 months ago which showed urea 5.4, creatinine 70 and eGFR 81.  Repeat bloods this week showed urea 5.0, creatinine 138 and eGFR 35.  I advised her to stop her losartan and rechecked it the following day and it improved to urea 5.4, creatinine 81 and eGFR 68.

I have advised her to stay off her losartan and aim to check her BP next week and will consider felodipine for her hypertension.

Do I need to do anything further to investigate this lady or should I just avoid ARBs and ACEi and treat her hypertension as required with felodipine?

What further information would you seek before giving your opinion?

See more of the history or available results?

She has a history of ischaemic heart disease and peripheral vascular disease.

No urine has yet been sent for protein quantification.

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

If this represents a doubling of serum creatinine with no other precipitant then this is suggestive of renal artery stenosis, particularly if she has vascular disease elsewhere.

On the other hand, if she was unwell when the creatinine rose then this may just be the combined effects of dehydration and losartan.

The key issue would be if the urine dipstick is positive for protein.  If she were to have proteinuria then one could argue the need for recommencing losartan again.  If she has proteinuria and creatinine rises again with losartan then it would be reasonable to refer her to the renal clinic.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Hypertension, renovascular disease and ACEI (17)

This 65 year old lady has a history of resistant hypertension and renal artery stenosis.  She previously had angioplasty to the left renal artery in 1994 and 1997 and had a right renal artery stent inserted in 2002 for an ostial stenosis.  She has been maintained on antihypertensive treatment since, though good control has never been obtained.

 She was kept on lisinopril until she was admitted with a haematemesis 2 years ago.  Her lisinopril was stopped but reintroduced and titrated up to 10mg. Her potassium rose to 5.6 on repeated measurement and lisinopril was stopped.

 Blood pressure control remains poor with levels typically around 170-180 systolic.  Do you think it would be a good idea to give her a small dose of lisinopril again?

What further information would you seek before giving your opinion?

See more of the history or available results?

Her eGFR has slowly declined and is 43 at present and PCR is 117.

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

She was well on her previous ACEI & her baseline state hasn’t changed.  It was, and always is, approriate to stop her ACEI when she was critically unwell, but she is now well, hypertensive & proteinuric, so yes – give her the lisinopril back & watch and see what happens to her U&Es.  I would accept up to a 20% increase in creatinine and potassium up to 6.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Optimising an ACEI (16)

An 83 year old woman attends the GP surgery for a blood pressure review.

Blood pressure has been high for a while (systolic ~160).  She was taking ramipril 1.25mg and diltiazem HCL 360 mg OD.  She had been taking bendrofluazide but this was stopped during a recent hospital admission due to hypokalaemia.   BP a couple of weeks ago is still very high with values of 218/93 and 200/100. Consequently, I initially increased her ramipril 10 days ago to 2.5mg OD.  Her BP this week is 210/78 and repeat U+Es were ok, so I increased the dose again to 5mg.

She is sytemically well other than for a recent altered bowel and mild weight loss for which she has been referred to colorectal.

I was planning to increase ramipril to 10mg as tolerated but I am not sure how quickly I should be increasing the dose.   I am concerned about her high BP and also concerned about increasing the dose too quickly due to her age.  I also wonder if she requires any further investigation in view of her significant proteinuria?

What further information would you seek before giving your opinion?

See more of the history or available results?

Urine  ACR 467 and PCR 259.  No haematuria.  Her eGFR is 50 and stable.

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

You’re doing all that I’d do. The proteinuria level is technically above the recommended referral threshold (PCR 100), but at her age I’d be unlikely to go on to do a biopsy unless she was actually nephrotic or had deteriorating function.   In view of the proteinuria, maximising ACEi would be my first step too.   This can be done quickly (days to weeks) provided BP and renal f(x) are monitored.

 If her eGFR drifts down or there is an increase in proteinuria then it would be worth referring her to the renal clinic. That said, you can allow up to around a 20% rise in creatinine around the time of institution of ACE inhibition.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Incidental finding of a small scarred kidney (15)

A 60 year old lady has recently been found to have a small scarred right kidney.  This was discovered incidentally when having an abdominal ultrasound scan to investigate slightly deranged LFTs.  Her left kidney is normal.

The scan was arranged by the dermatologists who have been seeing her because of intermittent facial swelling since June 2008.  They think she has angioedema and have started her on various antihistamines.  Other PMH includes self-limiting sarcoidosis, fibromyalgia, hypothyroidism and hypercholesterolaemia, which is well controlled on a statin.

Should I be arranging any more tests on her and if so, which?

What further information would you seek before giving your opinion?

See more of the history or available results?

Results of investigations are as follows;

Blood – Urea 4.2 / Creatinine 82 / eGFR >60,

Urinalysis normal – ACR 2.9.

Last BP 108/60.  No history of hypertension.

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

The answer is simple – do nothing.  This is almost undoubtedly the end-stage of a chronic process, quite possibly childhood reflux.  Her left kidney has compensated for the loss of the right without any obvious harm in that her creatinine is normal, she’s not hypertensive and she has no proteinuria.

As she’s managing on only one kidney you need to be vigilant in case of later development of problems such as hypertension, diabetes etc, but at this stage I’d reassure her that she’s done very well, has a relatively common complaint and should not be alarmed.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Unilateral cysts as an incidental finding (14)

A 79 year old gentleman had an abdominal ultrasound scan due to the incidental finding of abnormal LFTS.  This was reported to show slightly increased echogenicity of the liver in keeping with fatty infiltration.  He was also noted to have small, simple cortical cysts, with the largest measuring 36mm by 31mm, in his left kidney.  The visualised pancreas, aorta, right kidney, gall bladder and biliary tree all appeared normal and the spleen measured 9.8 cm, which was also normal.

The reason I write is to establish whether any further action is required regarding his cysts in his left kidney or whether in fact they can be ignored as they are not causing him any symptoms at present and should be viewed as an incidental finding only?

 What further information would you seek before giving your opinion?

See more of the history or available results?

Results of investigations are as follows;

 Blood – Urea 7 / Creatinine 102 / eGFR >60 / Electrolytes within normal ranges

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

This should be viewed as an incidental finding and you can essentially just ignore the result.  It is not an uncommon finding and not expected to give rise to any symptoms or indicate an adverse renal prognosis.  Of note, complex cysts can indicate malignancy but this is not what is being described here.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read:

Incidental finding of abnormal renal ultrasound (13)

A 47 year old man recently had an ultrasound scan, and the report stated: right kidney could not be identified in the renal bed or right pelvic region. Left kidney =16.6cm, presumably due to compensatory hypertrophy. The left kidney appears normal in echopattern with no hydronephrosis or renal calculi. 

He is not aware of having had his kidney removed. The scan was requested as he had a dull ache in both renal angles and abdominal bloating.  He still gets a dull ache over his right loin a couple of times per week, lasting a few hours.  He does not need to take analgesia for this discomfort.  No aggravating factors.  He wonders himself if he could have pulled a muscle as he works delivering food.  He sometimes feels pulling in right groin when he bends forward.

Does he need any kind of follow up with regards to having 1 kidney, such as regular blood tests to check his kidney function?

 What further information would you seek before giving your opinion?

See more of the history or available results?

Results of investigations are as follows;

Bloods: FBC and U+Es normal

 BP: 148/87

We discussed lifestyle advice regarding his blood pressure, as he is not keen to start medication.  I have arranged to repeat the blood pressure reading in 2 months and if still elevated commence him on amlodipine.

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

This man just needs sensible attention to general healthcare and cardiovascular risk.

Single kidneys are common and, as in this case, the opposite one compensates for the loss of the other.  He will almost undoubtedly do well but probably should know that anything else that comes along in the next few decades that injures kidneys e.g. worsening hypertension, diabetes, NSAIDS,etc should probably be looked at with care and attention.

I would treat his hypertension as you are doing and repeat his bloods perhaps yearly as you might do for anyone with hypertension.


More?

Go to the Advice Line page, where things are sorted by complexity and subtopic.

Things to read: