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Castel-Branco MM, Lavrador M, Cabral AC, Pinheiro A, Fernandes J, Figueiredo IV, Fernandez-Llimos F. Discrepancies among equations to estimate the glomerular filtration rate for drug dosing decision making in aged patients: a cross sectional study. Int J Clin Pharm 2024; 46:411-420. [PMID: 38151688 PMCID: PMC10960755 DOI: 10.1007/s11096-023-01677-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/20/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Patients often require adjustments to drug doses due to impaired renal function. Glomerular filtration rate (GFR) estimation using various equations can result in discrepancies, potentially leading to different dose adjustment recommendations. AIM To determine the clinical significance of discrepancies observed between different equations used to estimate GFR for drug dose adjustments in a real-world group of patients over 65 years in primary care. METHOD The Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Berlin Initiative Study 1 equations were applied to estimate GFR in a group of patients over 65 years old attending a primary care center. Results were compared using Bland-Altman plots, and limits of agreement (LoA) and overall bias were calculated. Regression analyses were conducted to identify the null difference GFR and the slope of differences for each pairwise comparison. RESULTS A total of 1886 patients were analyzed. Differences between patient-adjusted and body surface area (BSA)-normalized versions of the equations were not clinically relevant for dose adjustments, with LoAs below 20 mL/min. However, discrepancies among the original versions of several equations presented LoAs over 30 mL/min. Greater differences were found between CG and MDRD or CKD-EPI equations. CONCLUSION Clinically relevant differences in GFR estimation were observed among different equations, potentially impacting drug dose adjustments. However, discrepancies were not considered significant when comparing patient-adjusted and BSA-normalized versions of the equations, particularly for patients with BSA close to the average.
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Affiliation(s)
- M Margarida Castel-Branco
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
- Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Marta Lavrador
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
- Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana C Cabral
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
- Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | | | | | - Isabel Vitória Figueiredo
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
- Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Fernando Fernandez-Llimos
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal.
- Applied Molecular Biosciences (UCIBIO), University of Porto, Porto, Portugal.
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Drug dosing in cancer patients with decreased kidney function: A practical approach. Cancer Treat Rev 2020; 93:102139. [PMID: 33370636 DOI: 10.1016/j.ctrv.2020.102139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
Correct drug dosing of anticancer agents is essential to obtain optimal outcomes. Overdosing will result in increased toxicity, treatment interruption and possible cessation of anticancer treatment. Underdosing may result in suboptimal anti-cancer effects and may increase the risk of cancer-related mortality. As it is practical nor feasible to perform therapeutic drug monitoring for all anti-cancer drugs, kidney function is used to guide drug dosing for those drugs whose primary mode of excretion is through the kidney. However, it is not well-established what method should be utilized to measure or estimate kidney function and the choice of method does influence treatment decisions regarding eligibility for anti-cancer drugs and their dose. In this review, we will provide an overview regarding the importance of drug dosing, the preferred method to determine kidney function and a practical approach to drug dosing of anticancer drugs.
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Ando Y, Hayashi T, Shiouchi H, Tanaka C, Ito K, Nishibe S, Miyata N, Horiba R, Yanagi H, Fujii T, Kawada K, Ikeda Y, Yamada S. Effect of Obesity on Hematotoxicity Induced by Carboplatin and Paclitaxel Combination Therapy in Patients with Gynecological Cancer. Biol Pharm Bull 2020; 43:669-674. [PMID: 32037352 DOI: 10.1248/bpb.b19-00916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Despite in vivo studies suggesting that obesity increases carboplatin (CBDCA) bone marrow toxicity, the American Society of Clinical Oncology recommends that full weight-based cytotoxic chemotherapy doses be used to treat obese patients with cancer. Accordingly, the present study retrospectively investigated the effect of body mass index (BMI) on bone marrow toxicity in patients with gynecological cancer who underwent paclitaxel and carboplatin (TC) therapy after eliminating the effect of the target area under the curve (AUC). Risk factors for CBDCA bone marrow toxicity were also identified. A total of 110 patients with primary gynecological cancer or gynecological cancer of unknown primary origin who underwent TC therapy with a target AUC of 5-6 were included herein. Patients with a BMI of ≥25 and <25 kg/m2 were assigned to the obesity and control groups, respectively, and evaluated according to changes in hematological test values (platelet, white blood cell, and hemoglobin counts) starting from initial TC therapy administration until 21 d after the second treatment course. The obesity group had a significantly higher thrombocytopenia rate than the control group. Risk factors for thrombocytopenia ≥ grade 2 included BMI ≥25 kg/m2. Among patients with primary gynecological cancer or gynecological cancer of unknown primary origin who had a BMI of ≥25 kg/m2, those receiving CBDCA may be at increased risk for thrombocytopenia ≥ grade 2 when the dosage is calculated using the Calvert formula with the creatinine clearance level.
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Affiliation(s)
- Yosuke Ando
- Department of Clinical Pharmacy, Fujita Health University School of Medicine
| | - Takahiro Hayashi
- Department of Clinical Pharmacy, Fujita Health University School of Medicine.,College of Pharmacy, Kinjo Gakuin University
| | | | | | - Kaori Ito
- Department of Hematology, Fujita Health University School of Medicine
| | - Seira Nishibe
- Department of Clinical Pharmacy, Fujita Health University School of Medicine
| | - Nanaho Miyata
- Department of Clinical Pharmacy, Fujita Health University School of Medicine
| | - Ruri Horiba
- Department of Clinical Pharmacy, Fujita Health University School of Medicine
| | - Hisano Yanagi
- Department of Medical Oncology, Fujita Health University School of Medicine
| | - Takuma Fujii
- Department of Obstetrics and Gynecology, Fujita Health University School of Medicine
| | - Kenji Kawada
- Department of Medical Oncology, Fujita Health University School of Medicine
| | | | - Shigeki Yamada
- Department of Clinical Pharmacy, Fujita Health University School of Medicine
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Horie S, Oya M, Nangaku M, Yasuda Y, Komatsu Y, Yanagita M, Kitagawa Y, Kuwano H, Nishiyama H, Ishioka C, Takaishi H, Shimodaira H, Mogi A, Ando Y, Matsumoto K, Kadowaki D, Muto S. Guidelines for treatment of renal injury during cancer chemotherapy 2016. Clin Exp Nephrol 2018; 22:210-244. [PMID: 28856465 PMCID: PMC5805816 DOI: 10.1007/s10157-017-1448-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shigeo Horie
- Department of Urology, Juntendo University Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
- Department of Advanced Informatics for Genetic Disease, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Mototsugu Oya
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yoshinari Yasuda
- Department of CKD Initiatives/Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Komatsu
- Division of Nephrology, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroyuki Nishiyama
- Department of Urology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chikashi Ishioka
- Department of Clinical Oncology, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Hiromasa Takaishi
- Keio Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Hideki Shimodaira
- Department of Clinical Oncology, Institute of Development, Aging and Cancer, Tohoku University, Miyagi, Japan
| | - Akira Mogi
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yuichi Ando
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Aichi, Japan
| | - Koji Matsumoto
- Division of Medical Oncology, Hyogo Cancer Center, Hyogo, Japan
| | - Daisuke Kadowaki
- Department of Clinical Pharmacology, Faculty of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoru Muto
- Department of Urology, Juntendo University Graduate School of Medicine, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
- Department of Advanced Informatics for Genetic Disease, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Dinsa H, Nedi T, Berha AB. Concordance between modification of diet in renal disease, chronic kidney disease epidemiology collaboration and Cockcroft-Gault equations in patients with chronic kidney disease at St. Paul's hospital millennium medical college, Addis Ababa, Ethiopia. BMC Nephrol 2017; 18:368. [PMID: 29262858 PMCID: PMC5738756 DOI: 10.1186/s12882-017-0783-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 12/07/2017] [Indexed: 01/13/2023] Open
Abstract
Background The most commonly used glomerular filtration rate estimating equations for drug dosing are Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. However there is still a concern about whether to use MDRD and CKD-EPI interchangeably with CG for drug dosage adjustment. Methods The study was initiated to determine the concordance between MDRD, CKD-EPI and CG equations and associated factors in patients with chronic kidney disease at Saint Paul’s Hospital Millennium Medical College (SPHMMC). This was a cross sectional study which involved patient chart review and physicians self-administered questionnaire. Serum creatinine level ≥ 1.2 mg/dL was used as a cutoff point in pre-selection of patients. The correctness of the drug dose prescribed for the level of renal function were compared to the drug database (Lexi-Comp) available through Up-to-date version 21.2. Results Among the total of 422 patients, 249 (59%) were males. Mean age of patients was 46.09 years. The use of MDRD equation for drug dose adjustment by physicians working in the renal clinic of SPHMMC was six out of nine physicians. The Pearson correlation coefficient between the CG with MDRD and CKD-EPI equations was r = 0.94, P < 0.001 and r = 0.95, P < 0.001, respectively. The concordance between the CG with MDRD and CKD-EPI equations for FDA assigned kidney function categories was 73.7%, Kappa = 0.644 and 74.9%, Kappa = 0.659, respectively. Concordance between the CG with MDRD and CKD-EPI equations for the drug dosing recommendation was 89.6%, kappa = 0.782 and 92%, kappa = 0.834, respectively. Age > 70 years was associated with discordance between CG and MDRD equations for drug dosing recommendation whereas serum creatinine 1.2–3.5 mg/dL, weight < 61 Kg and age > 70 years were associated with discordance between the CG with MDRD and CKD-EPI equations for FDA assigned kidney function categories. However, none of the factors associated with discordance between CG and CKD-EPI for drug dosing. Conclusion MDRD equation can be used interchangeably with CG equation for drug dosing recommended in all adult patients between the age of 18 and 70 years. CKD-EPI can be used interchangeably with CG in all adult Ethiopian patients with CKD. Electronic supplementary material The online version of this article (10.1186/s12882-017-0783-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hunduma Dinsa
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Teshome Nedi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Alemseged Beyene Berha
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.
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Manzano-Fernández S, Andreu-Cayuelas JM, Marín F, Orenes-Piñero E, Gallego P, Valdés M, Vicente V, Lip GY, Roldán V. Comparación de las ecuaciones de filtrado glomerular estimado para determinar la posología de los nuevos anticoagulantes orales para pacientes con fibrilación auricular. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Manzano-Fernández S, Andreu-Cayuelas JM, Marín F, Orenes-Piñero E, Gallego P, Valdés M, Vicente V, Lip GYH, Roldán V. Comparison of estimated glomerular filtration rate equations for dosing new oral anticoagulants in patients with atrial fibrillation. ACTA ACUST UNITED AC 2014; 68:497-504. [PMID: 25457087 DOI: 10.1016/j.rec.2014.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/13/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES New oral anticoagulants require dosing adjustment according to renal function. We aimed to determine discordance in hypothetical recommended dosing of these drugs using different estimated glomerular filtration rate equations in patients with atrial fibrillation. METHODS Cross-sectional analysis of 910 patients with atrial fibrillation and an indication for oral anticoagulation. The glomerular filtration rate was estimated using the Cockcroft-Gault, Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations. For dabigatran, rivaroxaban, and apixaban we identified dose discordance when there was disagreement in the recommended dose based on different equations. RESULTS Among the overall population, relative to Cockcroft-Gault, discordance in dabigatran dosage was 11.4% for Modification of Diet in Renal Disease and 10% for Chronic Kidney Disease Epidemiology Collaboration, discordance in rivaroxaban dosage was 10% for Modification of Diet in Renal Disease and 8.5% for the Chronic Kidney Disease Epidemiology Collaboration. The lowest discordance was observed for apixaban: 1.4% for Modification of Diet in Renal Disease and 1.5% for the Chronic Kidney Disease Epidemiology Collaboration. In patients with Cockcroft-Gault<60mL/min or elderly patients, discordances in dabigatran and rivaroxaban dosages were higher, ranging from 13.2% to 30.4%. Discordance in apixaban dosage remained<5% in these patients. CONCLUSIONS Discordance in new oral anticoagulation dosages using different equations is frequent, especially among elderly patients with renal impairment. This discordance was higher in dabigatran and rivaroxaban dosages than in apixaban dosages. Further studies are needed to clarify the clinical importance of these discordances and the optimal anticoagulant dosages depending on the use of different equations to estimate renal function.
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Affiliation(s)
- Sergio Manzano-Fernández
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - José M Andreu-Cayuelas
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Esteban Orenes-Piñero
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Pilar Gallego
- Servicio de Hematología, Hospital Rafael Méndez, Lorca, Murcia, Spain
| | - Mariano Valdés
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Vicente Vicente
- Unidad de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Gregory Y H Lip
- Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | - Vanessa Roldán
- Unidad de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
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Tortorici MA, Nolin TD. Kidney function assessment and its role in drug development, review and utilization. Expert Rev Clin Pharmacol 2014; 7:523-32. [DOI: 10.1586/17512433.2014.922865] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
Appropriate dosage adjustments for patients with chronic kidney disease (CKD) are critical for patient safety. This article reviews adjustments for common antidiabetic, antibiotic, analgesic, and antithrombotic medications, as well as important patient teaching information for over-the-counter (OTC) medications.
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Affiliation(s)
- Kim Zuber
- Kim Zuber is a PA at Metropolitan Nephrology in Alexandria, Virginia. Anne Marie Liles is an associate clinical professor in the department of pharmacy practice in Auburn University's Harrison School of Pharmacy in Auburn, Alabama. Jane Davis is an NP in the department of nephrology at the University of Alabama at Birmingham. The authors have indicated no relationships to disclose relating to the content of this article
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Dooley MJ, Poole SG, Rischin D. Dosing of cytotoxic chemotherapy: impact of renal function estimates on dose. Ann Oncol 2013; 24:2746-52. [PMID: 23928359 DOI: 10.1093/annonc/mdt300] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Oncology clinicians are now routinely provided with an estimated glomerular filtration rate on pathology reports whenever serum creatinine is requested. The utility of using this for the dose determination of renally excreted drugs compared with other existing methods is needed to inform practice. PATIENTS AND METHODS Renal function was determined by [Tc(99m)]DTPA clearance in adult patients presenting for chemotherapy. Renal function was calculated using the 4-variable Modification of Diet in Renal Disease (4v-MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft and Gault (CG), Wright and Martin formulae. Doses for renal excreted cytotoxic drugs, including carboplatin, were calculated. RESULTS The concordance of the renal function estimates according to the CKD classification with measured Tc(99m)DPTA clearance in 455 adults (median age 64.0 years: range 17-87 years) for the 4v-MDRD, CKD-EPI, CG, Martin and Wright formulae was 47.7%, 56.3%, 46.2%, 56.5% and 60.2%, respectively. Concordance for chemotherapy dose for these formulae was 89.0%, 89.5%, 85.1%, 89.9% and 89.9%, respectively. Concordance for carboplatin dose specifically was 66.4%, 71.4%, 64.0%, 73.8% and 73.2%. CONCLUSION All bedside formulae provide similar levels of concordance in dosage selection for the renal excreted chemotherapy drugs when compared with the use of a direct measure of renal function.
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Affiliation(s)
- M J Dooley
- Department of Pharmacy, Alfred Health, Melbourne
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Abstract
BACKGROUND Glomerular filtration rate (GFR) is used in the calculation of carboplatin dose. Glomerular filtration rate is measured using a radioisotope method (radionuclide GFR (rGFR)), however, estimation equations are available (estimated GFR (eGFR)). Our aim was to assess the accuracy of three eGFR equations and the subsequent carboplatin dose in an oncology population. PATIENTS AND METHODS Patients referred for an rGFR over a 3-year period were selected; eGFR was calculated using the Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and Cockcroft-Gault (CG) equations. Carboplatin doses were calculated for those patients who had received carboplatin chemotherapy. Bias, precision and accuracy were examined. RESULTS Two hundred and eighty-eight studies met the inclusion/exclusion criteria. Paired t-tests showed significant differences for all three equations between rGFR and eGFR with biases of 12.3 (MDRD), 13.6 (CKD-EPI) and 7.7 ml min(-1) per 1.73 m(2) (CG). An overestimation in carboplatin dose was seen in 81%, 87% and 66% of studies using the MDRD, CKD-EPI and CG equations, respectively. CONCLUSION The MDRD and CKD-EPI equations performed poorly compared with the reference standard rGFR; the CG equation showed smaller bias and higher accuracy in our oncology population. On the basis of our results we recommend that the rGFR should be used for accurate carboplatin chemotherapy dosing and where unavailable the use of the CG equation is preferred.
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Nyman HA, Dowling TC, Hudson JQ, Peter WLS, Joy MS, Nolin TD. Comparative evaluation of the Cockcroft-Gault Equation and the Modification of Diet in Renal Disease (MDRD) study equation for drug dosing: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy. Pharmacotherapy 2012; 31:1130-44. [PMID: 22026399 DOI: 10.1592/phco.31.11.1130] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Accurate assessment of kidney function is an important component of determining appropriate drug dosing regimens. Nearly all manufacturer-recommended dosage adjustments are based on creatinine clearance ranges derived from clinical pharmacokinetic studies performed during the drug development process. The Cockcroft-Gault (CG) equation provides an estimate of creatinine clearance and is the equation most commonly used to determine drug dosages in patients with impaired kidney function. The Modification of Diet in Renal Disease (MDRD) study equation has also been proposed for this purpose. Published studies report that drug dosages determined by the two equations do not agree in 10-40% of cases. However, interpretation and comparison of these studies are complicated by the variable creatinine methods used for calculating CG and MDRD estimates, the patient populations studied, and a lack of outcomes data demonstrating the clinical significance of dosing discrepancies. Moreover, the impact of reporting standardized serum creatinine values on the accuracy of the CG equation and corresponding drug dosing regimens have been questioned. Currently, no prospective pharmacokinetic studies have been conducted with use of the MDRD equation to generate dosing recommendations, and limited data are available to support its use in some patient populations representing demographic extremes. Collectively, these issues have resulted in considerable confusion among clinicians and have fueled a healthy debate on whether or not to use the MDRD equation to determine drug dosages. Each of these issues is reviewed, and a proposed algorithm for using creatinine-based kidney function assessments in drug dosing is provided. Knowledge of the advantages, limitations, and clinical role of each equation will facilitate their safe and effective use in drug dosing.
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Affiliation(s)
- Heather A Nyman
- University of Utah Hospitals and Clinics, Salt Lake City, Utah, USA
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Use of estimated glomerular filtration rate for drug dosing in the chronic kidney disease patient. Curr Opin Nephrol Hypertens 2011; 20:482-91. [PMID: 21709552 DOI: 10.1097/mnh.0b013e328348c11f] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW Assessment of kidney function is necessary to stage chronic kidney disease (CKD) and appropriately dose medications. The Cockcroft-Gault equation provides an estimate of creatinine clearance (eClCr) and is the method commonly referenced in pharmacokinetic studies. The Modification of Diet in Renal Disease (MDRD) and CKD-Epidemiology Collaboration (EPI) equations provide an estimate of glomerular filtration rate (eGFR), with the MDRD eGFR now automatically reported by most clinical laboratories. This review describes the differences in the Cockcroft-Gault, MDRD, and CKD-EPI equations and considerations when applying estimates from these equations for drug dosing. RECENT FINDINGS Studies evaluating drug-dosing regimens using eClCr and eGFR differ in their results depending on the population in which the equation is applied, the adjustment factors used to account for body size, and the number of dosing levels for a particular medication. The largest study to evaluate drug regimen design by method concluded that either the eGFR or Cockcroft-Gault estimates could be used for drug dosing. Differences in methodology among studies are a key factor in evaluating these results and will be highlighted in this review. SUMMARY The Cockcroft-Gault, MDRD, and CKD-EPI equations provide reasonable estimates of kidney function; however, clinicians must understand the limitations when using these estimates for drug regimen design.
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Ainsworth NL, Marshall A, Hatcher H, Whitehead L, Whitfield GA, Earl HM. Evaluation of glomerular filtration rate estimation by Cockcroft-Gault, Jelliffe, Wright and Modification of Diet in Renal Disease (MDRD) formulae in oncology patients. Ann Oncol 2011; 23:1845-53. [PMID: 22104575 DOI: 10.1093/annonc/mdr539] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim was to evaluate the accuracy of Cockcroft-Gault, Jelliffe, Wright and Modification of Diet in Renal Disease (MDRD) formulae as a substitute for the gold standard measure of glomerular filtration rate (GFR) using chromium 51 EDTA. PATIENTS AND METHODS Retrospective analysis of GFR measurements in oncology patients from a University Teaching Hospital over 3 years was carried out. Bias and precision of estimates of GFR were compared with measured GFR. RESULTS Six hundred and sixty patients with measured GFR (median 90 ml/min, range 23-179 ml/min) were identified. Cockcroft-Gault produced the smallest bias (median percentage error -1.4%) and highest precision (median absolute percentage error 14.0%) and was the most accurate for carboplatin dosing. For patients>30% over their ideal body weight (IBW), using IBW+30% in the Cockcroft-Gault formula was more precise than using actual body weight or IBW. The Wright formula was most accurate for patients aged 70+years and patients with a body mass index (BMI)≥30 but overestimated GFR when GFR<50 ml/min. CONCLUSIONS When measured GFR is unavailable, we advise estimating GFR using the Cockcroft-Gault formula and using IBW+30% for patients weighing>30% over their IBW. If the GFR is ≥50 ml/min and the patient is >70 years and/or BMI≥30, the Wright formula gives the best estimate of GFR.
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Affiliation(s)
- N L Ainsworth
- Oncology Centre, Addenbrooke's Hospital, and Department of Oncology, University of Cambridge, Cambridge, UK.
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Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2011; 80:1122-37. [PMID: 21918498 DOI: 10.1038/ki.2011.322] [Citation(s) in RCA: 291] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Drug dosage adjustment for patients with acute or chronic kidney disease is an accepted standard of practice. The challenge is how to accurately estimate a patient's kidney function in both acute and chronic kidney disease and determine the influence of renal replacement therapies on drug disposition. Kidney Disease: Improving Global Outcomes (KDIGO) held a conference to investigate these issues and propose recommendations for practitioners, researchers, and those involved in the drug development and regulatory arenas. The conference attendees discussed the major challenges facing drug dosage adjustment for patients with kidney disease. In particular, although glomerular filtration rate is the metric used to guide dose adjustment, kidney disease does affect nonrenal clearances, and this is not adequately considered in most pharmacokinetic studies. There are also inadequate studies in patients receiving all forms of renal replacement therapy and in the pediatric population. The conference generated 37 recommendations for clinical practice, 32 recommendations for future research directions, and 24 recommendations for regulatory agencies (US Food and Drug Administration and European Medicines Agency) to enhance the quality of pharmacokinetic and pharmacodynamic information available to clinicians. The KDIGO Conference highlighted the gaps and focused on crafting paths to the future that will stimulate research and improve the global outcomes of patients with acute and chronic kidney disease.
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Jones MA, Golightly LK, Stolpman NM. Use of Recalibrated Serum Creatinine Concentrations for Adjustment of Drug Dosages: Determination of Values Compatible with Conventional Dosing Recommendations. Ann Pharmacother 2011; 45:748-56. [DOI: 10.1345/aph.1p676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Measurement of serum creatinine concentration is central to evaluation of kidney function. Recent efforts to increase the accuracy of this evaluation have led to recalibration of laboratory instruments. Recalibrated creatinine concentrations often are lower than previously reported. OBJECTIVES: To derive a method for converting recalibrated serum creatinine (R-SCr) concentrations into values that are compatible with recommended equations for calculation of estimated creatinine clearance. METHODS: Beginning with a proprietary array of recalibrated and corresponding non-recalibrated serum creatinine (NR-SCr) numerical data provided by the instrument manufacturer, relationships were examined with exponential and linear regression analyses. The validity of derived values for NR-SCr obtained through these analyses was tested by comparison of proprietary and derived serum creatinine concentrations and calculated creatinine clearance values. RESULTS: Analyses revealed that relationships between R-SCr and NR-SCr creatinine were essentially linear. Rearranging and solving the equation for a straight line described this relationship as x = (y - b)/m, where x is the derived creatinine value, y is the R-SCr concentration, and, for our laboratory instrument, best parameters for m and b equal to 0.987 and −0.07, respectively. Use of these parameters to derive NR-SCr values was shown to significantly decrease positive bias in subsequent creatinine clearance calculations. CONCLUSIONS: As compared to R-SCr concentrations, use of derived NR-SCr values can improve the predictive performance of conventional equations used to calculate estimated creatinine clearance.
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Affiliation(s)
- Michael A Jones
- Michael A Jones PharmD, Informatics Pharmacist-CDS Specialist, University of Colorado Hospital, Anschutz Medical Campus, Aurora, CO
| | - Larry K Golightly
- Larry K Golightly PharmD BCPS, Medication Use Evaluation/Adverse Drug Reaction Coordinator, University of Colorado Hospital, Anschutz Medical Campus; Clinical Assistant Professor, School of Pharmacy, University of Colorado
| | - Nancy M Stolpman
- Nancy M Stolpman PharmD PhD, Pharmacy Director, University of Colorado Hospital, Anschutz Medical Campus; Clinical Assistant Professor, School of Pharmacy, University of Colorado
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