Nephrology

Question 1

Chronic Kidney Disease

Answer 1

Kidney health checks for: Obese, ATSI>30yo, Diabetes, HTN, Established CVD, FHx kidney disease, Smoking
If eGFR<60 -> Repeat 7/7. If >20% drop for renal referral. If stable then repeat twice in 3/12
If elevated uACR (Males >2.5mg, Females >3.5mg) repeat twice within 3/12. (preferably first morning void). Need elevated in 2 of 3 uACR

Mx: ACEi/ARB decrease glomerular blood flow. Providing eGFR drops <25%, continue. If drop >25% for nephrology referral. Care with potassium, if >5.5 not to commence as can ACEi/ARB raise K approx 0.5mmol. Can use ACEi/ARB at all stages of CKD. Measure PTH + Ca/Phos 6-12 monthly eGFR<35

Nephrology referral: eGFR<30, Persistent significant macroalbuminuria (>30mg/mmol), sustained decrease eGFR >25% or 15ml/min in 12/12, CKD with HTN unable to be controlled with 3 agents

Question 2

Haematuria - causes

Answer 2

RENAL - Benign renal mass (abscess, angiomyolipoma), Malignant renal mass (RCC/TCC), Glomerula bleeding (IgA nephropathy, thin basement membrane disease, Alport syndrome), Structural disease (Polycystic kidney disease), Pyelonephritis, Hydronephrosis/distension, Malignant HTN, AVM, Hypercalcuria, Sickle Cell Disease

URETER - Malignancy, Stone, Structure, Post-surgery

BLADDER - TCC/SCC, radiation, cystitis, bladder stone

PROSTATE - BPH, Prostate Ca, Surgery, catheterisation, Urethritis,

OTHER - Analgesic nephropathy (Can be due to paracetamol, metabolite of phenacetin), Endometriosis of urinary tract, Infection, Malignancy, Stone, TB, Schistomiasis, Trauma/surgery, Exercise-induced haematuria, Bleeding disorder/anticoagulant

Question 3

Proteinuria causes

Answer 3

Diabetic nepropathy
Hypertensive nephropathy
Multiple Myeloma
Structural kidney disease - polycystic kidneys
Nephrotic syndrome - minimal change disease, focal segmented glomerulosclerosis, membranous nephropathy
Amyloidoisis
Congestive cardiac failure

Orthostatic proteinuria in children common (normal). Rare >30 years old.

Assessment with first void uACR, urine microscopy (red cell casts/dysmorphic red cells/crystals), HbA1c, UEC/renal function, Serum protein electrophoresis (MM), 24hr BP monitor (hypertensive nephropathy), renal tract ultrasound (Structural disease/kidney volume).

• if signs of systemic disease, consider ANA/ENA/Anti-neutrophil cytoplasmic ABs/Anti-glomerular basement membrane ABs/complement studies
• if risk for HBV/HCV, for serology + HIV serology.

Question 4

Nephrotic syndrome

Answer 4

Proteinuria >3.5g protein/24hr
Hypoalbuminuria <3g/dL
Peripheral oedema

Most common causes
- Diabetes, amyloidosis, SLE

Without hypoalbuminaemia/peripheral oedema = focal segmented glomerulosclerosis
In children = minimal change disease most common

Question 5

Diabetes medications in CKD

Answer 5

Metformin

• dose reduce at eGFR 30-60.
• Contraindicated <30

SGLT2 inhibitors (-flozins)
- contraindicated eGFR <45

DPP4 inhibitors (Gliptins)

• Safe with dose adjustment
• Linagliptin requires NO DOSE ADJUSTMENT

Sulfonylureas (Gliclazide)
- Dose reduction eGFR <30

GLP-1 receptor antagonist (Exenatide/Dulaglutide)
- Contraindicated eGFR <30