You are reviewing a 65-year-old in the renal clinic. He has been on haemodialysis for chronic kidney disease for the past 6 years.
What is he most likely to die from?
Correct Answer E: CKD on haemodialysis - most likely cause of death is IHD.
Cardiovascular events account for 50% of the mortality in patients receiving dialysis.
Chronic kidney disease: causes:
Common causes of chronic kidney disease:
Which one of the following is not a feature of HIV-associated nephropathy?
Correct Answer A:
HIV: renal involvement: Renal involvement in HIV patients may occur as a consequence of treatment or the virus itself. Protease inhibitors such as indinavir can precipitate intratubular crystal obstruction.
HIV-associated nephropathy (HIVAN) accounts for up to 10% of end-stage renal failure cases in the United States. Antiretroviral therapy has been shown to alter the course of the disease. There are five key features of HIVAN:
A 62-year-old man attends your clinic. He has a history of hypertension and atrial fibrillation for which he is anticoagulated with warfarin. A urine dipstick taken 8 weeks ago during a routine hypertension clinic appointment showed blood +. This has been repeated on two further occasions.
What is the most appropriate action?
Correct Answer D: The incidence of non-visible haematuria is similar in patients taking warfarin to the general population therefore these patients should be investigated as normal.
Haematuria:
The management of patients with haematuria is often difficult due to the absence of widely followed guidelines. It is sometimes unclear whether patients are best managed in primary care, by urologists or by nephrologists.
The terminology surrounding haematuria is changing. Microscopic or dipstick positive haematuria is increasingly termed non-visible haematuria whilst macroscopic haematuria is termed visible haematuria.
Causes of transient or spurious non-visible haematuria:
Causes of persistent non-visible haematuria:
Management:
Current evidence does not support screening for haematuria. The incidence of non-visible haematuria is similar in patients taking aspirin/warfarin to the general population hence these patients should also be investigated.
Testing:
NICE urgent cancer referral guidelines:
A 61-year-old man with a history of hypertension presents with central chest pain. Acute coronary syndrome is diagnosed and conventional management is given. A few days later a diagnostic coronary angiogram is performed. The following week a deteriorating of renal function is noted associated with a purpuric rash on his feet.
What is the most likely diagnosis?
Correct Answer D: Cholesterol embolization is a well-documented complication of coronary angiography.
Cholesterol embolization:
Overview:
Features:
A 62-year-old man with a diabetic nephropathy and hypertension is reviewed. His current medication is insulin, bendroflumethiazide, ramipril and amlodipine. On examination blood pressure is 144/78 mmHg. Blood tests reveal the following:
Renal function was similar to 3 months ago.
Correct Answer B: As the eGFR is 29 ml/min switching bendroflumethiazide to furosemide would be the next step in controlling his blood pressure. Please see the guidelines in the external links section.
Chronic kidney disease: hypertension:
The majority of patients with chronic kidney disease (CKD) will require more than two drugs to treat hypertension.
ACE inhibitors are first line and are particularly helpful in proteinuric renal disease (e.g. diabetic nephropathy). As these drugs tend to reduce filtration pressure a small fall in glomerular filtration pressure (GFR) and rise in creatinine can be expected. NICE suggest that a decrease in eGFR of up to 25% or a rise in creatinine of up to 30% is acceptable, although any rise should prompt careful monitoring and exclusion of other causes (e.g. NSAIDs). A rise greater than this may indicate underlying renovascular disease. Furosemide is useful as a anti-hypertensive in patients with CKD, particularly when the GFR falls to below 45 ml/min*. It has the added benefit of lowering serum potassium. High doses are usually required. If the patient becomes at risk of dehydration (e.g. Gastroenteritis) then consideration should be given to temporarily stopping the drug.
*the NKF K/DOQI guidelines suggest a lower cut-off of less than 30 ml/min
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