In daily practice, most of the practitioners often see one or two patients having long standing hypertension, diabetes or both; specially elderly patients who have come for the first time. While asking for blood tests remember to test the serum creatinine levels. You will pick up many patients of chronic renal failure (CRF), in whom, creatinine level is slightly more than normal. Of course, this calls for better control of hypertension and diabetes, and half-yearly follow up of creatinine.
Often the patients ask me the significance of CRF with a creatinine of 1.6 or 2. I usually explain the patients that both the kidneys have failed or become weak (the word ‘weak’ is normally used if the patient is very sensitive) and the patient will now need religious follow up with blood tests, to check the silent rise of creatinine over the next few years.
The next question I expect to hear, "if it rises to certain level, for example 8 or 10, then what is to be done"? My answer would be that the patient would have to go on a long term dialysis, for lifetime, unless he succeeds in getting a kidney donor. Such a statement will normally frighten the patient, who will certainly change his doctor.
If you do not tell him so frankly, and if after 5 years his creatinine rises to a level, where he has to go on lifetime dialysis, he would always think that it was your bad management of illness, which has landed him in this situation.
On such occasions, do ask for GFR test (Glomerular Filtration Rate). Metropolis laboratory in Mumbai has already started doing it. A normal GFR is within 120 ml. GFR falls with age, though patients of CRF will always have a low GFR. However, several studies have shown that if the GFR is less than 30%, there are nearly one-third chances of the patient needing lifetime dialysis, after a few years. But if it is more, for example in the vicinity of 40-60%, there is only 1% chance of the same.
Thus, all the family physicians should be asking for GFR in all patients having raised creatinine as an incidental finding (though not in case of a hospitalised patient with an acute illness), so that one can confidently tell the patient about his future. Such a patient (with very low GFR) will have to start collecting finances for the future. It appears to me that soon most of the laboratories will start doing this test, which really requires only applying a formula, involving details of age and weight of the patient, as well as the level of creatinine.
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.