GEM - chronic kidney disease (CKD) in primary care

Chronic Kidney Disease

Some statements about chronic kidney disease (CKD). Which one is false?

• a) the classification of CKD used in the QOF is based on five stages of CKD
• b) persistent haematuria (after exclusion of other causes, e.g. urological disease) is evidence of chronic kidney damage
• c) an estimated GFR of GFR 60-89 mL/min/1.73 m2 is sufficient for the diagnosis of stage two CKD
• f) a patient on dialysis is classified as stage 5 CKD
• GPN reference

What are the general principles for treatment for all stages of CKD?

• GPN reference

Glomerular filtration Rate

The glomerulus produces a selective ultrafiltrate of the blood. The rate of ultrafiltration is called the glomerular filtration rate which is about 120 ml/min or 170 litres per day. This is written 120 ml/min/1.73m2, to emphasise the fact that the rate is closely related to the body surface area. In the primary care setting, estimated GFR is the appropriate way of estimation of GFR rather than a formal creatinine clearance test.

The 4-variable Modification of Diet in Renal Disease (MDRD) equation is a method of estimating GFR. Is the GFR calculated by this equation affected by race and/or sex of the patient?

• GPN reference

Monitoring GFR

• an annual creatinine (and consequent eGFR) should be undertaken annually if a patient is on long-term treatment with potentially nephrotoxic drugs, including ACEIs and ARBs NSAIDs lithium carbonate mesalazine and other 5-aminosalicylic acid drugs calcineurin inhibitors (Cyclosporin, Tacrolimus)
• other groups requiring monitoring of eGFR include GPNreference

Microalbuminuria

• MJ is a caucasian 43 year old type 2 diabetic. He is currently on treatment with metformin 1g bd and glimepiride 1mg per day. A recent HbA1c was 7.2%. A urine albumin creatinine ratio (from the first sample of the morning) revealed a result of 2.6 mg/mmol. His latest blood pressure is 145/85 mmHg.
  • is this urine albumin ratio significant? GPN reference
  • what other causes of microalbuminuria should be considered? GPN reference
  • NICE guidance:
• how often does NICE suggest the urine albumin ratio need to be repeated in order to confirm the presence of microalbuminuria in this case?
• GPN reference
• if this patient has microalbuminuria confirmed on subsequent investigation, and has a creatinine of 115 micromol/l, what stage of CKD has he got GPN reference.
  • why is the finding of microalbuminuria significant in terms of diagnosis of stage of CKD in this case? GPN reference
• at greater than what level of creatinine has NICE suggested that metformin should not be prescribed? GPN reference

Proteinuria

• what is the definition of proteinuria? GPN reference
• what points are important to consider in the history and examination of a patient with proteinuria? GPN reference
• if there is a persistent proteinuria of 120 mg/mmol then is this a criteria for nephrology referral? GPN reference

Further information from GPnotebook:

• CKD section
• microalbuminuria section
• proteinuria section