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Arguments aside for one moment about what methods we should be using. I had an interesting conversation with the North Devon commissioning team around Cystatin availability and enzymatic creatinines today. They were following up on the NICE guidance and wanted to get some feel for the numbers involved. So we did 215527 Cre’s for primary care last financial year covering a population of 375,000, quite a substantial sum if we were to switch to enzymatic. The CCG lead suggested that any renal function requests that were requested on the back of QOF screening (hypertension etc, etc) that indicated patients should be put on the CKD register (CKD>3) would always get a follow up renal function request if that were to be the case. One suggestion that came out of this was to restrict a Cystatin measurement to the second confirmatory test if the malb/cre was <3.0 and eGFR 45-60 (CKD3a) The cystatin measurement would then give a much more accurate measurement of eGFR and overcome the problem of Jaffe Cre overestimating CRe and creating a false positive. So in this scenario Cystatin would be acting as the gatekeeper test. It may help to avoid relegating Jaffe to the long grass just yet. BW John From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Kilpatrick, Eric Sent: 03 September 2014 14:53 To: [log in to unmask] Subject: Re: NICE CG182 and Cystatin etc Hi David I am sure you feel as I do that the profession should be leading on this. I think we both attended the Standardisation Workshop that Gifford Batstone organised earlier this year and there was bewilderment that ‘we’ had not acted on topics such as enzymatic creatinine, standardising methodologies to calculate adjusted calciums or even recommending one unit for alcohol reporting. The bewilderment was present amongst our other Pathology colleagues but was greatest amongst the GPs and lay people in attendance. While the ACB is making inroads in addressing adjusted calcium and alcohol, we felt that NICE guidance should be more than sufficient in justifying a move to ‘specific’ creatinine methods. My own view relates to your ‘My creatinine is 82umol/l (Jaffe) and pretty stable’ comment as it is indeed the change in creatinine that is at least as important as the absolute value and so for it to change because we are flipping between methods or because the patient has developed an illness or has started a drug that Jaffe does not like seems unacceptable to me. Lastly, I wonder if I’m the only one having difficulty working out your gender from your eGFR and creatinine! Best wishes Eric From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of David James Sent: 03 September 2014 09:25 To: [log in to unmask] Subject: Re: NICE CG182 and Cystatin etc I think the enzymatic creatinine issue is bigger than the cystatin one Question for the hive. Does every creatinine we measure need to be enzymatic? Accepting limitations of eGFR as a screening tool in primary care, if patient has a compensated Jaffe result which gives an eGFR of say 80, what is likliehood of enzymatic creat measurement giving an eGFR that is going to change actions on part of GP? My creatinine is 82umol/l (Jaffe) and pretty stable (eGFR 85 – you can now work out my age and sex), if my creatinine changes, my renal function has changed. Is it not more important to use enz creat if an eGFR reaches e.g. 70 or 65, to avoid “misdiagnosis” of patients, setting off a chain of events both within thehealth economy, and perhaps potentially in their personal lives? Cost is the usual limitation in this (and for those who will jump in saying we get it enz creat at no extra cost in our MSC, remember there is no such thing as a free lunch, you are paying for it in there somewhere) perhaps a more focussed approach on use of enz creatcould take a large sting out of the financial tail? WARNING – this posting is likely to provoke a response from Finlay M ☺ DJ From: OConnor John (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST) [mailto:[log in to unmask]] Sent: 03 September 2014 09:09 To: David James; [log in to unmask]<mailto:[log in to unmask]> Subject: RE: NICE CG182 and Cystatin etc As long as the CCG’s accept that its outside the tariff, should be ok if we get the fully recovered cost. We did this with BNP across Devon and that worked out fine. The other issue with the NICE guidance is that we are encouraged to use enzymatic creatinine which again would be a significant cost pressure. My take on that would be to unbundle Cre from the renal profile and charge as a separate item under tariff. This will be much harder for labs working under block contract and not PBR BW John From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of David James Sent: 03 September 2014 08:29 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: NICE CG182 and Cystatin etc That’s informal message I have had dj From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Reynolds Tim (RJF) BHFT Sent: 03 September 2014 08:28 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: NICE CG182 and Cystatin etc I think the guidance says that commissioners should consider using cystatin. Therefore, they will consider it and decide it is too expensive; and we we remain exactly as we are... ************************************************************************************** Prof. Tim Reynolds Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead, Burton Hospitals NHS Foundation Trust work tel: 01283 511511 ext 4035 work fax: 01283 593064 work email: [log in to unmask]<mailto:[log in to unmask]> work URL: www.burtonhospitals.nhs.uk<http://www.burtonhospitals.nhs.uk> This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035 [Picture of tree not available] Please consider the environment before printing this e-mail ________________________________ From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Barlow Ian (NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST) Sent: 02 September 2014 3:40 PM To: [log in to unmask]<mailto:[log in to unmask]> Subject: NICE CG182 and Cystatin etc --- This message was sent from an email address external to NHSmail but gives the appearance of being from an NHSmail (@nhs.net) address. The recipient should verify the sender and content before acting upon information contained within. The identified sender is [log in to unmask]<mailto:[log in to unmask]> --- Dear collective, Are UK labs planning on moving from MDRD to the Chronic Kidney Disease Epidemiology Collaboration (CKD‑EPI) creatinine equation to estimate eGFR? Moreover, just in case our GPs start demanding Cystatin c (which is quite likely I fear) I am seeking a UK lab that is able to provide Cystatin c assay/results that complies with this:- “1.1.8 Clinical laboratories should use cystatin C assays calibrated to the international standard to measure serum cystatin C for cystatin C-based estimates of GFR. [new 2014]” Any out there? Many thanks Ian ******************************************************************************************************************** This message may contain confidential information. If you are not the intended recipient please inform the sender that you have received the message in error before deleting it. Please do not disclose, copy or distribute information in this e-mail or take any action in reliance on its contents: to do so is strictly prohibited and may be unlawful. Thank you for your co-operation. 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