David I completely agree with you. But triaging the request to cascade a Jaffe or enzymatic would certainly be a challenge with our current IT. I would have to set it up as a new test. Then there is a problem of dealing with a composite historical view of past results if by any chance there is a switch in the method used for measurement in any given patient. The thought of the extra complication that has been introduced with the new AKI algorithm, particularly around the requirement to use median creatinine levels over the past 12 months fills me with dread at the thought of trying to implement in that context

BW John

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 J

DJ

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

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