101
|
Bouquegneau A, Vidal-Petiot E, Vrtovsnik F, Cavalier E, Rorive M, Krzesinski JM, Delanaye P, Flamant M. Modification of Diet in Renal Disease versus Chronic Kidney Disease Epidemiology Collaboration equation to estimate glomerular filtration rate in obese patients. Nephrol Dial Transplant 2013; 28 Suppl 4:iv122-30. [PMID: 24026245 DOI: 10.1093/ndt/gft329] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Obesity is a recognized risk factor for both the development and progression of chronic kidney disease (CKD). Accurate estimation of glomerular filtration rate (GFR) is thus important in these patients. We tested the performances of two creatinine-based GFR estimates, the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, in an obese population. METHODS Patients with body mass index (BMI) > 30 kg/m(2) were included. The reference method for measured GFR (mGFR) was (51)Cr-EDTA (single-injection method, two blood samples at 120 and 240 min). Both indexed and non-indexed results were considered. Serum creatinine was measured using the IDMS-traceable compensated Jaffe method. Mean bias (eGFR-mGFR), precision (SD around the bias) and accuracy within 30% (percentage of estimations within 30% of mGFR) were calculated for both equations. RESULTS The population included 366 patients (185 women) from two different areas. Mean age was 55 ± 14 years, and mean BMI was 36 ± 7 kg/m(2). Mean mGFR was 56 ± 26 mL/min/1.73 m(2) (71 ± 35 mL/min without indexation). In the total population, mean bias was +1.9 ± 14.3 and +4.6 ± 14.7 mL/min/1.73 m(2) (P < 0.05), and accuracy 30% was 80 and 76% for the MDRD and CKD-EPI equations (P < 0.05), respectively. In patients with mGFR > 60 mL/min/1.73 m(2), mean bias was +4.6 ± 18.4 and +9.3 ± 17.2 mL/min/1.73 m(2) (P < 0.05), and accuracy 30% was 81 and 79% (NS) for the MDRD and CKD-EPI equations, respectively. CONCLUSIONS The CKD-EPI equation did not outperform the MDRD study equation in this population of obese patients.
Collapse
Affiliation(s)
- Antoine Bouquegneau
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium
| | | | | | | | | | | | | | | |
Collapse
|
102
|
MDRD versus CKD-EPI equation to estimate glomerular filtration rate in kidney transplant recipients. Transplantation 2013; 95:1211-7. [PMID: 23511243 DOI: 10.1097/tp.0b013e318288caa6] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The new Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine-based equation was developed to address the systematic underestimation of the glomerular filtration rate (GFR) by the Modification of Diet in Renal Disease (MDRD) Study equation in patients with a relatively well-preserved kidney function. The performance of the new equation for kidney transplant recipients is discussed. METHODS We analyzed the performances of the CKD-EPI equation in comparison with the MDRD Study equation in 825 stable kidney transplant recipients. Bias, precision, and accuracy within 30% of true GFR were determined. GFR was measured by urinary clearance of inulin (n=488) and plasma clearance of Cr-EDTA (n=337). RESULTS Mean measured GFR (mGFR) was 50±19 mL/min/1.73 m. On the whole cohort, bias was significantly lower for MDRD Study equation compared with CKD-EPI creatinine. This superiority translates into a better accuracy (80% and 74% for the MDRD and CKD-EPI creatinine, respectively). The best performance of the MDRD Study equation is confirmed both in the subgroups of patients with mGFR <60 mL/min/1.73 m and between 60 and 90 mL/min/1.73 m. For mGFR >90 mL/min/1.73 m, there were no significant differences between the two equations in terms of performance. CONCLUSIONS The CKD-EPI creatinine equation does not offer a better GFR prediction in renal transplant patients compared with the MDRD Study equation, even in the earlier CKD stages.
Collapse
|
103
|
Delanaye P, Mariat C. The applicability of eGFR equations to different populations. Nat Rev Nephrol 2013; 9:513-22. [DOI: 10.1038/nrneph.2013.143] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
104
|
Pattaro C, Riegler P, Stifter G, Modenese M, Minelli C, Pramstaller PP. Estimating the glomerular filtration rate in the general population using different equations: effects on classification and association. Nephron Clin Pract 2013; 123:102-11. [PMID: 23797027 DOI: 10.1159/000351043] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 04/03/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Several formulas for glomerular filtration rate (GFR) estimation, based on serum creatinine or cystatin C, have been proposed. We assessed the impact of some of these equations on estimated GFR (eGFR) and chronic kidney disease (CKD) prevalence, and on the association with cardiovascular risk factors, in a general population sample characterized by a young mean age. METHODS We studied 1,199 individuals from three Alpine villages enrolled into the MICROS study. eGFR was obtained with the 4- and 6-parameter MDRD study equations, the Virga equation, and with the three CKD-EPI formulas for creatinine, cystatin C, and the combination of creatinine and cystatin C. We assessed the concordance between quantitative eGFR levels, CKD prevalence, and in terms of association with total, LDL, and HDL cholesterol. RESULTS The highest and lowest eGFR levels corresponded to the cystatin C-based and MDRD-4 equations, respectively. CKD prevalence varied from 1.8% (Virga) to 5.8% (MDRD-4). The CKD-EPI based on creatinine showed the highest agreement with all other equations. Agreement between methods was higher at lower eGFR levels, older age, and in the presence of diabetes and hypertension. Creatinine-based estimates of eGFR were associated with total and low-density lipoprotein but not high-density lipoprotein cholesterol. The opposite was observed for the cystatin C-based GFR. CONCLUSION GFR estimation is strongly affected by the chosen equation. Differences are more pronounced in healthy and younger individuals. To identify CKD risk factors, the choice of the equation is of secondary importance to the choice of the biomarker used in the formula. If eGFR is not calibrated to a gold standard GFR in the general population, reports about CKD prevalence should be considered with caution.
Collapse
Affiliation(s)
- Cristian Pattaro
- Center for Biomedicine, European Academy of Bolzano/Bozen (EURAC), Bolzano, Italy.
| | | | | | | | | | | |
Collapse
|
105
|
Performance of creatinine and cystatin C-based glomerular filtration rate estimating equations in a European HIV-positive cohort. AIDS 2013; 27:1573-81. [PMID: 23435293 DOI: 10.1097/qad.0b013e32835fac30] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To validate glomerular filtration rate (GFR) estimating equations in white HIV-infected patients based on serum creatinine and/or serum cystatin C. DESIGN Single-center, cross-sectional evaluation of the predictive performance of GFR estimators. METHODS GFR was measured by iohexol plasma clearance. Serum creatinine (Scr) and serum cystatin C (Scyst) were measured by traceable and standardized methods. We evaluated the performance of the Modification of Diet in Renal Disease (MDRD) and the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equations. We also studied the performance of the cystatin C-based equation (CKD-EPI Scyst) and the combined cystatin and creatinine-based equation (CKD-EPI combined), as recently proposed by the CKD-EPI group. RESULTS Two hundred and three participants (18% of women) were included. Mean age was 49 ± 10 years. Mean measured GFR (mGFR) was 95 ± 24 ml/min per 1.73 m². CKD-EPI and CKD-EPI combined significantly outperformed the MDRD equation. The percentage of estimating results within 30% of mGFR was 75, 82 and 81% for the MDRD, CKD-EPI and CKD-EPI combined equation, respectively. Results favoring the CKD-EPI and CKD-EPI combined equation were especially observed for patients with mGFR over 90 ml/min per 1.73 m². CONCLUSION In our European HIV cohort, we confirmed that the creatinine-based CKD-EPI equation should replace the MDRD study equation. However, global performance of this equation remains worse than the performance observed in the general population. This lesser performance is particularly relevant in patients with measured GFR under and around 60 ml/min per 1.73 m². Moreover, the specific interest of Scyst-based equations is not confirmed in this population.
Collapse
|
106
|
Rule AD, Bailey KR, Lieske JC, Peyser PA, Turner ST. Estimating the glomerular filtration rate from serum creatinine is better than from cystatin C for evaluating risk factors associated with chronic kidney disease. Kidney Int 2013; 83:1169-76. [PMID: 23423253 PMCID: PMC3661736 DOI: 10.1038/ki.2013.7] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease risk factors may associate with the estimated glomerular filtration rate (eGFR) differently than with the measured GFR. To examine this, we evaluated 1150 patients (mean age 65 years) in two community cohorts for risk factors, measured GFR by iothalamate clearance, and eGFR based on creatinine (Cr), cystatin C (CysC), or both. The interaction between each risk factor and eGFR (relative to measured GFR) identified risk factor associations with eGFR along non-GFR pathways. In a subset of 40 patients with two visits, the mean coefficient of variation was 8.2% for measured GFR, 6.4% for eGFRCr, 8.2% for eGFRCr-CysC, and 10.7% for eGFRCysC. The measured GFR was better correlated with eGFRCr-CysC (r, 0.74) than eGFRCr (r, 0.70) or eGFRCysC (r, 0.68). Lower measured GFR associated with lower 24-hour urine creatinine, albuminuria, hypertension, diabetes, higher triglycerides, and higher uric acid. Lower eGFRCr had these same associations except for an association with higher 24-hour urine creatinine along a non-GFR pathway. Lower eGFRCysC and eGFRCr-CysC also had these same associations but also associated with obesity, albuminuria, hypertension, diabetes, higher triglycerides, higher C-reactive protein, and higher uric acid along non-GFR pathways. Thus, cystatin C improves estimation of GFR over creatinine alone; however, the association between most of the risk factors and GFR was more accurate by eGFR based on creatinine alone. This is explained by the association of these risk factors with the non-GFR determinants of cystatin C.
Collapse
Affiliation(s)
- Andrew D Rule
- Division of Nephrology and Hypertension, Division of Epidemiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | | | | | |
Collapse
|
107
|
Rule AD, Glassock RJ. GFR estimating equations: getting closer to the truth? Clin J Am Soc Nephrol 2013; 8:1414-20. [PMID: 23704300 DOI: 10.2215/cjn.01240213] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The application of serum creatinine and cystatin C in patients with CKD has been limited to using estimated glomerular filtration rate (eGFR). Criteria for choosing the best GFR estimating equation are 1) accuracy in estimating measured GFR, 2) optimal discrimination of clinical outcomes, and 3) association with CKD risk factors and outcomes similar to that of measured GFR. Notably, these criteria are often not in agreement; and while the last criterion is the most important, it has been widely overlooked. The primary problem with eGFR is that the non-GFR determinants of serum creatinine and cystatin C, as well as their surrogates (age, sex, and race), associate with CKD risk factors and outcomes. This leads to a distorted understanding of CKD, though eGFR based on serum creatinine appears to be less biased than eGFR based on cystatin C. Because of this problem, the use of eGFR should be limited to settings where knowing actual GFR is relevant and eGFR is more informative about GFR than serum creatinine or cystatin C alone. Such settings include staging CKD severity by GFR and dosing medications cleared by glomerular filtration. Alternatively, the diagnosis of CKD, the longitudinal progression of CKD, and prognostic models for CKD are settings where serum creatinine and cystatin C can be better applied and interpreted without eGFR.
Collapse
Affiliation(s)
- Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | | |
Collapse
|
108
|
Kovács F, Sárváry E, Remport Á. Comparison of seven estimated glomerular filtration rate equations in kidney patients. Orv Hetil 2013; 154:415-25. [DOI: 10.1556/oh.2013.29571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Introduction: The degree of glomerular filtration rate determines the stages of chronic renal disease and, therefore, knowledge on its estimation is essential. Aims: Two standardized creatinine based estimated glomerular filtration rate equations and five equations based on the immunoturbidimetric determination of cystatin C were compared. Methods: The distribution of the analytes and the equations, their relations, as well as the differences among the estimated glomerular filtration rates and their chronic kidney disease stages assignments were studied. Results: The equations based on cystatin C classified more patient into stage 1, while the creatinine based ones more into stages 2, 3 and 4. The equations published as Grubb1, Grubb2 and Larsson classified more patients while the equations created by Tan and Sjöström classified fewer into stage 5 compared to the creatinine based equations. The equations of Grubb1 and Grubb2 resulted in the most similar stage assignment. The occurence of stages between 3 and 5 was the lowest using the equation of Sjöström. Conclusions: The different equations for the estimation of glomerular filtration rate modify significantly the chronic kidney disease stage assignment which may have an influence on the treatment and outcome measures of the patients. Orv. Hetil., 2013, 154, 415–425.
Collapse
Affiliation(s)
- Ferenc Kovács
- Kanizsai Dorottya Kórház Központi Laboratórium Nagykanizsa Szekeres J. út 2–8. 8800
| | - Enikő Sárváry
- Semmelweis Egyetem, Általános Orvostudományi Kar Transzplantációs és Sebészeti Klinika, Központi Laboratórium Budapest
| | - Ádám Remport
- Szent Imre Kórház, Dél-budai Nefrológiai Központ Nefrológiai Profil és B. Braun Avitum Hungary Zrt. 1. Sz. Dialízisközpont Budapest
| |
Collapse
|
109
|
|
110
|
|
111
|
Doshi MD, Goggins MO, Li L, Garg AX. Medical outcomes in African American live kidney donors: a matched cohort study. Am J Transplant 2013; 13:111-8. [PMID: 23094818 DOI: 10.1111/j.1600-6143.2012.04303.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 08/31/2012] [Accepted: 09/01/2012] [Indexed: 01/25/2023]
Abstract
It is uncertain if live kidney donation increases future risk of hypertension and kidney disease in African Americans. We conducted a cohort study across two transplant centers enrolling African Americans who donated between 1993 and 2006. A comparison group of African American nondonors were selected from healthy participants in the Coronary Artery Risk Development in Young Adults (CARDIA) prospective cohort study. A total of 103 donors and 235 matched nondonors were assessed at mean ( ± SD) of 6.8 ± 2.3 and 6.4 ± 2.2 years after donation or cohort entry, respectively. The primary outcome was risk of hypertension in donors at follow-up. The secondary outcomes were proportion of donors with eGFR <60 mL/min/1.73 m2 and microalbuminuria. Hypertension risk was higher in donors compared to nondonors (42/103 [40.8%] vs. 42/235 [17.9%]), absolute risk difference 22.9% (95% confidence interval 12.2-33.6%) and relative risk 2.4 (95% confidence interval 1.7-3.4). Of the 42 donors with hypertension, 22 (52.4%) were untreated. Sixteen donors (15.5%) had an eGFR <60 mL/min/1.73 m(2) , 6 (5.8%) had microalbuminuria and none were on dialysis. Our retrospective study shows that live kidney donation is associated with increased risk of hypertension in African Americans and emphasizes the importance of donor follow-up.
Collapse
Affiliation(s)
- M D Doshi
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA.
| | | | | | | |
Collapse
|
112
|
Harman G, Akbari A, Hiremath S, White CA, Ramsay T, Kokolo MB, Craig J, Knoll GA. Accuracy of cystatin C-based estimates of glomerular filtration rate in kidney transplant recipients: a systematic review. Nephrol Dial Transplant 2012; 28:741-57. [PMID: 23275574 DOI: 10.1093/ndt/gfs498] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND As with creatinine, cystatin C can be incorporated into a formula to estimate the glomerular filtration rate (GFR). The overall performance of cystatin C-based equations in kidney transplantation is unclear with conflicting results between studies. METHODS Systematic review of adult kidney transplant recipients. Studies that reported mean bias (mean difference between the measured and estimated GFRs) or accuracy of the cystatin C-based GFR estimation equation (e.g. percentage of estimates within 30% of the measured GFR) against the measured GFR using renal or plasma clearance of contrast agents, radioisotopes or inulin were included. RESULTS The search identified 10 studies that examined 14 different cystatin C-based estimating equations (n = 5 equations evaluated in more than one study). The Le Bricon equation had the best performance with a bias that ranged from -6.4 to +2.8 mL/min/1.73 m(2); 85% (95% CI, 82-88) of estimates were within 30% of the measured GFR. For the other equations, 66-82% of estimates were within 30% of the measured GFR. For the modification of diet in renal disease (MDRD) equation, 68% (95% CI, 65-72) of estimates were within 30% of the measured GFR. CONCLUSIONS The cystatin C-based Le Bricon equation was the most accurate, and most of the cystatin C-based equations showed improvements in 30% and 50% accuracy compared with the creatinine-based MDRD equation. Cystatin C-based equations may offer an advantage over the MDRD equation in kidney transplant recipients. Estimating equations re-expressed with standardized cystatin C have been developed and their accuracy needs to be tested in the kidney transplant population.
Collapse
Affiliation(s)
- Gavin Harman
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
113
|
Delanaye P, Schaeffner E, Ebert N, Cavalier E, Mariat C, Krzesinski JM, Moranne O. Normal reference values for glomerular filtration rate: what do we really know? Nephrol Dial Transplant 2012; 27:2664-72. [PMID: 22802582 DOI: 10.1093/ndt/gfs265] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In nephrology, chronic kidney disease is defined by both proteinuria and measurement of glomerular filtration rate (GFR). This article focuses on GFR and different ways to define its normal reference values. In this context, we compare two perspectives: first the reference values defined by measuring GFR in normal individuals (the 'classical way') and secondly a fixed cut-off value at 60 mL/min/1.73 m2 according to the associated mortality risk (the 'prognostic way'). Following the classical way, we can assert that normal GFR values are largely over 60 mL/min/1.73 m2 in healthy subjects, at least before the age of 70 years. However, we know that GFR physiologically decreases with age, and in adults older than 70 years, values below 60 mL/min/1.73 m2 could be considered normal. Following the 'prognostic way', the fixed cut-off of 60 mL/min/1.73 m2 has been retained in the K-DIGO guidelines. However, we challenge this concept and the fact that the variable 'age' is poorly taken into account in these data. There is an obvious discrepancy between the reference values defined either by the 'classical way' or by the 'prognostic way' which we think could be largely reduced, if age was better taken into consideration in these definitions.
Collapse
Affiliation(s)
- Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège, CHU Sart Tilman, Liège, Belgium.
| | | | | | | | | | | | | |
Collapse
|
114
|
Masson I, Maillard N, Tack I, Thibaudin L, Dubourg L, Delanaye P, Cavalier E, Bonneau C, Kamar N, Morelon E, Moranne O, Alamartine E, Mariat C. GFR estimation using standardized cystatin C in kidney transplant recipients. Am J Kidney Dis 2012; 61:279-84. [PMID: 23141866 DOI: 10.1053/j.ajkd.2012.09.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 09/27/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND The utility of serum cystatin C (SCysC) as a filtration marker in kidney transplantation is uncertain. We took advantage of the recent validation of a reference calibrator for SCysC and of newly developed CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equations (2012) expressed for use with standardized SCysC level to reassess the performance of SCysC as a filtration marker in kidney transplant recipients. STUDY DESIGN Study of diagnostic test accuracy. SETTING & PARTICIPANTS 670 kidney transplant recipients from 3 centers undergoing glomerular filtration rate (GFR) measurements from December 2006 to November 2012. INDEX TEST Estimated GFR (eGFR) using the 2012 SCysC-based and serum creatinine (SCr)/SCysC-based CKD-EPI equations (eGFR(cys) and eGFR(cr-cys), respectively) and the 2009 SCr-based CKD-EPI equation (eGFR(cr)), with SCysC and SCr measured at a single laboratory between April 2011 and June 2011. REFERENCE TEST Measured GFR (mGFR) using urinary clearance of inulin. RESULTS Bias (the difference between mGFR and eGFR) was significantly smaller for eGFR(cys) and eGFR(cr-cys) versus eGFR(cr) (-2.82 and -0.54 vs +4.4 mL/min/1.73 m(2), respectively; P < 0.001). Precision (standard deviation of the mean bias) also was better for eGFR(cys) and eGFR(cr-cys) versus eGFR(cr) (12 and 11 vs 13 mL/min/1.73 m(2) [P < 0.001 for both comparisons]). Accuracy (percentage of GFR estimates within 30% of mGFR) was greater for eGFR(cys) and eGFR(cr-cys) versus eGFR(cr) (81% and 86% vs 75%, respectively [P = 0.004 and P < 0.001]). Net reclassification index with respect to mGFR of 30 mL/min/1.73 m(2) for eGFR(cr-cys) and eGFR(cys) versus eGFR(cr) was 18.8% [95% CI, 8.6%-28.9%] and 22.5% [95% CI, 10.2%-34.9%]. LIMITATIONS Patients were exclusively of European descent; association with transplant outcome was not evaluated. CONCLUSIONS Our data validate the use of both the newly developed SCysC-based and SCr/SCysC-based CKD-EPI equations (2012) in kidney transplant recipients. Both equations perform better than the SCr-based CKD-EPI equation (2009).
Collapse
Affiliation(s)
- Ingrid Masson
- Service de Néphrologie Dialyse Transplantation rénale, CHU Hopital Nord, Saint-Etienne, France
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
115
|
Performance of GFR equations in Japanese subjects. Clin Exp Nephrol 2012; 17:352-8. [DOI: 10.1007/s10157-012-0704-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 09/28/2012] [Indexed: 10/27/2022]
|
116
|
Dousdampanis P, Trigka K, Fourtounas C. Diagnosis and management of chronic kidney disease in the elderly: a field of ongoing debate. Aging Dis 2012; 3:360-72. [PMID: 23185717 PMCID: PMC3501392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 08/03/2012] [Accepted: 08/03/2012] [Indexed: 05/13/2024] Open
Abstract
Chronic kidney disease (CKD) is rather common in elderly adults who comprise the fastest growing subset of patients with end-stage renal disease (ESRD). At present, there are no specific guidelines and recommendations regarding early identification and management of elderly with CKD and the current CKD classification system may overestimate its exact prevalence. Screening strategies based either in a more accurate formula of estimation of GFR alone, or preferably in combination with proteinuria are urgently needed in order to raise awareness and to promote early diagnosis of CKD in the elderly. The number of elderly dialysis patients is also increasing and may lead to severe socio-economic problems worldwide. Both hemodialysis and peritoneal dialysis can sustain life, but present various disadvantages. There is a trend for home based dialysis therapies but the results are based on a small number of patients. Recent reports indicate that dialysis may not provide a clear benefit over non-dialysis regarding survival and quality of life issues, especially in the presence of extensive comorbidities. Current practices around the world regarding access to dialysis in the elderly are rather controversial, reflecting each country's health policies and ethical patterns. Although advanced age should not be considered as an absolute contraindication for kidney transplantation, it is not frequently offered in elderly ESRD patients due to the shortage of renal grafts. Global judgment of all physical and mental/psychological issues and full informed consent regarding possible complications are mandatory before listing elderly ESRD patients for kidney transplantation. As scientific evidence is rather scarce, there is an urgent need for prospective studies and an individualized approach for the diagnosis and treatment of the elderly CKD patients, in order to optimize care and improve quality of life in this special population.
Collapse
Affiliation(s)
| | | | - Costas Fourtounas
- Department of Internal Medicine- Nephrology, Patras University Hospital, Patras, Greece
| |
Collapse
|
117
|
Kilbride HS, Stevens PE, Eaglestone G, Knight S, Carter JL, Delaney MP, Farmer CKT, Irving J, O'Riordan SE, Dalton RN, Lamb EJ. Accuracy of the MDRD (Modification of Diet in Renal Disease) study and CKD-EPI (CKD Epidemiology Collaboration) equations for estimation of GFR in the elderly. Am J Kidney Dis 2012; 61:57-66. [PMID: 22889713 DOI: 10.1053/j.ajkd.2012.06.016] [Citation(s) in RCA: 185] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 06/12/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Glomerular filtration rate (GFR) is a measure of kidney function, commonly estimated using equations that adjust serum creatinine concentration for age, race, and sex. The Modification of Diet in Renal Disease (MDRD) Study equation is widely used, but underestimates GFR at higher levels. The serum creatinine-based Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI(cr)) equation generally provides more accurate estimation at GFR >60 mL/min/1.73 m(2). Newer equations have been reported using cystatin C concentration either alone (CKD-EPI(cys)) or in combination with creatinine concentration (CKD-EPI(cr-cys)). None of these equations has been well validated in older people. We tested the accuracy of these equations in people 74 years or older compared with GFR measured by a reference method. STUDY DESIGN Diagnostic test evaluation in a prospective cohort. SETTING & PARTICIPANTS Participants (n = 394; median age, 80 [range, 74-97] years) recruited from nephrology clinics and the community. INDEX TEST GFR estimated using the MDRD Study, CKD-EPI(cr), CKD-EPI(cys) and CKD-EPI(cr-cys) equations. REFERENCE TEST GFR measured using an iohexol clearance method. RESULTS Median measured GFR was 53.4 (range, 7.2-100.9) mL/min/1.73 m(2). MDRD Study-, CKD-EPI(cr)-, and CKD-EPI(cr-cys)-estimated GFRs overestimated GFR (median differences of 3.5 [P< 0.001], 1.7 [P < 0.001], and 0.8 [P = 0.02] mL/min/1.73 m(2), respectively); the CKD-EPI(cys) equation was unbiased. Accuracy (percentage of estimates within 30% of measured GFR [P(30)]) was 81%, 83%, 86%, and 86% for the MDRD Study, CKD-EPI(cr), CKD-EPI(cys), and CKD-EPI(cr-cys) equations, respectively. Accuracy of the MDRD Study equation was inferior (P = 0.004) to the CKD-EPI(cr) equation at GFR >60 mL/min/1.73 m(2). LIMITATIONS Those of non-European ancestry were not included. For practical reasons, only a 4-hour sampling protocol was used for iohexol clearance. CONCLUSIONS The CKD-EPI(cr) equation appeared less biased and was more accurate than the MDRD Study equation. No equation achieved an ideal P(30) in the overall population. Our data suggest that GFR estimation is as satisfactory in older people of European ancestry as it has been reported to be in younger individuals.
Collapse
Affiliation(s)
- Hannah S Kilbride
- The Kent Kidney Care Centre, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, United Kingdom
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
118
|
Delanaye P, Mariat C, Moranne O, Cavalier E, Flamant M. L’estimation du débit de filtration glomérulaire en 2012 : quelle valeur ajoutée pour la nouvelle équation CKD-EPI ? Nephrol Ther 2012; 8:199-205. [DOI: 10.1016/j.nephro.2012.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 03/16/2012] [Accepted: 03/18/2012] [Indexed: 10/28/2022]
|
119
|
Rothenbacher D, Klenk J, Denkinger M, Karakas M, Nikolaus T, Peter R, Koenig W. Prevalence and determinants of chronic kidney disease in community-dwelling elderly by various estimating equations. BMC Public Health 2012; 12:343. [PMID: 22574773 PMCID: PMC3490787 DOI: 10.1186/1471-2458-12-343] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 04/27/2012] [Indexed: 11/30/2022] Open
Abstract
Background Chronic kidney disease (CKD) represents a global public health problem. Few data exist in the elderly. The objective of the current study is to estimate the prevalence of CKD by means of various established and new equations and to identify the main determinants of CKD in elderly. Methods The ActiFE Ulm (Activity and Function in the Elderly in Ulm) study is a population-based cohort study in people of 65 years and older. Kidney function was assessed by means of estimated glomerular filtration rate (eGFR) based on two creatinine- (Cr-; MDRD, CKD-EPI) and one cystatin C - (CysC-) based method. The relationship between various potential risk factors and CKD was quantified using unconditional logistic regression. Results A total of 1471 subjects were in the final analysis (mean age 75.6 years, SD 6.56). Overall, prevalence of CKD (eGFR < 60 mL/min/1.73 m2) was 34.3% by MDRD, 33.0% by CKD-EPI, and 14.6% by the CysC-based eGFR. All eGFRs showed statistically significant correlations with C-reactive protein, uric acid, as well as with lipid values. In multivariable analysis age was clearly related to prevalence of CKD and the risks were highest with the CysC-based equation. Females had a higher risk for CKD stages 3–5 with MDRD (OR 1.63; 95% CI: 1.23–2.16) whereas the OR was 1.23 (95% CI 0.92–1.65) with the CKD-Epi and OR = 0.89 (95% CI 0.58–1.34) with the CysC-based equation after multivariable adjustment. Although the cystatin C based definition of CKD resulted in a lower prevalence compared to the creatinine based ones, other measures of renal damage such as albuminuria were more prevalent in those defined by CysC-eGFR. Conclusions Prevalence of CKD is very variable based on the used estimating equation. More work is needed to evaluate the various estimating equations especially in elderly before we are able to assess the practical consequences of the observed differences.
Collapse
Affiliation(s)
- Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Helmholtzstr 22, D-89081, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
120
|
Matsushita K, Mahmoodi BK, Woodward M, Emberson JR, Jafar TH, Jee SH, Polkinghorne KR, Shankar A, Smith DH, Tonelli M, Warnock DG, Wen CP, Coresh J, Gansevoort RT, Hemmelgarn BR, Levey AS. Comparison of risk prediction using the CKD-EPI equation and the MDRD study equation for estimated glomerular filtration rate. JAMA 2012; 307:1941-51. [PMID: 22570462 PMCID: PMC3837430 DOI: 10.1001/jama.2012.3954] [Citation(s) in RCA: 721] [Impact Index Per Article: 60.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
CONTEXT The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation more accurately estimates glomerular filtration rate (GFR) than the Modification of Diet in Renal Disease (MDRD) Study equation using the same variables, especially at higher GFR, but definitive evidence of its risk implications in diverse settings is lacking. OBJECTIVE To evaluate risk implications of estimated GFR using the CKD-EPI equation compared with the MDRD Study equation in populations with a broad range of demographic and clinical characteristics. DESIGN, SETTING, AND PARTICIPANTS A meta-analysis of data from 1.1 million adults (aged ≥ 18 years) from 25 general population cohorts, 7 high-risk cohorts (of vascular disease), and 13 CKD cohorts. Data transfer and analyses were conducted between March 2011 and March 2012. MAIN OUTCOME MEASURES All-cause mortality (84,482 deaths from 40 cohorts), cardiovascular mortality (22,176 events from 28 cohorts), and end-stage renal disease (ESRD) (7644 events from 21 cohorts) during 9.4 million person-years of follow-up; the median of mean follow-up time across cohorts was 7.4 years (interquartile range, 4.2-10.5 years). RESULTS Estimated GFR was classified into 6 categories (≥90, 60-89, 45-59, 30-44, 15-29, and <15 mL/min/1.73 m(2)) by both equations. Compared with the MDRD Study equation, 24.4% and 0.6% of participants from general population cohorts were reclassified to a higher and lower estimated GFR category, respectively, by the CKD-EPI equation, and the prevalence of CKD stages 3 to 5 (estimated GFR <60 mL/min/1.73 m(2)) was reduced from 8.7% to 6.3%. In estimated GFR of 45 to 59 mL/min/1.73 m(2) by the MDRD Study equation, 34.7% of participants were reclassified to estimated GFR of 60 to 89 mL/min/1.73 m(2) by the CKD-EPI equation and had lower incidence rates (per 1000 person-years) for the outcomes of interest (9.9 vs 34.5 for all-cause mortality, 2.7 vs 13.0 for cardiovascular mortality, and 0.5 vs 0.8 for ESRD) compared with those not reclassified. The corresponding adjusted hazard ratios were 0.80 (95% CI, 0.74-0.86) for all-cause mortality, 0.73 (95% CI, 0.65-0.82) for cardiovascular mortality, and 0.49 (95% CI, 0.27-0.88) for ESRD. Similar findings were observed in other estimated GFR categories by the MDRD Study equation. Net reclassification improvement based on estimated GFR categories was significantly positive for all outcomes (range, 0.06-0.13; all P < .001). Net reclassification improvement was similarly positive in most subgroups defined by age (<65 years and ≥65 years), sex, race/ethnicity (white, Asian, and black), and presence or absence of diabetes and hypertension. The results in the high-risk and CKD cohorts were largely consistent with the general population cohorts. CONCLUSION The CKD-EPI equation classified fewer individuals as having CKD and more accurately categorized the risk for mortality and ESRD than did the MDRD Study equation across a broad range of populations.
Collapse
Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
121
|
Juutilainen A, Kastarinen H, Antikainen R, Peltonen M, Salomaa V, Tuomilehto J, Jousilahti P, Sundvall J, Laatikainen T, Kastarinen M. Comparison of the MDRD Study and the CKD-EPI Study equations in evaluating trends of estimated kidney function at population level: findings from the National FINRISK Study. Nephrol Dial Transplant 2012; 27:3210-7. [PMID: 22492828 DOI: 10.1093/ndt/gfs047] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There are no data comparing the Modification of Diet in Renal Disease (MDRD) Study and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Study equations in the evaluation of time-dependent trend of estimated glomerular filtration rate (eGFR) in the general population. METHODS Changes in eGFR and in the association of eGFR with kidney disease and cardiovascular disease (CVD) risk factors across age groups were estimated in two independent cross-sectional population surveys in Finland in 2002 and 2007 with 11 277 study participants, aged 25-74 years, using both the MDRD and the CKD-EPI equations. RESULTS A trend towards decreasing eGFRs between the study years was observed using both equations, but the trend was more substantial when using the MDRD equation. The MDRD equation yielded lower estimates of eGFR than the CKD-EPI equation, with small mean difference between the equations at low eGFR level but substantial at the level of only mildly decreased or near-normal to normal kidney function. Decrease of eGFR was associated with an increase in CKD and CVD risk factors. However, an increase of risk factors was not observed among those who had mildly decreased eGFR by only the MDRD equation but not by the CKD-EPI equation. CONCLUSION In comparison with the CKD-EPI equation, the MDRD equation augmented the trend of increasing prevalence of CKD, showed a weaker association with risk factors and tended to assign impaired renal function to individuals without an excess of cardiovascular risk factors.
Collapse
Affiliation(s)
- Auni Juutilainen
- Institute of Clinical Medicine/Internal Medicine, University of Eastern Finland, Kuopio, Finland. Auni Juutilainen; E-mail:
| | | | | | | | | | | | | | | | | | | |
Collapse
|
122
|
Horio M, Yasuda Y, Imai E. Ethnic factors of the glomerular filtration rate estimating equation. Kidney Int 2012; 81:799; author reply 799-800. [DOI: 10.1038/ki.2011.489] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
123
|
The implications of anatomical and functional changes of the aging kidney: with an emphasis on the glomeruli. Kidney Int 2012; 82:270-7. [PMID: 22437416 DOI: 10.1038/ki.2012.65] [Citation(s) in RCA: 198] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Aging is both a natural and inevitable biological process. With advancing age, the kidneys undergo anatomical and physiological changes that are not only the consequences of normal organ senescence but also of specific diseases (such as atherosclerosis or diabetes) that occur with greater frequency in older individuals. Disentangling these two processes, one pathologic and the other physiologic, is difficult. In this review we concentrate on the glomerular structural and functional alterations that accompany natural aging. We also analyze how these changes affect the identification of individuals of advancing age as having chronic kidney disease (CKD) and how these changes can influence prognosis for adverse outcomes, including all-cause mortality, end-stage renal disease, cardiovascular events and mortality, and acute kidney injury. This review describes important shortcomings and deficiencies with our current approach and understanding of CKD in the older and elderly adult.
Collapse
|
124
|
Rule AD, Sasiwimonphan K, Lieske JC, Keddis MT, Torres VE, Vrtiska TJ. Characteristics of renal cystic and solid lesions based on contrast-enhanced computed tomography of potential kidney donors. Am J Kidney Dis 2012; 59:611-8. [PMID: 22398108 DOI: 10.1053/j.ajkd.2011.12.022] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 12/20/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND The presence of a few renal cysts is considered of little relevance in healthy adults, although acquired renal cystic disease occurs in advanced kidney failure. The objective of this study was to detail renal cystic and solid lesions and identify any association with clinical characteristics. STUDY DESIGN Clinical-pathologic correlation. SETTING & PARTICIPANTS Potential kidney donors undergoing a standardized evaluation at the Mayo Clinic in 2000-2008. PREDICTORS Age, kidney function, and chronic kidney disease risk factors. MEASUREMENTS Renal cystic and solid lesions by contrast-enhanced computed tomographic images. OUTCOMES Cyst number, diameter, and location. RESULTS After excluding 8 with cystic disease, 7 of whom had autosomal dominant polycystic kidney disease, there were 1,948 potential kidney donors (42% men; mean age, 43 years). A cortical, medullary, or parapelvic cyst ≥5 mm was present in 12%, 14%, or 2.8%. For ages 19-49 years, 39%, 22%, 7.9%, and 1.6% had a cortical or medullary cyst ≥2, ≥5, ≥10, and ≥20 mm in diameter. For ages 50-75 years, 63%, 43%, 22%, and 7.8% had a cortical or medullary cyst ≥2, ≥5, ≥10, and ≥20 mm in diameter. The 97.5th percentile for number of cortical and medullary cysts ≥5 mm increased with age (10 for men and 4 for women in the 60- to 69-year group). After age and sex adjustment, cortical and medullary cysts ≥5 mm were associated with higher 24-hour urine albumin excretion, as well as increased body surface area, hypertension, and higher glomerular filtration rate in some analyses. Angiomyolipomas, hyperdense cysts, and enhancing masses or cysts with concerning features for malignancy occurred in 2.2%, 1.2%, and 0.6% and were associated with older age (P ≤ 0.05 for each). LIMITATIONS Persons with known chronic kidney disease were excluded. CONCLUSIONS Renal cysts are common, particularly in older men, and may be a marker of early kidney injury because they associate with albuminuria, hypertension, and hyperfiltration.
Collapse
Affiliation(s)
- Andrew D Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | | | | | | |
Collapse
|
125
|
Wagner D, Kniepeiss D, Stiegler P, Zitta S, Bradatsch A, Robatscher M, Müller H, Meinitzer A, Fahrleitner-Pammer A, Wirnsberger G, Iberer F, Tscheliessnigg K, Reibnegger G, Rosenkranz AR. The assessment of GFR after orthotopic liver transplantation using cystatin C and creatinine-based equations. Transpl Int 2012; 25:527-36. [PMID: 22369048 DOI: 10.1111/j.1432-2277.2012.01449.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The measurement of kidney function after orthotopic liver transplantation (OLT) is still a clinical challenge. Cystatin C (CysC) has been proposed as a more accurate marker of renal function than serum creatinine (sCr). The aim of this study was to evaluate sCr- and CysC-based equations including the Chronic kidney disease (CKD)-EPI to determine renal function in liver transplant recipients. CysC and sCr were measured in 49 patients 24 months after OLT. The glomerular filtration rate (GFR) was calculated using the MDRD 4, the Cockroft-Gault, Hoek, Larsson, and the CKD-EPI equations based on sCr and/or CysC. As reference method, inulin clearance (IC) was estimated. Bias, precision, and accuracy of each equation were assessed and compared with respect to IC. Forty-five percent had a GFR < 60 ml/min/1.73 m(2) according to the IC. The Larsson, the Hoek and the CKD-EPI-CysC formula identified the highest percentage of patients with CKD correctly (88%, 88%, and 84%, respectively). The sCr-based equations showed less bias than CysC-based formulas with a similar precision. All CysC-based equations were superior as compared with sCr-based equations in the assessment of renal function in patients with an IC < 60 ml/min/1.73 m(2).
Collapse
Affiliation(s)
- Doris Wagner
- Department of Surgery, Division of Transplant Surgery, Medical University of Graz, Graz, Austria.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
126
|
Rule AD, Bailey KR, Turner ST. What Is the Goal With Endogenous Filtration Markers—Estimation of GFR or Prediction of Kidney Outcomes? Am J Kidney Dis 2011; 58:865-7. [DOI: 10.1053/j.ajkd.2011.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 10/11/2011] [Indexed: 11/11/2022]
|
127
|
West SL, Jamal SA, Lok CE. Tests of neuromuscular function are associated with fractures in patients with chronic kidney disease. Nephrol Dial Transplant 2011; 27:2384-8. [PMID: 22102617 DOI: 10.1093/ndt/gfr620] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Fractures are common in individuals with chronic kidney disease (CKD), and tests of neuromuscular function (NMT) discriminate well among fractured and non-fractured patients with Stage 5 CKD on dialysis. The ability of NMT to discriminate fracture status in patients with Stages 3-5 CKD is unknown. METHODS In this cross-sectional study, we sought to determine in adult patients with Stages 3-5 CKD (eGFR by the Modification of Diet in Renal Disease equation) if NMT [timed up and go (TUG), 6-min walk (6MW) and grip strength] could discriminate fracture status (self-reported low-trauma fractures since age 40 and/or vertebral fractures by morphometry). We conducted logistic regression and receiver-operating characteristic (ROC) curves for each predictor [expressed as area under the ROC curves (AUROC) with 95% confidence intervals (CI)]. RESULTS Data was available for 125 men and 86 women. The mean age was 63.3 ± 15.5 years, duration of CKD was 96.7 ± 125.3 months and one-third had diabetes. Patients with fractures were older and fell more frequently (P < 0.05). After adjusting for age, weight and sex, for every standard deviation increase in TUG and 6MW, the risk of fracture increased [odds ratio (OR): 1.68; 95% CI: 1.40-2.02] and decreased (OR: 0.53; 95% CI: 0.52-0.54), respectively. Both the TUG and 6MW could discriminate among those with and without fractures (AUROC: 0.90; 95% CI:0.84-0.95, AUROC: 0.87; 95% CI: 0.80-0.94, respectively). CONCLUSIONS The TUG and 6MW are able to discriminate fracture status in patients with Stages 3-5 CKD. These tests do not require specialized expertise/equipment and are an inexpensive method to assess for the presence of fractures.
Collapse
Affiliation(s)
- Sarah L West
- Department of Exercise Sciences, University of Toronto, Toronto, Ontario, Canada.
| | | | | |
Collapse
|
128
|
|