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A case of renal failure

01 May 2013

Mrs B was a 44-year-old teacher with two children. She smoked ten cigarettes a day and was overweight. She saw her GP, Dr T, about knee pain and he prescribed ibuprofen and advised her to lose weight. The ibuprofen helped so she continued to take it long-term.

Later that year she saw Dr T again, complaining of itching. Dr T thought the likely issue was a change in washing powder so prescribed antihistamines and suggested she switched brands. He also requested some blood tests including renal function. Her creatinine was slightly raised at 138 and her eGFR (estimated glomerular filtration rate) was 38 (indicative of chronic kidney disease stage 3b). Dr T had documented “blood tests OK, repeat in three months”.

Mrs B forgot to have her repeat blood tests but saw the nurse and different GPs several times over the next few years with minor ailments. The issue was not raised again by any of the health professionals. A nurse had documented her BP as 125/80 when she had attended for travel vaccinations.

Three years later, she consulted Dr R, another GP at the practice, complaining of breast tenderness. His notes remarked on a diagnosis of CKD stage 3 but Mrs B was not informed of the diagnosis and no investigation or further follow-up was made.

Another year later, Mrs B made an appointment with Dr R because she was struggling with anxiety and was concerned about palpitations. She was stressed at work and was waiting for some cosmetic surgery that she was nervous about. Dr R checked her BP and found it greatly elevated at 216/107.

He prescribed her diazepam and propranolol and arranged an ECG on the same day, which showed ventricular hypertrophy. Dr R arranged blood tests the following day and rechecked her blood pressure. Her eGFR was 21, indicative of CKD stage 4. Her creatinine was 226 and urea 10.6. Mrs B was informed about a problem with her kidney function and was referred and seen the same day by a nephrologist, Dr W.

Dr W started treatment with amlodipine, bisoprolol, alphacalcidol, simvastatin, ranitidine and aspirin. He informed Mrs B that she had renal failure and accelerated hypertension. Mrs B underwent detailed investigation with blood tests, urinalysis and ultrasound.

In Dr W’s opinion, her chronic renal failure was caused by a combination of smoking, a bad family history of vascular disease (and possibly renal disease), and hypercholesterolaemia, which, combined with the adverse effects of NSAIDs, produced an ischaemic interstitial disease that became rapidly worse with the sudden development of severe uncontrolled hypertension.

Mrs B was told that progression to end-stage renal failure was almost certain and that she would require dialysis or transplantation within five to ten years. She was told that her life expectancy with dialysis could be 10-15 years and 15-20 years with transplantation. She would need a complex drug regime, dietary restrictions and indefinite outpatient follow-up.

Mrs B was devastated and felt that the diagnosis and treatment of her renal failure had been delayed. She was struggling with fatigue and was unable to cope at work. She made a claim against both GPs.

Expert GP opinion acknowledged that there had been a big shift in clinical practice since the case took place. Guidance has changed regarding the recognition and labelling of chronic kidney disease. Expert opinion considered that at the time, few GPs would have recognised that the slightly elevated creatinine and the eGFR of 38 were likely to represent significant renal disease.

Dr T’s actions in arranging to repeat the test in three months were found to be very reasonable, but expert opinion would have been critical if this had not been communicated to the patient. Dr T was criticised for failing to notice that Mrs B’s renal function had not been rechecked, as repeat testing could have led to an inquiry about potentially nephrotoxic drugs such as NSAIDs, and a timely referral to the nephrologists.

Dr R was criticised for failing to identify the low eGFR and raised serum creatinine and that the plan to repeat the renal function tests had not occurred. Repeat testing and nonurgent referral should have taken place.

Renal physician opinion was also sought, which found that an urgent repeat/confirmatory test should have been ordered. Mrs B should have been examined for potential causes and complications of renal disease.

The GP should have sent urine for culture and ACR (albumin: creatinine ratio) estimation and carried out dipstick testing for blood. Blood tests should have been arranged to exclude diabetes, anaemia and nephrotic syndrome.

Expert opinion also suggested that an urgent referral within a week should have been made if the hypertension was marked and the rise in creatinine rapid. In the absence of a rising creatinine and in the presence of a normal blood pressure, the patient would normally have been seen within two months. Had this been done, the severe episode of hypertension could have been avoided and renal function preserved.

The timely withdrawal of NSAIDs would have been of some benefit. As a result of missed opportunities for referral and intervention, progression to end-stage renal failure was almost certain and dialysis or transplantation would be required. The claim was settled for a substantial sum.

Learning points

  • This case occurred before 2008 and the expert opinion follows practice that was current at the time. Guidelines surrounding the management of CKD have since been updated – see NICE, Chronic kidney disease – Early identification and management of chronic kidney disease in adults in primary and secondary care.
  • Good note-keeping is important. This is vital for a good defence. It was useful that Dr T documented that he had advised Mrs B to return for blood tests in three months.
  • Steps to ensure continuity of care would have made it easier to notice that Mrs B had not returned for the planned follow-up. GPs should review previous notes when seeing patients, to put the consultation into context and continue with existing management plans.
  • It is important to keep up-to-date and be familiar with guidelines and developments that affect your work.