Renal disease

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 hypercholesterolemia, which, combined with the adverse effects
of NSAIDs, produced an ischemic 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.