Hi Gary, If creatinine is long-term above the reference range and stable what is the eGFR? I would have thought likely <60 and patient has stable CKD in which case should they not be regularly monitored? Unless of course you have lots of weightlifters which is why the GP is not concerned. As Mike says, when the algorithm was developed the group decided to add this comment to all flagged creatinines with no previous in 12 months basically to highlight the two likely causes.



Best wishes

Anne

Dr Anne Dawnay PhD FRCPath

Consultant Biochemist for HSL at UCLH

Clinical Lead UCLH Clinical Biochemistry & Chair UCLH POCT Committee

Tel 020 344 72954 direct dial



Date:    Wed, 28 Oct 2015 08:43:07 +0000

From:    "Bosomworth Mike (LEEDS TEACHING HOSPITALS NHS TRUST)"

         <[log in to unmask]>

Subject: Re: ?AKI ?CKD patient results



A one off serum creatinine above the reference range is difficult to interpret without knowledge of the patient. All the ?AKI ?CKD comment is trying to do is to make the person managing the patient consider AKI or CKD. With full knowledge of the patient neither may be applicable e.g. the patient may train with weights regularly.



At one point Gary you say that the patient has always had a raised creatinine which infers that there are previous result to compare to. Again it is back to reviewing the patient. The algorithm in truth is only saying that the person managing the patient should consider AKI.



There will always have to be some degree of local configuration of comments because there will be local care pathways etc for AKI and CKD.



Kind regards



Dr Mike Bosomworth

Clinical Service Lead for Blood Sciences and Specialist Laboratory Medicine

Tel: 0113 3922340

Mobile: 07789174344



-----Original Message-----

From: ACB AKI-Detection-Algorithm [mailto:[log in to unmask]] On Behalf Of Hill Robert (NORTH BRISTOL NHS TRUST)

Sent: 27 October 2015 17:45

To: [log in to unmask]

Subject: Re: ?AKI ?CKD patient results



Thanks for your comments Gary,



You are highlighting that what works in secondary care does not necessarily work in primary care. Patients who have a single serum creatinine result that is outside the reference interval are effectively on the periphery of the algorithm with insufficient information to generate an AKI warning stage test result. Nevertheless, to ignore such results makes little sense in the context of trying to increase the detection of AKI in primary care.

So the issue is, if we are to do something, what should we do? It does not seem unreasonable to us to invite a closer inspection of the results and to suggest a repeat. A suggestion, to us implies a fairly weak degree of compulsion and can be dismissed when knowledge of the patient's clinical status requires it.



That said, the wording of comments is a fine art and the same words mean different things to different people. We can always improve or even make the comment locally configurable.

Other comments are welcome on this.



Dr Robert Hill

Chair Detection Workstream

Think Kidneys National Programme

________________________________________

From: ACB AKI-Detection-Algorithm [[log in to unmask]] On Behalf Of Gary Mascall [[log in to unmask]]

Sent: 23 October 2015 14:42

To: [log in to unmask]

Subject: ?AKI ?CKD patient results



Since reporting AKI warnings using the WinPath interpretation of the national algorithm, we have seen large numbers of samples (approx 85% of the number of AKI warnings 1 to 3) where the creatinine is above the relevant upper reference limit but with no creatinine in the previous 12 months.

So this is reported as per national algorithm as ?AKI ?CKD suggest repeat.

It is creating a problem for Primary Care clinicians who rightly tell us the patient isn't on annual/regular monitoring, but has always had creatinine of a similar level, and waves are starting to be created.



I realise the algorithm was initially for secondary care, but as we already had something in place for primary care we decided to go "big bang" and introduce it across all clinical areas. So, this may be a problem others only reporting on secondary care patients have not yet encountered, but it is something you do need to be aware of.



Possibly when the algorithm is reviewed this issue might be addressed? I can envisage a few ways to improve things, but as these are outside of the algorithm, and something we have no control of the software to change, this really does need some thought and consideration.



Gary Mascall

Worcestershire Acute Hospitals NHS Trust.






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