Tag Archives: CKD

Anaemia, heart failure and CKD (21)

Posted on by

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)

Posted on by

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)

Posted on by

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:

Hypertension, renovascular disease and ACEI (17)

Posted on by

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)

Posted on by

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:

Drop in GFR in Alcohol Dependence (8)

Posted on by

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?

What further information would you seek before giving your opinion?

See more of the history or available results?

Current medication; Bendroflumethiazide, Folic acid, Atorvastatin, Amiodarone, Levothyroxine, Enalapril, Hydroxocobalamin, Paracetamol.

Now consider what advice you would give.

Write your advice


Now read what the expert wrote

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.

More?

Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below

Things to read:

Gout Prevention in CKD (12)

Posted on by

Please advise on dose titration of allopurinol and gout management in this 62 year old man with CKD3 and multiple medical problems. He recently developed gout with a urate of 0.86. His CKD is stable, with eGFRs usually between 30-40 (latest eGFR 33).

I have given colchicine but pain is persistent and urate still very high.

Past medical history includes; Cor pulmonale, Type 2 Diabetes, COPD, AF, Morbid obesity (BMI 52).

He can attend clinics – would you recommend a medical or renal referral?


What further information would you seek before giving your opinion?

See more of the history or available results?

Current Medications; Metformin, Gliclazide, Digoxin, Lisinopril (5mg), Warfarin, Amiodarone, Furosemide (250mg/day)

Now consider what advice you’d give

Write your advice

Now read what the expert wrote

I have always thought that response to colchicine is almost useful as a diagnostic test; if he’s getting pain despite colchicine, is it really gout or is it another condition in conjunction with a high urate?

As for allopurinol, start when inflammation has subsided at 100mg / day. In CKD it is recommended to start low dose and titrate dose till urate <.35. Check urea and urate every few weeks.

If we are sure this is gout, and if colchicine is not settling his pain, he could have a short course of steroids‚ something like 5 days of prednisolone (20mg OD), but that may play up with his diabetes.

Does he need to be seen in clinic? – possibly and almost certainly if this problem becomes more complex. If gout control is difficult, rheumatology might be best first stop. His renal function is not deteriorating.

2 further thoughts;
1. He is close to the point where metformin is contra-indicated, in which case he may need to get into the diabetic clinic for advice on insulin
2. He is on a huge dose of furosemide which will undoubtedly push his urate up. If he has cor-pulmonale, I would expect him to have some peripheral oedema because of his right-ventricular pressures. If he is free of peripheral fluid, and especially if his BP is low or low-normal. I would cut his diuretic back a bit, allow him to gain some fluid in order to see what happens.

More?

Go to the Advice Line home page, where things are sorted by complexity and subtopic, or next/previous at the top of this page, or take a lucky dip from the cases below

Things to read:

Anaemia in CKD (11)

Posted on by

This fairly fit 83 year old lady with a history of hypertension usually has an eGFR around 40.  She is on lisinopril 10mg and furosemide 40mg (best tolerated combination, bendroflumethiazide did not have any effect on blood pressure) and her BP is well controlled on this combination at around 130/68 at her latest visit.

For several months she has had a haemoglobin of around 106 g/l.  Her haematinics and blood indices are otherwise normal apart from a slightly low haematocrit of 0.32.

Is an eGFR of around 40 low enough to cause renal anaemia?  She is only a little tired, are we best just to monitor things?  Should I be looking for another cause for her anaemia?

Now consider what advice you would give

Write your advice

Now read what the expert wrote

That haemoglobin is a little low for that eGFR, but it may be that you find no other cause. There is a big range of Hb values at any eGFR, including at end stage.

It is unusual to drop below 100g/l until eGFR is substantially less than 30, but she isn’t below 100. This level of renal impairment could be compounding another cause and look for deficiencies of haematinics and check a CRP as an indicator of inflammation.

Interestingly ACEi do worsen renal anaemia slightly. However the effect isn’t huge, if this is the best combination for her, she might prefer to tolerate the slightly lower Hb.  Her current level of Hb is above the level at which guidelines would recommend commencing EPO therapy.

More?

Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below

Things to read:

[To do list; picture]

Incidental Discovery of Stage 4 CKD (9)

Posted on by

This 87 year old man has had a marked deterioration in his renal function.  6 years ago urea was 9.6 and creatinine 168.  Routine blood tests 2 weeks ago revealed urea 12.2, creatinine 244 and eGFR 22.  He has no symptoms and is feeling well. 

He does have a history of prostate problems and is currently awaiting urology assessment regarding symptoms of BPH. 

On examination pulse 70, BP 145/80, heart sounds 1+2, no peripheral or sacral oedema, chest clear with fine occasional respiratory crepitations in bases, abdomen soft and non-tender.  I have arranged an USS bladder and kidneys to exclude any high residual volumes or obstructive neuropathy.  Thank you for your advice on any further management you would recommend for this patient.

What further information would you seek before giving your opinion?

See more of the history or available results?

Current Medication; Aspirin, Daktocort, Movicol

Now consider which one of these three options to go for: 

  1. Give Advice
  2. See in Outpatients non-urgently
  3. Send this patient to us now!

Write your advice

Now read what the expert wrote

You’ve already answered – or are in the process of answering – the first question – does he have urinary retention and obstruction? He is of the right age and sex and is known to have prostatic disease. He is otherwise well, with no causative medicines and no hypertension to treat. As he is well, I’m guessing that he has‚ “gone off” and has now plateaued but it would be important to repeat all these to make sure this isn’t an acute renal failure that’s getting worse. If he demonstrates blood ++++ and/or protein ++++ we would be concerned.

Might I suggest that if his scan is normal, and especially if his U&E are getting worse, you ask us to see him? I’m hopeful however that this is good old obstruction which will improve with catheterisation. If his scan is positive, I’d have thought that the latter should be done without delay.

More?

Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below

Things to read:

[To do list; picture]

Decreasing GFR in a Diabetic (6)

Posted on by

I would appreciate your advice about this 78 year old lady with IHD and NIDDM diagnosed 12 years ago. She was diagnosed with CKD stage 3 four years ago in 2006 (this is the first time her creatinine was elevated). Her renal function is steadily declining with a current eGFR of 32

PCR was 0.08 on 4/8/09 and an abdominal ultrasound scan showed normal kidneys in February 2006. Last HBA1c was 7.4 in July 09. BP is 138/78. She is almost stage 4 CKD

1) Should I refer her to a renal clinic?
2) Should I alter her medication (eg. Metformin)?
3) Do you have any other suggestions?

What further information would you seek before giving your opinion?

See more of the history or available results?

Current Medications;

Aspirin 75mg OD, Simvastatin 10mg OD, Co-dydramol prn, Bumetamide 1mg OD, Allopurinol 300mg OD, Omeprazole 20mg OD, Amitriptyline 20mg nocte, Metformin 500mg TID, Lisinopril 10mg OD, Ferrous sulphate 200mg BD

Now consider which one of these three options to go for: 

  1. Give Advice
  2. See in Outpatients non-urgently
  3. Send this patient to us now!

Write your advice

Now read what the expert wrote

Her function is actually remarkably stable – losing 0.5mls/min/yr in terms of eGFR.

Her BP is close to adequate – target would be <130/80

She has no significant proteinuria on an ACEi.

She is appropriately on a statin, aspirin and ACEi.

The big issue is metformin. She is close to where Metformin should be stopped on the basis of absolute GFR, but she looks, on basis of all evidence, to be at low risk of progression in terms of renal disease. Stopping metformin will potentially de-stabilise her diabetic control and therefore a pragmatic approach would be to discuss the risk with her and leave her on Metformin.

However she should understand clearly that if she develops any intercurrent illness -especially vomiting or diarrhoea, she should stop both metformin and lisinopril until she has recovered.

I do not think there is any added value in her coming to a renal clinic.

More?

Go to the Advice Line page, where things are sorted by complexity and subtopic, or take a lucky dip from the cases below

Things to read:

[To do list; picture]