Abstract
The performance of glomerular filtration rate- (GFR-) estimating equations was studied against creatinine clearance measured by 24-hour urine collection (CrCl24h-urine) in critically ill patients. Methods. In this substudy of the PermiT trial (https://clinicaltrials.gov/ct2/show/ISRCTN68144998), patients from King Abdulaziz Medical City-Riyadh who had CrCl24h-urine were included. We estimated GFR using Cockroft–Gault (CG), modification of diet in renal disease study (MDRD), chronic kidney disease epidemiology collaboration (CKD-EPI), and Jelliffe equations. For the CG equation, we entered the actual weight in one calculation (CGactual-wt), and if BMI ≥30 kg/m2, we entered the ideal body weight (CGideal-wt) and the adjusted body weight (CGadjusted-wt) in two calculations. We calculated the MDRD equation based on 4 (MDRD-4) and 6 variables (MDRD-6). The performance of these equations was assessed by different ways including Spearman correlation, bias (difference between estimated GFR and CrCl24h-urine), precision (standard deviation of bias), and Bland–Altman plot analysis. Results. The cohort consisted of 237 patients (age 45 ± 20 years, males 75%, mechanically ventilated 99% with serum creatinine 101 ± 94 µmol/L and CrCl24h-urine 108 ± 69 ml/min/1.73 m2). The correlations between the different equations and CrCl24h-urine were modest (r: 0.62 to 0.79; p < 0.0001). Bias was statistically significant for CGactual-wt (21 ml/min), CGadjusted-wt (12 ml/min), and MDRD-6 (-10 ml/min) equations. Precision ranged from 46 to 54 ml/min. The sensitivity of equations to correctly classify CrCl24h-urine 30–59.9 ml/min/1.73 m2 was 17.2% for CGactual-wt, 30.0% for CGideal-wt, 31.0% for CGadjusted-wt, 31.0% for MDRD-4, 39.1% for MDRD-6, 13.8% for CKD-EPI, and 34.5% for Jelliffe equation. Conclusions. Commonly used GFR-estimating equations had limited ability to properly estimate CrCl24h-urine and to correctly classify GFR into clinically relevant ranges that usually determine dosing of medications.
Highlights
Appropriate dosing of medications is frequently dependent on renal function. e Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines consider GFR as the preferred measure of kidney function rather than serum creatinine (Cr) and recommend estimating GFR in most circumstances and measuring it when greater accuracy is required [1]
Measured urinary Cr clearance (CrCl) is more widely available, but it may overestimate GFR because of Cr filtration and secretion; the latter can be affected by medications known to compete with active tubular secretion of Cr [24]
One study found that urinary CrCl with short collection times (1–2 h) had the highest correlation with measured GFR using inulin clearance (r 0.921). e median bias for measured urinary CrCl was 11 mL/min/1.73 m2 for GFR 90ml/min [17]
Summary
Appropriate dosing of medications is frequently dependent on renal function. e Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines consider GFR as the preferred measure of kidney function rather than serum creatinine (Cr) and recommend estimating GFR in most circumstances and measuring it when greater accuracy is required [1]. Appropriate dosing of medications is frequently dependent on renal function. E Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines consider GFR as the preferred measure of kidney function rather than serum creatinine (Cr) and recommend estimating GFR in most circumstances and measuring it when greater accuracy is required [1]. Despite being the gold standard for assessment of renal function, this measurement is not routinely performed in clinical practice as it is complex, impractical, costly, and not widely available. Estimation of GFR using methods that are practical and timely is desirable in all patients in general. Is might be more important in critically ill patients as they have increased prevalence of kidney dysfunction [3] and frequently exhibit augmented renal clearance (ARC) [4, 5]. Proper dosing of medications in these patients would enhance their therapeutic effect, reduce potential toxicities, and improve patient outcomes [6, 7]
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