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Acute & Chronic Kidney Disease Renal Pathologies Part 1 Dr Steven Gopaul NOVEMBER 14TH 2021 17:00 BRITISHINDIANMEDICASSOCIATIONNDIANMEDICS @BIMA BIMA Clinical Crash Course Dr Steven Gopaul is an FY1 Foundation Doctor with a keen interest in General Surgery and Urology. He is an international medical graduate. Steven has a strong interest in medical education and has delivered over 10 lectures to medical students. In his free time, he likes to watch/play any type of sport and stock investing. Dr Steven Gopaul FY1 East of England Deanery BIMA Clinical Crash Course Contents ● Acute Kidney Injury (AKI) ● Chronic Kidney Disease (CKD) sgopaul@doctors.org.uk BIMA Clinical Crash Course Objectives ● Recognise signs and symptoms ● Urea & Electrolytes interpretation ● Basic understanding of the condition ● Management of the condition BIMA Clinical Crash CourseBasic anatomy BIMA Clinical Crash CourseWhat is AKI? ● Impaired renal function ● >1.5x increase in creatinine ● 25% or more decline in eGFR Prerenal x Renal x Postrenal ● 15% of all inpatients, of which, the mortality rate is 25-30% BIMA Clinical Crash CourseRisk factors for AKI ● CKD ● Organ failure (heart & liver) ● Chronic diseases such as Diabetes ● Previous AKI ● > 65yrs ● Nephrotoxic drugs ● Radiocontrast BIMA Clinical Crash CoursePresentation of Acute Kidney Injury ● Reduced urine output (<0.5ml/kg/hour) ● Oedema around the body ● Arrhythmias ● Pericarditis ● Encephalopathy BIMA Clinical Crash Course Prerenal ● Most common ● Volume loss and decreased renal perfusion ● Medication BIMA Clinical Crash CourseQuestion time… You are the on-call surgical junior doctor and have been asked to review an incredibly healthy 89 year old female with low urinary output (420mls) despite having 2L of IV fluids administered over 8hrs. She was admitted with small bowel obstruction. After examining her , you review her admission investigations and EPMA (medications). You notice her K+ is 6.0mmol/L and she has a Creatinine of 346 micromol/L. It appears she was given some medications in A&E whilst she was being triaged, without her weight being calculated. What medication could be causing the abnormal U&E’s? 1. 400mg Gentamicin 2. 250mg Paracetamol 3. 2.5 mg Oramorph (Morphine) 4. 500mg Amoxicillin BIMA Clinical Crash CourseRenal Structural injury ● Glomerulonephritis (RPGN, Goodpasture syndrome, MPGN, PIGN), VTE, Vasculitis, DIC, Hypertension, transplant rejection Tubular injury ● Rhabdomyolysis, tumour lysis syndrome, medications (Methotrexate, anti-virals, aminoglycosides, cisplatin & radiocontrast agents Interstitial injury ● Medications (NSAIDs & Allopurinol), infection and systemic disease (lupus, leukemia and Sjogren) BIMA Clinical Crash CoursePostrenal Ureteric obstruction ● Stones, tumour and fibrosis Bladder obstruction ● Stones, BPH, tumour, neurogenic bladder and clot Urethral obstruction ● Strictures, tumour and phimosis BIMA Clinical Crash CourseUrea & Electrolytes BIMA Clinical Crash CourseInterpretation BIMA Clinical Crash CourseQuestion 2 A 70 year old gentleman presents to the Surgical SDEC with a P/C of not being able to urinate for the last 9 hours, despite having urge. PMHx of T2DM and chronic back pain after a RTC 50 years ago. His regular medications are Metformin, Ibuprofen and Lansoprazole. NKDA. His bloods today show: Na 139mmol/L (135-145), K 4.8mmol/L (3.5-5.0), Bicarbonate 22mmol/L (22-29), Urea 7.1 mmol/L (2.0- 7.0) and Creatinine 200 micromol/L (55 -120) What AKI stage is he in? 1. AKI 1 2. AKI 2 3. AKI 3 4. AKI 4 BIMA Clinical Crash CourseManagement ● Fluids but… ● Stop any nephrotoxic drug ● Treat any electrolyte disbalance ● ?consider loop diuretics ● Refer to a Nephrologist ● Dialysis BIMA Clinical Crash CourseCase study A 57 year old gentleman with a PMHx of T2DM and Hypertension presents to his GP with fatigue and weight gain of 4.5kg over the last 3 months. O/E there is bilateral pitting peripheral oedema and cotton wool patches on fundoscopic examination. His observations are normal except for his BP which is 158/92 mmHg (not new). What’s going on here? BIMA Clinical Crash CourseChronic Kidney Disease ● 5 stages ● Often goes unrecognised until well advanced ● Affects around 10% of people worldwide ● Most common cause is Diabetes, then Hypertension ● Pathophysiology is dependent on the cause but in general there is an increase in intra-glomerular pressure, increase in glomerular permeability…which all leads to renal scarring and progressive loss of function BIMA Clinical Crash CourseRisk factors ● Diabetes ● Hypertension ● >50 years old ● Obesity ● Black or Hispanic ethnicity ● Family history ● Male ● Smoking ● Childhood kidney disease BIMA Clinical Crash CourseStages? BIMA Clinical Crash CoursePresentation of CKD ● Fatigue ● Oedema ● Restless legs ● Dyspnoea/Orthopnoea ● Foamy or cola-coloured urine ● Osteomalacia/Osteoporosis ● Nausea with/without vomiting ● Pruritus ● Anorexia BIMA Clinical Crash Course Why fatigue? ● Reduced EPO levels, which causes normocytic anaemia ● Reduced erythropoiesis due to uraemia toxicity ● Reduced absorption of Iron 1. Get the Hb up (10-12 g/dL) 2. Erythropoiesis-stimulating agents (ESA) / IV Iron if on haemodialysis 3. EPO BIMA Clinical Crash CourseWhy Oedema? BIMA Clinical Crash CourseWhy Osteomalacia? ● 1-alpha hydroxylation normally occurs in the kidneys and if they’re damaged… low vitamin D and… low calcium ● The parathyroid gland works harder due to the low calcium and so there are high phosphate levels 1. Limit phosphate intake 2. Phosphate binders 3. Calcitriol, Alfacalcidol 4. Parathyroidectomy BIMA Clinical Crash CourseQuestion 3 A 62 year old lady with stage 3a CKD visits her GP to discuss the results of her annual eGFR test. For the last 3 years her eGFR has been 59, 51 and 35 respectively. What is the most appropriate step in her management? 1. Step up eGFR monitoring to 3 monthly 2. Prescribe an ACE inhibitor 3. Refer to a nephrologist 4. Urine dipstick BIMA Clinical Crash CourseQ3 explained NICE guidelines: ● If eGFR falls below 30 or progressively by >15 in a year, refer to a nephrologist ● A urinary albumin:creatinine ratio (ACR) of 70mg/mmol or more, unless proteinuria known to be associated with DM and is being managed ● A urinary ACR of 30mg/mmol or more together with persistent haematuria, after exclusion of a UTI ● Hypertension that remains uncontrolled despite the use of at least 4 antihypertensive drugs at therapeutic doses ● A suspected or confirmed rare or genetic cause of CKD, like Polycystic kidney disease ● Suspected renal artery stenosis ● A suspected complication of CKD BIMA Clinical Crash CourseProteinuria ● Is an important marker of CKD, especially for diabetic nephropathy ● ACR is preferred to protein:creatinine ratio (PCR). ● First thing in AM, if ACR between 3-70mg/mmol, it should be confirmed by a subsequent early morning sample. If >70mg/mmol, no repeat needed BIMA Clinical Crash CourseACR interpretation If ACR is 3mg/mmol or more, it is confirmed clinically important proteinuria NICE guidelines: ● A urinary albumin:creatinine ratio (ACR) of 70mg/mmol or more, unless proteinuria known to be associated with DM and is being managed ● A urinary ACR of 30mg/mmol or more together with persistent haematuria, after exclusion of a UTI ● Consider referral to a nephrologist for people with an ACR between 3-29mg/mmol who have persistent haematuria and other risk factors such as declining eGFR, or cardiovascular disease BIMA Clinical Crash CourseBIMA Clinical Crash CourseManaging hypertension in CKD ● ACE inhibitors ● ARB’s ● Renin-angiotensin system blockers ● Furosemide especially when the GFR < 45ml/min BIMA Clinical Crash CourseManagement of diabetic nephropathy ● Effective screening ; ACR ● Dietary protein restriction ● Aim for BP <130/80 mmHg ● Control BP via antihypertensives ● Control dyslipidaemia with statins BIMA Clinical Crash CourseQuestion 4 A 65 year old man with T2 DM presents to his GP for an annual routine diabetes check. As part of the routine check up, he needs to be tested for diabetic nephropathy. He denies having any signs and symptoms of chronic kidney disease and his prior urine tests have been normal. His diabetes is well controlled by Metformin. How best should the patient be screened for diabetic nephropathy? 1. Measure the protein:creatinine ratio on a spot urine sample. If results abnormal, repeat with a first pass morning urine specimen 2. Measure the ACR on a spot urine sample. If abnormal, repeat with a first pass morning urine specimen 3. Perform a urine dipstick test 4. Take bloods and monitor the HbA1c BIMA Clinical Crash CourseQuestion 5 What are the differences between Acute kidney injury vs. Chronic kidney disease? BIMA Clinical Crash Course References ● PassMedicine textbook and question bank ● BMJ Best Practice BIMA Clinical Crash CourseTHANK YOU FOR LISTENING ANY QUESTIONS sgopaul@doctors.org.uk BIMA Clinical Crash Course