Renal Flashcards
CKD evaluation investigations
- US KUB
- urine ACR
- Fasting lipids
- Fasting glucose
- Urine MCS
- FBC, CRP, ESR
- Repeat EUCs 1 week
Other than CKD, Causes for proteinuria (Other than CKD)
- UTI
- Heavy exercise (transient)
- CCF
- acute febrile illness (transient)
- NSIADS
- menstruation
Causes of proteinuria
- Diabetic nephropathy
- Hypertensive nephropathy /nephrosclerosis
- PKD
- Minimal change disease
- Multiple myeloma
- Nephrotic syndrome (Focal segmental glomerulosclerosis (FSGS) , minimal change disease)
- Amyloidosis
- CCF
- Rhabdo
- UTI
- Exercise
- Menstruation
How to detect proteinuria (albuminuria)
- Urine ACR (First void ACR !!! is best)
- Repeat ACR (always do one) first void to confirm
(dipstick not sensitive enough)
Confirmed if 2/3 positive
CKD if present for 3 months
Special case CKD investigations
When suspecting autoimmune cause: SLE (joint pain,
- ANA
- ENA
- Complement
- Anti- glomerular basement membrane antibody
- Anti- neutrophil cytoplasmic antibody
Risk factors for hepatitis
- HIV, HBC, HCV
> 40 % MM suspected
- Serum protein electrophoresis
Diabetic medication cautions in CKD
SGLT2s
- Dapglifozin: Contraindicated eGFR< 25
Metformin:
- Reduce dose eGFR 30-60
- Contraindicated <30
- Temporarily stop in periods of illness
DPP4s
- No dose adjustment needed for linagliptin (GOOD)
Sulphonylureas
- Dose reduce <30
- increased hypo risk
GLP1s
- Contraindicated <30
Antihyperglycaemic choice 2nd line (following metformin) for CKD
SGLT2 PREFERRED
(dapaglifozin,)
Note: dose reduce if eGFR < 45
Empagliflozin can be used until >25
OR
GLP1
(Liraglutide, dulaglutide, semaglutide)
Microalbuminuria levels
(ACR mg/mmol)
(mg/day)
Male:
2.5 - 25
Female:
3.5 - 35
mg/day= 30-300
Macroalbuminuria
Male: >25
Female: >35
> 300 mg/day
What is a kidney health check & how often
eGFR
ACR
BP
1-2 yrs
(annually for HTN or DM)
Indications for kidney health check
- HTN
- Diabetes
- CVD
- family hx renal failure
- obesity
- smoking
- ASTI >30
Raised ACR what to do?
Repeat ACR
Within 3 months
First void best
Reduced eGFR what to do? (and cut off)
<60 = Repeat within 7 days
NOTE:
Then if stable but reduced: repeat twice in 3 months
If >20% reduction then consider AKI (d/w nephrologist)
Indications for nephrology referral in CKD
- eGFR <30
- ACR >30
- sustained decreased eGFR (25%/yr OR >15 /yr
- HTN on >3 agents
- Albuminuria and haematuria
Haematuria and renal impairment causes
- Glomerularnephritis: IgA or PSGN
- Hypertensive nephropathy
- Analgesic nephropathy (eg paracetemol)
- Malignancy
- MM
- PKD
- Angiomyelolipoma
CKD treatment goals (for KFP)
- BP <130/80
- Annual influenza/pneumococcal (for DM or ESKD)
- etOH <2/d
- salt <6g/day
- HBa1c <7
- PA: 150-300 moderate intensity
- LIPIDS:
statin if >50
or <50 with DM, CVD, Ischaemic stroke, high risk CVD - Ferritin >100
eGFR reduction with ACEi/ARB
<25% within 2 months
If >25% then cease & refer to nephrologist
Special investigations for CKD evaluation (for cause)
Signs of systemic disease (rash, pulmonary symptoms, arthritis)
- ANA, ENA, complement
- Anti- neutrophil cytoplasmic antibody
- Anti- GBM antibody
HIV/HCV/HBV serology
> 40 and concerns for MM: serum and urine protein electrophoresis
SICK DAY medications to avoid
(SADMANS)
S: Sulfonylureas
A: ACEi
D: Diuretics
M: Metformin
A: ARB
N: NSAIDs
S: SGLT2
Cyst number for cut off for PKD
<39 yrs: 3 in total
40-59: 2 in each kidney
> 60: 4 in each kidney
Renal stone prevention advice
- Maintain hydration aiming for clear urine
- Low sodium
- Low oxalate intake
- Low protein
- Limits sugary beverages
- Healthy BMI (weight loss)
Nephritic syndrome features
Haematuria
Protein +
HTN
Low urine volume
Nephritic syndrome associated diseases
PSGN
IgA nephropathy
Rapidly progressive glomerularnephritis
HSP
Nephrotic sydnrome features
Protein+++
Frothy urine
oedema
Albumin and haematuria - what to do ?
Refer to renal physician
Risk factors for urothelial carcinoma
> 40
Smoker
Male
Industrial dyes
Cyclophosphamide
Kidney stone gold standard Scan
CT KUB
If you see stone on CT KUB what test do you also order?
XRAY KUB to see if radiolucent so you work out whether you can just do XRAY for FU scan
UROLITHIASIS: indications for urgent referral
- Single kidney
- Septic
- Renal Failure
- Uncontrollable pain
- Complete urinary obstruction
- Pre-existing CKD
- Stone >7mm
UROLITHIASIS: Immediate and long term investigations
CTKUB (and xray KUB)
EUC
MSU
Serum calcium
Serum urate
Stone analysis
24 urine collection for volume, calcium, oxalate, citrate and uric acid
Diet advice to reduce UROLITHIASIS
- Low salt
- Low oxalate
- Low Protein
- Low high fructose drinks and foods
- Enough water to ensure clear urine
- Normal calcium intake
UROLITHIASIS: management at discharge?
- NSAID: celecoxib 200mg daily
- Tamsulosin 400mcg daily
- Paracetemol
- STRAIN URINE - allow for stone analysis
- Return if fever
- GP 4 weeks for repeat CT KUB
Cystitis in pregnancy 1st line
Nitrofurantoin 5 days
UTI children 1st line
Bactrim
Causes of haematuria
- Glomerular nephritis: IGA nephropathy
- HTN nephropathy
- UTI /pyelo
- PKD
- Stone
- Analgesic nephropathy
- Angiomyolipoma
Aboriginal & TSI CKD screening - how often to do kidney health check (hint <30 and over 30)
- <30 then screen ANNUALLY for RISK FACTORS (smoking, family hx, diabetes, obesity)
- If Risk factor then Kidney health check every 2 years
> 30 every TWO YEARS
First line investigations for CKD newly diagnosed…
- Renal US
- FBC, CRP, ESR
- Urine ACR & repeat eGFR
- Lipids
- Glucose
- Urine microscopy, red cells and casts & crystals
