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Mike You have not even mentioned all the fiddle factors. So for the Roche kinetic Jaffe, this is a rate blanking assay to minimise interference from Bilirubin. So to correct for non specific reaction from pseudo-creatinine chromogens, including proteins and ketones, all the results are corrected by a fiddle factor of -26 umol/L. Then there is a further fiddle factor applied to the eGFR EPI calculation to try and bring that result into line with IDMS methodology. Even Fagin would have been proud of such extensive fiddling!!. So perhaps your not in a minority of stable analytical difference it may all be down to a mathematical quirk. Just another example to add to my factors affecting uncertainty of measurement for the next ISO inspection. Cheers John From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of COLLINS MICHAEL (RM1) Norfolk and Norwich University Hospital Sent: 03 September 2014 12:46 To: [log in to unmask] Subject: Re: NICE CG182 and Cystatin etc My Jaffe creatinine was stable at 100 umol/L. My enzymatic creatinine is stable at 88 umol/L. I am one of the minority of patients who have different enzymatic and Jaffe creatinine results. We used to cascade enzymatic creatinine on babies and patients with interference (eg high bilirubin of haemolysis). This is very much a second best arrangement because creatinine results will then change with the method. There is also interference from high glucose in compensated Jaffe methods. There will also be problems with users who amend drug doses according to calculated creatinine clearance. EQAS results show just how poor the Jaffe method is compared to enzymatic. We should all move to enzymatic creatinine now. Mike Collins QA Officer Laboratory Medicine Norfolk & Norwich University Hospital ________________________________ From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of OConnor John (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST) Sent: 03 September 2014 09:35 To: [log in to unmask] Subject: Re: NICE CG182 and Cystatin etc 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 From: David James [mailto:[log in to unmask]] Sent: 03 September 2014 09:25 To: OConnor John (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST); [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] 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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NHSmail is the secure email and directory service available for all NHS staff in England and Scotland NHSmail is approved for exchanging patient data and other sensitive information with NHSmail and GSi recipients NHSmail provides an email address for your career in the NHS and can be accessed anywhere ******************************************************************************************************************** ------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. 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