1
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Teaford HR, Stevens RW, Rule AD, Mara KC, Kashani KB, Lieske JC, O'Horo J, Barreto EF. Prediction of Vancomycin Levels Using Cystatin C in Overweight and Obese Patients: a Retrospective Cohort Study of Hospitalized Patients. Antimicrob Agents Chemother 2020; 65:e01487-20. [PMID: 33106257 PMCID: PMC7927827 DOI: 10.1128/aac.01487-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/16/2020] [Indexed: 01/16/2023] Open
Abstract
The use of the kidney function biomarker cystatin C (cysC) can improve the accuracy of vancomycin dosing for target trough attainment in nonobese patients. It is unknown whether cysC can also improve vancomycin target trough attainment in overweight and obese patients. We conducted a retrospective observational study of overweight or obese hospitalized adults with stable renal function administered intravenous vancomycin between January 2011 and July 2019. Linear regression models were used to predict initial steady-state vancomycin troughs using several factors, including various cysC- and serum creatinine (SCr)-based estimates of kidney function. We compared the predicted proportion of patients within the target trough range (10 to 20 mg/liter) using the derived models to that observed from usual care. Of the 200 included patients, the mean trough level was 15 ± 6.3 mg/liter. The optimal model to predict the initial trough included both cysC and SCr (R2 = 0.48) rather than either biomarker alone. This model predicted that 79% (95% confidence interval [CI], 73% to 85%) of troughs could be between 10 and 20 mg/liter compared to the 62% observed in clinical practice (P < 0.001), a 1.3-fold increase. This study is the first to examine the role of cysC in predicting vancomycin levels in an exclusively overweight or obese population. While dosing models based on cysC appear promising in this setting, prospective validation is needed.
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Affiliation(s)
| | - Ryan W Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - John O'Horo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
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2
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Teaford HR, Barreto JN, Vollmer KJ, Rule AD, Barreto EF. Cystatin C: A Primer for Pharmacists. PHARMACY 2020; 8:E35. [PMID: 32182861 PMCID: PMC7151673 DOI: 10.3390/pharmacy8010035] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/22/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Pharmacists are at the forefront of dosing and monitoring medications eliminated by or toxic to the kidney. To evaluate the effectiveness and safety of these medications, accurate measurement of kidney function is paramount. The mainstay of kidney assessment for drug dosing and monitoring is serum creatinine (SCr)-based estimation equations. Yet, SCr has known limitations including its insensitivity to underlying changes in kidney function and the numerous non-kidney factors that are incompletely accounted for in equations to estimate glomerular filtration rate (eGFR). Serum cystatin C (cysC) is a biomarker that can serve as an adjunct or alternative to SCr to evaluate kidney function for drug dosing. Pharmacists must be educated about the strengths and limitations of cysC prior to applying it to medication management. Not all patient populations have been studied and some evaluations demonstrated large variations in the relationship between cysC and GFR. Use of eGFR equations incorporating cysC should be reserved for drug management in scenarios with demonstrated outcomes, including to improve pharmacodynamic target attainment for antibiotics or reduce drug toxicity. This article provides an overview of cysC, discusses evidence around its use in medication dosing and in special populations, and describes practical considerations for application and implementation.
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Affiliation(s)
- Hilary R. Teaford
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Jason N. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
| | - Kathryn J. Vollmer
- College of Pharmacy and Health Sciences, Drake University, Des Moines, IA 50311, USA;
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA;
- Division of Epidemiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Erin F. Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA; (H.R.T.); (J.N.B.)
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN 55905, USA
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3
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Šálek T, Vodička M, Gabrhelík T. Estimated glomerular filtration rate in patients overdosed with gentamicin. J LAB MED 2020. [DOI: 10.1515/labmed-2019-0124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
The aim of this study was to compare the estimated glomerular filtration rate (eGFR) from serum creatinine (eGFRcrea) and cystatin C (eGFRcys) in patients with elevated serum trough levels of gentamicin before the next planned dose during treatment in the intensive care unit (ICU).
Methods
This was a retrospective observational study. Patients who stayed in an ICU, received a once-daily dose of gentamicin, and who had results from all serum gentamicin trough levels, eGFRcrea and eGFRcys analyses were included in the study. Overdosed patients were defined as those with serum gentamicin trough levels above 1 mg/L before the next dose. Gentamicin was measured by a particle-enhanced turbidimetric immunoassay (PETIA). Creatinine and cystatin C were measured by standardized methods.
Results
The median age (range) was lower in all patients with gentamicin concentration measurements than in overdosed patients (67 [19–96] vs. 75 [48–99] years, respectively; p < 0.0001). The median interquartile range (IQR) of the eGFRcrea was higher than that of the eGFRcys in overdosed patients (60 [44–79] mL/min/1.73 m2 vs. 41 [29–58] mL/min/1.73 m2, respectively; p < 0.0001). The median IQR of the eGFRcrea was higher than that of the eGFRcys in controls (87 [78–98] mL/min/1.73 m2 vs. 66 [54–93] mL/min/1.73 m2, respectively; p < 0.0001).
Conclusions
Overdosed patients had both a lower eGFRcrea and eGFRcys than controls. Elderly patients are the most commonly overdosed patients. We recommend measuring cystatin C and calculating the eGFRcys and combined equation (eGFRcrea + cys) in ICU patients over 65 years of age, which would enable improved gentamicin dosage adjustments.
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Affiliation(s)
- Tomáš Šálek
- Department of Clinical Biochemistry and Pharmacology , Tomas Bata Hospital , Havlíčkovo nábřeží 600 , 76275 Zlín , Czech Republic
- Department of Biomedical Sciences , Medical Faculty of the University of Ostrava , Syllabova 19 , 703 00 Ostrava – Zábřeh , Czech Republic
| | - Martin Vodička
- Department of Pharmacy, Tomas Bata Hospital , Zlín , Czech Republic
| | - Tomáš Gabrhelík
- Department of Anaesthesiology and Resuscitation , Tomas Bata Hospital , Zlín , Czech Republic
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4
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Barreto EF, Rule AD, Murad MH, Kashani KB, Lieske JC, Erwin PJ, Steckelberg JM, Gajic O, Reid JM, Kane-Gill SL. Prediction of the Renal Elimination of Drugs With Cystatin C vs Creatinine: A Systematic Review. Mayo Clin Proc 2019; 94:500-514. [PMID: 30713050 DOI: 10.1016/j.mayocp.2018.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 07/05/2018] [Accepted: 08/07/2018] [Indexed: 01/08/2023]
Abstract
Serum cystatin C has been proposed as a kidney biomarker to inform drug dosing. We conducted a systematic review to synthesize available data for the association between serum cystatin C and drug pharmacokinetics, dosing, and clinical outcomes in adults (≥18 years). PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus were systematically searched from 1946 to September 2017 to identify candidate studies. Studies of cystatin C as a predictor for acute kidney injury or for management of contrast-associated acute kidney injury were excluded. Also, studies were excluded if drug concentrations were unavailable and if a reference standard for drug dosing (eg, serum creatinine) was not concurrently reported. The outcomes of interest included drug clearance (L/h), concentrations (mg/L), target level achievement (%), therapeutic failure (%), and drug toxicity (%). We included 28 articles that evaluated 16 different medications in 3455 participants. Vancomycin was the most well-studied drug. Overall, cystatin C-based estimated glomerular filtration rate (eGFRCystatin C) was more predictive of drug levels and drug clearance than eGFRCreatinine. In only one study were target attainment and outcomes compared between 2 drug-dosing regimens, one based on eGFRCreatinine-Cystatin C and one dosed with the Cockcroft-Gault creatinine clearance equation. Compared with eGFRCreatinine, use of eGFRCystatin C to predict elimination of medications via the kidney was as accurate, if not superior, in most studies, but infrequently were data on target attainment or clinical outcomes reported. Drug-specific dosing protocols that use cystatin C to estimate kidney function should be tested for clinical application.
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Affiliation(s)
- Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Joel M Reid
- Division of Medical Oncology, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
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5
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Peters BJ, Rule AD, Kashani KB, Lieske JC, Mara KC, Dierkhising RA, Barreto EF. Impact of Serum Cystatin C-Based Glomerular Filtration Rate Estimates on Drug Dose Selection in Hospitalized Patients. Pharmacotherapy 2018; 38:1068-1073. [PMID: 30120844 DOI: 10.1002/phar.2175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE Serum creatinine (Sc r ) concentration is used to calculate estimated glomerular filtration rate (eGFR) for medication dosing. Serum cystatin C (CysC) concentration has been proposed as an adjunct or alternative to Scr . This study sought to evaluate the possible impact of using CysC in eGFR equations on drug dose recommendations in hospitalized patients with infections. DESIGN Retrospective analysis of prospectively collected data. SETTING Large academic tertiary care medical center. PATIENTS A total of 308 adults with suspected or documented infections and stable kidney function who were hospitalized between 2012 and 2015. MEASUREMENTS AND MAIN RESULTS Standardized Sc r and CysC measured at the time of antibiotic dosing were used to estimate GFR from the three Chronic Kidney Disease Epidemiology Collaborative (CKD-EPI) equations using Sc r (eGFRCr ), CysC(eGFRCysC ), or a combination of Sc r and CysC (eGFRCr-CysC ), and these values were compared with estimated creatinine clearance (eClcr ) from the Cockcroft-Gault equation (standard of care for drug dosage adjustments). The eGFRs were categorized into five common dosage adjustment strata (lower than 20, 20-49, 50-79, 80-130, and higher than 130 ml/min), and agreement between equations was tested with the weighted κ statistic. Recommended drug doses varied considerably between the eClcr and the CKD-EPI equations (weighted κ [95% confidence interval]: eGFRCr 0.73 [0.68-0.79], eGFRCysC 0.42 [0.35-0.5], eGFRCr-CysC 0.65 [0.6-0.71]). If eGFRCr, eGFRCysC , or eGFRCr-CysC were used instead of eClcr to dose drugs, 11%, 12%, and 8% of doses, respectively, would be higher, and 12%, 38%, and 24% of doses, respectively, would be lower. CONCLUSION Significant discordance in drug doses was observed when the CKD-EPI equations were used in place of eClcr . When CysC was included in eGFR equations, recommended doses were often lower. Further study is needed to develop and test drug-specific dosing guidelines that incorporate alternate renal biomarkers and/or more contemporary eGFR equations.
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Affiliation(s)
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.,Division of Epidemiology, Mayo Clinic, Rochester, Minnesota
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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6
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Hudson JQ, Nolin TD. Pragmatic Use of Kidney Function Estimates for Drug Dosing: The Tide Is Turning. Adv Chronic Kidney Dis 2018; 25:14-20. [PMID: 29499882 DOI: 10.1053/j.ackd.2017.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 01/13/2023]
Abstract
Creatinine clearance has been the most common method of estimating kidney function for the purpose of drug dosing for decades. The availability and extensive clinical use of estimated glomerular filtration rate (eGFR) now provides clinicians a potential alternative. Currently, data demonstrating the validity of eGFR-based drug dosing is limited, but proof of principle has been established and the tide related to use of eGFR for drug dosing appears to be turning. Use of the same kidney function estimate for management of kidney disease, drug development and dosing, and harmonization in all clinical arenas would be ideal. Use of multiple equations can lead to differences in kidney function estimates and corresponding drug dosing regimens, which necessitates clinical judgment and a pragmatic approach when rendering drug dosing decisions. Careful consideration of the risk-benefit ratio of individual drugs and dosing regimens within each patient is warranted. Going forward, FDA guidance will likely incentivize pharmaceutical manufacturers to generate eGFR-based dosing recommendations in addition to creatinine clearance for inclusion in the label of newly approved drugs. However, dosing information for currently approved drugs will continue to be based on creatinine clearance alone, so clinicians must be vigilant in the assessment of kidney function in order to provide optimal pharmacotherapy.
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7
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Higdon EA, Kimmons LA, Duhart BT, Hudson JQ. Disagreement in Estimates of Kidney Function for Drug Dosing in Obese Inpatients. J Pharm Pract 2017; 32:41-47. [PMID: 29105574 DOI: 10.1177/0897190017737895] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND: The Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations are used to estimate kidney function. However, utility has been questioned in the obese population. OBJECTIVE: To evaluate differences in estimates of kidney function in obese patients and implications for drug dosing. METHODS: This was a retrospective study of adult inpatients with a body mass index ≥30 kg/m2 and stable kidney function. Patients were categorized based on creatinine clearance (CrCl): group 1-CrCl ≥ 60 mL/min and group 2-CrCl 15 to 59 mL/min. Mean estimates of kidney function and recommended doses of 8 renally eliminated medications were compared. RESULTS: For the 166 patients included, mean estimates using CG, MDRD, and CKD-EPI for group 1 were 87 (23) mL/min, 91 (21) mL/min, and 96 (23) mL/min, respectively. Group 2 estimates were 42 (13) mL/min, 51 (15) mL/min, and 51 (16) mL/min, respectively. MDRD and CKD-EPI estimates were significantly higher than CG in 125 (75%) and 140 (84%) patients, respectively. Dose discrepancies were most often due to higher dose recommendations using MDRD or CKD-EPI compared to CG. CONCLUSION: Careful consideration of the method used to estimate kidney function, the method used for developing dosing recommendations, and the risk-benefit profile is warranted when designing drug regimens in obese individuals.
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Affiliation(s)
- Emily A Higdon
- 1 Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Lauren A Kimmons
- 2 Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Benjamin T Duhart
- 3 Department of Clinical Pharmacy, The University of Tennessee, Memphis, TN, USA
| | - Joanna Q Hudson
- 3 Department of Clinical Pharmacy, The University of Tennessee, Memphis, TN, USA.,4 Department of Medicine (Nephrology), The University of Tennessee, Memphis, TN, USA
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8
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Lim G, Park HD, Sung HJ. A Correlation Analysis of Serum Creatinine Based eGFR and Serum Cystatin C Based eGFR with Thyroid Dysfunction Patients. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2017. [DOI: 10.15324/kjcls.2017.49.3.203] [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] Open
Affiliation(s)
- Gu Lim
- Department of Biomedical Laboratory Sciences, College of Health Science, Eulji University, Seongnam, Korea
- BK21 Plus Program, Department of Senior Healthcare, Graduate School, Eulji University, Daejeon, Korea
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho Joong Sung
- Department of Biomedical Laboratory Sciences, College of Health Science, Eulji University, Seongnam, Korea
- BK21 Plus Program, Department of Senior Healthcare, Graduate School, Eulji University, Daejeon, Korea
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9
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Chew-Harris JSC, Chin PKL, Florkowski CM, George P, Endre Z. Removal of body surface area normalisation improves raw-measured glomerular filtration rate estimation by the Chronic Kidney Disease Epidemiology Collaboration equation and drug dosing in the obese. Intern Med J 2016; 45:766-73. [PMID: 25904102 DOI: 10.1111/imj.12791] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/16/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND/AIM We aimed to compared estimated glomerular filtration rate (eGFR) according to the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI), with (mL/min/1.73 m(2) ) and without body surface area (BSA) normalisation (CKD-EPI_noBSA, mL/min) against measured (99m) Technetium - diethylenepentaacetic acid (Tc-DTPA GFR) (mL/min) in 222 individuals, including 80 with malignancy. METHODS BSA was calculated for each individual using the Du Bois equation. The CKD-EPI and CKD-EPI_noBSA equations were compared with measured Tc-DTPA GFR with respect to bias, proportion within 30% of GFR (P30) and root mean square error for predicting levels of GFR, and concordance in relation to carboplatin dosing. RESULTS The mean (SD) for BSA and measured GFR for the entire group was 1.99 (0.25) m(2) and 127 (41) mL/min respectively. The P30 for Tc-DTPA GFR was significantly higher with the CKD-EPI_noBSA (80%) than with the CKD-EPI equation (63%, P = 0.0001). In those with body mass index (BMI) > 30 kg/m(2) , the P30 values for the CKD-EPI_noBSA and CKD-EPI were 74% and 42% respectively (P < 0.0001). Carboplatin dosing concordance for the cancer patients using the CKD-EPI and CKD-EPI_noBSA equation was 71% and 56% respectively (P = 0.07). In 78 individuals with BMI > 30 kg/m(2) , concordance in relation to carboplatin dosing using CKD-EPI_noBSA was 65% compared with 26% with the CKD-EPI (P < 0.0001). CONCLUSION The CKD-EPI without normalisation (CKD-EPI_noBSA) equation was superior to the CKD-EPI equation in estimating raw-measured Tc-DTPA GFR (mL/min).
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Affiliation(s)
- J S C Chew-Harris
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.,Pathology, University of Otago, Christchurch, New Zealand
| | - P K L Chin
- Medicine, University of Otago, Christchurch, New Zealand.,Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - C M Florkowski
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.,Pathology, University of Otago, Christchurch, New Zealand
| | - P George
- Clinical Biochemistry Unit, Canterbury Health Laboratories, Christchurch, New Zealand.,Pathology, University of Otago, Christchurch, New Zealand
| | - Z Endre
- Medicine, University of Otago, Christchurch, New Zealand.,Prince of Wales Hospital, Sydney, Australia
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10
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Delanaye P, Flamant M, Cavalier É, Guerber F, Vallotton T, Moranne O, Pottel H, Boffa JJ, Mariat C. [Dosing adjustment and renal function: Which equation(s)?]. Nephrol Ther 2015; 12:18-31. [PMID: 26602880 DOI: 10.1016/j.nephro.2015.07.472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022]
Abstract
While the CKD-EPI (for Chronic Kidney Disease Epidemiology) equation is now implemented worldwide, utilization of the Cockcroft formula is still advocated by some physicians for drug dosage adjustment. Justifications for this recommendation are that the Cockcroft formula was preferentially used to determine dose adjustments according to renal function during the development of many drugs, better predicts drugs-related adverse events and decreases the risk of drug overexposure in the elderly. In this opinion paper, we discuss the weaknesses of the rationale supporting the Cockcroft formula and endorse the French HAS (Haute Autorité de santé) recommendation regarding the preferential use of the CKD-EPI equation. When glomerular filtration rate (GFR) is estimated in order to adjust drug dosage, the CKD-EPI value should be re-expressed for the individual body surface area (BSA). Given the difficulty to accurately estimate GFR in the elderly and in individuals with extra-normal BSA, we recommend to prescribe in priority monitorable drugs in those populations or to determine their "true" GFR using a direct measurement method.
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Affiliation(s)
- Pierre Delanaye
- Service de néphrologie, dialyse et transplantation, CHU Sart-Tilman, université de Liège, 4000 Liège, Belgique
| | - Martin Flamant
- Service d'explorations fonctionnelles, hôpital Bichat, AP-HP, université Paris Diderot, Paris, France
| | - Étienne Cavalier
- Service de chimie clinique, CHU Sart-Tilman, université de Liège, 4000 Liège, Belgique
| | - Fabrice Guerber
- Laboratoire Oriade-Vizille, 75, chemin de la Terrasse, 38220 Vizille, France
| | - Thomas Vallotton
- Laboratoire Vialle, Bastia et Syndicat des jeunes biologistes médicaux, 20600 BastiaFrance
| | - Olivier Moranne
- EA 2415, biostatistique, épidémiologie et santé publique, institut universitaire de recherche clinique, université de Montpellier, 34093 Montpellier, France
| | - Hans Pottel
- Department of Primary Care and Public Health at Kulak, KU Leuven Kulak, 8500 Kortrijk, Belgique
| | - Jean-Jacques Boffa
- Inserm 1155, service de néphrologie et dialyse, hôpital Tenon, AP-HP, université Pierre-et-Marie-Curie, 75020 Paris, France
| | - Christophe Mariat
- Service de néphrologie, dialyse et transplantation, hôpital Nord, CHU de Saint-Étienne, université Jean-Monnet, 42055 Saint-Étienne, France.
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11
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Steinke T, Moritz S, Beck S, Gnewuch C, Kees MG. Estimation of creatinine clearance using plasma creatinine or cystatin C: a secondary analysis of two pharmacokinetic studies in surgical ICU patients. BMC Anesthesiol 2015; 15:62. [PMID: 25927897 PMCID: PMC4426534 DOI: 10.1186/s12871-015-0043-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 04/21/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In ICU patients, glomerular filtration is often impaired, but also supraphysiological values are observed ("augmented renal clearance", >130 mL/min/1.73 m(2)). Renally eliminated drugs (e.g. many antibiotics) must be adjusted accordingly, which requires a quantitative measure of renal function throughout all the range of clinically encountered values. Estimation from plasma creatinine is standard, but cystatin C may be a valuable alternative. METHODS This was a secondary analysis of renal function parameters in 100 ICU patients from two pharmacokinetic studies on vancomycin and betalactam antibiotics. Estimated clearance values obtained by the Cockcroft-Gault formula (eCLCG), the CKD-EPI formula (eCLCKD-EPI) or the cystatin C based Hoek formula (eCLHoek) were compared with the measured endogenous creatinine clearance (CLCR). Agreement of values was assessed by modified Bland-Altman plots and by calculating bias (median error) and precision (median absolute error). Sensitivity and specificity of estimates to identify patients with reduced (<60 mL/min/1.73 m(2)) or augmented (>130 mL/min/1.73 m(2)) CLCR were calculated. RESULTS The CLCR was well distributed from highly compromised to supraphysiological values (median 73.2, range 16.8-234 mL/min/1.73 m(2)), even when plasma creatinine was not elevated (≤0.8 mg/dL for women, ≤1.1 mg/dL for men). Bias and precision were +13.5 mL/min/1.73 m(2) and ±18.5 mL/min/1.73 m(2) for eCLCG, +7.59 and ±16.8 mL/min/1.73 m(2) for eCLCKD-EPI, and -4.15 and ±12.9 mL/min/1.73 m(2) for eCLHoek, respectively, with eCLHoek being more precise than the other two (p < 0.05). The central 95% of observed errors fell between -59.8 and +250 mL/min/1.73 m(2) for eCLCG, -83.9 and +79.8 mL/min/1.73 m(2) for eCLCKD-EPI, and -103 and +27.9 mL/min/1.73 m(2) for eCLHoek. Augmented renal clearance was underestimated by eCLCKD-EPI and eCLHoek. Patients with reduced CLCR were identified with good specificity by eCLCG, eCLCKD-EPI and eCLHoek (0.95, 0.97 and 0.91, respectively), but with less sensitivity (0.55, 0.55 and 0.83). For augmented renal clearance, specificity was 0.81, 0.96 and 0.96, but sensitivity only 0.69, 0.25 and 0.38. CONCLUSIONS Normal plasma creatinine concentrations can be highly misleading in ICU patients. Agreement of the cystatin C based eCLHoek with CLCR is better than that of the creatinine based eCLCG or eCLCKD-EPI. Detection and quantification of augmented renal clearance by estimates is problematic, and should rather rely on CLCR.
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Affiliation(s)
- Thomas Steinke
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stefan Moritz
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stefanie Beck
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Martini-Str. 52, 20246, Hamburg, Germany.
| | - Carsten Gnewuch
- Institute for Clinical Chemistry and Laboratory Medicine, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Martin G Kees
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin - Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Hudson JQ, Nolin TD. Estimated GFR and Cystatin C for Drug Dosing: Moving Beyond Proof of Concept to Clinical Translation? Am J Kidney Dis 2015; 65:534-6. [DOI: 10.1053/j.ajkd.2014.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 11/19/2014] [Indexed: 11/11/2022]
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