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The Ticking Time Bomb

Dr Charlie Tomson

Consultant Nephrologist, Southmead Hospital, Bristol and NKF Medical Advisor

Using pictures of the cartoon characters Superman and Cruella DeVille, Dr Tomson explained how the new Glomerular Filtration Rate (GFR) test is able to present a more accurate profile of a patient’s kidney function than simply measuring creatinine clearance levels.

'Whilst I am not actively looking forward to meeting and treating Ms DeVille, her body would produce a lower creatinine clearance level compared with Superman's. This, using a creatinine clearance measurement may at first glance have indicated a healthy kidney function, when in fact the reverse is true. Ms DeVille would definitely benefit from my care! So we needed to find a measurement of kidney function that takes things like weight and muscle make-up into consideration and this is exactly what GFR tests do.'

Dr Tomson displayed slides (eg above) indicating the definition of what stage 1 through to stage 5 Chronic Kidney Disease (CKD) actually means;

‘Stage 1 is defined as ‘kidney damage, some other evidence of kidney damage but with a completely normal GFR, Stage 2 is defined as ‘some other evidence of kidney damage and a GFR of 60 – 90 which is in fact pretty close to normal, Stage 3 is defined as ‘where definite reduction in GFR – between 30 and 60 and even here some people will split this group up even further into those with a GFR of 35 – 45 and those with GFR of 45 – 60, Stage 4 is defined as ‘a pending need for renal replacement treatment’ and Stage 5 as a GFR of 15 which is a stage at which many people will require either high quality of palliative care for End Stage Kidney Disease, or dialysis treatment or a transplant. At Stage 5 we need to be actively engaged in speaking with all these patients!

Apart from other stuff I was doing in America, I was agreeing a Nationally recognised set of guidelines to help GPs recognise the GFR blood test result in at risk patients and get those patients referred to us sooner. It has been proved in studies carried out in Bristol and Portsmouth that patients who crash land into the system fare far less well than those who progress through each stage with the right care and information. But no one ever told the GPs this!

So, which patients do we need to see? I know we cannot see all stage 3 CKD patients on my patch for instance because if I did I would be seeing around 180 patients a day! I am passionately keen to see the right patients to prevent those patients crash landing the system - having unplanned dialysis, using vast hospital resources in the process. We need to ensure patients are seen by the right people at the right time and this needs to be in advance of them running into trouble!

Soon, as patients and GPs get to grips with the GFR tests it is my hope that patients will soon be in a position to ask ‘What is my GFR, What is my BP? What are you doing with this result? What else do I need to do?’ these questions will be welcomed by modern doctors. If the patient then progresses into stage 3, questions relating to haemoglobin need to be asked and then every patient who progresses to stage 4 and 5 should have had the opportunity to discuss with a consultant a choice of which dialysis is appropriate or indeed if palliative care is required. This system means we get to see ALL patients to discuss their needs and this will, we hope, prevent incorrect assumptions being made in some cases where say, a patient might have been considered too old or too sick for treatment previously.

Question 1: Won't what you suggest require additional funding - not only in terms of staff resources but staff training, communication and the interactive skills needed when dealing with the responses?

Dr Tomson: That is a good point but if we just pour more resources into the current system it will be like pouring more fuel into a model T Ford - it isn't going to go any faster, so we may as well redesign the system.

Question 2: What is being done to develop the culture in which patients are actively encouraged to participate in the way suggested?

Dr Tomson: I think this will be a typical British compromise and patients are going to have to come to organisations such as the NKF for guidance. Some of this will be down to patients knowing they have kidney disease and knowing what that means and that is why the Expert Patient Programme is being developed - although this Programme may not progress as quickly as we would like.

Question 3: I am a NKF friend on this Programme – and I don’t know who the enemies are? I agree that payment to GPs may be the way and even though I am a non-executive on a Primary Care Trust I see that many are stimulated by money. But I am concerned that the local health economy in general does not have the capacity to accommodate this. Is there a place for a Kidney Service – part of the NHS but independent of it?

Dr Tomson: Much of what you say I agree with; there is indeed huge waste in the system. But the most important thing to achieve is to remove that waste. A system independent of the NHS will not serve the many kidney patients who have to deal with not just kidney failure – they have more than one medical condition and this would complicate their treatment.