Cases/Renal and Urology

Man Whose Kidney Function Dropped After Starting Ramipril — Free SCA Practice Case

Man whose kidney function dropped after starting ramipril

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Bernard Tolliver

Age

63 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. You are returning his call about blood test results.

Reason for Encounter

"I was told to ring for my blood results."

Medical Records

●PMH: Type 2 diabetes for 4 years. Hypertension, found at the diabetes review 4 weeks ago.
●Medications: Metformin 500 mg twice daily. Atorvastatin 20 mg daily. Ramipril 2.5 mg daily, started 3 weeks ago.
●Allergies: NKDA.
●Social: Housing surveyor.

Results

●4 weeks ago: creatinine 88, eGFR 85, potassium 4.6, urine ACR normal.
●2 days ago: creatinine 123, eGFR 57, potassium 5.4.

Patient Script

For the friend playing the patient role

Character Overview: You are Bernard Tolliver, a 63 year old housing surveyor who inspects repairs for a housing association. You work from home on Tuesdays and Thursdays and are out visiting properties the other days. You live with your wife Rhona, who is retired from the post office. Your son Callum and his young son Teddy, aged 3, visit most weekends. Four years ago you were told you had type 2 diabetes, which you manage with tablets and have kept under control. At the diabetes review four weeks ago your blood pressure was high on two readings, so the doctor started you on a new tablet called ramipril three weeks ago. You had a blood test two days ago and the surgery asked you to ring about the results. You are careful, like to understand the reasons behind things, and take your tablets exactly as printed on the box. You feel well today and have rung expecting to be told it is all fine. Your brother in law Keith went on dialysis a few years ago and the word "kidney" frightens you. You are polite and a little anxious, and you ask short, direct questions.

Opening Sentence: "Hello doctor, I'm ringing about my blood results. The surgery asked me to call. Is everything all right?"

History if Asked (Data Gathering Phase)

●The new tablet: "Ramipril 2.5 milligrams, one each morning, since the diabetes review. I've not missed a dose. The nurse said I'd need a blood test a couple of weeks after, and I got round to it two days ago."
●Why it was started: "My blood pressure was 154 over 92 at the review and again on the second check. I wore the home monitor for a week afterwards and the average was about 150 over 90. The doctor said that with the diabetes, this was the tablet to start with."
●Side effects of the tablet: "None really. No cough, no swelling of my face or lips. I was a bit light headed on standing for a day or two during the bug, but not since."
●The stomach bug: "My grandson brought it home. It started about six days ago. Loose watery diarrhoea, six or seven times a day for three days, and I felt sick but wasn't actually sick. No blood, no black stools. The last loose one was three days ago and I've been normal since. I had a slight temperature the first evening and nothing since."
●What he drank and ate during the bug: "I didn't feel like eating, so very little for two days, some toast and tea. I drank less than usual too, maybe three or four cups a day. I was thirsty and my mouth was dry. Since the weekend I've been eating and drinking normally."
●What he did with his tablets during the bug: "I carried on with all of them, every day, the ramipril, the metformin and the statin. Nobody told me to do otherwise, and I didn't want to undo the good of the new tablet. I took them with sips of water, even on the worst day."
●Passing water: "On the worst two days I passed much less and it was dark. It has been back to normal since I started drinking again. No pain, no blood, no frothy urine, and the stream is fine. I get up once a night at most."
●How he feels now: "Fine, honestly. A bit tired the first days after the bug but I've been back at work since Monday. No nausea, no palpitations, no muscle weakness or cramps, no breathlessness, and my ankles are not swollen."
●Home blood pressure: "I have a monitor from the pharmacy. The day of the worst diarrhoea it was 118 over 70 and I felt woozy. Since then it has been about 134 over 82 each morning."
●Painkillers and over the counter medicines: "Only paracetamol, and I've not needed it this month. No ibuprofen, no naproxen, no anti inflammatory gels or tablets. "
●Salt substitute: "Since the blood pressure was found to be high I've been cutting down on salt. We swapped to that low sodium salt, LoSalt, on everything about four weeks ago. Rhona uses it in cooking too."
●Other supplements or medicines: "No potassium tablets, no herbal remedies, no antibiotics. Just the three tablets."
●Other possible causes of kidney trouble: "I stopped smoking twelve years ago after about twenty years of ten a day. No pain in my calves when I walk, no heart trouble, no strokes, and no stones. I have never been told my kidneys were a problem. My urine test at the review was normal."

Ideas, Concerns, Expectations

Gating note: Bernard does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he hoped to hear.

●Ideas: He thinks the new tablet may have "gone for his kidneys". He heard that blood pressure tablets can harm the kidneys and wonders if he took the wrong dose. "Is it the ramipril? Has it damaged my kidneys? Is that why the result has come back?"
●Concerns: He is afraid he is heading the way of his brother in law Keith, who started dialysis three times a week a few years ago. He is also worried that stopping a tablet will let his blood pressure and diabetes slip. "Keith's kidneys went and now he's on a machine three days a week. I don't want that for Rhona to have to watch."
●Expectations: He wants the result explained in plain words, to know whether he must stop the ramipril, and what to do so it does not happen again. "Do I carry on with it? And what should I have done when I was ill?"

If Asked: Medical History and Medications

Gating note: Bernard answers each of these plainly when the doctor asks about it.

●Other health problems: "Type 2 diabetes for four years and now the blood pressure. Nothing else. No kidney problems that I know of, no gout, no prostate trouble."
●Medicines: "Metformin 500 milligrams twice a day, atorvastatin 20 at night and the ramipril. No inhalers, no water tablets."
●Allergies: "None."
●Family history: "My father had a heart attack at 70. No kidney problems in the family except Keith, Rhona's sister's husband."

Social History and Lifestyle Impact

●Work: Housing surveyor, inspecting repairs. He drives to properties and sometimes climbs ladders. He was at home on the worst days of the bug.
●Home: Lives with Rhona. Callum and Teddy visit most weekends. Teddy was ill with the bug a few days before him.
●Availability for tests: Can have bloods taken at the surgery or hospital any morning before nine, because he starts site visits after that, and has his home monitor to hand. He has a mobile phone and checks it often.

If Asked: Associated Symptoms

Gating note: Bernard answers these only when asked. Every one is negative unless stated.

●If asked about chest pain, palpitations, fainting or blackouts: "No, none of that."
●If asked about muscle weakness, tingling or cramps: "No."
●If asked about breathlessness or swollen ankles: "No, and I can walk the dog as usual."
●If asked about passing blood, burning, flank pain or fever now: "No. The temperature was only that first night."
●If asked about vomiting right now or inability to keep drinks down: "No, I'm eating and drinking properly."

Responses to Management (The Negotiation Phase)

●
If the doctor explains the result and the likely cause:
- ●Reaction: Anxious, then steadier. "So it's not the kidneys failing?" If told it is a change that is likely to be linked to the diarrhoea and dehydration and can be put right: "I did feel dried out. I just assumed the tablets would help." He asks, "Did I do something wrong by carrying on with my tablets?" If the doctor is vague and offers no explanation: "But what does it mean, doctor? Is it serious?"
●
If the doctor suggests pausing the ramipril for a few days and repeating the blood test:
- ●Reaction: Cautious. "Won't my blood pressure go up?" If told his readings will be checked at home and when the ramipril would restart: "All right, I can do the morning readings and write them down." If he is told to stop it for good: "For good? But the nurse said this was the tablet I needed. Is there something else I can have?" If told to carry on unchanged, he says: "Right, if you're happy. I'll carry on then." and does not push back.
●
If the doctor asks about salt substitutes or potassium:
- ●Reaction: Surprised. "The LoSalt? I thought it was better for me than ordinary salt." He accepts advice to stop using it: "I'll tell Rhona to go back to the normal salt, but a lot less of it."
●
If the doctor gives advice about when he is ill in future (sick day advice):
- ●Reaction: Interested and practical. "So if I've got diarrhoea or I'm being sick, I stop the ramipril and the metformin for a day or two? When do I start again?" If the doctor mentions water tablets or anti inflammatories: "I don't take any of those, but I'll remember." He repeats it back well when asked, and would like it in writing or by text.
●
If the doctor arranges the repeat blood test:
- ●Reaction: Agreeable. "I can go in the morning before nine on any day. When would you like it? And who will tell me the result?" If given an unspecific timescale such as "in a few weeks": "Is that not too long? Should I not be tested sooner?"
●
If the doctor gives safety netting:
- ●Reaction: Wants specifics. "What should I look out for? What would mean I need to ring straight away?" If the advice is vague he asks, "Is it the passing less water that I should watch?" He repeats back the list clearly when it is given.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Bernard is a 63 year old man with type 2 diabetes and newly diagnosed hypertension, started on ramipril 2.5 mg three weeks ago. His creatinine has risen from 88 to 123 micromol/L (about 40%), his eGFR has fallen from 85 to 57 and his potassium is 5.4. He had three days of diarrhoea with poor drinking and kept taking every tablet. The station tests whether the candidate can tell an expected change from one that needs action, find the cause, protect the kidneys without losing a useful drug, and give sick day advice.
●The model plan has six parts. Recognise that the rise is above the 30% creatinine threshold and look for other causes. Identify volume depletion with ramipril and metformin continued, and the potassium salt substitute. Pause ramipril until the result is repeated. Repeat creatinine, eGFR and potassium within about a week. Explain what happens next in each case. Give sick day and safety netting advice.
●Acceptable alternatives: reducing the ramipril dose instead of pausing it, or continuing it at the same dose with a firm repeat within a few days once he is drinking normally and has no symptoms, as long as the decision is explained and a repeat test is booked. Pausing metformin until the repeat is also reasonable, although eGFR 57 does not require it. Not acceptable: carrying on with no repeat, or labelling him intolerant of ACE inhibitors from this single result.

What Change Is Expected After Starting an ACE Inhibitor

●ACE inhibitors lower pressure inside the glomerulus, so a small fall in eGFR and a small rise in creatinine after starting are expected and usually settle. NICE guideline NG203 (chronic kidney disease) tells prescribers to measure potassium and eGFR before starting a renin angiotensin system antagonist and again 1 to 2 weeks after starting and after each dose increase. The BNF says renal function and electrolytes should be checked before starting and monitored during treatment.
●The same guideline says the dose should not be modified if the eGFR falls by less than 25% or the creatinine rises by less than 30% from baseline, and the test should be repeated in 1 to 2 weeks. Bernard is over that line on both counts, because creatinine has risen by about 40% and eGFR has fallen by about 33%.
●These recommendations were written for adults with chronic kidney disease. They are widely applied after starting ACE inhibitors and ARBs in other adults, and the candidate should use the thresholds the same way here.

When the Rise Is Above the Threshold

●NG203 recommendation 1.6.23 says that when the creatinine rise is 30% or more, or the eGFR fall is 25% or more, the prescriber should investigate other causes such as volume depletion or concurrent medicines including NSAIDs. If no other cause is found, the antagonist should be stopped or reduced to a previously tolerated lower dose, with an alternative antihypertensive added if needed.
●Bernard has an obvious other cause. He had diarrhoea with reduced fluids and scanty dark urine for two days, and kept taking ramipril. Reduced circulating volume and an ACE inhibitor together lower glomerular filtration. He takes no NSAIDs, has no urinary symptoms, and has no vascular disease to suggest renal artery stenosis.
●If the rise had persisted despite correction of the dehydration and no other cause, a further cause such as renal artery stenosis would be considered, and ramipril would be stopped or reduced as above. This is a point for the repeat test, not for today.

Why Pausing and Rechecking Is the Model Answer

●NICE guideline NG148 (acute kidney injury, recommendation 1.2.14) says to consider temporarily stopping ACE inhibitors and ARBs in adults with diarrhoea, vomiting or sepsis until their clinical condition has improved and stabilised. Bernard has recovered clinically but his result still reflects the illness, so pausing the drug while the repeat is awaited is consistent with this advice.
●A pause of several days is low risk. His blood pressure is only mildly raised, he has a home monitor, and a short delay in treatment does not matter. Permanent cessation, or recording an adverse reaction, would deny a diabetic man with hypertension a first line drug that NICE hypertension guideline NG136 recommends for adults with type 2 diabetes of any age. If an ACE inhibitor is not tolerated, an ARB is the alternative. Do not combine an ACE inhibitor with an ARB.

Potassium and the Salt Substitute

●A potassium of 5.4 is above the reference range but below the 6.0 level at which NG203 recommendation 1.6.19 says to stop a renin angiotensin system antagonist when other drugs that raise potassium have been discontinued. NG203 also advises not routinely starting these drugs in adults with CKD if the pretreatment potassium is above 5.0. In a well man this does not need emergency treatment.
●The hidden cause here is a low sodium salt substitute used on everything for four weeks. These products replace sodium with potassium and can raise potassium in people taking ACE inhibitors; the BNF (potassium chloride, patient advice) names LoSalt and says such products should not be used in renal failure because potassium intoxication may result. A good candidate asks about salt substitutes, advises him to stop and to return to ordinary salt in small amounts, and explains that this will help the potassium on repeat testing.
●Also advise avoiding NSAIDs, potassium supplements and new over the counter products until the results are settled.

After the Repeat Result

●If creatinine and eGFR return close to baseline and potassium is normal, ramipril can be restarted, usually at 1.25 to 2.5 mg, with a further check 1 to 2 weeks later and after each dose increase. The BNF advises increasing the dose for hypertension at intervals of 2 to 4 weeks.
●If the rise persists with no other cause, NG203 advises stopping ramipril or reducing it to a previously tolerated dose. An alternative such as a calcium channel blocker would then be chosen for blood pressure, and the persistent change investigated, including urine dipstick, ACR and consideration of renal artery stenosis or an ultrasound.
●If the potassium is 6.0 or more, or he becomes unwell, the plan changes to urgent assessment the same day.
●Home blood pressure should be recorded during the pause. His recent average of about 134/82 means a short pause is safe, and persistently high readings or symptoms should prompt contact.

Sick Day Advice

●Bernard kept taking all of his tablets during his illness because nobody had told him otherwise. NG148 supports temporarily stopping ACE inhibitors and ARBs during diarrhoea, vomiting or sepsis. The BNF for metformin advises interrupting treatment if dehydration occurs.
●A good plan tells him that if he has vomiting, diarrhoea, or a fever with sweats and is not eating or drinking, he should temporarily stop ramipril and metformin, and any NSAID or diuretic if he ever takes one, and keep drinking fluids. He should restart once the illness has settled and he is eating and drinking normally again, and should ask for advice if he is still unwell after two days. NG148 gives the principle (until the clinical condition has improved and stabilised) but no interval; local sick day leaflets usually say 24 to 48 hours after recovery, so accept any sensible interval. Atorvastatin does not need to be stopped.
●Offer the advice in writing or by text and ask him to say it back. Record it in his notes and on his repeat template so that future reviews include it.

Safety Netting and Follow Up

●Same day contact is needed for passing little or no urine, vomiting or diarrhoea that returns, inability to keep drinks down, fainting or marked dizziness, palpitations, new muscle weakness, breathlessness or swelling. Say whom to ring, including out of hours.
●Agree a named day for the repeat blood test, how he will be told the result, and what he does with the ramipril in the meantime. Plan the next checks, and keep annual diabetes reviews including urine ACR.

Common Mistakes in This Station

●Telling him the result is normal because it was only "a small change" after starting ramipril, without calculating the percentage.
●Stopping ramipril permanently or recording an ACE inhibitor intolerance from one result.
●Carrying on unchanged without a repeat test, or booking the repeat weeks away.
●Missing the salt substitute because the candidate never asked about it, and missing that he took ramipril and metformin through the diarrhoea.
●Treating a potassium of 5.4 in a well man as an emergency, or ignoring it.
●Giving sick day advice that covers only ramipril and not metformin, or leaving it without a restart plan.
●Blaming him for continuing his tablets, or using terms such as eGFR and nephrotoxic without explaining.
●Failing to plan blood pressure cover during the pause.

Mapped to the RCGP curriculum topic: Renal and Urology.

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