Incidental Discovery of Stage 4 CKD (9)

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.

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Current Medication; Aspirin, Daktocort, Movicol

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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.


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Decreasing GFR in a Diabetic (6)

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?

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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

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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.


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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.

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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

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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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