Comment: modification of diet in renal disease and modified Cockcroft-Gault formulas in predicting aminoglycoside elimination

Comparison of four renal function estimation equations for pharmacokinetic modeling of gentamicin in geriatric patients

Most aminoglycoside pharmacokinetic models include an index of renal function, such as creatinine clearance, to describe drug clearance. However, the best clinical descriptor of renal function for the pharmacokinetic modeling of aminoglycosides has not been established. This analysis was based on 412 gentamicin concentrations from 92 geriatric patients who received intravenous gentamicin for various infectious diseases. Four two-compartment population models were fitted to gentamicin concentrations in a learning set of 64 patients using the nonparametric adaptive grid (NPAG) algorithm. Each model included an index of renal function, namely, the Cockcroft-Gault (CG), Jelliffe (JEL), modification of diet in renal disease (MDRD), or modified MDRD (MDRDm; adjusted to individual body surface area) equation as a covariate influencing gentamicin serum clearance. Goodness of fit and predictive performance of the four models were compared using standard criteria in both the learning set and in a validation set of 28 patients. A final analysis was performed to estimate the population pharmacokinetic parameter values of the entire 92-patient group. In the learning set, the CG-based model best fit the data, followed by JEL-, MDRD-, and MDRDm-based models, with relative reductions of the Akaike information criterion of 29.4, 20.2, 14.2, and 4.2, respectively. Bias and precision of population predictions were significantly different among the four models. In the validation set, individual predictions from the four models showed marginally different biases. The final estimation confirmed the previous results. Specifically, the CG-based model showed predictive performance that was comparable to or better than that of the MDRD-based model at each stage of the analysis. This study shows that methods used to estimate renal function should not be considered interchangeable for the model-based estimation of gentamicin concentrations.