1. Making life easier… Dr Michael Gordon GP Gleadless Medical Centre Sheffield michael.gordon@sheffield.ac.uk

2. Making life easier… Dr Michael Gordon Primary Care Lead Yorkshire & The Humber Renal Network

3. Making life easier… Dr Michael Gordon (emisWeb expert…not)

4. Making life easier… A Protocol for ACR interpretation

5. ACR measurement fiddly but important • Measure albumin:creatinine ratio on a spot urine sample (preferably early morning) • If the initial ACR is >30 and <70 mg/mmol, confirm by a subsequent early morning sample. If the initial ACR is >70mg/mmol a repeat sample need not be tested • In people without diabetes, clinically significant proteinuria is present when ACR >30mg/mmol. • In people with diabetes microalbuminuria (ACR >2.5mg/ mmol in men and ACR >3.5mg/mmol in women) is clinically significant

6. The Challenges • NICE output • QOF requirements • Remembering everything v knowing where to look • Getting excited about niche areas – e.g. CKD • Thinking hard when tired – Lab results.

7. Proteinuria predicts progression of CKD RR of progression Urine protein excretion (g/day) Ann Intern Med 2003;139:244-252

8. Proteinuria and CV mortality Muntner P et al JASN 2002;13:745

9. CVD the big killer

10. Traditional solution…The Wall Chart For • Brighten the room • Info at fingertips • Promotes humility Against • Clutter • Get lost • Undermine aura of omniscience • Gathering data to check

13. When the ACR is 3 • What do you need to know about the patient to make sense of the result? • What else do you need to know to care for the patient optimally?

14. Facts (Concepts) • Gender • Diabetic? • CKD already? • Latest and previous eGFR • Coded for microalbuminuria already • Previous ACR readings • BP – latest • BP – appropriate target • ACE/ARB use • ACE/ARB allergy

15. emisWeb Protocols • Check the facts (concepts) • Follow user defined flowchart • End in user specified output • Applicable in a wide range of clinical situations

16. emis Web protocols – building blocks • Concepts • Something asked of the recorded data • e.g. gender, Lastest BP < 140/90, coding present • Questions • Posed to the operator • e.g. has the patient got specific symptoms • Outputs • Guidance for the operator • e.g. a text box saying repeat in 1 year

17. emisWeb protocols – construction process • Pencil, paper rubber • Build in emisWeb • Whiteboard, post-it notes, peer scrutiny • Attach to f12 key to run • Engage colleagues to test

18. Mrs A • Type 2 Diabetes • Latest BP 140/82 • Not coded for microalbuminuria/proteinuria • No recent consultation with UTI symptoms • 2 previous ACRs > 3.5 • Allergic to ace/arb • Latest ACR - 3.6

19. Mr B • Type 2 Diabetes • Latest eGFR 65 • Latest BP 129/79 • No recent symptoms of UTI • On Ramipril • Previous ACRs two > 2.5 • No microalbuminuria coded • Latest ACR - 25

20. Mr C • Not diabetic • Last eGFR 45 • CKD stage 3 coded • Latest BP 120/78 • On Losartan • No UTI symptoms • Latest ACR - 35

21. Ms D • Not diabetic • CKD stage 3 coded • Last eGFR 50 • Latest BP 130/80 • No UTI symptoms • Latest ACR - 50

22. Acknowledgements • NHS Kidney Care – How to Guides • Hosting videos and protocol to download • Partners at Gleadless Medical