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Failure to monitor renal impairment

19 July 2018

By Dr Ellen Welch, GP

Mr J, a 63-year-old gardener, visited Dr C for his annual health check and routine bloods were requested. Dr A, another GP in the surgery, reviewed the results and noted that Mr J had moderate renal impairment, with an eGFR of 59 ml/min/1.73m2 and he coded Mr J as having chronic kidney disease stage 3. 

The laboratory recommended that the blood test should be repeated within the next five days. Dr A assumed that Dr C would follow his patient up since he was the doctor who requested the initial blood tests.

A week later, Mr J was seen again by Dr C. He had a sore finger after pruning some trees, and this was the focus of the consultation. The blood results were not discussed and a repeat test was not mentioned as Dr C assumed that Dr A, as the doctor who reviewed the blood results, would have arranged subsequent testing and follow up.

Six months later, Mr J had an appointment with Dr A regarding his painful osteoarthritis. Naproxen was prescribed and placed on repeat prescription. The patient’s previous blood results were overlooked and a repeat renal function was not requested.

Another year passed and Mr J consulted this time with an episode of diarrhoea and vomiting. Bloods were checked and showed an eGFR of 50 ml/min/1.73m2. The result was recorded by the duty doctor as being consistent with moderate renal impairment, but no further action was taken.

Mr J continued to receive naproxen on repeat prescription for a further two years, and during this time had documented medication reviews by both Dr A and Dr C. He was then reviewed by a locum doctor at the surgery, who noted a degree of renal impairment and stopped the naproxen. Blood tests had not been carried out for a two-year period, so the locum requested a renal function test, which showed a deteriorating eGFR of 44 ml/min/1.73m2. Mr J was referred to the nephrology team for review, and his renal function gradually improved after the naproxen was discontinued.

A claim was brought against Dr C and Dr A for continuing to prescribe naproxen despite evidence of renal impairment, and for failing to monitor Mr J’s renal function, which had an adverse impact on Mr J’s prognosis.

Expert opinion

Medical Protection investigated the claim and instructed experts in general practice and nephrology. The GP expert reviewing this case criticised the failure of both doctors to initially recheck Mr J’s renal function in order to confirm or refute a diagnosis of chronic kidney disease. He noted several missed opportunities to act on the abnormal blood results, and was critical of the GPs for prescribing naproxen on a repeat basis without checking Mr J’s renal function initially and at least on an annual basis.

The expert nephrologist considered that although the continued prescription of naproxen was likely to have contributed to Mr J’s deterioration in renal function, most of the kidney damage occurred prior to the medication being commenced. He agreed that Mr J should have undergone further investigation after the second eGFR result showed a deterioration, and felt it was likely that the naproxen would have been withdrawn at this point. He felt the naproxen was unlikely to have had a clinically significant effect on Mr J’s long-term prognosis.

Outcome 

On the basis of the nephrologist’s report, a letter of response was served, admitting there were missed opportunities to repeat Mr J’s blood tests, but denying that this resulted in a clinically significant difference to his renal function. The claim was subsequently discontinued.

The New Zealand position

As we are a no-fault jurisdiction, with the Accident Compensation Corporation (ACC) covering treatment injury claims, it is very rare for a claim to be brought against a health provider.  

A similar situation as the case described above was investigated by the Health and Disability Commissioner (HDC). In this New Zealand case (13HDC01041) an elderly patient was prescribed a non-steroidal anti-inflammatory (NSAID) for musculoskeletal pain and gout. The patient had multiple co-morbidities and known chronic kidney disease. An alert had been placed in the file regarding a previous reaction to an NSAID. The GP was not cognisant of this alert when the anti-inflammatory was prescribed. Sadly, the patient died from multi-organ failure secondary to acute on chronic renal failure.  

Following the HDC investigation, the HDC was unable to determine whether or to what degree the prescribing of the NSAID to the patient had contributed to the patient’s death. Regardless, the GP was found in breach of The Code of Patient Rights. The GP was required to provide a written apology to the patient’s wife and undergo further training on good prescribing practice. The GP was referred to the New Zealand Medical Council.

 

 

Learning points
  • Safety nets should be in place to ensure abnormal blood results are appropriately followed up – at both a practice and individual level. GP surgeries differ in their approach to following up results, but the requesting and reviewing clinicians should know where their own responsibilities lie. In this situation, both Dr A and Dr C assumed the other was managing Mr J with respect to his renal function, as a result of which his follow up was missed.

  • Patients taking potentially nephrotoxic medication on a long-term basis should be regularly reviewed and consideration should be given to the need to monitor renal function. Electronic records allow this to be done at a practice level, by conducting clinical audits of all patients coded with chronic kidney disease to ensure they are managed appropriately. 
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