A man with CKD and a cancelled knee op (1)

Dear Doctor, this 73 year old gentleman had been awaiting a knee operation, but this was cancelled as a result of pre-operative blood tests revealing altered renal function.  We repeated these tests and these show U 7.2,  Cr 185 and eGFR 31.  He also had a macrocytic anaemia,  and a GGT of 239.  He admits to drinking more than he should.  His dipstick tested positive for protein and glucose,  and he is currently awaiting a GTT as his random glucose was 9.8.  We unfortunately have no records of previous blood tests.
He keeps well,  otherwise,  and his only relevant previous history is osteoarthritis.
We have organised repeat U&E,  B12/folate, Ca and PO4,  GTT,  and urine sample for protein:creatinine ratio.  I have also organised a renal ultrasound.  I would be grateful for any further advice,  or other investigations we should be performing at this stage.

What further information would you seek before giving your opinion?

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Unfortunately we couldn’t find any historic blood test results either. So we asked what drugs he was taking:

  • Co-Codamol 8mg/500mg tabs 1 or 2 tabs every 4 to 6 hours as required

Now consider which one of these three options to go for: (1) Give Advice, (2) See in Outpatients non-urgently, or (3) Send this patient to us now!

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His eGFR of 31 keeps him (just) in Stage 3 CKD rather than 4.  Most likely he has had renal impairment for some time and this is fairly stable, but the proteinuria result will be relevant.  At stage 3 CKD the triggers for referral are officially PCR >100, or deteriorating function, or proteinuria plus haematuria.  These because they highlight patients at increased risk of deterioration.

Hope that is helpful, let us know if you’ve any more Qs.

Other points left unsaid: there isn’t really a great reason for doing any renal imaging in this gentleman if he has no urinary symptoms, and his figures are stable.  We didn’t comment on his drugs because he isn’t on anything nephrotoxic.  The codeine in co-codamol isn’t usually enough to accumulate symptomatically at this level of renal function.


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