1
|
Costa E Silva VT, Gil LA, Inker LA, Caires RA, Costalonga E, Coura-Filho G, Sapienza MT, Castro G, Estevez-Diz MDP, Zanetta DMT, Antonângelo L, Marçal L, Tighiouart H, Miao S, Mathew P, Levey AS, Burdmann EA. Glomerular Filtration Rate Estimation Using β 2-Microglobulin and β-Trace Protein in Adults With Solid Tumors: A Prospective Cross-Sectional Study. Am J Kidney Dis 2024; 84:339-348.e1. [PMID: 38537905 DOI: 10.1053/j.ajkd.2024.01.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/06/2023] [Accepted: 01/02/2024] [Indexed: 05/26/2024]
Abstract
RATIONALE & OBJECTIVE β2-Microglobulin (B2M) and β-trace protein (BTP) are novel endogenous filtration markers that may improve the accuracy of estimated glomerular filtration rate (eGFR) beyond creatinine and cystatin C (eGFRcr-cys), but they have not been assessed in patients with cancer. STUDY DESIGN Cross-sectional analysis. SETTING & PARTICIPANTS Prospective cohort of 1,200 patients with active solid tumors recruited between April 2015 and September 2017. EXPOSURE CKD-EPI equations without race combining B2M and/or BTP with creatinine with or without cystatin C (2-, 3-, or 4-marker panel eGFR). OUTCOME Performance of equations compared with eGFRcr-cys and non-GFR determinants of serum B2M and BTP (SB2M, and SBTP, respectively). Measured GFR (mGFR) was determined using the plasma clearance of chromium-51 labeled ethylenediamine tetraacetic acid (51Cr-EDTA). ANALYTICAL APPROACH Bias was defined as the median of the differences between mGFR and eGFR, and 1-P30 was defined as the percentage of estimates that differed by more than 30% from the mGFR (1-P30). Linear regression was used to assess association of clinical and laboratory variables with SB2M, and SBTP after adjustment for mGFR. RESULTS Mean age and mGFR were 58.8±13.2 SD years and 78.4±21.7 SD mL/min/1.73m2, respectively. Performance of the 3-marker and 4-marker panel equations was better than eGFRcr-cys (lesser bias and 1-P30). Performance of 2-marker panel equations was as good as eGFRcr-cys (lesser bias and similar 1-P30). SB2M and SBTP were not strongly influenced by cancer site. LIMITATIONS Participants may have had better clinical performance status than the general population of patients with solid tumors. CONCLUSIONS B2M and BTP can improve the accuracy of eGFR and may be useful as confirmatory tests in patients with solid tumors, either by inclusion in a multimarker panel equation with creatinine and cystatin C, or by substituting for cystatin C in combination with creatinine. PLAIN-LANGUAGE SUMMARY The most accurate method to assess estimate kidney function is estimated glomerular filtration rate (eGFR) using creatinine and cystatin C (eGFRcr-cys). We studied whether using β2-microglobulin (B2M) and/or β-trace protein (BTP) with creatinine with or without cystatin C (2-, 3-, or 4-marker panel eGFR) might be useful in patients with active solid tumors. The performance of the 3-marker and 4-marker panel equations was better than eGFRcr-cys. Performance of 2-marker panel equations was as good as eGFRcr-cys. We conclude that B2M and BTP can improve the accuracy of eGFR and may be useful as a confirmatory test in patients with solid tumors either by inclusion in multimarker panel equation with creatinine and cystatin C or by substituting for cystatin C in combination with creatinine.
Collapse
Affiliation(s)
- Verônica T Costa E Silva
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Laboratório de Investigação Médica (LIM) 16, Serviço de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Luiz A Gil
- Laboratório de Investigação Médica (LIM) 66, Serviço de Geriatria, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Renato A Caires
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Elerson Costalonga
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - George Coura-Filho
- Serviço de Medicina Nuclear, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo T Sapienza
- Radiology and Oncology Department, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gilberto Castro
- Serviço de Oncologia Clínica, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Maria D P Estevez-Diz
- Serviço de Oncologia Clínica, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Dirce Maria T Zanetta
- Department of Epidemiology, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Leila Antonângelo
- Laboratório de Investigação Médica (LIM) 03, Division of Clinical Pathology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Lia Marçal
- Laboratório de Investigação Médica (LIM) 03, Division of Clinical Pathology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Biostatistics, Epidemiology, and Research Design Center, Tufts Medical Center, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Paul Mathew
- Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Emmanuel A Burdmann
- Laboratório de Investigação Médica (LIM) 12, Serviço de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
2
|
Muglia L, Di Dio M, Filicetti E, Greco GI, Volpentesta M, Beccacece A, Fabbietti P, Lattanzio F, Corsonello A, Gembillo G, Santoro D, Soraci L. Biomarkers of chronic kidney disease in older individuals: navigating complexity in diagnosis. Front Med (Lausanne) 2024; 11:1397160. [PMID: 39055699 PMCID: PMC11269154 DOI: 10.3389/fmed.2024.1397160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/27/2024] [Indexed: 07/27/2024] Open
Abstract
Chronic kidney disease (CKD) in older individuals is a matter of growing concern in the field of public health across the globe. Indeed, prevalence of kidney function impairment increases with advancing age and is often exacerbated by age-induced modifications of kidney function, presence of chronic diseases such as diabetes, hypertension, and cardiovascular disorders, and increased burden related to frailty, cognitive impairment and sarcopenia. Accurate assessment of CKD in older individuals is crucial for timely intervention and management and relies heavily on biomarkers for disease diagnosis and monitoring. However, the interpretation of these biomarkers in older patients may be complex due to interplays between CKD, aging, chronic diseases and geriatric syndromes. Biomarkers such as serum creatinine, estimated glomerular filtration rate (eGFR), and albuminuria can be significantly altered by systemic inflammation, metabolic changes, and medication use commonly seen in this population. To overcome the limitations of traditional biomarkers, several innovative proteins have been investigated as potential, in this review we aimed at consolidating the existing data concerning the geriatric aspects of CKD, describing the challenges and considerations in using traditional and innovative biomarkers to assess CKD in older patients, highlighting the need for integration of the clinical context to improve biomarkers' accuracy.
Collapse
Affiliation(s)
- Lucia Muglia
- Centre for Biostatistics and Applied Geriatric Clinical Epidemiology, Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Michele Di Dio
- Unit of Urology, Department of Surgery, Annunziata Hospital, Cosenza, Italy
| | - Elvira Filicetti
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Giada Ida Greco
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Mara Volpentesta
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Alessia Beccacece
- Centre for Biostatistics and Applied Geriatric Clinical Epidemiology, Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Paolo Fabbietti
- Centre for Biostatistics and Applied Geriatric Clinical Epidemiology, Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (IRCCS INRCA), Ancona, Italy
| | - Andrea Corsonello
- Centre for Biostatistics and Applied Geriatric Clinical Epidemiology, Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Sciences, School of Medicine and Digital Technologies, University of Calabria, Arcavacata di Rende, Italy
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Soraci
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| |
Collapse
|
3
|
Delanaye P, Pottel H, Cavalier E, Flamant M, Stehlé T, Mariat C. Diagnostic standard: assessing glomerular filtration rate. Nephrol Dial Transplant 2024; 39:1088-1096. [PMID: 37950562 DOI: 10.1093/ndt/gfad241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Indexed: 11/12/2023] Open
Abstract
Creatinine-based estimated glomerular filtration rate (eGFR) is imprecise at individual level, due to non-GFR-related serum creatinine determinants, including atypical muscle mass. Cystatin C has the advantage of being independent of muscle mass, a feature that led to the development of race- and sex-free equations. Yet, cystatin C-based equations do not perform better than creatinine-based equations for estimating GFR unless both variables are included together. The new race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation had slight opposite biases between Black and non-Black subjects in the USA, but has poorer performance than that the previous version in European populations. The European Kidney Function Consortium (EKFC) equation developed in 2021 can be used in both children and adults, is more accurate in young and old adults, and is applicable to non-white European populations, by rescaling the Q factor, i.e. population median creatinine, in a potentially universal way. A sex- and race-free cystatin C-based EKFC, with the same mathematical design, has also be defined. New developments in the field of GFR estimation would be standardization of cystatin C assays, development of creatinine-based eGFR equations that incorporate muscle mass data, implementation of new endogenous biomarkers and the use of artificial intelligence. Standardization of different GFR measurement methods would also be a future challenge, as well as new technologies for measuring GFR. Future research is also needed into discrepancies between cystatin C and creatinine, which is associated with high risk of adverse events: we need to standardize the definition of discrepancy and understand its determinants.
Collapse
Affiliation(s)
- Pierre Delanaye
- Department of Nephrology-Dialysis-Transplantation, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium
- Department of Nephrology-Dialysis-Apheresis, Hôpital Universitaire Carémeau, Nîmes, France
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak Kortrijk, Kortrijk, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, University of Liège (ULiege), CHU Sart Tilman, Liège, Belgium
| | - Martin Flamant
- Assistance Publique-Hôpitaux de Paris, Bichat Hospital, and Université Paris Cité, UMR 1149, Paris, France
| | - Thomas Stehlé
- Assistance Publique-Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Christophe Mariat
- Service de Néphrologie, Dialyse et Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, France
| |
Collapse
|
4
|
Balasch MM, Roumelioti ME, Argyropoulos CP. Comparison of Glomerular Filtration Rate Equations in a Rural New Mexico Cohort: Results from the COMPASS Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.10.24308724. [PMID: 38946981 PMCID: PMC11213067 DOI: 10.1101/2024.06.10.24308724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Rationale and Objective The NKF-ASN Task Force recommends accurate kidney function estimation avoiding biases through racial adjustments. We explored the use of multiple kidney function biomarkers and hence estimated glomerular filtration rate (eGFR) equations to improve kidney function calculations in an ethnically diverse patient population. Study design Prospective community cohort study. Setting and Participants rural New Mexico clinic with patients > 18 yo. Methods Markers of kidney function, IDMS-Creatinine (SCr), chemiluminescence Beta-2 Microglobulin (B2M), Nephelometry-calibrated ELISA Cystatin C (CysC), inflammation, glucose tolerance, demographics, BUN/UACR from the baseline visit of the COMPASS cohort, were analyzed by Kernel-based Virtual Machine learning methods. Results Among 205 participants, the mean age was 50.1, 62% were female, 54.1% Hispanic American and 30.2% Native American. Average kidney function biomarkers were: SCr 0.9 mg/dl, B2M 1.8 mg/L, and CysC 0.7 mg/dl. The highest agreement was observed between SCr and B2M-based eGFR equations [mean difference in eGFRs: (4.48 ml/min/1.73m2], and the lowest agreement between B2M and CysC-based eGFR equations (-24.75 ml/min/1.73m2). There was no pattern of association between the differences in eGFR measures and gender. In the continuous analyses, the absolute eGFR value (p<2 x 10-16) and serum albumin (p =6.4 x 10-5) predicted the difference between B2M- and SCr-based e-GFR. The absolute eGFR value (p<2 x 10-16) and age (p =7.6 x 10-5) predicted the difference between CysC- and SCr-based e-GFR. Limitations Relatively small sample size, elevated inflammatory state in majority of study participants and no inulin excretion rate measurements. Conclusion B2M should be strongly considered as a kidney function biomarker fulfilling the criteria for the NKF-ASN. B2M's eGFR equation does not need adjustment for gender or race and showed the highest agreement with SCr-based eGFR equations.
Collapse
Affiliation(s)
- Monica Moya Balasch
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, MSC 04-2785, Albuquerque, New Mexico, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, MSC 04-2785, Albuquerque, New Mexico, USA
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, MSC 04-2785, Albuquerque, New Mexico, USA
| |
Collapse
|
5
|
Iversen E, Christensen KM, Walls AB, Eickhoff MK, von Scholten BJ, Frimodt-Møller M, Hansen TW, Persson F, Rossing P, Rotbain Curovic V, Houlind MB. Performance of new and panel CKD-EPI equations in European adults with type 2 diabetes. Diabetes Obes Metab 2024; 26:2501-2504. [PMID: 38449081 DOI: 10.1111/dom.15536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Esben Iversen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | | | - Anne Byriel Walls
- The Capital Region Pharmacy, Herlev, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | | | - Bernt Johan von Scholten
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Novo Nordisk A/S, Data Science, Copenhagen, Denmark
- Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | | | - Tine Willum Hansen
- Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
- The Capital Region Pharmacy, Herlev, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
6
|
Li T, Grams ME, Inker LA, Chen J, Rhee EP, Warady BA, Levey AS, Denburg MR, Furth SL, Ramachandran VS, Kimmel PL, Coresh J. Consistency of metabolite associations with measured glomerular filtration rate in children and adults. Clin Kidney J 2024; 17:sfae108. [PMID: 38859934 PMCID: PMC11163224 DOI: 10.1093/ckj/sfae108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Indexed: 06/12/2024] Open
Abstract
Background There is interest in identifying novel filtration markers that lead to more accurate GFR estimates than current markers (creatinine and cystatin C) and are more consistent across demographic groups. We hypothesize that large-scale metabolomics can identify serum metabolites that are strongly influenced by glomerular filtration rate (GFR) and are more consistent across demographic variables than creatinine, which would be promising filtration markers for future investigation. Methods We evaluated the consistency of associations between measured GFR (mGFR) and 887 common, known metabolites quantified by an untargeted chromatography- and spectroscopy-based metabolomics platform (Metabolon) performed on frozen blood samples from 580 participants in Chronic Kidney Disease in Children (CKiD), 674 participants in Modification of Diet in Renal Disease (MDRD) Study and 962 participants in African American Study of Kidney Disease and Hypertension (AASK). We evaluated metabolite-mGFR correlation association with metabolite class, molecular weight, assay platform and measurement coefficient of variation (CV). Among metabolites with strong negative correlations with mGFR (r < -0.5), we assessed additional variation by age (height in children), sex, race and body mass index (BMI). Results A total of 561 metabolites (63%) were negatively correlated with mGFR. Correlations with mGFR were highly consistent across study, sex, race and BMI categories (correlation of metabolite-mGFR correlations between 0.88 and 0.95). Amino acids, carbohydrates and nucleotides were more often negatively correlated with mGFR compared with lipids, but there was no association with metabolite molecular weight, liquid chromatography/mass spectrometry platform and measurement CV. Among 114 metabolites with strong negative associations with mGFR (r < -0.5), 27 were consistently not associated with age (height in children), sex or race. Conclusions The majority of metabolite-mGFR correlations were negative and consistent across sex, race, BMI and study. Metabolites with consistent strong negative correlations with mGFR and non-association with demographic variables may represent candidate markers to improve estimation of GFR.
Collapse
Affiliation(s)
- Taibo Li
- MD-PhD Program, Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Morgan E Grams
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, NYU Grossman School of Medicine, New York City, NY, USA
- Department of Medicine and Department of Epidemiology, NYU Grossman School of Medicine, New York City, NY, USA
| | - Lesley A Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Jingsha Chen
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - Eugene P Rhee
- Nephrology Division and Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Broad Institute of Harvard and MIT, Cambridge, MA, USA
| | - Bradley A Warady
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Michelle R Denburg
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Nephrology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - Susan L Furth
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Nephrology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - Vasan S Ramachandran
- Department of Population Health Sciences, University of Texas School of Public Health San Antonio, San Antonio, TX, USA
| | - Paul L Kimmel
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Medicine, NYU Grossman School of Medicine, New York City, NY, USA
| |
Collapse
|
7
|
Chavali K, Coker H, Youngblood E, Karaduta O. Proteogenomics in Nephrology: A New Frontier in Nephrological Research. Curr Issues Mol Biol 2024; 46:4595-4608. [PMID: 38785547 PMCID: PMC11120334 DOI: 10.3390/cimb46050279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/25/2024] Open
Abstract
Proteogenomics represents a transformative intersection in nephrology, uniting genomics, transcriptomics, and proteomics to unravel the molecular intricacies of kidney diseases. This review encapsulates the methodological essence of proteogenomics and its profound implications in chronic kidney disease (CKD) research. We explore the proteogenomic pipeline, highlighting the integrated analysis of genomic, transcriptomic, and proteomic data and its pivotal role in enhancing our understanding of kidney pathologies. Through case studies, we showcase the application of proteogenomics in clear cell renal cell carcinoma (ccRCC) and Autosomal Recessive Polycystic Kidney Disease (ARPKD), emphasizing its potential in personalized treatment strategies and biomarker discovery. The review also addresses the challenges in proteogenomic analysis, including data integration complexities and bioinformatics limitations, and proposes solutions for advancing the field. Ultimately, this review underscores the prospective future of proteogenomics in nephrology, particularly in advancing personalized medicine and providing novel therapeutic insights.
Collapse
Affiliation(s)
- Kavya Chavali
- Adventist Health Hanford Family Medicine Residency Program, ONE Adventist Health Way, Roseville, CA 95661, USA
| | - Holley Coker
- Department of Physician Assistant Studies, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
| | - Emily Youngblood
- Department of Physician Assistant Studies, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
| | - Oleg Karaduta
- Department of Physician Assistant Studies, University of Arkansas for Medical Sciences, 4301 W Markham Street, Little Rock, AR 72205, USA
| |
Collapse
|
8
|
Siddique SM, Tipton K, Leas B, Jepson C, Aysola J, Cohen JB, Flores E, Harhay MO, Schmidt H, Weissman GE, Fricke J, Treadwell JR, Mull NK. The Impact of Health Care Algorithms on Racial and Ethnic Disparities : A Systematic Review. Ann Intern Med 2024; 177:484-496. [PMID: 38467001 DOI: 10.7326/m23-2960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND There is increasing concern for the potential impact of health care algorithms on racial and ethnic disparities. PURPOSE To examine the evidence on how health care algorithms and associated mitigation strategies affect racial and ethnic disparities. DATA SOURCES Several databases were searched for relevant studies published from 1 January 2011 to 30 September 2023. STUDY SELECTION Using predefined criteria and dual review, studies were screened and selected to determine: 1) the effect of algorithms on racial and ethnic disparities in health and health care outcomes and 2) the effect of strategies or approaches to mitigate racial and ethnic bias in the development, validation, dissemination, and implementation of algorithms. DATA EXTRACTION Outcomes of interest (that is, access to health care, quality of care, and health outcomes) were extracted with risk-of-bias assessment using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and adapted CARE-CPM (Critical Appraisal for Racial and Ethnic Equity in Clinical Prediction Models) equity extension. DATA SYNTHESIS Sixty-three studies (51 modeling, 4 retrospective, 2 prospective, 5 prepost studies, and 1 randomized controlled trial) were included. Heterogenous evidence on algorithms was found to: a) reduce disparities (for example, the revised kidney allocation system), b) perpetuate or exacerbate disparities (for example, severity-of-illness scores applied to critical care resource allocation), and/or c) have no statistically significant effect on select outcomes (for example, the HEART Pathway [history, electrocardiogram, age, risk factors, and troponin]). To mitigate disparities, 7 strategies were identified: removing an input variable, replacing a variable, adding race, adding a non-race-based variable, changing the racial and ethnic composition of the population used in model development, creating separate thresholds for subpopulations, and modifying algorithmic analytic techniques. LIMITATION Results are mostly based on modeling studies and may be highly context-specific. CONCLUSION Algorithms can mitigate, perpetuate, and exacerbate racial and ethnic disparities, regardless of the explicit use of race and ethnicity, but evidence is heterogeneous. Intentionality and implementation of the algorithm can impact the effect on disparities, and there may be tradeoffs in outcomes. PRIMARY FUNDING SOURCE Agency for Healthcare Quality and Research.
Collapse
Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania; and Center for Evidence-Based Practice, Penn Medicine, Philadelphia, Pennsylvania (S.M.S.)
| | - Kelley Tipton
- ECRI-Penn Medicine Evidence-based Practice Center, ECRI, Plymouth Meeting, Pennsylvania (K.T., C.J., J.R.T.)
| | - Brian Leas
- Center for Evidence-Based Practice, Penn Medicine, Philadelphia, Pennsylvania (B.L., E.F., J.F.)
| | - Christopher Jepson
- ECRI-Penn Medicine Evidence-based Practice Center, ECRI, Plymouth Meeting, Pennsylvania (K.T., C.J., J.R.T.)
| | - Jaya Aysola
- Leonard Davis Institute of Health Economics, University of Pennsylvania; Division of General Internal Medicine, University of Pennsylvania; and Penn Medicine Center for Health Equity Advancement, Penn Medicine, Philadelphia, Pennsylvania (J.A.)
| | - Jordana B Cohen
- Division of Renal-Electrolyte and Hypertension, University of Pennsylvania; and Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania (J.B.C.)
| | - Emilia Flores
- Center for Evidence-Based Practice, Penn Medicine, Philadelphia, Pennsylvania (B.L., E.F., J.F.)
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania; Center for Evidence-Based Practice, Penn Medicine; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania; and Division of Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania (M.O.H.)
| | - Harald Schmidt
- Department of Medical Ethics & Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania (H.S.)
| | - Gary E Weissman
- Leonard Davis Institute of Health Economics, University of Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania; and Division of Pulmonary and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania (G.E.W.)
| | - Julie Fricke
- Center for Evidence-Based Practice, Penn Medicine, Philadelphia, Pennsylvania (B.L., E.F., J.F.)
| | - Jonathan R Treadwell
- ECRI-Penn Medicine Evidence-based Practice Center, ECRI, Plymouth Meeting, Pennsylvania (K.T., C.J., J.R.T.)
| | - Nikhil K Mull
- Center for Evidence-Based Practice, Penn Medicine; and Division of Hospital Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (N.K.M.)
| |
Collapse
|
9
|
Fino NF, Adingwupu OM, Coresh J, Greene T, Haaland B, Shlipak MG, Costa E Silva VT, Kalil R, Mindikoglu AL, Furth SL, Seegmiller JC, Levey AS, Inker LA. Evaluation of novel candidate filtration markers from a global metabolomic discovery for glomerular filtration rate estimation. Kidney Int 2024; 105:582-592. [PMID: 38006943 PMCID: PMC10932836 DOI: 10.1016/j.kint.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 11/27/2023]
Abstract
Creatinine and cystatin-C are recommended for estimating glomerular filtration rate (eGFR) but accuracy is suboptimal. Here, using untargeted metabolomics data, we sought to identify candidate filtration markers for a new targeted assay using a novel approach based on their maximal joint association with measured GFR (mGFR) and with flexibility to consider their biological properties. We analyzed metabolites measured in seven diverse studies encompasing 2,851 participants on the Metabolon H4 platform that had Pearson correlations with log mGFR and used a stepwise approach to develop models to < -0.5 estimate mGFR with and without inclusion of creatinine that enabled selection of candidate markers. In total, 456 identified metabolites were present in all studies, and 36 had correlations with mGFR < -0.5. A total of 2,225 models were developed that included these metabolites; all with lower root mean square errors and smaller coefficients for demographic variables compared to estimates using untargeted creatinine. Seventeen metabolites were chosen, including 12 new candidate filtration markers. The selected metabolites had strong associations with mGFR and little dependence on demographic factors. Candidate metabolites were identified with maximal joint association with mGFR and minimal dependence on demographic variables across many varied clinical settings. These metabolites are excreted in urine and represent diverse metabolic pathways and tubular handling. Thus, our data can be used to select metabolites for a multi-analyte eGFR determination assay using mass spectrometry that potentially offers better accuracy and is less prone to non-GFR determinants than the current eGFR biomarkers.
Collapse
Affiliation(s)
- Nora F Fino
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Ogechi M Adingwupu
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Josef Coresh
- Department of Population Health, NYU Langone, New York, New York, USA
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Ben Haaland
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affair Medical Center and University of California, San Francisco, San Francisco, California, USA
| | - Veronica T Costa E Silva
- Serviço de Nefrologia, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Laboratório de Investigação Médica 16, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ayse L Mindikoglu
- Margaret M. and Albert B. Alkek Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA; Michael E. DeBakey Department of Surgery, Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, USA
| | - Susan L Furth
- Department of Pediatrics, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jesse C Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA.
| |
Collapse
|
10
|
Inker LA, Tighiouart H, Adingwupu OM, Ng DK, Estrella MM, Maahs D, Yang W, Froissart M, Mauer M, Kalil R, Torres V, de Borst M, Klintmalm G, Poggio ED, Seegmiller JC, Rossing P, Furth SL, Warady BA, Schwartz GJ, Velez R, Coresh J, Levey AS. Performance of GFR Estimating Equations in Young Adults. Am J Kidney Dis 2024; 83:272-276. [PMID: 37717845 PMCID: PMC11080956 DOI: 10.1053/j.ajkd.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/08/2023] [Accepted: 06/21/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Lesley A Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Ogechi M Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Derek K Ng
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Michelle M Estrella
- Department of Medicine, Division of Nephrology, San Francisco VA Health Care System and University of California, San Francisco, California
| | - David Maahs
- Division of Endocrinology, Department of Pediatrics, and Stanford Diabetes Research Center, Stanford School of Medicine, Palo Alto, California
| | - Wei Yang
- Departments of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc Froissart
- Clinical Trial Unit, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Michael Mauer
- Divisions of Pediatric and Adult Nephrology, University of Minnesota, Minneapolis, Minnesota
| | - Roberto Kalil
- Department of Medicine, Division of Nephrology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vicente Torres
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Martin de Borst
- Faculty of Medical Sciences, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Emilio D Poggio
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jesse C Seegmiller
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and the Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susan L Furth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - George J Schwartz
- Department of Pediatrics, Pediatric Nephrology, University of Rochester Medical Center, Rochester, New York
| | | | - Josef Coresh
- Department of Epidemiology, John Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrew S Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
11
|
Abenavoli C, Provenzano M, Ksiazek SH, Hu L, Cuna V, Manna GL, Comai G, Baraldi O. Role of Estimated Glomerular Filtration Rate in Clinical Research: The Never-Ending Matter. Rev Cardiovasc Med 2024; 25:1. [PMID: 39077647 PMCID: PMC11262368 DOI: 10.31083/j.rcm2501001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 07/31/2024] Open
Abstract
Background Chronic kidney disease (CKD) burden is crucial both on a global scale and at individual patient level, affecting morbidity and mortality directly and through its effect on both cardiovascular damage and CKD progression to end-stage-kidney-disease (ESKD). Unfortunately, the awareness of CKD is poor, with few CKD patients conscious of the severity of their health status. The principal biomarker of kidney function is estimated glomerular filtration rate (eGFR). Methods We searched the literature and present a review article with the aim of summarizing the role of eGFR in clinical research. In particular, we report the eGFR role as a prognostic, enrichment and endpoint biomarker and its role in the early detection of CKD. Results eGFR has a major role as a biomarker in clinical research. As a prognostic marker, eGFR reduction is associated with cardiovascular events, ESKD and mortality. As an enrichment biomarker, eGFR values are pivotal for selecting patients to be included in randomized and observational studies; it helps to test a pre-defined drug in early CKD or in more advanced CKD allowing also to avoid screening failures and to shorten the duration of clinical trials. Moreover, eGFR decline (expressed as a percentage of reduction from baseline or continuous slope) can be considered a good endpoint in clinic trials overcoming delays whilst waiting for hard endpoints to develop. Conclusions eGFR is a strong clinical measure for both observational and intervention studies. It is also helpful in screening the general population for kidney disease and, in particular, to increase awareness of CKD.
Collapse
Affiliation(s)
- Chiara Abenavoli
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Sara H. Ksiazek
- Department of Medicine VI with Nephrology and Dialysis, Clinic Ottakring, 1170 Vienna, Austria
| | - Lilio Hu
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Vania Cuna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
| | - Olga Baraldi
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| |
Collapse
|
12
|
Adingwupu OM, Barbosa ER, Palevsky PM, Vassalotti JA, Levey AS, Inker LA. Cystatin C as a GFR Estimation Marker in Acute and Chronic Illness: A Systematic Review. Kidney Med 2023; 5:100727. [PMID: 37928862 PMCID: PMC10623366 DOI: 10.1016/j.xkme.2023.100727] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Rationale & Objective Creatinine-based GFR estimating (eGFRcr) equations may be inaccurate in populations with acute or chronic illness. The accuracy of GFR equations that use cystatin C (eGFRcys) or creatinine-cystatin C (eGFRcr-cys) is not well studied in these populations. Study Design A systematic review of original articles identified from PubMed and expert sources. Two reviewers screened articles independently and identified those meeting inclusion criteria. Setting & Study Populations Adults and children with acute or chronic illness. Selection Criteria for Studies Studies published since 2011 that compared performance of eGFRcr, eGFRcys, and eGFRcr-cys relative to measured GFR (mGFR), used standardized assays for creatinine or cystatin C, and used eGFR equations developed using such assays. Studies of ambulatory clinical populations or research studies in populations with only CKD, kidney transplant recipients, only diabetes, kidney donor candidates, and community-based cohorts were excluded. Data Extraction Data extracted from full text. Analytical Approach Bias and percentages of estimates within 30% of mGFR (P30) of eGFR compared with mGFR were evaluated. Results Of the 179 citations, 26 studies met the inclusion criteria: 24 in adults and 2 in children in clinical populations with cancer (n=5), HIV (n=5), cirrhosis (n=3), liver transplant (n=3), heart failure (n=2), neuromuscular diseases (n=1) critical illness (n=5), and obesity (n=2). In general, eGFRcr-cys had greater accuracy than eGFRcr or eGFRcys equations among study populations with cancer, HIV, and obesity, but did not perform consistently better in cirrhosis, liver transplant, heart failure, neuromuscular disease, and critical illness. Limitations Participants were selected because of concern for inaccurate eGFRcr, which may bias results. Most studies had small sample sizes, limiting generalizability. Conclusions eGFRcr-cys improves GFR estimation in populations with a variety of acute and chronic illnesses, providing indications for cystatin C measurement. Performance was poor in many studies, suggesting the need for more frequent mGFR. Plain-Language Summary Kidney function, specifically glomerular filtration rate (GFR), estimated using creatinine (eGFRcr) is often inaccurate in people with acute and chronic illness. The accuracy of estimates using cystatin C alone (eGFRcys) or together with creatinine (eGFRcr-cys) is not well studied in these populations. We conducted a systematic review to address the knowledge gap. Of the 179 papers reviewed, we identified 26 studies in clinical populations with cancer (n=5); HIV (n=5); cirrhosis (n=3); liver transplant (n=3); heart failure (n=2); neuromuscular disease (n=1); critical illness (n=5); and obesity (n=2). In general, eGFRcr-cys improved the GFR estimation in HIV, cancer, and obesity, providing indications for cystatin C measurement. Performance was poor in many studies, suggesting the need for more frequent measured GFR.
Collapse
Affiliation(s)
- Ogechi M. Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA
| | | | - Paul M. Palevsky
- Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Joseph A. Vassalotti
- Icahn School of Medicine at Mount Sinai, New York, NY; National Kidney Foundation, Inc, New York, NY
| | - Andrew S. Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Lesley A. Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, MA
| |
Collapse
|
13
|
Iversen E, Bengaard AK, Leegaard Andersen A, Tavenier J, Nielsen RL, Juul-Larsen HG, Jørgensen LM, Bornæs O, Jawad BN, Aharaz A, Walls AB, Kallemose T, Dalhoff K, Nehlin JO, Hornum M, Feldt-Rasmussen B, Damgaard M, Andersen O, Houlind MB. Performance of Panel-Estimated GFR Among Hospitalized Older Adults. Am J Kidney Dis 2023; 82:715-724. [PMID: 37516299 DOI: 10.1053/j.ajkd.2023.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 07/31/2023]
Abstract
RATIONALE & OBJECTIVE Older adults represent nearly half of all hospitalized patients and are vulnerable to inappropriate dosing of medications eliminated through the kidneys. However, few studies in this population have evaluated the performance of equations for estimating the glomerular filtration rate (GFR)-particularly those that incorporate multiple filtration markers. STUDY DESIGN Cross-sectional diagnostic test substudy of a randomized clinical trial. SETTING & PARTICIPANTS Adults≥65 years of age presenting to the emergency department of Copenhagen University Hospital Amager and Hvidovre in Hvidovre, Denmark, between October 2018 and April 2021. TESTS COMPARED Measured GFR (mGFR) determined using 99mTc-DTPA plasma clearance compared with estimated GFR (eGFR) calculated using 6 different equations based on creatinine; 3 based on creatinine and cystatin C combined; and 2 based on panels of markers including creatinine, cystatin C, β-trace protein (BTP) and/or β2-microglobulin (B2M). OUTCOME The performance of each eGFR equation compared with mGFR with respect to bias, relative bias, inaccuracy (1-P30), and root mean squared error (RMSE). RESULTS We assessed eGFR performance for 106 patients (58% female, median age 78.3 years, median mGFR 62.9mL/min/1.73m2). Among the creatinine-based equations, the 2009 CKD-EPIcr equation yielded the smallest relative bias (+4.2%). Among the creatinine-cystatin C combination equations, the 2021 CKD-EPIcomb equation yielded the smallest relative bias (-3.4%), inaccuracy (3.8%), and RMSE (0.139). Compared with the 2021 CKD-EPIcomb, the CKD-EPIpanel equation yielded a smaller RMSE (0.136) but larger relative bias (-4.0%) and inaccuracy (5.7%). LIMITATIONS Only White patients were included; only a subset of patients from the original clinical trial underwent GFR measurement; and filtration marker concentration can be affected by subclinical changes in volume status. CONCLUSIONS The 2009 CKD-EPIcr, 2021 CKD-EPIcomb, and CKD-EPIpanel equations performed best and notably outperformed their respective full-age spectrum equations. The addition of cystatin C to creatinine-based equations improved performance, while the addition of BTP and/or B2M yielded minimal improvement. FUNDING Grants from public sector industry (Amgros I/S) and government (Capital Region of Denmark). TRIAL REGISTRATION Registered at ClinicalTrials.gov with registration number NCT03741283. PLAIN-LANGUAGE SUMMARY Inaccurate kidney function assessment can lead to medication errors, a common cause of hospitalization and early readmission among older adults. Several novel methods have been developed to estimate kidney function based on a panel of kidney function markers that can be measured from a single blood sample. We evaluated the accuracy of these new methods (relative to a gold standard method) among 106 hospitalized older adults. We found that kidney function estimates combining 2 markers (creatinine and cystatin C) were highly accurate and noticeably more accurate than estimates based on creatinine alone. Estimates incorporating additional markers such as β-trace protein and β2-microglobulin did not further improve accuracy.
Collapse
Affiliation(s)
- Esben Iversen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre.
| | - Anne Kathrine Bengaard
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Department of Clinical Medicine, University of Copenhagen, Copenhagen; Capital Region Pharmacy, Herlev, Denmark
| | - Aino Leegaard Andersen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Juliette Tavenier
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | | | - Helle Gybel Juul-Larsen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Lillian Mørch Jørgensen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Emergency Department, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Olivia Bornæs
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Baker Nawfal Jawad
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Anissa Aharaz
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Capital Region Pharmacy, Herlev, Denmark
| | - Anne Byriel Walls
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen; Capital Region Pharmacy, Herlev, Denmark
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Kim Dalhoff
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Jan Olof Nehlin
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Bo Feldt-Rasmussen
- Department of Nephrology, Copenhagen University Hospital Rigshospitalet, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Morten Damgaard
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Emergency Department, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre; Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen; Capital Region Pharmacy, Herlev, Denmark
| |
Collapse
|
14
|
Kasozi RN, Meeusen JW, Lieske JC. Estimating glomerular filtration rate with new equations: can one size ever fit all? Crit Rev Clin Lab Sci 2023; 60:549-559. [PMID: 37259709 PMCID: PMC10592396 DOI: 10.1080/10408363.2023.2214812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/25/2023] [Accepted: 05/13/2023] [Indexed: 06/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ramla N. Kasozi
- Department of Family Medicine, Mayo Clinic, Jacksonville, FL
| | - Jeffrey W. Meeusen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - John C. Lieske
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
- Department of Internal Medicine, Division of Nephrology and Hypertension Mayo Clinic, Rochester, MN
| |
Collapse
|
15
|
Kure N, Krogstrup NV, Oltean M, Jespersen B, Birn H, Nielsen MB. β-Trace Protein and β2-Microglobulin do not Improve Estimation of Glomerular Filtration Rate in Kidney Transplant Recipients Compared With Creatinine and Cystatin C. Transplant Proc 2023; 55:2071-2078. [PMID: 37806869 DOI: 10.1016/j.transproceed.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Reliable estimates of glomerular filtration rate (eGFR) are important for detecting changes in graft function in kidney transplant recipients. Current eGFR equations are based on plasma creatinine and/or cystatin C; however, these are associated with significant bias. This study investigated if equations based on β-trace protein (BTP) and β2-microglobulin (B2M) performed better than the 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on creatinine and cystatin C among kidney transplant recipients. METHODS We included samples and data from the clinical trial CONTEXT. Glomerular filtration rate (GFR) was measured by plasma clearance of an exogenous marker. The eGFR was calculated using the CKD-EPI equations for estimating GFR from BTP and/or B2M and the 2021 CKD-EPI creatinine and creatinine-cystatin C equations. The GFR estimates were evaluated 3 (n = 82) and 12 (n = 64) months after transplant using mean bias, precision, and accuracy. Furthermore, we analyzed the ability of the equations to correctly classify the direction of changes in measured GFR from 3 to 12 months. RESULTS Among the BTP- and B2M-based equations, the combined eGFR-BTP-B2M performed best with respect to precision (SD = 7.64 mL/min/1.73 m2) and accuracy (±10% from measured GFR = 36%). The eGFR-BTP-B2M and the eGFR-creatinine-cystatin C (2021) performed similarly when comparing precision, accuracy, and residuals (P = .481). The BTP- and/or B2M-based equations did not perform better than the eGFR-creatinine-cystatin C (2021) in correctly classifying the direction of changes in measured GFR from 3 to 12 months. CONCLUSIONS β-trace protein and/or B2M do not improve the estimation of GFR when compared with creatinine- and cystatin C-based 2021 CKD-EPI equations.
Collapse
Affiliation(s)
- Nathalie Kure
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Nicoline V Krogstrup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Renal Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Marie Bodilsen Nielsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark.
| |
Collapse
|
16
|
Erratum Regarding "A New Panel-Estimated GFR, Including β 2-Microglobulin and β-Trace Protein and Not Including Race, Developed in a Diverse Population" [Am J Kidney Dis. 2021;77(5):673-683]. Am J Kidney Dis 2023; 82:378-379. [PMID: 37612005 DOI: 10.1053/j.ajkd.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
|
17
|
Williams P. Retaining Race in Chronic Kidney Disease Diagnosis and Treatment. Cureus 2023; 15:e45054. [PMID: 37701164 PMCID: PMC10495104 DOI: 10.7759/cureus.45054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Abstract
The best overall measure of kidney function is glomerular filtration rate (GFR) as commonly estimated from serum creatinine concentrations (eGFRcr) using formulas that correct for the higher average creatinine concentrations in Blacks. After two decades of use, these formulas have come under scrutiny for estimating GFR differently in Blacks and non-Blacks. Discussions of whether to include race (Black vs. non-Black) in the calculation of eGFRcr fail to acknowledge that the original race-based eGFRcr provided the same CKD treatment recommendations for Blacks and non-Blacks based on directly (exogenously) measured GFR. Nevertheless, the National Kidney Foundation and the American Society of Nephrology Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease removed race in CKD treatment guidelines and pushed for the immediate adoption of a race-free eGFRcr formula by physicians and clinical laboratories. This formula is projected to negate CKD in 5.51 million White and other non-Black adults and reclassify CKD to less severe stages in another 4.59 million non-Blacks, in order to expand treatment eligibility to 434,000 Blacks not previously diagnosed and to 584,000 Blacks previously diagnosed with less severe CKD. This review examines: 1) the validity of the arguments for removing the original race correction, and 2) the performance of the proposed replacement formula. Excluding race in the derivation of eGFRcr changed the statistical bias from +3.7 to -3.6 ml/min/1.73m2 in Blacks and from +0.5 to +3.9 in non-Blacks, i.e., promoting CKD diagnosis in Blacks at the cost of restricting diagnosis in non-Blacks. By doing so, the revised eGFRcr greatly exaggerates the purported racial disparity in CKD burden. Claims that the revised formulas identify heretofore undiagnosed CKD in Blacks are not supported when studies that used kidney failure replacement therapy and mortality are interpreted as proxies for baseline CKD. Alternatively, a race-stratified eGFRcr (i.e., separate equations for Blacks and non-Blacks) would provide the least biased eGFRcr for both Blacks and non-Blacks and the best medical treatment for all patients.
Collapse
Affiliation(s)
- Paul Williams
- Life Sciences, Lawrence Berkeley National Laboratory, Berkeley, USA
| |
Collapse
|
18
|
Iversen E, Walls AB, Petersen A, Jensen PS, Kallemose T, Andersen A, Nielsen RL, Bengaard AK, Juul-Larsen HG, Bornaes O, Damgaard M, Andersen O, Tavenier J, Houlind MB. Estimated glomerular filtration rate based on creatinine, cystatin C, β-trace protein and β2 microglobulin in patients undergoing nontraumatic lower extremity amputation. Br J Clin Pharmacol 2023; 89:1789-1798. [PMID: 36511684 DOI: 10.1111/bcp.15639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/28/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS The study's aim is to compare current and new equations for estimating glomerular filtration rate (GFR) based on creatinine, cystatin C, β-trace protein (BTP) and β2 microglobulin (B2M) among patients undergoing major amputation. METHODS This is a secondary analysis of data from a prospective cohort study investigating patients undergoing nontraumatic lower extremity amputation. Estimated GFR (eGFR) was calculated using equations based on creatinine (eGFRcre[2009] and eGFRcre[2021]), cystatin C (eGFRcys), the combination of creatinine and cystatin C (eGFRcomb[2012] and eGFRcomb[2021]) or a panel of all 4 filtration markers (eGFRpanel). Primary outcome was changed in eGFR across amputation according to each equation. Two case studies of prior amputation with GFR measured by 99mTc-DTPA clearance are described to illustrate the relative accuracies of each eGFR equation. RESULTS Analysis of the primary outcome included 29 patients (median age 75 years, 31% female). Amputation was associated with a significant decrease in creatinine concentration (-0.09 mg/dL, P = 0.004), corresponding to a significant increase in eGFRcre[2009] (+6.1 mL/min, P = 0.006) and eGFRcre[2021] (+6.3 mL/min, P = 0.006). Change across amputation was not significant for cystatin C, BTP, B2M or equations incorporating these markers (all P > 0.05). In both case studies, eGFRcre[2021] yielded the largest positive bias, eGFRcys yielded the largest negative bias and eGFRcomb[2012] and eGFRcomb[2021] yielded the smallest absolute bias. CONCLUSION Creatinine-based estimates were substantially higher than cystatin C-based estimates before amputation and significantly increased across amputation. Estimates combining creatinine and cystatin were stable across amputation, while the addition of BTP and B2M is unlikely to be clinically relevant.
Collapse
Affiliation(s)
- Esben Iversen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Anne Byriel Walls
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- The Capital Region Pharmacy, Herlev, Denmark
| | - Annamarie Petersen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- The Capital Region Pharmacy, Herlev, Denmark
| | - Pia Søe Jensen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
- The Research Unit of Orthopedic Nursing, Department of Orthopedic Surgery, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Aino Andersen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Rikke Lundsgaard Nielsen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Anne Kathrine Bengaard
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
- The Capital Region Pharmacy, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Helle Gybel Juul-Larsen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Olivia Bornaes
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Morten Damgaard
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Emergency Department, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Juliette Tavenier
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
| | - Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital Amager & Hvidovre, Hvidovre, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- The Capital Region Pharmacy, Herlev, Denmark
| |
Collapse
|
19
|
Xiang ST, Cao Y, Dong J, Li C, Duan Y, Li X, Qiu J. Association of urine phthalate metabolites levels with kidney function in 1610 US adolescents. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2023:10.1007/s11356-023-27389-0. [PMID: 37148507 DOI: 10.1007/s11356-023-27389-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 04/28/2023] [Indexed: 05/08/2023]
Abstract
Phthalates are widely used as plasticizer or fragrance ingredients in various consumer products worldwide. However, evidence for the overall effects of mixed exposure to phthalate on kidney function has not been widely investigated. The purpose of this article was to assess the association of urine phthalate metabolite levels and kidney injury parameters in adolescents. We used data from the combined 2007-2016 National Health and Nutrition Examination Survey (NHANES). We fitted weighted linear regressions and Bayesian kernel machine regressions (BKMR) models to explore the association of urinary phthalate metabolites with four parameters of kidney function after adjusting for covariates. Weighted linear regression models showed that MiBP (β = 8.057; PFDR = 0.016) was significantly positively associated with eGFR and MEP (β = -0.799; PFDR < 0.001) was significantly negatively correlated with BUN. BKMR analysis showed that the higher the concentration of phthalate metabolite mixture, the higher eGFR in adolescents. Based on the results of these two models, our findings revealed that mixed exposure to phthalates was associated with elevated eGFR in adolescents. However, as the study is cross-sectional, reverse causality is possible, and altered kidney function may impact the concentration of phthalate metabolites in urine.
Collapse
Affiliation(s)
- Shi-Ting Xiang
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Yuhan Cao
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, 110 Xiangya Road, Changsha, 410078, China
| | - Jie Dong
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Chao Li
- Department of Epidemiology and Medical Statistics, Xiangya School of Public Health, Central South University, 110 Xiangya Road, Changsha, 410078, China
| | - Yanying Duan
- Department of Occupational and Environmental Health, Xiangya School of Public Health, Central South University, 110 Xiangya Road, Changsha, 410078, China
| | - Xun Li
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China
| | - Jun Qiu
- Hunan Children's Research Institute (HCRI), Hunan Children's Hospital, 86 Ziyuan Road, Changsha, 410007, China.
| |
Collapse
|
20
|
Eneanya ND, Adingwupu OM, Kostelanetz S, Norris KC, Greene T, Lewis JB, Beddhu S, Boucher R, Miao S, Chaudhari J, Levey AS, Inker LA. Social Determinants of Health and Their Impact on the Black Race Coefficient in Serum Creatinine-Based Estimation of GFR: Secondary Analysis of MDRD and CRIC Studies. Clin J Am Soc Nephrol 2023; 18:446-454. [PMID: 36723299 PMCID: PMC10103283 DOI: 10.2215/cjn.0000000000000109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND The cause for differences in serum creatinine between Black and non-Black individuals incorporated into prior GFR-estimating equations is not understood. We explored whether social determinants of health can account for this difference. METHODS We conducted a secondary analysis of baseline data of the Modification of Diet in Renal Disease and Chronic Renal Insufficiency Cohort studies ( N =1628 and 1423, respectively). Data in both study cohorts were stratified by race (Black versus non-Black). We first evaluated the extent to which the coefficient of Black race in estimating GFR from creatinine is explained by correlations of race with social determinants of health and non-GFR determinants of creatinine. Second, we evaluated whether the difference between race groups in adjusted mean creatinine can be explained by social determinants of health and non-GFR determinants of creatinine. RESULTS In models regressing measured GFR on creatinine, age, sex, and race, the coefficient for Black race was 21% (95% confidence interval, 0.176 to 0.245) in Modification of Diet in Renal Disease and 13% (95% confidence interval, 0.097 to 0.155) in the Chronic Renal Insufficiency Cohort and was not attenuated by the addition of social determinants of health, alone or in combination. In both studies, the coefficient for Black race was larger at lower versus higher income levels. In models, regressing creatinine on measured GFR, age, and sex, mean creatinine was higher in Black versus non-Black participants in both studies, with no effect of social determinants of health. CONCLUSIONS Adjustment for selected social determinants of health did not influence the relationship between Black race and creatinine-based estimated GFR.
Collapse
Affiliation(s)
- Nwamaka D. Eneanya
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ogechi M. Adingwupu
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Keith C. Norris
- Department of Medicine, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Julia B. Lewis
- Department of Medicine, Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Srinivasan Beddhu
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, Utah
| | - Robert Boucher
- Department of Internal Medicine, Division of Nephrology & Hypertension, University of Utah Health Sciences, Salt Lake City, Utah
| | - Shiyuan Miao
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Juhi Chaudhari
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Andrew S. Levey
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Lesley A. Inker
- Department of Medicine, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
21
|
Zhang L, Wang T, Shen Y, Luo L, Xu G, Xie L. Increased Plasma Homocysteine Levels Are Associated with Left Ventricular Hypertrophy in Hypertensive Patients with Normal Renal Function. Kidney Blood Press Res 2023; 48:277-286. [PMID: 36996765 DOI: 10.1159/000529903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 02/22/2023] [Indexed: 04/01/2023] Open
Abstract
INTRODUCTION Renal function has an important bearing on plasma homocysteine levels. Plasma homocysteine is related to left ventricular hypertrophy (LVH). However, it remains unclear whether the association between plasma homocysteine levels and LVH is influenced by renal function. This study aimed to investigate relationships among left ventricular mass index (LVMI), plasma homocysteine levels, and renal function in a population from southern China. METHODS A cross-sectional study was performed in 2,464 patients from June 2016 to July 2021. Patients were divided into three groups based on gender-specific tertiles of homocysteine levels. LVMI ≥115 g/m2 for man or ≥95 g/m2 for woman was defined as LVH. RESULTS LVMI and the percentage of LVH were increased, while estimated glomerular filtration rate (eGFR) was decreased with the increase in homocysteine levels, both significantly. Multivariate stepwise regression analysis showed that eGFR and homocysteine were independently associated with LVMI in patients with hypertension. No correlation was observed between homocysteine and LVMI in patients without hypertension. Stratified by eGFR, further analysis confirmed homocysteine was independently associated with LVMI (β = 0.126, t = 4.333, p < 0.001) only in hypertensive patients with eGFR ≥90 mL/(min·1.73 m2), not with 60≤ eGFR <90 mL/(min·1.73 m2). Multivariate logistic regression indicated that in hypertensive patients with eGFR ≥90 mL/(min·1.73 m2), the patients in high tertile of homocysteine levels had a nearly twofold increased risk of occurring LVH compared with those in low tertile (high tertile: OR = 2.780, 95% CI: 1.945-3.975, p < 0.001). CONCLUSION Plasma homocysteine levels were independently associated with LVMI in hypertensive patients with normal eGFR.
Collapse
Affiliation(s)
- Lingyu Zhang
- Department of General Practice, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,
- Fujian Provincial Clinical Research Center for Geriatric Hypertension Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China,
- Department of International Medical Services, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China,
| | - Tingjun Wang
- Department of General Practice, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Clinical Research Center for Geriatric Hypertension Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of International Medical Services, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yihua Shen
- Fujian Provincial Clinical Research Center for Geriatric Hypertension Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of International Medical Services, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Geriatrics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Li Luo
- Fujian Provincial Clinical Research Center for Geriatric Hypertension Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of International Medical Services, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Geriatrics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guoyan Xu
- Department of General Practice, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Clinical Research Center for Geriatric Hypertension Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of International Medical Services, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liangdi Xie
- Department of General Practice, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Provincial Clinical Research Center for Geriatric Hypertension Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Fujian Hypertension Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of International Medical Services, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Geriatrics, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| |
Collapse
|
22
|
Ballew SH, Zhou L, Surapaneni A, Grams ME, Windham BG, Selvin E, Coresh J, Miao S, Inker LA, Levey AS. A Novel Creatinine Muscle Index Based on Creatinine Filtration: Associations with Frailty and Mortality. J Am Soc Nephrol 2023; 34:495-504. [PMID: 36735317 PMCID: PMC10103307 DOI: 10.1681/asn.0000000000000037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/09/2022] [Indexed: 01/27/2023] Open
Abstract
SIGNIFICANCE STATEMENT Low muscle mass is related to frailty and increased mortality in older adults. However, muscle mass is not easily assessed in routine clinical practice. This paper describes a novel creatinine muscle index (CMI) on the basis of serum creatinine and cystatin C. CMI was moderately associated with frailty among older adults. A significantly higher proportion of individuals with weak grip strength were in the lowest tertile of CMI. The index was also associated with mortality. These results are consistent with the hypothesis that creatinine filtration may be an index of muscle mass, which may have utility in clinical practice. BACKGROUND Low muscle mass is related to frailty and increased mortality in older adults. However, muscle mass is not easily assessed in routine clinical practice. METHODS This study describes a novel creatinine muscle index (CMI) on the basis of serum creatinine and cystatin C in a community-based sample of older adults from the Atherosclerosis Risk in Communities Study. Analyses included 4639 participants who attended visit 5 (2011-2013) and 12,786 participants who attended visit 2 (1990-1992). CMI was defined as creatinine filtration (the product of serum creatinine times eGFR on the basis of cystatin C) and was analyzed in sex-specific tertiles. Cross-sectional associations of CMI with a frailty trichotomy, defined by the number (robust [0]/prefrail [1-2]/frail [3-5]) of five frailty components (weight loss, slowness, exhaustion, weakness, and low physical activity), were studied using polychotomous logistic regression and binary logistic regression with each frailty component. Cox regression was used to estimate associations of CMI at visit 5 and visit 2 with mortality. Models were adjusted for demographics, clinical variables, and comorbid conditions. RESULTS CMI (tertile 1 versus 3) was moderately associated with frailty (visit 5: adjusted odds ratio 4.23 [95% confidence interval (CI), 2.02 to 8.87] in men and 2.34 [95% CI, 1.41 to 3.89] in women) and with mortality (visit 5: adjusted hazard ratio 1.45 [95% CI, 1.08 to 1.94] in men and 1.55 [95% CI, 1.13 to 2.12] in women; similar results were seen at visit 2). CONCLUSION Lower CMI was associated with frailty and increased mortality, two clinical outcomes known to be associated with decreased muscle mass. Creatinine filtration may be an index of muscle mass and have utility in clinical practice, particularly at low levels.
Collapse
Affiliation(s)
- Shoshana H. Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Linda Zhou
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
- Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - B. Gwen Windham
- Division of Geriatrics, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Andrew S. Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
23
|
Iversen E, Boesby L, Hansen D, Houlind MB. Comparison of 24-hour urinary creatinine clearance and estimated glomerular filtration rate based on a panel of filtration markers in patients with chronic kidney disease. Pharmacol Res Perspect 2022; 10:e01002. [PMID: 36069238 PMCID: PMC9449817 DOI: 10.1002/prp2.1002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 11/22/2022] Open
Abstract
Diagnosis and management of chronic kidney disease (CKD) requires accurate assessment of glomerular filtration rate (GFR). In practice, GFR is typically estimated by equations based on creatinine concentration in blood, but creatinine is affected by non-GFR factors such as age and sex. Alternative filtration markers such as cystatin C, beta-trace protein (BTP), and beta-2 microglobulin (B2M) may be less dependent on age and sex, but equations combining these markers have not been investigated in patients with chronic kidney disease (CKD). In this cross-sectional study of 50 patients with CKD stage 3-4, we compared kidney function estimates based on creatinine, cystatin C, BTP, B2M, or a combination of markers. Compared to the creatinine/cystatin C combination equation, the panel equation yielded a mean difference of only 2.8 ml/min/1.73 m2 , indicating that switching to the panel equation would be unlikely to affect management.
Collapse
Affiliation(s)
- Esben Iversen
- Department of Clinical ResearchCopenhagen University Hospital Amager and HvidovreHvidovreDenmark
- Icahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Lene Boesby
- Department of NephrologyCopenhagen University Hospital Herlev and GentofteCopenhagenDenmark
- Department of Internal MedicineZealand University Hospital RoskildeRoskildeDenmark
| | - Ditte Hansen
- Department of NephrologyCopenhagen University Hospital Herlev and GentofteCopenhagenDenmark
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Morten Baltzer Houlind
- Department of Clinical ResearchCopenhagen University Hospital Amager and HvidovreHvidovreDenmark
- Capital Region PharmacyHerlevDenmark
- Department of Drug Design and PharmacologyUniversity of CopenhagenCopenhagenDenmark
| |
Collapse
|
24
|
Gansevoort RT, Anders HJ, Cozzolino M, Fliser D, Fouque D, Ortiz A, Soler MJ, Wanner C. What should European nephrology do with the new CKD-EPI equation? Nephrol Dial Transplant 2022; 38:1-6. [PMID: 36069913 PMCID: PMC9869851 DOI: 10.1093/ndt/gfac254] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
| | - Hans-Joachim Anders
- Renal Division, Hospital of the Ludwig Maximilans University, Munich, Germany
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan, Renal Division, ASST Santi Paolo e Carlo, Milan, Italy
| | - Danilo Fliser
- Department of Internal Medicine IV, Renal and Hypertensive Disease, University Medical Center, Homburg, Saar, Germany
| | - Denis Fouque
- Department of Nephrology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Pierre-Benite, University of Lyon, France
| | - Alberto Ortiz
- Department of Nephrology, IIS-Fundacion Jimenez Diaz- UAM, Madrid, Spain,Department of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
| | - Maria José Soler
- Department of Nephrology, Hospital Vall d'Hebron, Barcelona, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Christoph Wanner
- Department of Internal Medicine I and Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
25
|
Ali A. Living Kidney Donation: Glomerular Filtration Rate-Based Donor Selection Criteria. EXP CLIN TRANSPLANT 2022; 20:65-69. [DOI: 10.6002/ect.donorsymp.2022.o5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
26
|
Trans JG, Krogstrup NV, Oltean M, Jespersen B, Nielsen MB, Birn H. A comparison of four established GFR formulas to estimate measured GFR and changes in GFR in adult kidney transplant recipients. Scand J Clin Lab Invest 2022; 82:296-303. [PMID: 35697079 DOI: 10.1080/00365513.2022.2084697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The accurate assessment of glomerular filtration rate (GFR) is important in the follow-up of kidney transplant recipients in order to identify graft dysfunction. A number of formulas have been proposed to calculate GFR from endogenous plasma markers such as creatinine or cystatin C since measuring GFR using exogenous markers is troublesome. This study compares and evaluates the ability of four different GFR formulas to estimate kidney graft function and to detect changes in GFR in kidney transplant recipients. The study included patients from the prospective, multicenter CONTEXT trial in kidney transplant recipients. GFR was measured using plasma clearance of 51Cr-EDTA and estimated using the MDRD, CKD-EPI Creatinine, CKD-EPI Cystatin C and CKD-EPI Cystatin C + Creatinine equations at three (n = 83) and twelve (n = 65) months post-transplantation. For each formula mean bias, precision, and accuracy were evaluated. The MDRD equation had the lowest mean bias (0.2 ml/min/1.73 m2), whereas the CKD-EPI Cystatin C + Creatinine equation had the highest precision (8 ml/min/1.73 m2). Accuracy at three months were similar for all equations (P30 > 80%) except for the CKD-EPI Cystatin C equation, which performed poorer (P30 = 55%). None of the formulas evaluated avoided misclassification of changes in GFR. The most optimal combination of precision and accuracy suggests the use of CKD-EPI Creatinine + Cystatin C equation in kidney transplant recipients.
Collapse
Affiliation(s)
| | - Nicoline V Krogstrup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Nephrology, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Marie Bodilsen Nielsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
27
|
Gutiérrez OM, Sang Y, Grams ME, Ballew SH, Surapaneni A, Matsushita K, Go AS, Shlipak MG, Inker LA, Eneanya ND, Crews DC, Powe NR, Levey AS, Coresh J. Association of Estimated GFR Calculated Using Race-Free Equations With Kidney Failure and Mortality by Black vs Non-Black Race. JAMA 2022; 327:2306-2316. [PMID: 35667006 PMCID: PMC9171658 DOI: 10.1001/jama.2022.8801] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/11/2022] [Indexed: 12/14/2022]
Abstract
Importance At a given estimated glomerular filtration rate (eGFR), individuals who are Black have higher rates of mortality and kidney failure with replacement therapy (KFRT) compared with those who are non-Black. Whether the recently adopted eGFR equations without race preserve racial differences in risk of mortality and KFRT at a given eGFR is unknown. Objective To assess whether eGFR equations with and without race and cystatin C document racial differences in risk of KFRT and mortality in populations including Black and non-Black participants. Design, Setting, and Participants Retrospective individual-level data analysis of 62 011 participants from 5 general population and 3 chronic kidney disease (CKD) US-based cohorts with serum creatinine, cystatin C, and follow-up for KFRT and mortality from 1988 to 2018. Exposures Chronic Kidney Disease Epidemiology Collaboration equation with serum creatinine (eGFRcr with and without race), cystatin C (eGFRcys without race), or both markers (eGFRcr-cys without race). Main Outcomes and Measures The prevalence of decreased eGFR at baseline and hazard ratios of KFRT and mortality in Black vs non-Black participants were calculated, adjusted for age and sex. Analyses were performed within each cohort and with random-effect meta-analyses of the models. Results Among 62 011 participants (20 773 Black and 41 238 non-Black; mean age, 63 years; 53% women), the prevalence ratio (95% CI; percent prevalences) of eGFR less than 60 mL/min/1.73 m2 comparing Black with non-Black participants was 0.98 (95% CI, 0.93-1.03; 11% vs 12%) for eGFRcr with race, 0.95 (95% CI, 0.91-0.98; 17% vs 18%) for eGFRcys, and 1.2 (95% CI, 1.2-1.3; 13% vs 11%) for eGFRcr-cys but was 1.8 (95% CI, 1.7-1.8; 15% vs 9%) for eGFRcr without race. During a mean follow-up of 13 years, 8% and 4% of Black and non-Black participants experienced KFRT and 34% and 39% died, respectively. Decreased eGFR was associated with significantly greater risk of both outcomes for all equations. At an eGFR of 60 mL/min/1.73 m2, the hazard ratios for KFRT comparing Black with non-Black participants were 2.8 (95% CI, 1.6-4.9) for eGFRcr with race, 3.0 (95% CI, 1.5-5.8) for eGFRcys, and 2.8 (95% CI, 1.4-5.4) for eGFRcr-cys vs 1.3 (95% CI, 0.8-2.1) for eGFRcr without race. The 5-year absolute risk differences for KFRT comparing Black with non-Black participants were 1.4% (95% CI, 0.2%-2.6%) for eGFRcr with race, 1.1% (95% CI, 0.2%-1.9%) for eGFRcys, and 1.3% (95% CI, 0%-2.6%) for eGFRcr-cys vs 0.37% (95% CI, -0.32% to 1.05%) for eGFRcr without race. Similar patterns were observed for mortality. Conclusions and Relevance In this retrospective analysis of 8 US cohorts including Black and non-Black individuals, the eGFR equation without race that included creatinine and cystatin C, but not the eGFR equation without race that included creatinine without cystatin C, demonstrated racial differences in the risk of KFRT and mortality throughout the range of eGFR. The eGFRcr-cys equation may be preferable to the eGFRcr equation without race for assessing racial differences in the risk of KFRT and mortality associated with low eGFR.
Collapse
Affiliation(s)
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shoshana H. Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Aditya Surapaneni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Michael G. Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center, University of California, San Francisco
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Nwamaka D. Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Deidra C. Crews
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Neil R. Powe
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Andrew S. Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and the Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| |
Collapse
|
28
|
Poventud-Fuentes I, Garnett E, Akcan-Arikan A, Devaraj S. Comparison of Cystatin C and Creatinine-Based Equations with Measured Glomerular Filtration Rate in a Diverse Pediatric Population. J Appl Lab Med 2022; 7:1016-1024. [PMID: 35671191 DOI: 10.1093/jalm/jfac043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 05/09/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Accurate assessment of kidney function is essential for early detection of kidney damage. While measured glomerular filtration rate (mGFR) is occasionally used as a reference, estimated GFR (eGFR) from serum creatinine- and cystatin C (CysC)-based equations are routinely used in clinical practice as a reliable and less invasive approach. In pediatric populations, CysC-based equations provide a closer approximation as they are independent of body composition. Limited information is available on the performance of CysC-based equations in comparison with mGFR with tracers other than iohexol. Therefore, the goal of our study was to evaluate how eGFR, based on several CysC- and creatinine-based equations, with and without race correction, relates to mGFR in a diverse pediatric population. METHODS A total of 43 patients (7 months to 21 years) from diverse race/ethnicity were retrospectively studied to compare the mGFR from multiple blood sample collections after intravenous tracer injection (Tc-99mDTPA) with eGFR using 9 equations. Deming regression analyses were performed to assess correlation between the mGFR and eGFRs. RESULTS The average mGFR for this cohort was 95.0 mL/min/1.73 m2. Race-corrected (RC) equations gave overestimated eGFR across all ethnic groups, with the lowest bias for Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) CysC-creatinine (34.14 mL/min/1.73 m2). The best correlations to mGFR, percentage of eGFR within 30% of mGFR (P30), and lowest biases were from non-race-corrected (NRC) equations Chronic Kidney Disease in Children (CKiD) (0.6460, 65.1%, 2.86 mL/min/1.73 m2), CKD-EPI CysC (0.6858, 69.8%, 11.01 mL/min/1.73 m2), and Schwartz CysC (0.6876, 79.1%, -14.00 mL/min/1.73 m2). CONCLUSION Overall, CysC-based equations without race correction provide a good approximation of mGFR and a less invasive alternative to monitoring kidney function in pediatric population, irrespective of race/ethnicity.
Collapse
Affiliation(s)
- Izmarie Poventud-Fuentes
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Pathology, Texas Children's Hospital, Houston, TX, USA
| | - Emily Garnett
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Pathology, Texas Children's Hospital, Houston, TX, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sridevi Devaraj
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Pathology, Texas Children's Hospital, Houston, TX, USA
| |
Collapse
|
29
|
Past and Present Policy Efforts in Achieving Racial Equity in Kidney Transplantation. CURRENT TRANSPLANTATION REPORTS 2022; 9:114-118. [PMID: 35646512 PMCID: PMC9127821 DOI: 10.1007/s40472-022-00369-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/01/2022]
Abstract
Purpose of Review Recent Findings Summary
Collapse
|
30
|
Wang Y, Levey AS, Inker LA, Jessani S, Bux R, Samad Z, Yaqub S, Karger AB, Allen JC, Jafar TH. Performance of Serum β2-Microglobulin- and β-Trace Protein-Based Panel Markers and 2021 Creatinine- and Cystatin-Based GFR Estimating Equations in Pakistan. Kidney Med 2022; 4:100444. [PMID: 35402891 PMCID: PMC8988004 DOI: 10.1016/j.xkme.2022.100444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Yeli Wang
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Andrew S Levey
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Lesley A Inker
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Saleem Jessani
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Rasool Bux
- Department of Paediatrics (Division of Women & Child Health), Aga Khan University, Karachi, Pakistan
| | - Zainab Samad
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Sonia Yaqub
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN
| | - John C Allen
- Center for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School, Singapore
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Department of Medicine, Aga Khan University, Karachi, Pakistan.,Department of Renal Medicine, Singapore General Hospital, Singapore.,Duke Global Health Institute, Duke University, Durham, NC
| |
Collapse
|
31
|
Shaw-Gallagher M, Rangel FA, Sweeney KA, Digambaranath J, Siddiqui F, McKay M, Gadulka K, Davis JS. Everything Else. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2021.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
32
|
Asrani SK, Shankar N, da Graca B, Nadim MK, Cardenas A. Role of Novel Kidney Biomarkers in Patients With Cirrhosis and After Liver Transplantation. Liver Transpl 2022; 28:466-482. [PMID: 34714972 DOI: 10.1002/lt.26344] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 01/13/2023]
Abstract
Acute kidney injury (AKI) and chronic kidney disease (CKD) are important drivers of morbidity and mortality in patients with cirrhosis before and after liver transplantation (LT). In this review, we examine the role of novel kidney biomarkers for early recognition of kidney injury. Studies are limited by lack of reference standards, heterogeneous definitions of outcomes and biomarker cutoffs, and inconsistent diagnostic performance. Overall, a change in biomarker is more relevant than an absolute cutoff. Cystatin C and urinary neutrophil gelatinase-associated lipocalin (uNGAL) are the most studied candidate biomarkers and identify AKI or progression of AKI earlier than serum creatinine (sCr). Kidney injury molecule 1 and liver-type fatty acid-binding protein (L-FABP) also show potential. NGAL and interleukin 18 may play a role in differentiating acute tubular necrosis from other forms of AKI. Combining novel biomarkers with the Model for End-Stage Liver Disease score may assist prognosis. Persistent elevations in select markers (eg, NGAL) can portend irreversible injury. Several pretransplantation markers (including sCr) predict posttransplantation kidney dysfunction. Pretransplantation assessment of clinical factors (eg, age, diabetes) and novel markers (osteopontin and tissue inhibitor of metalloproteinases 1 [TIMP-1]) may predict renal kidney recovery after LT. Intraoperative changes in biomarkers predict early post-LT AKI. Prediction of CKD remains difficult, although a combination of biomarkers (eg, beta-2 microglobulin, CD40) is promising. Novel biomarkers have yet to replace sCr in guideline-based evaluation and management of kidney dysfunction in patients with cirrhosis. We propose a theoretical framework for practical incorporation of these biomarkers that considers patient characteristics (risk for irreversible injury), markers of functional and structural change, and assessment of the AKI-CKD continuum to identify patients at the highest risk for progressive kidney disease before and after LT.
Collapse
Affiliation(s)
| | | | | | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Andres Cardenas
- GI/Liver Transplant Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| |
Collapse
|
33
|
Iversen E, Hornum M, Lund TM, Houlind MB. Comment on Delanaye et al: Future perspectives regarding kidney function estimates and dose adjustments. Br J Clin Pharmacol 2022; 88:2998-2999. [PMID: 35118701 DOI: 10.1111/bcp.15195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/12/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Esben Iversen
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Mads Hornum
- Department of Nephrology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Trine Meldgaard Lund
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Morten Baltzer Houlind
- Department of Clinical Research, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark.,The Capital Region Pharmacy, Herlev, Denmark
| |
Collapse
|
34
|
Eneanya ND, Boulware LE, Tsai J, Bruce MA, Ford CL, Harris C, Morales LS, Ryan MJ, Reese PP, Thorpe RJ, Morse M, Walker V, Arogundade FA, Lopes AA, Norris KC. Health inequities and the inappropriate use of race in nephrology. Nat Rev Nephrol 2022; 18:84-94. [PMID: 34750551 PMCID: PMC8574929 DOI: 10.1038/s41581-021-00501-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.
Collapse
Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - L Ebony Boulware
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer Tsai
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Marino A Bruce
- Program for Research on Faith, Justice, and Health, Department of Behavioral and Social Sciences, University of Houston College of Medicine, Houston, TX, USA
| | - Chandra L Ford
- Center for the Study of Racism, Social Justice & Health, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Christina Harris
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Leo S Morales
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Michael J Ryan
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Peter P Reese
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Roland J Thorpe
- Program for Research on Men's Health, Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michelle Morse
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Valencia Walker
- Department of Paediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Antonio A Lopes
- Clinical Epidemiology and Evidence-Based Medicine Unit of the Edgard Santos University Hospital and Department of Internal Medicine, Federal University of Bahia, Salvador, Brazil
| | - Keith C Norris
- VA Greater Los Angeles Healthcare System, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| |
Collapse
|
35
|
Delgado C, Baweja M, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, Mendu ML, Miller WG, Moxey-Mims MM, Roberts GV, St Peter WL, Warfield C, Powe NR. A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis 2022; 79:268-288.e1. [PMID: 34563581 DOI: 10.1053/j.ajkd.2021.08.003] [Citation(s) in RCA: 326] [Impact Index Per Article: 163.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In response to a national call for re-evaluation of the use of race in clinical algorithms, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) established a Task Force to reassess inclusion of race in the estimation of glomerular filtration rate (GFR) in the United States and its implications for diagnosis and management of patients with, or at risk for, kidney diseases. PROCESS & DELIBERATIONS The Task Force organized its activities over 10 months in phases to (1) clarify the problem and evidence regarding GFR estimating equations in the United States (described previously in an interim report), and, in this final report, (2) evaluate approaches to address use of race in GFR estimation, and (3) provide recommendations. We identified 26 approaches for the estimation of GFR that did or did not consider race and narrowed our focus, by consensus, to 5 of those approaches. We holistically evaluated each approach considering 6 attributes: assay availability and standardization; implementation; population diversity in equation development; performance compared with measured GFR; consequences to clinical care, population tracking, and research; and patient centeredness. To arrive at a unifying approach to estimate GFR, we integrated information and evidence from many sources in assessing strengths and weaknesses in attributes for each approach, recognizing the number of Black and non-Black adults affected. RECOMMENDATIONS (1) For US adults (>85% of whom have normal kidney function), we recommend immediate implementation of the CKD-EPI creatinine equation refit without the race variable in all laboratories in the United States because it does not include race in the calculation and reporting, included diversity in its development, is immediately available to all laboratories in the United States, and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals. (2) We recommend national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm estimated GFR in adults who are at risk for or have chronic kidney disease, because combining filtration markers (creatinine and cystatin C) is more accurate and would support better clinical decisions than either marker alone. If ongoing evidence supports acceptable performance, the CKD-EPI eGFR-cystatin C (eGFRcys) and eGFR creatinine-cystatin C (eGFRcr-cys_R) refit without the race variables should be adopted to provide another first-line test, in addition to confirmatory testing. (3) Research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded. An investment in science is needed for newer approaches that generate accurate, unbiased, and precise GFR measurement and estimation without the inclusion of race, and that promote health equity and do not generate disparate care. IMPLEMENTATION This unified approach, without specification of race, should be adopted across the United States. High-priority and multistakeholder efforts should implement this solution.
Collapse
Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco Veterans Affairs Medical Center and Division of Nephrology, University of California San Francisco, San Francisco, California.
| | - Mukta Baweja
- Nephrology Division, Department of Medicine and Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Crystal A Gadegbeku
- Department of Nephrology and Hypertension, Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L Mendu
- Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - W Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Marva M Moxey-Mims
- Division of Nephrology, Children's National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Glenda V Roberts
- External Relations and Patient Engagement, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, Washington
| | - Wendy L St Peter
- College of Pharmacy, University of Minnesota, Minneapolis, Minnesota
| | | | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and University of California San Francisco, San Francisco, California.
| |
Collapse
|
36
|
Delgado C, Powe NR. Resolving the Debate: The Future of Using Race in Estimating Kidney Function. Adv Chronic Kidney Dis 2022; 29:5-16. [PMID: 35690404 DOI: 10.1053/j.ackd.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 11/11/2022]
Abstract
Racial and social unrest witnessed during 2020 ignited a national conversation about the appropriateness of the use of race in health care algorithms and in the estimation of kidney function in particular. The growing concerns over the use of race in kidney function-estimating equations prompted the National Kidney Foundation (NKF) and American Society of Nephrology to launch an effort for change by establishing a task force on reassessing the use of race in diagnosing kidney disease. After nearly a year examining the evidence and obtaining testimony from experts and stakeholders, the task force recommended the immediate implementation of the 2020 Chronic Kidney Disease-Epidemiology creatinine equation refit without race in all US laboratories; increased routine use of cystatin C for confirmation of estimated glomerular filtration rate in clinical decision-making and a call for research on glomerular filtration rate estimation with new endogenous filtration markers and on addressing disparities in health and health care. The NKF and American Society of Nephrology strongly encouraged rapid adoption of these new recommendations. Leadership efforts of the NKF have begun to lay the foundation for national implementation through laboratory engagement, clinician awareness, and patient education.
Collapse
Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco VA Medical Center, San Francisco, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA.
| | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, San Francisco, CA; Department of Medicine, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
37
|
Koelling EE, Jazaeri O. An overview of renal insufficiency, race, and glomerular filtration rate calculation for the vascular surgeon. J Vasc Surg 2021; 75:3-4. [PMID: 34949382 DOI: 10.1016/j.jvs.2021.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/07/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Erin E Koelling
- Division of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, Md; F. Edwards Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md.
| | - Omid Jazaeri
- Department of Bioengineering, Rocky Vista University School of Medicine, University of Colorado Denver, Aurora, Colo; Cardiothoracic and Vascular Surgery Associates, Aurora, Colo
| |
Collapse
|
38
|
Delgado C, Baweja M, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, Mendu ML, Miller WG, Moxey-Mims MM, Roberts GV, St. Peter WL, Warfield C, Powe NR. A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. J Am Soc Nephrol 2021; 32:2994-3015. [PMID: 34556489 PMCID: PMC8638402 DOI: 10.1681/asn.2021070988] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/05/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In response to a national call for re-evaluation of the use of race in clinical algorithms, the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) established a Task Force to reassess inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and management of patients with, or at risk for, kidney diseases. PROCESS DELIBERATIONS The Task Force organized its activities over 10 months in phases to ( 1 ) clarify the problem and evidence regarding eGFR equations in the United States (described previously in an interim report), and, in this final report, ( 2 ) evaluate approaches to address use of race in GFR estimation, and ( 3 ) provide recommendations. We identified 26 approaches for the estimation of GFR that did or did not consider race and narrowed our focus, by consensus, to five of those approaches. We holistically evaluated each approach considering six attributes: assay availability and standardization; implementation; population diversity in equation development; performance compared with measured GFR; consequences to clinical care, population tracking, and research; and patient centeredness. To arrive at a unifying approach to estimate GFR, we integrated information and evidence from many sources in assessing strengths and weaknesses in attributes for each approach, recognizing the number of Black and non-Black adults affected. RECOMMENDATIONS ( 1 ) For US adults (>85% of whom have normal kidney function), we recommend immediate implementation of the CKD-EPI creatinine equation refit without the race variable in all laboratories in the United States because it does not include race in the calculation and reporting, included diversity in its development, is immediately available to all laboratories in the United States, and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals. ( 2 ) We recommend national efforts to facilitate increased, routine, and timely use of cystatin C, especially to confirm eGFR in adults who are at risk for or have CKD, because combining filtration markers (creatinine and cystatin C) is more accurate and would support better clinical decisions than either marker alone. If ongoing evidence supports acceptable performance, the CKD-EPI eGFR-cystatin C (eGFRcys) and eGFR creatinine-cystatin C (eGFRcr-cys_R) refit without the race variables should be adopted to provide another first-line test, in addition to confirmatory testing. ( 3 ) Research on GFR estimation with new endogenous filtration markers and on interventions to eliminate race and ethnic disparities should be encouraged and funded. An investment in science is needed for newer approaches that generate accurate, unbiased, and precise GFR measurement and estimation without the inclusion of race, and that promote health equity and do not generate disparate care. IMPLEMENTATION This unified approach, without specification of race, should be adopted across the United States. High-priority and multistakeholder efforts should implement this solution.
Collapse
Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco Veterans Affairs Medical Center and Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Mukta Baweja
- Nephrology Division, Department of Medicine and Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nwamaka D. Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Crystal A. Gadegbeku
- Department of Nephrology and Hypertension, Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - W. Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Marva M. Moxey-Mims
- Division of Nephrology, Children’s National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Glenda V. Roberts
- External Relations and Patient Engagement, Kidney Research Institute and Center for Dialysis Innovation, University of Washington, Seattle, Washington
| | | | | | - Neil R. Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and University of California San Francisco, San Francisco, California
| |
Collapse
|
39
|
Chang AR, Chen J, Grams ME, Karger AB, Inker LA, Coresh J, Levey AS. β2-Microglobulin and β-Trace Protein in Patients Undergoing Bariatric Surgery: Non-GFR Determinants and Panel-estimated GFR Performance. Kidney Med 2021; 4:100401. [PMID: 35243311 PMCID: PMC8861947 DOI: 10.1016/j.xkme.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alex R. Chang
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
- Department of Population Health Sciences, Geisinger, Danville, Pennsylvania
- Address for Correspondence: Alex R. Chang, MD, MS, Kidney Health Research Institute, Geisinger, 100 N Academy Ave, Danville, PA 17822.
| | - Jingsha Chen
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Morgan E. Grams
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Amy B. Karger
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, Maryland
| | - Andrew S. Levey
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
40
|
Kalantar-Zadeh K, Norris KC, Moore LW. Overcoming Vestiges of Structural Racism in Kidney Care and Renal Nutrition and Revisiting Cockcroft-Gault Creatinine Clearance and Its Weight Index. J Ren Nutr 2021; 32:1-4. [PMID: 34836767 DOI: 10.1053/j.jrn.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, California.
| | - Keith C Norris
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| |
Collapse
|
41
|
Casal MA, Ivy SP, Beumer JH, Nolin TD. Effect of removing race from glomerular filtration rate-estimating equations on anticancer drug dosing and eligibility: a retrospective analysis of National Cancer Institute phase 1 clinical trial participants. Lancet Oncol 2021; 22:1333-1340. [PMID: 34399096 PMCID: PMC8425175 DOI: 10.1016/s1470-2045(21)00377-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Kidney function assessment by estimated glomerular filtration rate (eGFR) equations, such as the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation, is important to determine dosing and eligibility for anticancer drugs. Inclusion of race in eGFR equations calculates a higher eGFR at a given serum creatinine concentration for Black patients versus non-Black patients. We aimed to characterise the effect of removing race from the CKD-EPI equation on dosing and eligibility of anticancer drugs with kidney function cutoffs. METHODS We did a retrospective analysis of patients enrolled in phase 1 studies sponsored by the Cancer Therapy Evaluation Program between January, 1995, and October, 2010. eGFR based on creatinine (eGFRCr) was calculated by the CKD-EPI equation and a version of the CKD-EPI equation without the race term (CKD-EPIwithout race). Estimated creatinine clearance (eClCr) was calculated by the Cockcroft-Gault equation. Dosing simulations based on each assessment of kidney function were done for ten anticancer drugs with kidney function cutoffs for dosing (oxaliplatin, capecitabine, etoposide, topotecan, fludarabine, and bleomycin) or eligibility (cisplatin, pemetrexed, bendamustine, and mitomycin) based on labelling approved by the US Food and Drug Administration or consensus guidelines. The absolute proportion of patients eligible or in each renal dosing range was calculated for each drug. Eligibility and dosing discordance rates were also calculated. FINDINGS Demographics and laboratory values from 340 Black patients (172 men and 168 women) were used. Median age was 57 years (IQR 47-64), median bodyweight was 78·1 kg (67·0-89·8), median body surface area was 1·91 m2 (1·77-2·09), and median serum creatinine concentration was 0·9 mg/dL (0·8-1·1). Median eGFRCr or eClCr was 103 mL/min (85-122) calculated by CKD-EPI, 89 mL/min (73-105) by CKD-EPIwithout race, and 90 mL/min (72-120) by Cockcroft-Gault. Black patients were recommended to receive dose reductions or were rendered ineligible to receive drug more frequently when using CKD-EPIwithout race than when using CKD-EPI, but at a similar rate as when using Cockcroft-Gault. The number of patients ineligible for therapy or recommended to receive any renal dose adjustment when CKD-EPIwithout race versus CKD-EPI was used increased by 72% (from 25 of 340 to 43 of 340 patients) for cisplatin, by 120% (from five to 11) for pemetrexed, by 67% (from three to five) for bendamustine, by 150% (from ten to 25) for capecitabine, by 150% (from ten to 25) for etoposide, by 67% (from three to five) for topotecan, by 61% (from 74 to 119) for fludarabine, and by 163% (from eight to 21) for bleomycin. Up to 18% of patients had discordant recommendations using CKD-EPIwithout race versus CKD-EPI. INTERPRETATION Removing race from the CKD-EPI equation will calculate a lower eGFR for Black patients and exclude more patients from receiving anticancer therapy, which could lead to undertreatment of Black patients with cancer and adversely affect their outcomes. FUNDING National Institutes of Health.
Collapse
Affiliation(s)
- Morgan A Casal
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - S Percy Ivy
- Investigational Drug Branch, Cancer Therapy Evaluation Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Jan H Beumer
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Hematology/Oncology Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, PA, USA
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA; Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| |
Collapse
|
42
|
Delgado C, Baweja M, Burrows NR, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, Mendu ML, Miller WG, Moxey-Mims MM, Roberts GV, St Peter WL, Warfield C, Powe NR. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report From the NKF-ASN Task Force. Am J Kidney Dis 2021; 78:103-115. [PMID: 33845065 PMCID: PMC8238889 DOI: 10.1053/j.ajkd.2021.03.008] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For almost 2 decades, equations that use serum creatinine, age, sex, and race to estimate glomerular filtration rate (GFR) have included "race" as Black or non-Black. Given considerable evidence of disparities in health and health care delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non-GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase 1, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.
Collapse
Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco Veterans Affairs Medical Center, Division of Nephrology, University of California San Francisco, San Francisco, CA.
| | - Mukta Baweja
- Nephrology Division, Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Crystal A Gadegbeku
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Temple University, Philadelphia, PA
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Mallika L Mendu
- Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - W Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, VA
| | - Marva M Moxey-Mims
- Division of Nephrology, Children's National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Glenda V Roberts
- External Relations and Patient Engagement, Kidney Research Institute, Center for Dialysis Innovation, University of Washington, Seattle, WA
| | | | | | - Neil R Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA.
| |
Collapse
|
43
|
Delgado C, Baweja M, Burrows NR, Crews DC, Eneanya ND, Gadegbeku CA, Inker LA, Mendu ML, Miller WG, Moxey-Mims MM, Roberts GV, St. Peter WL, Warfield C, Powe NR. Reassessing the Inclusion of Race in Diagnosing Kidney Diseases: An Interim Report from the NKF-ASN Task Force. J Am Soc Nephrol 2021; 32:1305-1317. [PMID: 33837122 PMCID: PMC8259639 DOI: 10.1681/asn.2021010039] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
For almost two decades, equations that use serum creatinine, age, sex, and race to eGFR have included "race" as Black or non-Black. Given considerable evidence of disparities in health and healthcare delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important non GFR determinants of serum creatinine and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, or at risk for, kidney diseases. This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase one, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.
Collapse
Affiliation(s)
- Cynthia Delgado
- Nephrology Section, San Francisco Veterans Affairs Medical Center, Division of Nephrology, University of California San Francisco, San Francisco, California
| | - Mukta Baweja
- Nephrology Division, Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nilka Ríos Burrows
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Deidra C. Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nwamaka D. Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Crystal A. Gadegbeku
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Temple University, Philadelphia, Pennsylvania
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Mallika L. Mendu
- Division of Renal Medicine and Office of the Chief Medical Officer, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - W. Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia
| | - Marva M. Moxey-Mims
- Division of Nephrology, Children’s National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Glenda V. Roberts
- External Relations and Patient Engagement, Kidney Research Institute, Center for Dialysis Innovation, University of Washington, Seattle, Washington
| | | | | | - Neil R. Powe
- Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California
| |
Collapse
|
44
|
Eneanya ND, Kostelanetz S, Mendu ML. Race-Free Biomarkers to Quantify Kidney Function: Health Equity Lessons Learned From Population-Based Research. Am J Kidney Dis 2021; 77:667-669. [PMID: 33583623 DOI: 10.1053/j.ajkd.2020.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Sophia Kostelanetz
- Center for Clinical Quality and Implementation Research, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Mallika L Mendu
- Division of Renal Medicine and Department of the Chief Medical Officer, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Population Health, Mass General Brigham, Boston, MA
| |
Collapse
|
45
|
Delanaye P, Mariat C. Comparing Multiple-Biomarker Panels for Estimating GFR With Estimating Equations Without a Coefficient Distinguishing Black Individuals From Persons of Other Groups. Am J Kidney Dis 2021; 77:823-824. [PMID: 33571580 DOI: 10.1053/j.ajkd.2020.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/22/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Pierre Delanaye
- University of Liège, CHU Sart Tilman, Liège, Belgium; Hôpital Universitaire Carémeau, Nîmes, France
| | | |
Collapse
|
46
|
Inker LA, Levey AS. In Reply to "Multiple-Biomarker Panel Estimated GFR Is Not Optimal or Cost-Effective" and "Comparing Multiple-Biomarker Panels for Estimating GFR With Estimating Equations Without a Coefficient Distinguishing Black Individuals From Persons of Other Groups". Am J Kidney Dis 2021; 77:824. [PMID: 33571578 DOI: 10.1053/j.ajkd.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| |
Collapse
|
47
|
Grubb A, Christensson A, Björk J. Multiple-Biomarker Panel Estimated GFR Is Not Optimal or Cost-Effective. Am J Kidney Dis 2021; 77:823. [PMID: 33571579 DOI: 10.1053/j.ajkd.2020.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 01/21/2023]
|
48
|
Dyer O. Pulse oximetry may underestimate hypoxaemia in black patients, study finds. BRITISH MEDICAL JOURNAL 2020. [DOI: 10.1136/bmj.m4926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
49
|
|