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Haematinic Guidelines

HEFT Pathology Guideline Investigation and Referral Pathways for Anaemia in Primary Care

Produced by:

Dr Sukhbir Kaur (Senior Clinical Biochemist)

Approved by:

Dr Kartsios Charalampos (Consultant Haematologist)

 

Dr Marcus Mottershead (Consultant Gastroenterology)

This guidence covers the following areas

1. Anaemia Testing in Adults

2. Iron Deficiency Anaemia Testing in Adults

3. Iron Deficiency Anaemia Treatment and Monitoring Advice

4. Vitamin B12 Deficiency Testing, Treatment and Monitoring

5. Folate Deficiency Testing, Treatment and Monitoring Advice

6. Renal Anaemia Testing in Adults

biochemistry, haematology, haemainics

Read more: Haematinic Guidelines

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Lipid Clinic

What is it?

Adult lipid and cardiovascular risk clinic. We see patients with high blood fats/lipids, review their results to try and establish the cause of the high lipids and work out if treatment is required and, if so, what options are available to you. Some lipid conditions run in families and it may be that your relatives e.g. your children need testing. One major role of the clinic is to make sure that we do not miss asymptomatic relatives in order to try and prevent future heart attacks and strokes.

Who do we see?

Dyslipidaemias (high or deranged blood lipids). People with complications of lipid problems e.g. pancreatitis and premature vascular disease People with side effects to lipid lowering medication People with poor control on current medications who require more treatment Specialist testing particularly looking into families with potential genetic lipid conditions or family history of premature vascular disease such as heart attacks and strokes. Limited screening of relatives directly, advice in regards to when family screening is required and what tests to perform. Also see general Metabolic patients particularly at Good hope hospital and sometimes at Heartlands

Location?

Outpatient department in Heartlands.

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    Outpatient department Good Hope

    Contact information (if you want to speak to clinic organisers)?

    Booking service for appointment alterations via contact information on the appointment letter

    Contact Lipid clinic secretary for all other queries as follows:

    Heartlands hospital Secretary: 0121 42 43228 This email address is being protected from spambots. You need JavaScript enabled to view it.

    Good Hope hospital Secretary: 0121 42 47246 This email address is being protected from spambots. You need JavaScript enabled to view it.

    What are the prereferral tests?

    To help guide us with your management your GP will arrange for you to have some blood tests

    What do you need to bring?

    It is helpful to have a list of your medications if you can’t remember what they are.

    What do I need to do?

    Besides bringing your tablet list sometimes we ask people for fasting blood tests. Sometimes lipid tests can be done non-fasting. Please let us know if you cannot make an appointment as sometimes, even at late notice, an emergency patient can be asked to attend to fill your slot.

    What do we do?

    Diagnosis is based on your medical history, clinical examination and blood tests. Sometimes further investigations e.g. treadmill test may be indicated. Once a diagnosis is established then most treatment involves diet and lifestyle changes and some require medications, such as statins and fibrates, to reach treatment targets.

    Who will I see?

    The team at Heartlands consists of

    Dr Alan Jones (Consultant Chemical Pathologist)

    Dr Ummu Mayana (Honorary Consultant Chemical Pathologist)

    Dr Ateeq Syeed (consultant endocrinologist)

    Mrs Katherine Peers (Advanced Nurse Practitioner).

    Dr Sud Ramachandran (Consultant Chemical Pathologist) sees patients who have been referred to Good Hope at Good Hope Hospital. Heartlands and Good Hope are teaching hospitals therefore occasionally medical students and doctors in training may be present.

    Other services available?

    Some patients can be referred to the dietetics department for dietary advice. In rare cases we may ask cardiology or the diabetic team to become involved in your care. There is no paediatric or genetics service attached to the clinic. For children picked up in the clinic as having a genetic lipid disorder we refer them to the Birmingham Children’s Hospital to discuss further treatment.

    Useful links

    Diet advice

    Exercise Advice/counselling

    Heart UK

    BHF

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    Tumour Marker Use in Primary Care

    In the last 5 years requests for tumour marker tests from Primary Care have more than doubled. This high use in Primary Care is worrying because the majority of tumour markers (eg. CEA, CA19-9) are neither specific nor sensitive enough for use in the diagnosis of malignancy. See this link for a summary of the main tumour markers, their uses and limitations.

    The main use for tumour markers is in monitoring disease progression, treatment or recurrence of a histologically diagnosed cancer. A recent audit of Primary Care requests for tumour markers found that only 9% of CEA and 4% of CA19-9 were requested for these reasons; the rest being for non-specific symptoms.

    In contrast to the above, CA125 and PSA do have use in diagnosis of their related cancers, however it should also be noted that these are still only a diagnostic aid and should be used with caution as both can be raised in a number of other benign conditions (see table). Please click the relevant links below of links to guidelines relating to their use in Primary Care.

    CA125 link https://pathways.nice.org.uk/pathways/ovarian-cancer

    PSA link https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

    For symptoms and referral guidelines of other malignancies see the NICE Suspected Cancer Recognition and Referral guidelines. http://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral

    You can also use the search bar or test database on this website to find more specific information on the use of each tumour marker.

    Tumour marker

    Main application

    Other tumour elevations

    Other limitations

    CEA

    Monitoring colorectal adenocarcinomas

    Breast, lung, gastric, mesotheliomas, oesophageal and pancreatic

    Raised in smokers

    Raised in other benign renal, liver, lung or GI disease

    Poor sensitivity in early disease and may be absent/low in poorly differentiated tumours

    CA19-9

    Monitoring pancreatic carcinoma

     

    Raised in obstructive jaundice, cholestasis, cirrhosis, pancreatic hepatitis and non-malignant GI disease.

    Not present in those negative for the Lewis blood group determinant.

    CA125

    Monitoring ovarian carcinoma

     

    Raised in patients with ascites, pleural effusions or free fluid in the pelvis

    Raised in patients with congestive heart failure

    Raised in benign renal and liver disease and other adenocarcinomas

    Mildly raised in menstruation and the first two trimesters of pregnancy

    Can be raised in endometriosis

    CA15-3

    Monitoring breast cancer

    Lung, colon, ovary

    Raised in benign liver, breast, ovarian disease

    AFP

    Diagnosis and monitoring of hepatocellular carcinoma and germ cell tumours

    Gastric and other GI (oesophageal, pancreatic)

    Raised in pregnancy and neonates

    Raised in benign liver disease

    PSA

    Diagnosis and monitoring of prostate carcinoma

     

    Also elevated in benign prostatic conditions

    Increases with age (as prostate size increases)

    Elevated in UTI, catheterisation, prostatitis or other prostate manipulation

    hCG

    Diagnosis and monitoring of germ cell tumours and gestational trophoblastic neoplasia

    Lung

    Raised in pregnancy

    Transiently elevated with cannabis use

    LDH

    Diagnosis and monitoring of germ cell tumours

     

    Elevated in cardiac disease and benign liver disease

    Elevated in some anaemias relating to non-malignant disease

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    Clinical Decision Limits

    Phoning limits for biochemistry tests are as follows:

    Decision limits for phoning

    Analyte

    Phone results below or equal to:

    Phone results above or equal to:

    Units

    Notes

    Sodium

    120

    150

    mmol/L

     

    Potassium

    2.5

    6.5

    mmol/L

     

    Urea

    -

    Adults: 30

    Paediatrics: 10

    mmol/L

    Except those on renal wards or under renal consultants.

    Creatinine

    -

    Paediatrics: 200

    umol/L

    eGFR

    Adults: 15

    -

    ml/min

    AKI

    -

    2

     

    Not CKD patients (AKI 2 discretionary)

    Glucose

    2.5

    25

    mmol/L

     

    Calcium adjusted

    1.8

    3.5

    mmol/L

     

    Magnesium

    0.4

    -

    mmol/L

     

    Phosphate

    0.3

    -

    mmol/L

     

    AST

    -

    600

    U/L

     

    ALT

    -

    600

    U/L

     

    Total CK

    -

    5000

    U/L

     

    Amylase

    -

    500

    U/L

     

    Digoxin

    -

    2.5

    ng/mL

     

    Theophylline

    -

    25

    mg/L

     

    Phenytoin

    -

    25

    mg/L

     

    Lithium

    -

    1.5

    mmol/L

     

    Troponin T

    -

    GP only: >14

    ng/L

    GP only

    Ammonia

    -

    100

    umol/L

     

    Ethanol

    -

    Paediatrics only: any detectable

    mg/L

    Paediatrics only

    Paracetamol

    -

    10

    mg/L

    Not ED patients

    Salicylate

    -

    300

    mg/L

    Not ED patients

    Conj bilirubin (DBIL)

    -

    Paediatrics only:

    25

    umol/L

    Paediatrics only

    Total bilirubin

    -

    Paediatrics only: 225

    umol/L

    Paediatrics only

    Carbamazepine

    -

    25

    ug /mL

     

    Iron

    -

    ED only: 70

    umol/L

    ED only

    Phenobarbitone

    -

    70

    mg/L

     

    CSF Gluc

    3.3

    -

    mmol/L

     

    CSF Prot

    -

    0.45

    g/L

     

    Lactate

    -

    2.3

       

    CRP

    -

    300

       

    Total bile acids

    -

    20

       

    Methotrexate

    Phone all

    umol/L

     

     

    Immunology results to be telephoned:

    • CD4 count <200 cells/cumm or <10% on new patients (paediatric levels are different, but agreed with Paed consultants)
    • Lymphocyte subsets in infants <2yo: Any T cell subset below age-related normal range, any other abnormality suggesting SCID (e.g. MHC class II deficiency). (Note this is not exclusive: any abnormality may be discussed with requesting clinician)
    • New positive GBM antibodiest
    • New positive MPO antibodies
    • New positive PR3 antibodies
    • New paraprotein IgG , A or M  > 20g/L
      • IgD or IgE (any size)
      • serum monoclonal free light chains (any size, whether or not with intact paraprotein)

    Abnormal Laboratory Test Results – Triggers for Telephoning Results Haematology

    HaemoglobinWhite Blood Cell Count
    <8.0 g/dl normochromic and normocytic Low result – neutropenia <0.5 x 10 9/L
    <7.0 g/dl microcytic and hypochromic   High result – White cell count >40 x 10 9/L
    <7.0 g/dl macrocytic  or Lymph count > 20 x 10 9/L
    <5.0 g/dl renal patients Any presence of blast cells
    PlateletsClotting Studies
    Lower limit - <70 x 10 9/L   INR - >5.0
    Upper limit - >1000 x 10 9/L   PTT - >180 seconds
      Fibrinogen < 1.0g/l
    • All Positive Malaria Screens
    • All Anti FXa results >1.20 iu/ml
    • If the patient is known to the department and has had a similar result within the previous 7 days then the urgent contact is not necessary.

    HPA Microbiology – List of abnormal results telephoned to clinical staff

    Bacteriology

    • Gram stain results of positive blood culture on Day 1
    • Positive CSF results
    • Positive sterile site results
    • Significant in-patient results from enteric bench
    • Multi resistant gram negative and gram positive isolates including mupirocin resistant MRSA
    • Group B streptococcal isolates from neonates
    • Group A in patient isolates
    • Positive Legionella urinary antigen and Pneumococcal urine antigen results
    • Smear and culture positive Mycobacteria
    • Antibiotic assay results outside normal ranges
    • Any other significant results at the discretion of Medical Microbiologists

    Virology

    • Serological evidence of acute infection with Hep A, Hep B and in pregnant patients CMV, Parvovirus and Rubella
    • New diagnoses of HIV
    • VZV IgG negative from exposed patients at risk of severe VZV infection
    • New diagnosis of Hep B, Hep C and HIV in haemodialysis patients
    • Evidence of Hep B/Hep C and HIV in needle stick injury source patients
    • Clinically important positive respiratory PCR results i.e.: influenza, RSV in immunocompromised patients
    • Positive PCR results in outbreaks
    • Positive blood PCR for CMV and Adenovirus
    • Negative blood results for CMV PCR
    • Significant blood PCR results for EBV and Polyomavirus
    • All positive PCR results on CSF specimens
    • All positive Chlamydia PCR results on eye swabs
    • All positive PCR results from neonatal unit
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    Notice of the change to the equation used to calculate estimate glomerular filtration rate (eGFR) across UHB on November 22nd 2021

    On 22.11.201, the formula to calculate eGFR at UHB will be changed from MDRD to CKD-EPI. This is in line with long standing NICE guidance. This is a more accurate equation to estimate GFR. This will not affect the management of patients and should not lead to a major eGFR change on an individual patient basis. As per NICE guidance, it is no longer necessary to correct for ethnicity.

    Further information

    At present, eGFR is calculated at UHB using the MDRD equation. This equation was based upon measurements in patients with established renal disease. It uses creatinine, sex, age, and the ethnicity of the patient to estimate the GFR.  The group that developed the MDRD equation subsequently developed the CKD-EPI equation using data from patients who had normal and impaired renal function. Like MDRD, the original CKD-EPI equation used creatinine, sex, age, and the ethnicity of the patient to estimate the GFR however recent NICE guidance has recommended that ethnicity is no longer used. CKD-EPI is thought to reflect renal function better than the MDRD equation. Compared to measured GFR, performance of the two equations are similar when GFR is < 60 mL/min/1.73 m2 with the MDRD equation underestimating GFR at levels > 60 mL/min/1.73 m2 when compared to the CKD-EPI equation. It is thought that the impact on patient management will be minimal however there is a possibility that CKD classifications could change due to CKD-EPI more closely reflecting the ‘true’ GFR. NICE has recommended using the CKD-EPI equation to calculate eGFR since 2014 with ethnicity removal outlined this year.

    There is no change to specimen requirements or test requesting.

    For clinical queries relating to this change please contact Professor Paul Cockwell (This email address is being protected from spambots. You need JavaScript enabled to view it.). For laboratory queries please contact Dr Alex Lawson (This email address is being protected from spambots. You need JavaScript enabled to view it.).

    References

    Chronic kidney disease: assessment and management. NICE guideline [NG203]

    https://www.nice.org.uk/guidance/ng203/resources/chronic-kidney-disease-assessment-and-management-pdf-66143713055173

    UK Kidney Association The rationale for removing adjustment for ethnicity from eGFRcreatinine and recommendations for implementation of the change in practice

    https://ukkidney.org/sites/renal.org/files/guidelines/Rationale_and_recommendations_for_implementation_NICE%20CKD%20Guideline%202021.pdf

    Original CKD-EPI Paper – Comparison of MDRD and CKD-EPI

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2763564/pdf/nihms132246.pdf

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