next patient please: 15 minute cases

@PCIssuesAnswers#IandA2019

MAKING BEST PRACTICE EVERYDAY PRACTICE

Next patient please: 15 minute casesSpeaker(s):

Mental Health - Professor Joanne Reeve

Migraine / Headache – Dr Rob Howlett

CKD – Dr Kathryn Griffith

Heart Failure – Dr Yassir JavaidChair: Professor Dr Jim Moore

Driving primary care to deliver the best in cardiovascular health

Next Patient Please !Tips to help you to review your U and E ResultsKathryn E GriffithRetired


Conflicts of interest


Times have changed ? AKD and CKD 1990?


Times have changed ? AKD and CKD 1990?

NICE AKI Guideline 2013KDOQI Classification 2002NICE CKD Guideline 2011


Whose turn is it to review the results?


Patient 1

• Sodium 140 mmol/L• Potassium 4.5 mmol/L• Urea 5.0 mmol/L• Creatinine 50 umol/L


What do you need to know to interpret these results?


What do you need to know to interpret these results?• Reference range for lab• Age • Gender and ethnicity• Height and Weight ( muscle mass)• Context Sick or Stable• Pre test diagnosis• Previous results• Other tests• Co-morbidities?• Medications


Patient 1

• Sodium 140 mmol/L (133-145)

• Potassium 4.5 mmol/L (3.5-5.3)• Urea 5.0 mmol/L (2.5-7.8)• Creatinine 50 umol/L (79-118 depending on muscle mass)• ? Normal


What do you need to know to interpret these results?• Age • Gender and ethnicity• Height and weight• Context Sick or Stable• Pre test diagnosis• Previous results• Other tests• Co-morbidities?• Medications

• 55• Male• BMI 34• Well but new hypertension• Pre change of employment• No previous tests on the system• HbA1C 82 mmol/L• ?• Awaiting new BP meds


Diagnosis ?

•What message do you leave for the patient?


Diagnosis ?

•Hyperfilration phase of diabetic nephropathy

•Need to spend more on your health?


Thanks to the Edinburgh Renal Unit for this slide


Patient 2

• Sodium 142 mmol/L (133-145)• Potassium 4.5 mmol/L (3.5-5.3)• Urea 10.0 mmol/L (2.5-7.8)• Creatinine 120 umol/L (79-118)• MDRD eGFR 40 ml/min/1.73m2

• CKD?


What do you need to know to interpret Sylvias’ results?• Age • Gender and Ethnicity• Height and weight ( Build)• Context Sick or Stable• Pre test diagnosis• Previous results• Other tests• Co-morbidities?• Medications

• 78• Female white British• 62 kg BMI 24• Unwell• Recent UTI • Urine stick test blood and

protein• Treated with antibiotics


Patient 2 Previous Result 2 months ago

• Sodium 142 mmol/L (133-145)• Potassium 4.5 mmol/L (3.5-5.3)• Urea 5.0 mmol/L (2.5-7.8)• Creatinine 80 umol/L (79-118) to 120• MDRD eGFR 64ml/min/1.73m2

• ? AKI• ? Stage


Patient 2 ? AKI ? Other options?

• What do you do next?


Patient 2 : Think Kidneys!!• Think Risk of AKI• Elderly Lady, Coded for OA, Hypertension and AF• Think Cause • Recent infection, lives alone, ? Fluid intake (urea). ? Vomiting• Think Drugs• Drugs can cause AKI or accumulate in AKI• Treated with trimethoprim which blocks tubular excretion and can raise

creatinine 50% ? Pseudo AKI• Other medications include Bendroflumethiazide, Apixaban, Paracetamol,

OTC NSAID?• Think Fluids• Telephone assessement :- what are the best questions to ask?


Fluids: Good hydration reduces UTI AND AKI• Are you thirsty?• When did you last have a drink?• What colour is your urine?

• Or think alcoholic beverages pinot grigio to Guinness!!• Do you have a BP machine if so what is your BP?


Any other concerns for Sylvia??


eGFR v CrCL and Medications• 78 female• Height 5ft 2 inches or 157 cm• Weight 9st 11lb 62kg :- BMI 25• Creatinine 80 umol/L• eGFR 64ml/min/1.73m2

• Creatinine Clearance Cockroft Gault 50 ml/min• Creatinine 122 umol/L• eGFR 40 ml/min/1.73m2• Creatinine Clearance 32.9 ml/min• Does this impact on your prescribing??


DOAC/ NOAC and Kidney Function• Dose is determined by Creatinine Clearance not eGFR• Taking Apixaban 5mg bd• Recommended in NICE CKD Guideline• However• Recommended to reduce the dose to 2.5mg bd if 2 or more of • 80 and over, less than 61kg or creatinine 133 umol/L and over• In Renal Impairment section reduce the dose to 2.5mg bd if• CrCl 15-29 ml/min• Stop below 15ml/min


What actions do you take?

• Advice?• Visit?• Admit?• Medications?• Repeat Blood test?


Patient 3: 55 Male

• Potassium 5.3 mmol/L (3.5-5.3)• Urea 5.0 mmol/L (2.5-7.8)• Creatinine 160 umol/L (79-118 )• AKI Alert


Patient 3: 55 Male Previous Result 3 months ago

• Potassium 4.1 mmol/L (3.5-5.3)• Urea 4.0 mmol/L (2.5-7.8)• Creatinine 100 umol/L (79-118 )


What do you need to know to interpret these results?• Age • Gender and ethnicity• Height and weight• Context Sick or Stable• Pre test diagnosis• Previous results• Other tests• Co-morbidities?• Medications

55 Male White British• BMI 28• Poorly controlled hypertension• Dose of ACE increased 3 weeks ago• Previous tests on the system• 20% CVD risk FH IHD• Ex smoker• LVH on ECG• Amlodipine 10mg• Indapamide 2.5mg• Losartan dose increased from 50mg to 100mg


Patient 3: 55 Male

• What are the issues??


I remember when……..


Renal Artery Stenosis• Not just a cause of secondary hypertension• Minority of RAS cases are caused by congenital fibromuscular dysplasia• 80-90% are causes by atherosclerosis• 10% of people with hypertension will have RAAS caused by atherosclerosis • Some evidence of RAS in 54% in people with heart failure• Risk factors include age > 50, female gender, FH heart disease, smoking,

hypertension, diabetes, hyperlipidaemia, LVH is a pointer• > 50% is haemodynamically important as is bilateral disease• Hypertension Guidelines major on monitoring BP but don’t forget kidney function

as well• Reviews do not suggest benefit from intervention except in most extreme cases


Patient 3: 55 Male

• High CVD Risk and RAS • BP still 150/90• What are you going to do

next?


Learning points• Checking results takes time-especially if you don’t know the patient• Remember• Age, Gender and Ethnicity• Height and weight ( Build)• Context Sick or Stable• Pre test diagnosis• Previous results and other tests• Co-morbidities and Medications• eGFR diagnoses CKD but creatinine changes for AKI• You need creatinine, weight and Cockroft Gault for Medication dosing• Medicine changes all the time;- you need meetings like this!!


Thanks for all the good years Now back to normal life!!

next patient please: 15 minute cases

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