Accuracy Evaluation of 2021 Chronic Kidney Disease Epidemiology Collaboration, Full Age Spectrum and European Kidney Function Consortium Equations for Estimating Glomerular Filtration Rate in Type 2 Diabetes Mellitus and Healthy Adults

Is race adjustment necessary to estimate glomerular filtration rate in South Brazilians?

BACKGROUND AND AIMS

Race coefficients (RC) in equations to estimate glomerular filtration rate (GFR) have been highly questioned. We aimed to evaluate the performance of three equations, namely 2009 Chronic Kidney Disease Epidemiology Collaboration (2009 CKD-EPI), 2021 CKD-EPI, and European Kidney Function Consortium (EKFC) in self-reported Black and White Brazilians.

MATERIALS AND METHODS

Our cross-sectional study compared estimated GFR (eGFR) with 51Cr-EDTA measured GFR (mGFR) in healthy adults, patients with type 2 diabetes mellitus with or without chronic kidney disease (CKD), and in non-diabetic individuals with CKD. The performance of these equations was assessed using Bland-Altman plots, Lin's concordance correlation coefficient (CCC), bias, P30, and P15 accuracy.

RESULTS

Three hundred six White adults (aged 53 ± 17 years, 55% women, mean mGFR: 83 ± 32 mL/min/1.73 m2) and 48 Black participants (aged 53 ± 17 years, 58% women, mGFR: 90 ± 34 mL/min/1.73 m2) were included. No equation achieved the desirable P30 accuracy value of 90%, neither in White (2009 CKD-EPI:78%, 2021 CKD-EPI:76% and EKFC:77%, p = 0.368) nor in Black volunteers (respective values of 77%, 75%, and 77%; p = 0.882). The 2009 CKD-EPI showed the best performance in Black participants (bias: 4.04; CCC: 0.848), whereas the 2021 CKD-EPI performed better in Whites, with smaller bias (1.45), and better concordance correlation coefficient (0.790). The EKFC presented the worst performance. All equations underdiagnosed advanced CKD in White participants, but not in Black.

CONCLUSIONS

The 2021 CKD-EPI does not outperform the 2009 CKD-EPI. Instead, it underestimated the occurrence of CKD in White participants. Thus, we do not recommend replacing the 2009 with the new 2021 CKD-EPI in the Brazilian population.

Estimating glomerular filtration rate with new equations: can one size ever fit all?

Glomerular filtration rate (GFR) is thought to be the best overall indicator of kidney health. On an individual patient basis, a working knowledge of GFR is important to understand the future risk for chronic kidney disease (CKD) progression, enhanced risk for cardiovascular disease and death, and for optimal medical management including the dosing of certain drugs. Although GFR can be directly measured using exogenous compounds that are eliminated by the kidney, these methods are not scalable for repeated and routine use in clinical care. Thus, in most circumstances GFR is estimated, termed estimated GFR (eGFR), using serum biomarkers that are eliminated by the kidney. Of these, serum creatinine, and to a lesser extent cystatin C, are most widely employed. However, the resulting number is simply a population average for an individual of that age and sex with a given serum creatinine and/or cystatin C, while the range of potential GFR values is actually quite large. Thus, it is important to consider characteristics of a given patient that might make this estimate better or worse in a particular case. In some circumstances, cystatin C or creatinine might be the better choice. Ultimately it is difficult, if not impossible, to have an eGFR equation that performs equally well in all populations. Thus, in certain cases it might be appropriate to directly measure GFR for high consequence medical decision-making, such as approval for kidney donation or prior to certain chemotherapeutic regimens. In all cases, the eGFR thresholds of CKD stage should not be viewed as absolute numbers. Thus, clinical care should not be determined solely by CKD stage as determined by eGFR alone, but rather by the combination of an individual patient's likely kidney function together with their current clinical situation.

Comparison of the 2021 and 2009 Chronic Kidney Disease Epidemiology Collaboration Creatinine equation for estimated glomerular filtration rate in a Chinese population

OBJECTIVES

To retrospectively compare the clinical effects of the newly released 2021 and 2009 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations for estimated glomerular filtration rate based on creatinine (eGFRcr) in a Chinese population with a broad spectrum of clinical characteristics using historical data.

DESIGN AND METHODS

Patients and healthy individuals who visited the Zhongshan Hospital, Fudan University, between July 1, 2020, and July 1, 2022, were enrolled. The exclusion criteria were age < 18 years, amputees, pregnant women, patients with muscle-related diseases, and patients who had undergone ultrafiltration or dialysis. The final study population included 1,051,827 patients with a median age of 57 years; 57.24% of the enrolled individuals were men. eGFRcr was calculated using the 2009 and 2021 CKD-EPI equations and initial creatinine level. Results were evaluated statistically by sex, age, creatinine level, and CKD stage.

RESULTS

The 2021 equation increased the eGFRcr in all participants compared to the 2009 equation by 4.46%. The median eGFRcr deviation of the 2021 CKD-EPI equation compared to the 2009 CKD-EPI equation was 4 ml/min/1.73 m². 903443 subjects (85.89%) had higher eGFRcr owing to the utilization of the 2021 CKD-EPI equation, which did not cause CKD stage change. A total of 11.57% of subjects (121,666) had improved CKD stage with the 2021 CKD-EPI equation. 1.79% (18,817) had the same CKD stage with both equations, and 0.75% (7,901) had lower eGFRcr but no change in the CKD stage with the 2021 equation.

CONCLUSIONS

The 2021 CKD-EPI equation typically produces higher eGFRcr results than the 2009 version. Applying the new equation could lead to changes in the CKD stage for some patients, which doctors should consider. .

Meta-Analysis of the Effect of Nursing Intervention on Children with Type 2 Diabetes

Objective

To systematically evaluate the effect of nursing intervention on children with type 2 diabetes.

Methods

The randomized controlled trials (RCTs) on nursing intervention in children with type 2 diabetes in CNKI, VIP, WanFang, Chinese Biomedical Database (CBM), PubMed, The Cochrane Library, Embase, and Science were searched by the computer until July 2022. Two evaluators reviewed the articles, selected the information, and assessed their quality according to the inclusion criteria and exclusion criteria and then carried out meta-analysis with RevMan 5.3.

Results

A total of 5 RCT studies were kept, including 319 patients with type 2 diabetes (≤21 years old), where 162 patients were in the nursing group and 157 patients were in the control group. Meta-analysis revealed that, compared with routine nursing, nursing intervention could effectively control children's fasting blood glucose (FBG) (MD = -1.68, 95% CI (-2.19, -1.17), P < 0.00001), 2 h postprandial blood glucose (2hPG) (MD = -4.01, 95% CI (-4.70, -3.33), P < 0.00001), fasting insulin (FINS) (MD = -7.42, 95% CI (-10.63, -4.20), P < 0.00001), 2 h postprandial insulin (2hINS) (MD = -58.18, 95% CI (-103.24, -13.11), P = 0.01), triglycerides (TG) (MD = -0.41, 95% CI (-0.56, -0.25), P < 0.00001), and systolic blood pressure (SBP) (MD = -8.85, 95% CI (-14.67, -3.03), P = 0.003) and effectively maintain patients' blood glucose at a normal level (MD = -8.85, 95% CI (-14.67, -3.03), P = 0.003), where all the differences were statistically significant.

Conclusion

The existing evidence showed that nursing intervention has a significant effect in controlling normal blood glucose and improving insulin utilization in children with type 2 diabetes, which can effectively improve the therapeutic effect on children.