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Renal Medicine
March 27, 2018
We recently contacted Dr. Scott Brimble, nephrologist at St. Joseph’s Hospital, as part of our reaching out to specialties across our LHIN.

They have recently reviewed their referral data and they have a 19% growth rate each of the past 4 years, which is unsustainable. Only 11% of referrals for CKD or proteinuria were deemed "appropriate" and/or provided the required information based on Kidneywise (which is: basically 2 eGFR and ACR values, eGFR<30, ACR> 60, or eGFR 30-45/ACR30-59).

So, there is much room for improvement in referring patients with kidney disease and eConsult provides an efficient, quick way to streamline the whole process.

According to Dr. Brimble, sensible reasons to use eConsult could include:

1. Low eGFR
  • eGFR 30-44 x 2, ACR<30 and you are worried (e.g. progressing, unable to achieve BP targets, metabolic complications,etc.);
  • eGFR 20-29 x 2, ACR<30 and patient is frail, or travel a challenge, or things are stable/you are not too worried;
  • a decline that you are worried about

2. Proteinuria
  • ACR>60, patient is frail, or travel travel a challenge;
  • ACR 30-59, and you are worried (e.g. unable to achieve BP targets, evidence of eGFR decline, no obvious reason)
A recent case shows the utility of eConsult and the ability to engage in a bit of discussion in order to come up with a plan. The issue was a rising Creatinine, in a patient on a medication known to cause renal problems.

  • 58 year old male, has bipolar disorder, managing ok with stable mental status
  • Creat - 207 on Jul 28
  • Lithium reduced from 1050 mg to 600 mg
  • Creat - 205 on Nov 3
  • Most recent Creat - 219 on Feb 8
  • Bloodwork and meds were attached

Question for consultant: Any suggestions to manage rising Creatinine?

In the absence of other data I presume he has lithium-related renal disease - you might ask if he is polyuric or polydipsic (i.e. does he have nephrogenic diabetes insipidus from the lithium). He may have some element of volume depletion if that is the case although his serum sodium was fine. As per the guidelines at , I would order a urine ACR, urinalysis, extended lytes and serum PTH (patients can also develop hyperparathyroidism in this setting). Ensure his BP is adequately controlled and refer to a local nephrologist for further evaluation. I suspect they will order a renal US as well. If lithium-related disease is strongly suspected, a decision will need to be made re continuing the lithium, balancing the presumed benefits of the therapy for his mental health versus the ongoing renal complications. The renal disease does not necessarily stabilize or improve with cessation of the lithium, however.

The Referring Physician added a note and further attachments to the eReferral at a later date: "Sorry I forgot to include this, here are more labs from Jul 2015, how does incr PTH change management?"

He likely has lithium-induced hyperparathyroidism - the high PTH in and of itself could have been attributed to the CKD but the low-normal PO4 with high-normal calcium points to a primary disorder of sorts (e.g. caused by lithium). Nothing really changes, he is not hypercalcemic so is fine. I suppose it might be more reason to stop the lithium if an alternative agent is available. At this point I would refer to nephrology for an in-person consultation.
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