1. Kidney medicine and Immunosuppression: Top ten facts for acute/general physicians
Richard Smith

2. CD8
IL-4
AAAAAAAGGGHHHH !
TNF-a
IFN-g
IL-2
CD4

3. KIDNEYS

4. Case 1
74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease
Most recent HbA1c 7.4%
First thoughts?
Rx Ramipril 5mg daily and Metformin 500mg bd

5. Case 1
74 year old male with 12 year history of T2DM presents to casualty unwell with lower abdominal pain. Known to have diverticular disease
Rx Ramipril 5mg daily and Metformin 500mg bd
Pyrexial. BP 130/74. Euvolaemic
WCC 10.6x109/l CRP 48ng/ml
eGFR 42ml/min with a potassium of 4.2mmol/l

6. Case 2
92 year old is seen in clinic having been found by GP to have ‘CKD4’
She is well with an eGFR of 26ml/min
Rest of biochemistry is safe, urine reveals neither blood nor protein
What do I do?
USS shows echobright kidneys of 8.2cm and 8.4cm with no evidence of obstruction
eGFR was 28ml/min in 2008

7. Fact 1: Make sure patient is safe
Fact 2: Direction of travel is everything!
Fact 3: Risk factors for AKI include age >65, diabetes and ACEI/ARB
Fact 4: Infection is a trigger for AKI in at risk patients even if not involving
urinary tract

8. Case 3
A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.
What do I do?

9. Case 3
A 36 yr old woman who has been previously fit and well and who rarely attends the surgery presents complaining of increased tiredness. She is an active sportswoman who has noticed reduction in exercise tolerance over 3 weeks such that she has struggled on hills when jogging. For 3 days she has had a sore throat, ‘painful’ fingers and noticed a few ‘red spots’ on her right thigh. On examination you confirm that she has a palpable non-blanching purpuric rash on her thigh. BP is 164/90 but examination is otherwise unremarkable.
What do I do
Dipstick of urine revealed blood ++ and protein ++

10. Fact 5: Dipstick of urine is your get. out of jail free card
Fact 5: Dipstick of urine is your get out of jail free card Particularly if hypertension.

11. Kidney medicine in primary care: 7 minutes
Is glomerular perfusion threatened ?
Any suggestion of intrinsic kidney disease
Any suggestion of obstruction

13. Case 4 48 yr old man. Routine health check.
Found to have eGFR of 35ml/min
Referred for investigation of his “CKD 3”
No previous eGFR
Protein No haematuria
BP 122/74

14. Case 5 78 year old with stable CKD3. Rx Ramipril 5mg daily
eGFR June ml/min April ml/min
Cares for terminally ill husband therefore deferred R hip
replacement
What pain killers would you recommend?
Pharmacist recommended Ibuprofen 400mg daily
4th July ml/min
Stopped Brufen
14th July ml/min

15. X Fact 6: NSAID/COX inhibitors/COX-2 inhibitors
Fact 7: Consider stopping ACEI/ARB
Even in patient with stable kidney function if ‘at risk’

16. 16

17. NICE Guidance 28th August 2013
The National Confidential Enquiry into Patient Outcome and Death found that only half of patients with AKI had received 'good' care
Up to 30 per cent of cases of AKI can be prevented - that equates to at least 12,000 unnecessary deaths per year
Inadequate assessment of risk factors in 24% of patients admitted with AKI
Commonest risk factors not assessed were medication, co-morbidity and hypovolaemia

18. Immunosuppression

19. Antibodies
CnI: Tacrolimus and ciclosporin
Mycophenolate mofetil/Myfortic/Azathioprine
Sirolimus

20. BTS Guidelines More immunogenic Marginal donor CnI + Steroid + MMF +
Less immunogenic
CnI + Steroid
Marginal donor
Steroid + Ab + CnI + MMF
CRAN
Steroid + MMF
Steroid + Rapamycin
More immunogenic
CnI + Steroid + MMF +
Antibody

21. Case 6
38 year old female simultaneous pancreas kidney transplant recipient of 3 years. Stable graft function
Rx Tacrolimus, prednisolone and mycophenolate mofetil
Normally well
Presented to GP with vesicular rash on left side of chest

23. Fact 8: Beware herpes viruses!
Good at evading immune system
Need T cell responses and antibody responses to clear efficiently

26. Fact 8a: …………. and pneumocystis
Fact 9: For transplant patient continuation of immunosuppression critical

27. Perhaps commonest immunosuppressed patient to raise adrenaline levels will be transplant patient
Herpes viruses are main issue
Varicella strikes fear into my heart!
EBV main cause of lymphoma
CMV common. Needs to be recognised but not overdiagnosed.
Also pneumocystis. Soft story of breathlessness. No pyrexia. No signs.
Desaturate on exercise.