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GPs go forth

GPs' kidney targets have swamped labs with rising costs and workload

Labs threaten boycott of kidney disease tests

Laboratories are threatening to refuse to conduct chronic kidney disease tests for GPs because the new quality indicators have sent costs soaring.

Biochemistry labs can no longer bear the burden of tests for parathyroid hormone and vitamin D, which guidelines recommend for all patients with stage 3 CKD.

An analysis at one lab calculated the cost of following Royal College of Physicians/RCGP guidelines would be as much as £11,500 for a 10,000-patient practice.

Labs currently bear that cost themselves but are considering refusing to undertake tests any longer unless properly paid.

Dr Edmund Lamb, consultant clinical scientist at East Kent Hospitals and renal expert for the Association for Clinical Biochemistry, said: 'Parathyroid hormone and vitamin D are something all of us are struggling with. Those tests are extremely expensive.

'It's imperative labs are refunded for this work as the current situation may become unsustainable.'

Dr William Bartlett, a spokesperson for the association and consultant clinical scientist at Ninewells Hospital in Dundee, said: 'Every lab's workload has gone up considerably. There's a finite amount of money available. It is a possibility that people will have to say "we can't afford to provide this as a blanket service".'

Another lab head, who did not wish to be identified, confirmed labs would consider refusing to conduct tests if they were not paid properly.

Dr Bernhard Klebe, renal research registrar at East Kent Hospitals, undertook modelling of the effect of implementing guidelines. Parathyroid hormone and vitamin D tests alone came to £3,300 per 10,000-patient practice.

He urged GPs to ignore some aspects of the guidance.

'There isn't any evidence to support the guidance – we shouldn't do those tests. Parathyroid hormone and vitamin D should only be done in people with stage 3 who are progressing quickly to stage 4 and you're really worried about renal bone disease setting in.'

GP experts also backed a more cautious approach.

Professor Mike Kirby, professor in health and human

sciences at the University of Hertfordshire and a GP in

Letchworth, said: 'If you're sure the patient has stage 4 they should have it. To do it on all stage 3 you probably need some sort of PCT guideline – it needs to be costed.'

Guidelines stretch services

Tests recommended

for stage 3 CKD

• Annual measurement of haemoglobin, potassium, calcium and phosphate

• Measurement of parathyroid hormone concentration

when stage 3 CKD is first diagnosed

• Renal ultrasonography in patients with lower urinary tract symptoms or refractory hypertension or unexplained progressive fall in eGFR

What is feasible?

• Parathyroid hormone for all stage 4 and those with rapid decline in eGFR

• No automatic tests on stage 3 without local funding arrangements in place

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