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Symposium: Renal medicine

Reducing cardiovascular risk pivotal in diabetic kidney disease

21 Feb 2021Registered users

Diabetic kidney disease is associated with a very high risk of cardiovascular disease (CVD) and premature mortality from cardiovascular events. There is good evidence that multifactorial interventions that optimise BP, limit proteinuria and minimise cardiovascular risk can reduce morbidity and premature mortality. Early diabetic kidney disease is asymptomatic. Microalbuminuria, defined as a urinary ACR of 3-30 mg/mmol on two occasions three months apart is the earliest clinically detectable indicator of diabetic kidney disease. Excellent glycaemic control can delay onset of microalbuminuria.

Tight blood pressure control key in polycystic kidney disease

21 Feb 2021Registered users

Polycystic kidney disease (PKD) has an autosomal dominant mode of inheritance. Despite this 25% of patients will have no known family history and these cases are thought to be due to de novo mutations in the causative genes. PKD can present asymptomatically and should be considered in any patient with renal cysts noted on abdominal imaging, especially if there is a history of hypertension. Patients with PKD may present with hypertension before a decline in eGFR is noted. Cyst haemorrhage, rupture or infection can all present with acute loin pain. PKD can also cause a number of extrarenal complications.

Prompt recognition key in glomerulonephritis

24 Feb 2020Paid-up subscribers

Glomerulonephritis is the second most common cause of end stage renal disease in the UK and the most common cause in those under 35. Some forms can respond well to treatment if diagnosed early. However, if glomerulonephritis goes unrecognised, it can lead to irreversible loss of renal function. Glomerulonephritis can present in a wide variety of ways, ranging from asymptomatic urinary abnormalities to fulminant disease with life-threatening acute kidney injury and extra-renal manifestations. Asymptomatic invisible haematuria is common. In the absence of infection or a urological cause, glomerulonephritis should be considered. Significant proteinuria (> 1 g/day) in the absence of an identifiable cause warrants referral. 

GPs play an important role in identifying acute kidney injury

24 Feb 2020Paid-up subscribers

Acute kidney injury (AKI) is a common complication in hospitalised patients and is associated with an increased risk of chronic kidney disease (CKD) and higher mortality. Two thirds of AKI cases develop in the community prior to hospital admission. AKI may be challenging to recognise because it is typically asymptomatic. It is usually detected incidentally in the setting of another illness when a rise in serum creatinine from baseline is identified. Risk factors for AKI include age 65 or over, diabetes, CKD, neurological or cognitive impairment, heart failure and the use of potentially nephrotoxic medications. Recognition of those at risk should prompt earlier and more frequent testing of U&E during any acute illness. 

Tailoring dialysis modality to the patient

22 Feb 2019Registered users

End stage renal disease can be defined as the requirement for kidney transplantation or dialysis therapy. In the UK in 2016, of the 63,162 people receiving renal replacement therapy 53% were renal transplant recipients, 41% were on haemodialysis and 6% were on peritoneal dialysis. Dialysis should be started when: symptoms of uraemia impact on day to day living; the need is indicated by biochemical measures or uncontrollable fluid overload or at an eGFR of 5-7 ml/min/1.73 m2 in the absence of symptoms. The choice of dialysis modality is influenced by the individual’s functional status, social circumstances and confidence.

Management and prevention of renal and ureteric stones

22 Feb 2019Paid-up subscribers

Kidney stones are common with as many as 1 in 10 people developing a symptomatic stone. Up to 50% of stone formers will have at least one further symptomatic stone in their lifetime. Ureteric colic is unaffected by posture with patients often writhing in seemingly futile attempts to relieve pain. Immediate management comprises effective analgesia while urinalysis is the first step in confirming the diagnosis. One of the challenges facing the GP is to differentiate patients who warrant immediate hospital referral from those who can be seen less acutely.

Visible and non-visible haematuria may herald serious disease

22 Feb 2018Paid-up subscribers

Both visible (VH) and non-visible haematuria (NVH) may herald serious pathology e.g. malignancy or vasculitis. All patients with VH or symptomatic NVH should have urinalysis, urinary protein estimation (albumin:creatinine or protein:creatinine ratio), and a renal function test. These should also be requested if asymptomatic NVH persists, i.e. in two out of three samples over 6-8 weeks.

Prompt investigation improves outcomes for kidney cancer

22 Feb 2018Paid-up subscribers

Renal cell carcinoma should be suspected in the presence of: localising symptoms such as flank pain, a loin mass or haematuria; constitutional upset including weight loss, pyrexia and/or night sweats; or unexplained test results. Smoking, obesity and hypertension are common risk factors and all three demonstrate a dose-response relationship with the relative risk of renal cell carcinoma.

Diagnosis and management of nephrotic syndrome

22 Feb 2017Paid-up subscribers

Nephrotic syndrome is uncommon in general practice. A GP may only see two or three adult cases in their career. Nephrotic syndrome develops following pathological injury to renal glomeruli. This may be a primary problem, with a disease specific to the kidneys, or secondary to a systemic disorder such as diabetes mellitus. The most common cause in children is minimal change glomerulonephritis. In white adults, nephrotic syndrome is most frequently due to membranous nephropathy whereas in populations of African ancestry the most common cause of nephrotic syndrome is focal segmental glomerulosclerosis (FSGS). Diabetic nephropathy is the most common multisystem disease that can cause nephrotic syndrome. 

Pyelonephritis can lead to life-threatening complications

22 Feb 2017Paid-up subscribers

As distinct from cystitis and lower urinary tract infection (UTI), which are much more common, pyelonephritis involves the upper tract with potentially more serious sequelae. It is most commonly caused by bacterial infections, typically ascending from the lower urinary tract; haematological seeding from bacteraemia is less common.

 

Editorials

Should sertraline be used in CKD patients with depression?

23 Jan 2018Registered users

Sertraline is ineffective in patients with chronic kidney disease (CKD) and depression, a randomised controlled trial, from the USA, has found. This study suggests that the prescription of sertraline, and indeed any SSRI, to stage 3b-5 CKD patients with depression can no longer be justified. CBT is probably the best option and there is some evidence of its efficacy in end-stage CKD patients.

 

Special report

Improving outcomes for kidney transplantation

20 Dec 2018Paid-up subscribers

Kidney transplantation is the optimum form of renal replacement therapy for suitable patients with end-stage renal disease. A successful transplant represents a much closer approximation to true renal replacement with excretion of waste products, regulation of electrolytes and other substances, than dialysis. The longer a recipient has been dialysis dependent before transplantation the poorer the outcome. Living donor transplantation is associated with better graft and patient survival than transplantation from a deceased donor. A genetic relationship with the recipient is not a prerequisite to becoming a living donor. Having a living donor offers the opportunity of pre-emptive transplant (i.e. avoidance of dialysis altogether).

Early intervention can improve outcomes in acute kidney injury

22 Jun 2015Registered users

The incidence of acute kidney injury (AKI) is rising reflecting an increasingly elderly at-risk population, with multiple comorbidities, coupled with improved detection. AKI is potentially reversible so improvements in its recognition and early interventions could have a major impact on patient outcomes. Potential clues in the history for AKI include reduced fluid intake and/or increased fluid losses, urinary tract symptoms and recent drug ingestion.