New Ckd and Raised Urine Acr Booked to Discuss Results — Free SCA Practice Case
Diabetic woman with new CKD and raised urine ACR booked to discuss results
Station Timer
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
Materials for Candidate
Please review before starting the consultation
Full Name
Patricia Nolan
Age
74 years
Consultation Type
VideoAge
74
Situation
Video Consultation, booked to discuss blood and urine results.
Reason for Encounter
"I've come to discuss my results. The nurse rang and said something about my kidneys, and now I'm worried."
Medical Records
- ●PMH: Type 2 diabetes (11 years). Hypertension. Osteoarthritis.
- ●Medications: Metformin 1 g BD, amlodipine 5 mg OD, paracetamol PRN.
- ●Allergies: NKDA.
- ●Recent results (1 week ago): eGFR 52 mL/min/1.73 m² (55 a year ago; 61 two years ago). Urine ACR 14 mg/mmol (previously normal). HbA1c 56 mmol/mol. Potassium 4.4 mmol/L. No visible or non-visible haematuria. Total cholesterol 5.8 mmol/L. BP (home readings) averaging 142/84. Not on an ACE inhibitor/ARB or a statin.
Patient Script
For the friend playing the patient role
Character Overview: You are Patricia, a 74-year-old retired school secretary with type 2 diabetes for eleven years, treated with metformin. You had routine blood and urine tests, and the nurse phoned to say there was something about your kidneys and to book with the doctor — which frightened you. You feel completely well: no swelling, no urinary problems, no breathlessness. Your mother was on dialysis for the last two years of her life and you found that very distressing; your immediate fear is that you are heading for dialysis. You are willing to take tablets if they will help, but you dislike the idea of "yet more medication" and want to understand why. You are intelligent and ask sensible questions.
Opening Sentence: "Hello Doctor. I've come about my results. The nurse said something about my kidneys and told me to book in with you, and I've been worrying ever since. My mother was on dialysis at the end of her life — is that where this is heading?"
History if Asked (Data Gathering Phase)
- ●How she feels: "Honestly, I feel perfectly well. That's what's confusing — I've no symptoms at all."
- ●Her diabetes: "Eleven years now, on metformin twice a day. I take it reliably."
- ●Her mother: "My mother was on dialysis for her last two years. It was awful watching it. That's what's frightening me."
- ●Medication attitude: "I'll take what I need to, but I don't love the idea of adding more tablets. I'd want to understand why."
- ●What she wants: "I want to know what the results actually mean and what happens now."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.
- ●Ideas: Patricia assumes that "something wrong with the kidneys" means kidney failure and eventually dialysis. "In my mind, kidney trouble means kidney failure and dialysis."
- ●Concerns: Her dominant concern is ending up on dialysis like her mother; she is also wary of more medication. "My real fear is dialysis. And I'm not keen on piling on more tablets."
- ●Expectations: She wants her results explained plainly and to know what happens next. "I want it explained properly and to know the plan."
If Asked — CKD, Diabetes-Complication, and Risk-Factor Screen
The patient answers these only when directly asked.
- ●If asked about urinary symptoms (frequency, stream, nocturia, dysuria, retention): "No waterworks problems at all."
- ●If asked about visible blood in the urine or frothy urine: "No blood, and nothing frothy."
- ●If asked about ankle swelling, breathlessness, or fatigue: "No swelling, no breathlessness, and I'm not unusually tired."
- ●If asked about NSAIDs or other over-the-counter/herbal medicines: "Just paracetamol. I did take ibuprofen for my knees years ago but not now, and nothing herbal."
- ●If asked about hypoglycaemia or diabetes symptoms: "No funny turns, no thirst or excess weeing."
- ●If asked about foot checks, retinal screening, and diabetes reviews: "I go for my eye screening and foot checks — they've been fine."
- ●If asked about smoking and alcohol: "Never smoked. A small sherry at Christmas."
- ●If asked about diet and activity: "My diet's reasonable, though I like a biscuit. I walk the dog daily but nothing strenuous."
- ●If asked about family history of kidney disease: "My mother — but I think hers was from her diabetes too."
- ●If asked about blood-pressure monitoring: "I check it at home; it runs around 140 over 80-something."
Responses to Management (The Negotiation Phase)
- ●If the Doctor explains CKD and addresses the dialysis fear: "So this is early kidney damage, not kidney failure — and most people at this stage never need dialysis? That's a huge relief." (The tested point is explaining CKD accurately and addressing the dialysis fear proportionately.)
- ●If the Doctor explains the raised ACR: "The protein in my urine is the important bit? What does that show?" (The tested point is explaining albuminuria as a marker of kidney damage and cardiovascular risk.)
- ●If the Doctor recommends an ACE inhibitor: "Another tablet — what does that one do for my kidneys?" (The tested point is explaining ACE-inhibitor renal protection and gaining her agreement.)
- ●If the Doctor explains the follow-up blood test after starting it: "You'll recheck my blood in a couple of weeks? Why — is it risky?" (The tested point is explaining U&E monitoring after starting an ACE inhibitor, and that a small fall in kidney function is expected and acceptable.)
- ●If the Doctor recommends a statin: "And a cholesterol tablet as well? Is that for my kidneys or my heart?" (The tested point is explaining statin use for cardiovascular risk in CKD.)
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Staging CKD by Both eGFR and ACR
- ●Chronic kidney disease is staged by both eGFR (G stage) and albuminuria (A stage, by urine ACR). Albuminuria is an independent marker of kidney damage, progression risk, and cardiovascular risk — a raised ACR materially changes management, so eGFR must never be interpreted alone.
Confirm Chronicity and Exclude Reversible Causes
- ●Compare with previous results to confirm chronicity (versus acute kidney injury), and screen for reversible contributors — especially NSAIDs and other nephrotoxins, dehydration, and intercurrent illness.
ACE Inhibitor/ARB for Renal Protection
- ●In diabetes with ACR ≥3 mg/mmol, offer an ACE inhibitor or ARB and titrate to the maximum tolerated dose — the key renal-protective intervention.
Monitoring After Starting — and the Expected eGFR Dip
- ●Check U&Es and eGFR before starting and 1–2 weeks after starting or increasing an ACE inhibitor/ARB. A small fall in eGFR/rise in creatinine and potassium is expected and acceptable within defined limits; larger changes prompt review of the drug, volume status, and other nephrotoxins.
Cardiovascular Risk in CKD
- ●CKD substantially increases cardiovascular risk: offer atorvastatin 20 mg for primary prevention (NICE CG181), optimise blood pressure (a tighter target applies with significant albuminuria), and address smoking, weight, diet, and activity.
Diabetes Medicines and Renal Function
- ●Review metformin against renal function (dose reduction and cessation thresholds as eGFR falls) and individualise HbA1c targets in older people. Be aware of the renal and cardiovascular benefits of SGLT2 inhibitors in CKD with type 2 diabetes, as specified in current NICE guidance and local formulary.
Broader CKD Care, Referral, and Monitoring
- ●Advise avoiding NSAIDs, sick-day guidance for medicines, and immunisations; set a monitoring plan (eGFR, ACR, potassium, BP, HbA1c, lipids) matched to risk; and know the nephrology referral criteria — eGFR <30, ACR ≥70, rapid decline, unexplained CKD, or haematuria with albuminuria.
Common Candidate Mistakes in This Case
- ●Leaving the dialysis fear unaddressed: failing to place early CKD in proportion for a frightened patient.
- ●Interpreting eGFR without ACR: missing that albuminuria is what drives management here.
- ●Not starting (or not explaining) the ACE inhibitor: omitting the key renal-protective step, or adding tablets without justification.
- ●No post-initiation U&E check: starting an ACE inhibitor with no monitoring plan, or misrepresenting the expected eGFR dip.
- ●Forgetting cardiovascular risk and metformin review: omitting the statin, blood-pressure optimisation, or the metformin/renal-function review.