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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.
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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
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Lee S, Lee S, Jo S, Kim KA, Yang YJ, Lee JJ, Kim E, Park Y, Kyong T, Kim JH. Calf Circumference as an Indicator for Cystatin C Testing in Hospitalized Elderly Male Patients for Detecting Hidden Renal Impairment. J Clin Med 2023; 12:6899. [PMID: 37959364 PMCID: PMC10647781 DOI: 10.3390/jcm12216899] [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: 09/25/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Serum creatinine is used to measure the estimated glomerular filtration rate (eGFR); however, it is influenced by muscle mass and may therefore overestimate renal function in patients with sarcopenia. We examined calf circumference (CC) as a convenient muscle mass evaluation tool that can potentially indicate the need to test for cystatin C instead of creatinine in elderly inpatients. We retrospectively reviewed the electronic health record of 271 inpatients aged 65 or over. CC was determined by measuring the thickest part of the nondominant calf. eGFRcys and eGFRcr were calculated using cystatin C and creatinine levels, respectively. We evaluated optimum CC cutoff values using the eGFRcys/eGFRcr ratio for detecting hidden renal impairment (HRI, defined as eGFRcr ≥ 60 mL/min/1.73 m2 but eGFRcys < 60 mL/min/1.73 m2). CC showed a significant positive correlation with the eGFRcys/eGFRcr ratio in both sexes. The areas under the receiver operating characteristic curve were 0.725 and 0.681 for males and females, respectively. CC cutoffs with a sensitivity or specificity of 90% or 95% might be used to detect HRI in males. In conclusion, utilizing the optimum cutoff, CC could be a cost-effective screening tool for detecting HRI in elderly male patients using cystatin C as an add-on test.
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Affiliation(s)
- Sunghwan Lee
- Department of Laboratory Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (S.L.); (K.-A.K.)
| | - Seul Lee
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (S.L.); (S.J.)
| | - Sunhee Jo
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (S.L.); (S.J.)
| | - Kyung-Ah Kim
- Department of Laboratory Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (S.L.); (K.-A.K.)
| | - Yu Jin Yang
- Department of Nutrition, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (Y.J.Y.); (J.J.L.)
| | - Jung Joo Lee
- Department of Nutrition, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (Y.J.Y.); (J.J.L.)
| | - Eunsung Kim
- Department of Inpatient Nursing, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea;
| | - Yongjung Park
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul 06273, Republic of Korea;
| | - Taeyoung Kyong
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (S.L.); (S.J.)
| | - Jeong-Ho Kim
- Department of Laboratory Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, 363 Dongbaekjukjeon-daero, Giheung-gu, Yongin-si 16995, Gyeonggi-do, Republic of Korea; (S.L.); (K.-A.K.)
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Keddis MT, Howard MR, Galapia L, Barreto EF, Zhang N, Butterfield RJ, Rule AD. GFR estimated with creatinine rather than cystatin C is more reflective of the true risk of adverse outcomes with low GFR in kidney transplant recipients. Nephrol Dial Transplant 2023; 38:1898-1906. [PMID: 36646435 PMCID: PMC10387404 DOI: 10.1093/ndt/gfad007] [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: 10/05/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Serum cystatin C-based estimated glomerular filtration rate (eGFRcys) generally associates with clinical outcomes better than serum creatinine-based eGFR (eGFRcr) despite similar precision in estimating measured GFR (mGFR). We sought to determine whether the risk of adverse outcomes with eGFRcr or eGFRcys was via GFR alone or also via non-GFR determinants among kidney transplant recipients. METHODS Consecutive adult kidney transplant recipients underwent a standardized GFR assessment during a routine follow-up clinic visit between 2011 and 2013. Patients were followed for graft failure or the composite outcome of cardiovascular (CV) events or mortality through 2020. The risk of these events by baseline mGFR, eGFRcr and eGFRcys was assessed unadjusted, adjusted for mGFR and adjusted for CV risk factors. RESULTS There were 1135 recipients with a mean baseline mGFR of 55.6, eGFRcr of 54.8 and eGFRcys of 46.8 ml/min/1.73 m2 and a median follow-up of 6 years. Each 10 ml/min/1.73 m2 decrease in mGFR, eGFRcr or eGFRcys associated with graft failure [hazard ratio (HR) 1.79, 1.68 and 2.07, respectively; P < .001 for all) and CV events or mortality outcome (HR 1.28, 1.19 and 1.43, respectively; P < .001 for all). After adjusting for mGFR, eGFRcys associated with graft failure (HR 1.57, P < .001) and CV events or mortality (HR 1.49, P < .001), but eGFRcr did not associate with either. After further adjusting for CV risk factors, risk of these outcomes with lower eGFRcys was attenuated. CONCLUSION eGFRcr better represents the true relationship between GFR and outcomes after kidney transplantation because it has less non-GFR residual association. Cystatin C is better interpreted as a nonspecific prognostic biomarker than is eGFR in the kidney transplant setting.
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Affiliation(s)
- Mira T Keddis
- Division of Nephrology, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Leyton Galapia
- Division of Nephrology, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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Denic A, Mullan AF, Alexander MP, Wilson LD, Augustine J, Luehrs AC, Stegall MD, Kline TL, Sharma V, Thompson RH, Rule AD. An Improved Method for Estimating Nephron Number and the Association of Resulting Nephron Number Estimates with Chronic Kidney Disease Outcomes. J Am Soc Nephrol 2023; 34:1264-1278. [PMID: 36958059 PMCID: PMC10356139 DOI: 10.1681/asn.0000000000000124] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 02/15/2023] [Indexed: 03/25/2023] Open
Abstract
SIGNIFICANCE STATEMENT Nephron number currently can be estimated only from glomerular density on a kidney biopsy combined with cortical volume from kidney imaging. Because of measurement biases, refinement of this approach and validation across different patient populations have been needed. The prognostic importance of nephron number also has been unclear. The authors present an improved method of estimating nephron number that corrects for several biases, resulting in a 27% higher nephron number estimate for donor kidneys compared with a prior method. After accounting for comorbidities, the new nephron number estimate does not differ between kidney donors and kidney patients with tumor and shows consistent associations with clinical characteristics across these two populations. The findings also indicate that low nephron number predicts CKD independent of biopsy and clinical characteristics in both populations. BACKGROUND Nephron number can be estimated from glomerular density and cortical volume. However, because of measurement biases, this approach needs refinement, comparison between disparate populations, and evaluation as a predictor of CKD outcomes. METHODS We studied 3020 living kidney donors and 1354 patients who underwent radical nephrectomy for tumor. We determined cortex volume of the retained kidney from presurgical imaging and glomerular density by morphometric analysis of needle core biopsy of the donated kidney and wedge sections of the removed kidney. Glomerular density was corrected for missing glomerular tufts, absence of the kidney capsule, and then tissue shrinkage on the basis of analysis of 30 autopsy kidneys. We used logistic regression (in donors) and Cox proportional hazard models (in patients with tumor) to assess the risk of CKD outcomes associated with nephron number. RESULTS Donors had 1.17 million nephrons per kidney; patients with tumor had 0.99 million nephrons per kidney. A lower nephron number was associated with older age, female sex, shorter height, hypertension, family history of ESKD, lower GFR, and proteinuria. After adjusting for these characteristics, nephron number did not differ between donors and patients with tumor. Low nephron number (defined by <5th or <10th percentile by age and sex in a healthy subset) in both populations predicted future risk of CKD outcomes independent of biopsy and clinical characteristics. CONCLUSIONS Compared with an older method for estimating nephron number, a new method that addresses several sources of bias results in nephron number estimates that are 27% higher in donors and 1% higher in patients with tumor and shows consistency between two populations. Low nephron number independently predicts CKD in both populations.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Aidan F Mullan
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Luke D Wilson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Anthony C Luehrs
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Mark D Stegall
- Department of Surgery and Immunology, Mayo Clinic, Rochester, Minnesota
| | | | - Vidit Sharma
- Department of Urology, Mayo Clinic, Rochester, Minnesota
| | | | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota
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Lin Y, Chen J, Huang Y, Lin Y, Su Z. A methodological study of 2D shear wave elastography for noninvasive quantitative assessment of renal fibrosis in patients with chronic kidney disease. Abdom Radiol (NY) 2023; 48:987-998. [PMID: 36565332 DOI: 10.1007/s00261-022-03753-5] [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: 08/03/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE To determine the optimal measurement method of 2D shear wave elastography (2D-SWE) for noninvasive quantitative assessment of renal fibrosis in chronic kidney disease (CKD) patients. METHODS A total of 190 CKD patients were enrolled for 2D-SWE of right kidney. The success rates, coefficients of variation (CV), and pathological correlation of different measurement sites, body positions, and depths were compared. RESULTS (1) Measurement sites: Success rate in the middle part (100%) was higher than that in the lower pole (97.3%, P > 0.05). CV in the middle part (10.2%) was lower than that in the lower pole (16.4%, P < 0.05). Pathological correlation of the middle part (r = - 0.452, P < 0.05) was higher than that of the lower pole (r = 0.097, P > 0.05). (2) Body positions: Success rate in left lateral decubitus position (100%) was higher than that in supine (99.4%, P > 0.05) and prone position (99.4%, P > 0.05). CV was lowest (11.9%) and pathological correlation was highest (r = -0.256, P < 0.05) in prone position. (3) Measurement depths: Success rate at depth < 4 cm (100%) was higher than that at depth ≥ 4 cm (98.8%, P > 0.05). CV at depth < 4 cm (11.1%) was lower than that at depth ≥ 4 cm (14.4%, P < 0.05). Pathological correlation at depth < 4 cm (r = - 0.303, P < 0.05) was higher than that at depth ≥ 4 cm (r = - 0.156, P > 0.05). CONCLUSION The optimal measurement method of 2D-SWE for renal fibrosis assessment was prone position, renal middle part, and measurement depth < 4 cm.
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Affiliation(s)
- Yanjun Lin
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, 519000, Guangdong Province, China
| | - Jiaxin Chen
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, 519000, Guangdong Province, China
| | - Yongquan Huang
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, 519000, Guangdong Province, China
| | - Yuhong Lin
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, 519000, Guangdong Province, China.
| | - Zhongzhen Su
- Department of Ultrasound, Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, 519000, Guangdong Province, China.
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Ma Y, Lin J, Xia P, Zheng H, Cheng X, Ji P, Wu W, Hou L, Wang L, Zhu G, Qiu L, Zheng Y, Chen L. Comparison between the profiles of patients defined by age-adapted and fixed threshold CKD criteria, a national-wide, cross-sectional study. Clin Kidney J 2022; 15:2312-2321. [PMID: 36381365 PMCID: PMC9664565 DOI: 10.1093/ckj/sfac188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Indexed: 12/05/2022] Open
Abstract
Background Kidney function declines naturally with advancing age. Therefore an age-adapted estimated glomerular filtration rate (eGFR) threshold has been proposed instead of the fixed threshold for CKD definition. This study aims to describe and compare the profile of CKD patients defined by these two criteria in a Chinese population. Method We recruited adult participants with selected biochemical tests from the Chinese Physiological Constant and Health Condition survey conducted from 2007 to 2011, with the GFR estimated by the Chronic Kidney Disease Epidemiology Collaboration formula. The age-adapted threshold of eGFR is 75, 60 and 45 ml/min/1.73 m2 for the population <40 years of age, 40–64 years and >64 years, respectively. The fixed threshold is 60 ml/min/1.73 m2 for all ages. Results Among the recruited 23 438 participants, 480 were diagnosed with CKD by fixed threshold criteria, while 391 were diagnosed with CKD by age-adapted criteria. Patients diagnosed by fixed threshold criteria were significantly older (66.4 versus 43.4 years; P < .001) and had a higher prevalence of all CVD risk factors compared with the non-CKD population. In contrast, age-adapted criteria defined a younger patient group and were not significantly associated with diabetes or obesity. When adjusted by age and gender, fixed threshold–defined CKD was not significantly associated with the number of coexisting CVD risk factors, while age-adapted-defined CKD was significantly associated. We also found that the CKD patients defined by age-adapted criteria matched well with the 2.5th percentile of eGFR in Chinese individuals. When compared with their age- and gender-matched controls, patients included by age-adapted criteria but excluded by fixed threshold criteria had a significantly higher prevalence of hypertension (23.2% versus 7.7%; P < .001) and hyperuricaemia (25.0% versus 5.5%; P < .001), while patients included only by the fixed threshold criteria were not significantly different in the prevalence of CVD risk factors and CKD-related disturbance except for hyperuricaemia (41.2% versus 14.0%; P < .001). Conclusion An age-adapted criterion is more closely associated with CVD risk factors and CKD-related diseases compared with fixed threshold criteria.
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Affiliation(s)
- Yixin Ma
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Jianfeng Lin
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Hua Zheng
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Peili Ji
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Wei Wu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Lian Hou
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Li Wang
- Department of Epidemiology and Biostatistics, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Guangjin Zhu
- Department of Pathophysiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
| | - Yali Zheng
- Department of Nephrology, Affiliated Ningxia People's Hospital of Ningxia Medical University , Yinchuan , China
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College , Beijing , China
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Grasing M, Kennedy K, Sarnak MJ, Burns JM, Gupta A. Mild to moderate decrease in eGFR and cognitive decline in older adults. Nephrol Dial Transplant 2022; 37:1499-1506. [PMID: 34289074 PMCID: PMC9317170 DOI: 10.1093/ndt/gfab226] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Whether mild to moderately low estimated glomerular filtration rate (eGFR) is associated with cognitive decline in older adults is not clear. We evaluated changes in cognition in relation to baseline eGFR in older adults participating in the Alzheimer's Disease Neuroimaging Initiative (ADNI). METHODS This is a longitudinal secondary analysis of an established observational cohort. We used data from the ADNI, an National Institutes of Health-funded, multicenter longitudinal observational study that includes participants with and without cognitive impairment who were administered a comprehensive battery of neuropsychological tests every 6 months. We related the Chronic Kidney Disease Epidemiology Collaboration eGFR with previously validated cognition composite scores for memory (ADNI-Mem) and executive function (ADNI-EF) in multivariable linear regression analysis adjusted for age, sex, race and level of education. RESULTS A total of 1127 ADNI participants (mean age 74 ± 7 years, 57% men, 97% Caucasian, mean follow-up 6 ± 2.6 years) were included in the analysis. The mean baseline eGFR was 76 ± 19 mL/min/1.73 m2, with 6% with eGFR <45, 22% with eGFR 45-<60, 51% with eGFR 60-90 and 21% with eGFR >90 mL/min/1.73 m2 at baseline. Both ADNI-Mem and ADNI-EF scores declined over time. In the multivariable linear regression model, older age (β = -0.117, P = 0.01), female sex (β = 0.312, P < 0.001) and lower education (β = 0.079, P < 0.001) were associated with a decline in ADNI-Mem scores, whereas baseline eGFR (each 10 mL/min/1.73 m2 change) was not {β = -0.03 [confidence interval (CI) -0.06-0.001], P = 0.11}. Similarly, older age (β = -0.278, P < 0.001) and lower education (β = 0.099, P < 0.001) were associated with a decline in ADNI-EF scores, whereas baseline eGFR was not [β = 0.004 (95% CI -0.04-0.04), P = 0.84]. CONCLUSIONS In this cohort from the ADNI study, there was no association between baseline eGFR and cognitive decline in older adults with mild to moderately low eGFR.
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Affiliation(s)
- Michael Grasing
- University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - Mark J Sarnak
- Division of Nephrology and Hypertension, Tufts Medical Center, Boston, MA, USA
| | - Jeffrey M Burns
- Alzheimer’s Disease Center, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Aditi Gupta
- Alzheimer’s Disease Center, University of Kansas Medical Center, Kansas City, KS, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
- Jared Grantham Kidney Institute, University of Kansas Medical Center, Kansas City, KS, USA
- Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, KS, USA
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Paparazzo E, Geracitano S, Lagani V, Soraci L, Cozza A, Cosimo S, Morelli F, Corsonello A, Passarino G, Montesanto A. Clinical and Prognostic Implications of Estimating Glomerular Filtration Rate by Three Different Creatinine-Based Equations in Older Nursing Home Residents. Front Med (Lausanne) 2022; 9:870835. [PMID: 35559339 PMCID: PMC9087281 DOI: 10.3389/fmed.2022.870835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background According to the international literature, the percentage of nursing home (NH) residents with renal insufficiency is very high, ranging between 22 and 78%. Diminished kidney function represents a risk factor for drug overdosage, adverse drug reactions, end-stage renal disease, disability, morbidity, and mortality. Several studies suggested that screening for chronic kidney disease (CKD) in high-risk and older populations may represent a cost-effective approach to reducing progression to renal failure and CKD mortality. Objective This study aimed (i) to investigate to what extent CKD may be staged interchangeably by three different creatinine-based estimated glomerular filtration rate (eGFR) equations in a sample of older adults living in long-term care facilities; (ii) to investigate factors explaining differences among eGFR equations; and (iii) to compare the predictivity of different creatinine-based eGFR equations with respect to all-cause mortality. Methods A total of 522 residents aged 65 years and older participated in a prospective cohort study of 9 long-term care facilities in Calabria. eGFR was calculated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Berlin initiative study (BIS), and full age spectrum (FAS) equations. Disability in at least one activity of daily living (ADL), depression, cognitive impairment, comorbidity, and malnutrition was considered in the analysis. Statistical analysis was carried out by Bland-Altman analysis, and 2-year mortality was investigated by Kaplan-Meier curves and Cox regression analysis. Results Depending on the adopted equation, the prevalence of NH residents with impaired renal function (eGFR < 60 ml/min/1.73 m2) ranged between 58.2% for the CKD-EPI and 79.1% for the BIS1 equation. The average difference between BIS and FAS was nearly negligible (0.45 ml/min/1.73 m2), while a significant bias was detected between CKD-EPI and BIS and also between CKD-EPI and FAS (6.21 ml/min/1.73 m2 and 6.65 ml/min/1.73 m2, respectively). Although the eGFR study equations had comparable prognostic accuracy in terms of mortality risk, BIS and FAS were able to reclassify NH residents pertaining to a low-risk group with CKD-EPI, and this reclassification improves the discriminative capacity of CKD-EPI with respect to overall mortality. Conclusion Despite the relatively good correlation between eGFRs calculated using all adopted equations, the findings in this study reported clearly demonstrated that CKD-EPI and BIS/FAS equations are not interchangeable to assess eGFR among older people and particularly in institutionalized and frail older subjects.
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Affiliation(s)
- Ersilia Paparazzo
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Silvana Geracitano
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Vincenzo Lagani
- Institute of Chemical Biology, Ilia State University, Tbilisi, Georgia.,Biological and Environmental Sciences and Engineering Division (BESE), King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia
| | - Luca Soraci
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Annalisa Cozza
- Laboratory of Pharmacoepidemiology and Biostatistics, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | | | | | - Andrea Corsonello
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy.,Laboratory of Pharmacoepidemiology and Biostatistics, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Giuseppe Passarino
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Alberto Montesanto
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
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10
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The Clinical Significance of Shock Index and GFR in the Differential Diagnosis of Perforated Appendicitis. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1090115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Kaas-Hansen BS, Leal Rodríguez C, Placido D, Thorsen-Meyer HC, Nielsen AP, Dérian N, Brunak S, Andersen SE. Using Machine Learning to Identify Patients at High Risk of Inappropriate Drug Dosing in Periods with Renal Dysfunction. Clin Epidemiol 2022; 14:213-223. [PMID: 35228820 PMCID: PMC8881932 DOI: 10.2147/clep.s344435] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Dosing of renally cleared drugs in patients with kidney failure often deviates from clinical guidelines, so we sought to elicit predictors of receiving inappropriate doses of renal risk drugs. Patients and methods We combined data from the Danish National Patient Register and in-hospital data on drug administrations and estimated glomerular filtration rates for admissions between 1 October 2009 and 1 June 2016, from a pool of about 2.6 million persons. We trained artificial neural network and linear logistic ridge regression models to predict the risk of five outcomes (>0, ≥1, ≥2, ≥3 and ≥5 inappropriate doses daily) with index set 24 hours after admission. We used time-series validation for evaluating discrimination, calibration, clinical utility and explanations. Results Of 52,451 admissions included, 42,250 (81%) were used for model development. The median age was 77 years; 50% of admissions were of women. ≥5 drugs were used between admission start and index in 23,124 admissions (44%); the most common drug classes were analgesics, systemic antibacterials, diuretics, antithrombotics, and antacids. The neural network models had better discriminative power (all AUROCs between 0.77 and 0.81) and were better calibrated than their linear counterparts. The main prediction drivers were use of anti-inflammatory, antidiabetic and anti-Parkinson's drugs as well as having a diagnosis of chronic kidney failure. Sex and age affected predictions but slightly. Conclusion Our models can flag patients at high risk of receiving at least one inappropriate dose daily in a controlled in-silico setting. A prospective clinical study may confirm that this holds in real-life settings and translates into benefits in hard endpoints.
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Affiliation(s)
- Benjamin Skov Kaas-Hansen
- Clinical Pharmacology Unit, Zealand University Hospital, Roskilde, Denmark
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
- Section for Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Correspondence: Benjamin Skov Kaas-Hansen, Clinical Pharmacology Unit, Zealand University Hospital, Munkesoevej 18, Roskilde, 4000, Denmark, Tel +45 60 19 68 02, Email
| | | | - Davide Placido
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Hans-Christian Thorsen-Meyer
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care Medicine, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Anna Pors Nielsen
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Nicolas Dérian
- Data and Development Support, Region Zealand, Sorø, Denmark
| | - Søren Brunak
- NNF Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
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12
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Wang H, Bowe B, Cui Z, Yang H, Swamidass SJ, Xie Y, Al-Aly Z. A Deep Learning Approach for the Estimation of Glomerular Filtration Rate. IEEE Trans Nanobioscience 2022; 21:560-569. [PMID: 35100119 DOI: 10.1109/tnb.2022.3147957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
An accurate estimation of glomerular filtration rate (GFR) is clinically crucial for kidney disease diagnosis and predicting the prognosis of chronic kidney disease (CKD). Machine learning methodologies such as deep neural networks provide a potential avenue for increasing accuracy in GFR estimation. We developed a novel deep learning architecture, a deep and shallow neural network, to estimate GFR (dlGFR for short) and examined its comparative performance with estimated GFR from Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. The dlGFR model jointly trains a shallow learning model and a deep neural network to enable both linear transformation from input features to a log GFR target, and non-linear feature embedding for stage of kidney function classification. We validate the proposed methods on the data from multiple studies obtained from the NIDDK Central Database Repository. The deep learning model predicted values of GFR within 30% of measured GFR with 88.3% accuracy, compared to the 87.1% and 84.7% of the accuracy achieved by CKD-EPI and MDRD equations (p=0.051 and p<0.001, respectively). Our results suggest that deep learning methods are superior to equations resulting from traditional statistical methods in estimating glomerular filtration rate. Based on these results, an end-to-end predication system has been deployed to facilitate use of the proposed dlGFR algorithm.
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13
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Nishi S, Goto S, Mieno M, Yagisawa T, Yuzawa K. The Modified Chronic Kidney Disease Epidemiology Collaboration Equation for the Estimated Glomerular Filtration Rate Is Better Associated with Comorbidities than Other Equations in Living Kidney Donors in Japan. Intern Med 2021; 60:2757-2764. [PMID: 33716291 PMCID: PMC8479209 DOI: 10.2169/internalmedicine.6934-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective We studied three types of estimated glomerular filtration rate (eGFR) equations and evaluated which type was strongly associated with comorbidities in living kidney transplantation (LKT) donors. Methods We compared the Japanese modified eGFR, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration equations (Jm-eGFR, Jm-MDRD, and Jm-CKD-EPI, respectively) for Japanese LKT donors with respect to their relationships with obesity, hypertension, diabetes, cardiovascular disease, and stroke. Results Of the 8,176 enrolled Japanese LKT donors, the eGFR calculated using Jm-CKD-EPI (eGFR/Jm-CKD-EPI) detected significant differences in 4 of 5 comorbidities between the comorbidity-positive and comorbidity-negative groups, whereas the eGFR calculated using Jm-MDRD (eGFR/Jm-MDRD) and Jm-eGFR (eGFR/Jm-eGFR) detected only 3 and 1 comorbidities, respectively. The area under the receiver operating characteristic curve of Jm-CKD-EPI was larger than those of Jm-eGFR and Jm-MDRD for all five comorbidities. Conclusion We found that the eGFR/Jm-CKD-EPI correlated better with comorbidities than the eGFR/Jm-eGFR and eGFR/Jm-MDRD in Japanese LKT donors. We recommend using the eGFR/Jm-CKD-EPI for the initial assessment of the renal function in LKT donor candidates when evaluating the presence of associated comorbidities.
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Affiliation(s)
- Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Japan
| | - Makiko Mieno
- Center for Information, Jichi Medical University, Japan
| | - Takashi Yagisawa
- Department of Renal Surgery and Transplantation, Jichi Medical University Hospital, Japan
| | - Kenji Yuzawa
- National Hospital Organization Mito Medical Center, Japan
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14
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Matrat L, Ruiz M, Ecochard-Dugelay E, Loras-Duclaux I, Marotte S, Heissat S, Poinsot P, Sellier-Leclerc AL, Bacchetta J, Dubourg L, Peretti N. Combined use of creatinine and cystatin C improves the detection of renal dysfunction in children undergoing home parenteral nutrition. JPEN J Parenter Enteral Nutr 2021; 46:180-189. [PMID: 33733460 DOI: 10.1002/jpen.2108] [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: 12/16/2022]
Abstract
BACKGROUND Renal dysfunction can complicate home parenteral nutrition (HPN). The aims were, in the context of pediatric HPN, to assess renal function using the measured glomerular filtration rate (mGFR), determine the most accurate formula(s) to estimate GFR, and identify possible underlying mechanisms of renal impairment. METHODS A retrospective study was performed in 2 centers. Patients receiving HPN and aged 2-16 years without medical history of nephropathy were included. GFR was measured using iohexol clearance. Estimated GFR (eGFR) was calculated using creatinine, cystatin C-based, and combined (eGFRcr+cyst ) Schwartz formulas. RESULTS A total of 36 patients (18 females) were included; they received HPN for 8 (2-16) years. The primary digestive disease was short-bowel syndrome for 16 (44%) patients, gastrointestinal motility disorder for 10 (28%), or congenital diarrhea for 10 (28%). The median (range) mGFR was 99 (33-136) ml/min/1.73 m2 ; 9 (25%) patients had mildly decreased mGFR (<90 and ≥60 ml/min/1.73 m2 ), and 2 (6%) had mildly to severely decreased mGFR (<60 ml/min/1.73 m2 ). The eGFRcr+cyst formula was the most accurate and precise to estimate GFR. A significant negative correlation between mGFR and PN duration was found for patients receiving PN for 6-7/7 days (P = .008). Activation of the renin-angiotensin system was identified in 15 of 36 (42%) patients. CONCLUSION Renal dysfunction was frequent and correlated with the duration of PN only for patients with the most severe intestinal failure. The use of eGFRcr+cyst improves its detection in these patients. Chronic dehydration may be an underlying mechanism.
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Affiliation(s)
- Lucie Matrat
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Pierre-Bénite, France
| | - Mathias Ruiz
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | | | - Irène Loras-Duclaux
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Stéphanie Marotte
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Sophie Heissat
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Pierre Poinsot
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Pierre-Bénite, France.,CarMeN Laboratory, INRAE, INSERM, UMR1060, University Lyon 1, Pierre-Bénite, France
| | - Anne-Laure Sellier-Leclerc
- Centre de Référence des Maladies Rénales Rares, Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Justine Bacchetta
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Pierre-Bénite, France.,Centre de Référence des Maladies Rénales Rares, Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Laurence Dubourg
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Pierre-Bénite, France.,Centre de Référence des Maladies Rénales Rares, Service de Néphrologie, Rhumatologie et Dermatologie Pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Service d'Exploration Fonctionnelle Rénale, Département de Néphrologie, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Noël Peretti
- Pediatric Gastroenterology Hepatology and Nutrition Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, Pierre-Bénite, France.,CarMeN Laboratory, INRAE, INSERM, UMR1060, University Lyon 1, Pierre-Bénite, France
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15
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Hanna RM, Ferrey A, Rhee CM, Kalantar-Zadeh K. Renal-Cerebral Pathophysiology: The Interplay Between Chronic Kidney Disease and Cerebrovascular Disease. J Stroke Cerebrovasc Dis 2020; 30:105461. [PMID: 33199089 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Cerebrovascular disease has increasingly been linked to overall vascular health. Pathologic conditions like diabetes, hypertension, and kidney disease have been shown to affect brain health and cerebrovascular and nervous systems. Acute kidney injury (AKI) and chronic Kidney Disease (CKD) represent a variety of vascular insults that can adversely affect cerebral health. Hypertension, fluctuations in blood pressure, and diabetic vasculopathy are known risk factors for cerebrovascular disease associated with CKD. Other emerging areas of interest include endothelial dysfunction, vascular calcification due to calcium and phosphorus metabolism dysregulation, and uremic neuropathy present the next frontier of investigation in CKD and cerebrovascular health. METHODS It has become apparent that the interrelation of AKI and CKD with vascular health, chemical homeostasis, and hormonal regulation upset many aspects of cerebral health and functioning. Stroke is an obvious connection, with CKD patients demonstrating a higher proclivity for cerebrovascular accidents. Cerebral bleeding risk, uremic neuropathies, sodium dysregulation with impacts on nervous system, vascular calcification, and endothelial dysfunction are the next salient areas of research that are likely to reveal key breakthroughs in renal-cerebral pathophysiology. RESULTS In this review nephrological definition are discussed in a neuro-centric manner, and the areas of key overlap between CKD and cerebrovascular pathology are discussed. The multifaceted effects of renal function on the health of the brain are also examined. CONCLUSION This review article aims to create the background for ongoing and future neurological-nephrological collaboration on understanding the special challenges in caring for patients with cerebrovascular disease who also have CKD.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
| | - Antoney Ferrey
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
| | - Connie M Rhee
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology and Hypertension, University of California, Irvine, School of Medicine, 101 The City Drive South, City Tower, Suite 400, Orange, CA 92868, USA.
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16
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Gupta A, Kennedy K, Perales-Puchalt J, Drew D, Beddhu S, Sarnak M, Burns J. Mild-moderate CKD is not associated with cognitive impairment in older adults in the Alzheimer's Disease Neuroimaging Initiative cohort. PLoS One 2020; 15:e0239871. [PMID: 33036021 PMCID: PMC7546911 DOI: 10.1371/journal.pone.0239871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/14/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with cognitive impairment and dementia. We examined whether this relationship hold true in older adults, who have a higher prevalence of both CKD and dementia. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS We conducted a cross-sectional secondary analysis of an established observational cohort. We analyzed data from the Alzheimer's Disease Neuroimaging Initiative (ADNI), an NIH funded, multicenter longitudinal observational study, which includes participants with normal and impaired cognition and assesses cognition with a comprehensive battery of neuropsychological tests. We included a non-probability sample of all ADNI participants with serum creatinine measurements at baseline (N = 1181). Using multivariable linear regression analysis, we related the CKD Epidemiology Collaboration equation eGFR with validated composite scores for memory (ADNI-mem) and executive function (ADNI-EF). RESULTS For the 1181 ADNI participants, the mean age was 73.7 ± 7.1 years. Mean estimated glomerular filtration rate (eGFR) was 76.4 ± 19.7; 6% had eGFR<45, 22% had eGFR of 45 to <60, 51% had eGFR of 60-90 and 21% had eGFR>90 ml/min/1.73 m2. The mean ADNI-Mem score was 0.241 ± 0.874 and mean ADNI-EF score was 0.160 ± 1.026. In separate multivariable linear regression models, adjusted for age, sex, race education and BMI, there was no association between each 10 ml/ min/1.73 m2 higher eGFR and ADNI-Mem (β -0.02, 95% CI -0.04, 0.02, p = 0.56) or ADNI-EF (β 0.01, 95% CI -0.03, 0.05, p = 0.69) scores. CONCLUSION We did not observe an association between eGFR and cognition in the older ADNI participants.
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Affiliation(s)
- Aditi Gupta
- The Kidney Institute, University of Kansas Medical Center, Kansas City, KS, United States of America
- Division of Nephrology and Hypertension, University of Kansas Medical Center, Kansas City, KS, United States of America
- Alzheimer’s Disease Center, University of Kansas Medical Center, Kansas City, KS, United States of America
- * E-mail:
| | - Kevin Kennedy
- Kansas City Veterans Affairs, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Jaime Perales-Puchalt
- Alzheimer’s Disease Center, University of Kansas Medical Center, Kansas City, KS, United States of America
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - David Drew
- Division of Nephrology and Hypertension, Tufts Medical Center, Boston MA, United States of America
| | | | - Mark Sarnak
- Division of Nephrology and Hypertension, Tufts Medical Center, Boston MA, United States of America
| | - Jeffrey Burns
- Alzheimer’s Disease Center, University of Kansas Medical Center, Kansas City, KS, United States of America
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States of America
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17
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Clinical Implications of Estimating Glomerular Filtration Rate with Three Different Equations Among Older People. Preliminary Results of the Project "Screening for Chronic Kidney Disease among Older People across Europe (SCOPE)". J Clin Med 2020; 9:jcm9020294. [PMID: 31973029 PMCID: PMC7074235 DOI: 10.3390/jcm9020294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 12/17/2022] Open
Abstract
We aimed at investigating to what extent CKD may be staged interchangeably by three different eGFR equations in older people, and evaluating the source of discrepancies among equations in a population of 2257 patients older than 75 years enrolled in a multicenter observational study. eGFR was calculated by CKD-EPI, BIS and FAS equations. Statistical analysis was carried out by Bland–Altman analysis. κ statistic was used to quantify the agreement between equations in classifying CKD stages. The impact of selected variables on the difference among equations was graphically explored. The average difference between BIS and FAS was −0.24 (95% limits of agreement (95%LA = −4.64–4.14) mL/min/1.73 m2. The difference between CKD-EPI and BIS and between CKD-EPI and FAS was 8.97 (95%LA = −2.90–20.84) and 8.72 (95%LA = −2.11–19.56) mL/min/1.73 m2, respectively. As regards CKD stage classification, κ value was 0.47 for both CKD-EPI vs. FAS and CKD-EPI vs. BIS, while BIS and FAS had similar classificatory properties (κ = 0.90). Muscle mass was found related to the difference between CKD-EPI and BIS (R2 = 0.11) or FAS (R2 = 0.14), but not to the difference between BIS and FAS. In conclusion, CKD-EPI and BIS/FAS equations are not interchangeable to assess eGFR among older people. Muscle mass may represent a relevant source of discrepancy among eGFR equations.
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18
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Comparison of Performance of Equations for Estimated Glomerular Filtration Rate in Chinese Patients with Biopsy-Proven Diabetic Nephropathy. DISEASE MARKERS 2019; 2019:4354061. [PMID: 31636737 PMCID: PMC6766097 DOI: 10.1155/2019/4354061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023]
Abstract
Background The performance of various equations for estimated glomerular filtration rate (eGFR) in patients with diabetes remains controversial. We aimed to evaluate the performance of equations for eGFR in Chinese patients with diabetic nephropathy (DN). Methods This is a retrospective study included in 308 patients with type 2 diabetes and biopsy-proven DN who were followed up at least one year. eGFR was calculated using chronic kidney disease epidemiology (CKD-EPI) equations based on serum creatinine (eGFRCKD-EPI-Cr), cystatin C (eGFRCKD-EPI-CysC), and joint equations (eGFRCKD-EPI-Cr-CysC), respectively. End-stage kidney disease was defined by initiation of renal replacement therapy. The eGFR concordance between equations was assessed by Bland-Altman plots. Log-rank and multivariable logistic regression were employed to evaluate the performance of equations. Results Overall, the proportion of patients with eGFR < 60 mL/min/1.73m2 was 53%, 70%, and 61% by the equations of eGFRCKD-EPI-Cr, eGFRCKD-EPI-CysC, and eGFRCKD-EPI-Cr-CysC, respectively. Higher disconcordance was observed between equations when eGFR > 60 mL/min/1.73m2. Compared with eGFRCKD-EPI-Cr, 39% of patients were reclassified (reclassified group) from CKD 1-2 stages to CKD 3-5 stages by eGFRCKD-EPI-CysC and they presented significantly longer diabetic duration, heavier proteinuria, advanced pathological lesions, and poorer kidney outcomes. Multivariable logistic regression indicated cystatin C was independently associated with advanced glomerular classifications. Conclusion eGFR equations incorporating cystatin C are superior to eGFR based on creatinine alone for detecting kidney injury in the early stage. The independent association between cystatin C and glomerular classifications might contribute to it.
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19
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Glassock RJ, Rule AD. Optimally predicting mortality with kidney function markers is not the same as optimally determining how kidney function predicts mortality. Nephrol Dial Transplant 2018; 32:585-587. [PMID: 28339938 DOI: 10.1093/ndt/gfx007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/09/2017] [Indexed: 12/31/2022] Open
Affiliation(s)
- Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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20
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Estimation et mesure du débit de filtration glomérulaire : en quête de précision. Nephrol Ther 2018; 14 Suppl 1:S59-S66. [DOI: 10.1016/j.nephro.2018.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/01/2018] [Indexed: 11/22/2022]
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21
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Inker LA, Koraishy FM, Goyal N, Lentine KL. Assessment of Glomerular Filtration Rate and End-Stage Kidney Disease Risk in Living Kidney Donor Candidates: A Paradigm for Evaluation, Selection, and Counseling. Adv Chronic Kidney Dis 2018; 25:21-30. [PMID: 29499883 DOI: 10.1053/j.ackd.2017.09.002] [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] [Received: 07/05/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 12/27/2022]
Abstract
Living donor kidney transplantation is the preferred treatment option for ESRD. However, recent data suggest a small increase in the long-term risk of kidney failure in living kidney donors when compared to healthy nondonors. These data have led to a need for reconsideration of how donor candidates are evaluated and selected for donation. A Kidney Disease: Improving Global Outcomes (KDIGO) work group completed a comprehensive clinical practice guideline for evaluation of living kidney donor candidates in 2017, based on systematic evidence review, de novo evidence generation, and expert opinion. Central to the evaluation framework is assessment of glomerular filtration rate (GFR), which is used to screen for kidney disease and aid the prediction of long-term kidney failure risk after donation. Accurate estimation of the level of GFR and risk of kidney failure, and communication of estimated risks, can support evidence-based donor selection and shared decision-making. In this review, we discuss approaches to optimal GFR estimation in the donor evaluation process, long-term risk projection, and risk communication to donor candidates, integrating recommendations from the new KDIGO guideline, other recent literature, and experience from our own research and practice. We conclude by highlighting topics for further research in this important area of transplant medicine.
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22
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Abstract
Chronic kidney disease (CKD) is defined by persistent urine abnormalities, structural abnormalities or impaired excretory renal function suggestive of a loss of functional nephrons. The majority of patients with CKD are at risk of accelerated cardiovascular disease and death. For those who progress to end-stage renal disease, the limited accessibility to renal replacement therapy is a problem in many parts of the world. Risk factors for the development and progression of CKD include low nephron number at birth, nephron loss due to increasing age and acute or chronic kidney injuries caused by toxic exposures or diseases (for example, obesity and type 2 diabetes mellitus). The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. CKD complications such as anaemia, metabolic acidosis and secondary hyperparathyroidism affect cardiovascular health and quality of life, and require diagnosis and treatment.
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Guo M, Niu JY, Ye XW, Han XJ, Zha Y, Hong Y, Fang H, Gu Y. Evaluation of various equations for estimating renal function in elderly Chinese patients with type 2 diabetes mellitus. Clin Interv Aging 2017; 12:1661-1672. [PMID: 29070944 PMCID: PMC5640414 DOI: 10.2147/cia.s140289] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The clinical assessment of kidney function based on the estimated glomerular filtration rate (GFR) in older patients remains controversial. This study evaluated the concordance and feasibility of using various creatinine-based equations for estimating GFR in elderly Chinese patients with type 2 diabetes mellitus (T2DM). METHODS A cross-sectional analytical study was conducted in 21,723 older diabetic patients (≥60 years) based on electronic health records (EHR) for Minhang District, Shanghai, China. The concordance of chronic kidney disease (CKD) classification among different creatinine-based equations was assessed based on Kappa values, intraclass correlation coefficient (ICC) statistics, and the eGFR agreement between the equations was tested using Bland-Altman plots. The GFR was estimated using the Cockcroft-Gault (CG), Berlin Initiative Study 1 (BIS1), simplified Modification of Diet in Renal Disease (MDRD), MDRD modified for Chinese populations (mMDRD), chronic kidney disease epidemiology collaboration (CKD-EPI), CKD-EPI in Asians (CKD-EPI-Asia), and Ruijin equations. RESULTS Overall, the proportion of CKD stages 3-5 (eGFR <60 mL/min/1.73 m2) was calculated as 28.9%, 39.1%, 11.8%, 8.4%, 14.3%, 11.5%, and 12.7% by the eGFRCG, eGFRBIS1, eGFRMDRD, eGFRmMDRD, eGFRCKD-EPI, eGFRCKD-EPI-Asia, and eGFRRuijin equations, respectively. The concordance of albuminuria and decreased eGFR based on the different equations was poor by both the Kappa (<0.2) and ICC (<0.4) statistics. The CKD-EPI-Asia equation resulted in excellent concordance with the CKD-EPI (ICC =0.931), MDRD (ICC =0.963), mMDRD (ICC =0.892), and Ruijin (ICC =0.956) equations for the classification of CKD stages, whereas the BIS1 equation exhibited good concordance with the CG equation (ICC =0.809). In addition, significant differences were observed for CKD stage 1 among all these equations. CONCLUSION Accurate GFR values are difficult to estimate using creatinine-based equations in older diabetic patients. Kidney function is complex, and the staff need to be aware of the individualized consideration of other risk factors or markers of reduced renal function in clinical practice.
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Affiliation(s)
- Mei Guo
- Zhongshan-Xuhui Hospital, Affiliated with Fudan University
| | - Jian-Ying Niu
- The Fifth People's Hospital of Shanghai, Fudan University
| | - Xian-Wu Ye
- The Fifth People's Hospital of Shanghai, Fudan University
| | - Xiao-Jie Han
- The Fifth People's Hospital of Shanghai, Fudan University
| | - Ying Zha
- The Fifth People's Hospital of Shanghai, Fudan University
| | - Yang Hong
- The Fifth People's Hospital of Shanghai, Fudan University
| | - Hong Fang
- Shanghai Minhang Center for Disease Control and Prevention
| | - Yong Gu
- The Fifth People's Hospital of Shanghai, Fudan University.,Department of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
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Alaini A, Malhotra D, Rondon-Berrios H, Argyropoulos CP, Khitan ZJ, Raj DSC, Rohrscheib M, Shapiro JI, Tzamaloukas AH. Establishing the presence or absence of chronic kidney disease: Uses and limitations of formulas estimating the glomerular filtration rate. World J Methodol 2017; 7:73-92. [PMID: 29026688 PMCID: PMC5618145 DOI: 10.5662/wjm.v7.i3.73] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/17/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023] Open
Abstract
The development of formulas estimating glomerular filtration rate (eGFR) from serum creatinine and cystatin C and accounting for certain variables affecting the production rate of these biomarkers, including ethnicity, gender and age, has led to the current scheme of diagnosing and staging chronic kidney disease (CKD), which is based on eGFR values and albuminuria. This scheme has been applied extensively in various populations and has led to the current estimates of prevalence of CKD. In addition, this scheme is applied in clinical studies evaluating the risks of CKD and the efficacy of various interventions directed towards improving its course. Disagreements between creatinine-based and cystatin-based eGFR values and between eGFR values and measured GFR have been reported in various cohorts. These disagreements are the consequence of variations in the rate of production and in factors, other than GFR, affecting the rate of removal of creatinine and cystatin C. The disagreements create limitations for all eGFR formulas developed so far. The main limitations are low sensitivity in detecting early CKD in several subjects, e.g., those with hyperfiltration, and poor prediction of the course of CKD. Research efforts in CKD are currently directed towards identification of biomarkers that are better indices of GFR than the current biomarkers and, particularly, biomarkers of early renal tissue injury.
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Affiliation(s)
- Ahmed Alaini
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Helbert Rondon-Berrios
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Dominic S C Raj
- Division of Nephrology, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Joseph I Shapiro
- Marshall University Joan C. Edwards School of Medicine, Huntington, WV 25701, United States
| | - Antonios H Tzamaloukas
- Nephrology Section, Medicine Service, Raymond G. Murphy VA Medical Center, Albuquerque, NM 87108, United States
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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Molitoris BA. Rethinking CKD Evaluation: Should We Be Quantifying Basal or Stimulated GFR to Maximize Precision and Sensitivity? Am J Kidney Dis 2017; 69:675-683. [PMID: 28223001 PMCID: PMC5403623 DOI: 10.1053/j.ajkd.2016.11.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 11/14/2016] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease (CKD) is an increasing clinical problem. Although clinical risk factors and biomarkers for the development and progression of CKD have been identified, there is no commercial surveillance technology to definitively diagnose and quantify the severity and progressive loss of glomerular filtration rate (GFR) in CKD. This has limited the study of potential therapies to late stages of CKD when FDA-registerable events are more likely. Because patient outcomes, including the rate of CKD progression, correlate with disease severity and effective therapy may require early intervention, being able to diagnose and stratify patients by their level of decreased kidney function early on is key for translational progress. In addition, renal reserve, defined as the increase in GFR following stimulation, may improve the quantification of GFR based solely on basal levels. Various groups are developing and characterizing optical measurement techniques using new minimally invasive or noninvasive approaches for quantifying basal and stimulated kidney function. This development has the potential to allow widespread individualization of therapy at an earlier disease stage. Therefore, the purposes of this review are to suggest why quantifying stimulated GFR, by activating renal reserve, may be advantageous in patients and to review fluorescent technologies to deliver patient-specific GFR.
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Affiliation(s)
- Bruce A Molitoris
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indiana Center for Biological Microscopy, Rouderbush VA, Indianapolis, IN.
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Inker LA, Huang N, Levey AS. Strategies for assessing GFR and albuminuria in the living kidney donor evaluation. CURRENT TRANSPLANTATION REPORTS 2017; 4:13-23. [PMID: 28944160 PMCID: PMC5608095 DOI: 10.1007/s40472-017-0134-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW The international guideline development group Kidney Disease Improving Global Outcomes (KDIGO) recently published a comprehensive set of recommendations for living donor evaluation which contains a new framework for decision making in the evaluation of kidney donor candidates. RECENT FINDINGS The guidelines recommend that decisions to accept or decline a candidate donor should be based on incorporation of multiple sources of information pertaining to the donor candidate's likelihood of serious adverse outcomes after donation. Two central components of assessment of risk are glomerular filtration rate (GFR) and albuminuria. We describe strategies for clinical decision making in assessment of GFR and albuminuria in the evaluation of living kidney donor candidates. Our premise is that all measurements will contain error; no single test result should lead to a decision to accept or decline a donor candidate. SUMMARY A structured apporach to use of information from multiple sources (e.g. estimated and measured GFR, estimated and measured albuminuria) aids in test interpretation and can lead to increased accuracy of testing and efficiency of evaluation strategies.
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Affiliation(s)
| | - Naya Huang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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27
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Lee ES, Collier CP, White CA. Creatinine Assay Attainment of Analytical Performance Goals Following Implementation of IDMS Standardization: Further Improvements Required. Can J Kidney Health Dis 2017; 4:2054358117693353. [PMID: 28321322 PMCID: PMC5347424 DOI: 10.1177/2054358117693353] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/09/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The international initiative to standardize creatinine (Cr) assays by tracing reference materials to Isotope Dilution Mass Spectrometry (IDMS) assigned values was implemented to reduce interlaboratory variability and improve assay accuracy. OBJECTIVE The aims of this study were to examine whether IDMS standardization has improved Cr assay accuracy (bias), interlaboratory variability (precision), total error (TE), and attainment of recommended analytical performance goals. METHODS External Quality Assessment (EQA) data (n = 66 challenge vials) from Ontario, Canada, were analyzed. The bias, precision, TE, and the number of EQA challenge vials meeting performance goals were determined by assay manufacturer before (n = 32) and after (n = 34) IDMS implementation. RESULTS The challenge vials with the worst bias and precision were spiked with known common interfering substances (glucose and bilirubin). IDMS standardization improved assay bias (10.4%-1.6%, P < .001), but precision remained unchanged (5.0%-4.7%, P = .5) with performance goals not consistently being met. Precision and TE goals based on biologic variation were attained by only 29% to 69% and 32% to 62% of challenge vials. CONCLUSIONS While IDMS standardization has improved Cr assay accuracy and thus reduced TE, significant interlaboratory variability remains. Contemporary Cr assays do not currently meet the standards required to allow for accurate and consistent estimated glomerular filtration rate assessment and chronic kidney disease diagnosis across laboratories. Further improvements in Cr assay performance are needed.
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Affiliation(s)
- Elizabeth Sunmin Lee
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Christine P. Collier
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Christine A. White
- Division of Nephrology, Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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28
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Methven S, Gasparini A, Carrero JJ, Caskey FJ, Evans M. Routinely measured iohexol glomerular filtration rate versus creatinine-based estimated glomerular filtration rate as predictors of mortality in patients with advanced chronic kidney disease: a Swedish Chronic Kidney Disease Registry cohort study. Nephrol Dial Transplant 2017; 32:ii170-ii179. [DOI: 10.1093/ndt/gfw457] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 12/20/2016] [Indexed: 11/12/2022] Open
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Molitoris BA, Reilly ES. Quantifying Glomerular Filtration Rates in Acute Kidney Injury: A Requirement for Translational Success. Semin Nephrol 2017; 36:31-41. [PMID: 27085733 DOI: 10.1016/j.semnephrol.2016.01.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute kidney injury (AKI) remains a vexing clinical problem that results in unacceptably high patient mortality, development of chronic kidney disease, and accelerated progression to end-stage kidney disease. Although clinical risks factors for developing AKI have been identified, there is no reasonable surveillance technique to definitively and rapidly diagnose and determine the extent of severity of AKI in any patient. Because patient outcomes correlate with the extent of injury, and effective therapy likely requires early intervention, the ability to rapidly diagnose and stratify patients by their level of kidney injury is paramount for translational progress. Many groups are developing and characterizing optical measurement techniques using novel minimally invasive or noninvasive techniques that can quantify kidney function independent of serum or urinary measurements. The use of both one- and two-compartment models, as well as continuous monitoring, are being developed. This review documents the need for glomerular filtration rate measurement in AKI patients and discusses the approaches being taken to deliver this overdue technique that is necessary to help propel nephrology to individualization of care and therapeutic success.
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Affiliation(s)
- Bruce A Molitoris
- Division of Nephrology, Department of Medicine, Indiana Center for Biological Microscopy, Indiana University School of Medicine, Roudebush VA, Indianapolis, Indiana; FAST BioMedical, Indianapolis, Indiana.
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30
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Lee E, Collier CP, White CA. Interlaboratory Variability in Plasma Creatinine Measurement and the Relation with Estimated Glomerular Filtration Rate and Chronic Kidney Disease Diagnosis. Clin J Am Soc Nephrol 2017; 12:29-37. [PMID: 27827312 PMCID: PMC5220660 DOI: 10.2215/cjn.05400516] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/04/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The tracing of creatinine (Cr) reference materials to isotope dilution mass spectrometry-assigned values was implemented worldwide to reduce interlaboratory variability and improve assay accuracy. The aims of this study were to examine the current extent of interlaboratory variability and its effect on eGFR. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Leftover plasma from 2-3 consecutive days was obtained from 53 intensive care unit patients with a range of kidney functions. Individual patient samples were pooled and split and sent to 12 different laboratories for Cr measurement. For each patient, the mean Cr and Chronic Kidney Disease Epidemiology Collaboration eGFR (eGFR-EPI), assuming a 65-year-old nonblack woman, were determined. Interlaboratory variability was assessed by the range and SD of Cr and eGFR-EPI. This was repeated after stratifying by assay type and by the median Cr of 1.36 mg/dl. For patients whose eGFR-EPI range included 60 ml/min per 1.73 m2, the percentage of laboratories with eGFR-EPI<60 ml/min per 1.73 m2 was determined. RESULTS The mean±SD of the Cr and eGFR-EPI ranges were 0.20±0.09 mg/dl and 14±9 ml/min per 1.73 m2 for Cr<1.36 mg/dl. Jaffe Cr results were an average 0.1 mg/dl (Cr≥1.36 mg/dl) and 0.05 mg/dl (Cr<1.36 mg/dl) higher than enzymatic results (P<0.001 for both). Ten patients had an eGFR-EPI range that included 60 ml/min per 1.73 m2. Their median eGFR-EPI range was 15 ml/min per 1.73 m2. There was significant discordance in the diagnosis of CKD (eGFR-EPI<60 ml/min per 1.73 m2), with laboratories using Jaffe Cr methods making the diagnosis more frequently than those using enzymatic Cr methods (60% versus 39%). CONCLUSIONS Significant interlaboratory variability in Cr measurement still exists. Jaffe assays yield higher Cr values than enzymatic assays, leading to lower eGFR-EPIs and more frequent CKD diagnoses. Further improvements in assay performance are required to standardize patient CKD diagnosis and to facilitate longitudinal Cr monitoring across laboratories.
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Affiliation(s)
| | - Christine P. Collier
- Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada
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31
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Haley WE, Enders FT, Vaughan LE, Mehta RA, Thoman ME, Vrtiska TJ, Krambeck AE, Lieske JC, Rule AD. Kidney Function After the First Kidney Stone Event. Mayo Clin Proc 2016; 91:1744-1752. [PMID: 27776839 PMCID: PMC5140038 DOI: 10.1016/j.mayocp.2016.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 08/16/2016] [Accepted: 08/22/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine whether there is a persistent decline in kidney function after the first kidney stone event. PATIENT AND METHODS Incident symptomatic stone formers and age- and sex-matched controls underwent 2 study visits 90 days apart to assess kidney function, complete a survey, and have their medical records reviewed. Kidney function was compared between stone formers and controls adjusting for clinical, blood, and urine risk factors. RESULTS There were 384 stone formers and 457 controls. At visit 1, a median of 104 days after the stone event, stone formers compared with controls had similar serum creatinine (0.86 vs 0.84 mg/dL; P=.23), higher serum cystatin C (0.83 vs 0.72 mg/L; P<.001), higher urine protein (34.2 vs 19.7 mg/24 h; P<.001) levels, and were more likely to have albuminuria (24 h urine albumin >30 mg: 5.4% vs 2.2%; P=.02). Findings were similar after adjustment for risk factors and at visit 2, a median of 92 days after visit 1. In the 173 stone formers with serum creatinine levels from care before study participation, the mean serum creatinine level was 0.84 mg/dL before the stone event, increased to 0.97 mg/dL (P<.001) at the stone event, but returned to 0.85 mg/dL (P=.38) after the stone event (visit 1). CONCLUSIONS Incident symptomatic stone formers have a rise in serum creatinine levels that resolves. However, stone formers have sustained higher cystatin C levels and proteinuria that may affect long-term risk of chronic kidney disease.
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Affiliation(s)
- William E Haley
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Felicity T Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Lisa E Vaughan
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ramila A Mehta
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Maxton E Thoman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | | | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
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The conundrums of chronic kidney disease and aging. J Nephrol 2016; 30:477-483. [PMID: 27885585 DOI: 10.1007/s40620-016-0362-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/01/2016] [Indexed: 01/13/2023]
Abstract
Chronic kidney disease (CKD), as presently defined, is a common disorder. Aging is a nearly universal phenomenon that can affect renal anatomy and function, but at variable rates in individuals. Loss of nephrons and a decline in glomerular filtration rate (GFR) is a characteristic of normal aging, called renal senescence. Using fixed and absolute thresholds for defining CKD on the basis of GFR for all ages may lead to diagnostic uncertainty (a conundrum) in both young and older subjects. This brief review will consider the physiological and anatomical changes of the kidney occurring in the process of normal renal senescence focusing on GFR and will examine the relevance of these observation for the diagnosis of CKD using GFR as the distinguishing parameter. Once a better understanding of the pathobiology underlying renal senescence is obtained, specific interventions may become available to slow the process.
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Denic A, Glassock RJ, Rule AD. Structural and Functional Changes With the Aging Kidney. Adv Chronic Kidney Dis 2016. [PMID: 26709059 DOI: 10.1053/h.ackd.2015.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Senescence or normal physiologic aging portrays the expected age-related changes in the kidney as compared to a disease that occurs in some but not all individuals. The microanatomical structural changes of the kidney with older age include a decreased number of functional glomeruli from an increased prevalence of nephrosclerosis (arteriosclerosis, glomerulosclerosis, and tubular atrophy with interstitial fibrosis), and to some extent, compensatory hypertrophy of remaining nephrons. Among the macroanatomical structural changes, older age associates with smaller cortical volume, larger medullary volume until middle age, and larger and more numerous kidney cysts. Among carefully screened healthy kidney donors, glomerular filtration rate (GFR) declines at a rate of 6.3 mL/min/1.73 m(2) per decade. There is reason to be concerned that the elderly are being misdiagnosed with CKD. Besides this expected kidney function decline, the lowest risk of mortality is at a GFR of ≥75 mL/min/1.73 m(2) for age <55 years but at a lower GFR of 45 to 104 mL/min/1.73 m(2) for age ≥65 years. Changes with normal aging are still of clinical significance. The elderly have less kidney functional reserve when they do actually develop CKD, and they are at higher risk for acute kidney injury.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA; and Division of Nephrology and Hypertension, Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Richard J Glassock
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA; and Division of Nephrology and Hypertension, Division of Epidemiology, Mayo Clinic, Rochester, MN
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA; and Division of Nephrology and Hypertension, Division of Epidemiology, Mayo Clinic, Rochester, MN.
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El-Khoury JM, Bunch DR, Hu B, Payto D, Reineks EZ, Wang S. Comparison of symmetric dimethylarginine with creatinine, cystatin C and their eGFR equations as markers of kidney function. Clin Biochem 2016; 49:1140-1143. [PMID: 27452178 DOI: 10.1016/j.clinbiochem.2016.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 07/14/2016] [Accepted: 07/15/2016] [Indexed: 01/02/2023]
Abstract
OBJECTIVES Symmetric dimethylarginine (SDMA) is a catabolic product of arginine-methylated proteins and is an emerging biomarker for kidney function. A limited number of studies in selected populations have shown good correlation between SDMA and a few known markers of glomerular filtration rate (GFR). However, a comprehensive comparison of SDMA with all existing serum endogenous markers in a population with varied kidney function and against measured GFR is lacking. The objective of this study was to compare the correlations of SDMA, creatinine, cystatin C and their eGFR equations against GFR measured by iothalamate clearance in an adult population with varied kidney function. DESIGN & METHODS Left-over serum and plasma specimens were collected from 40 adults with normal and reduced kidney function. GFR was measured using a radioactive iothalamate procedure. Creatinine and cystatin C were measured on Roche Cobas 8000. SDMA was measured by a published liquid chromatography-tandem mass spectrometry method. RESULTS SDMA correlated highly with measured GFR (r=-0.84), which was better than creatinine (r=-0.70) but equivalent to cystatin C (r=-0.86) and the eGFR equations [MDRD and CKD-EPI (separate and combined)]. CONCLUSIONS SDMA is a strong marker of kidney function and further studies are needed to establish an eGFR formula that includes it for widespread clinical use.
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Affiliation(s)
- Joe M El-Khoury
- Department of Laboratory Medicine, Yale University, New Haven, CT 06510, United States
| | - Dustin R Bunch
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Drew Payto
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Edmunds Z Reineks
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Sihe Wang
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH 44195, United States.
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Levey AS, Inker LA. GFR as the "Gold Standard": Estimated, Measured, and True. Am J Kidney Dis 2016; 67:9-12. [PMID: 26708193 DOI: 10.1053/j.ajkd.2015.09.014] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 09/24/2015] [Indexed: 01/02/2023]
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Serum Cystatin C as an Indicator of Renal Function and Mortality in Liver Transplant Recipients. Transplantation 2016; 99:1431-5. [PMID: 25654627 DOI: 10.1097/tp.0000000000000552] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND/AIMS Chronic kidney disease (CKD) is an important comorbidity after liver transplantation (LT); however, reliable tools with which to evaluate these patients are limited. In this work, we examine the extent to which the addition of serum cystatin C improves glomerular filtration rate (GFR) estimation and mortality prediction, in comparison to various GFR-estimating equations. METHODS The GFR was measured in LT recipients by iothalamate clearance. Concurrent serum cystatin C was assayed in banked serum samples. Performance of GFR-estimating equations with and without cystatin C, including the modification of diet in renal disease and CKD-epidemiology collaboration formulas was assessed. The proportional hazards regression analysis was performed to determine the association between serum cystatin C and mortality. RESULTS A total of 586 iothalamate results were obtained in 401 patients after a mean of 4 years after LT. When compared to measured GFR, the formula with both creatinine and cystatin C, namely, CKD-epidemiology cr-cys, outperformed those with either marker alone. Performance of creatinine-based models was similar to one another. Serum cystatin C, by itself or as a part of an estimated GFR, was a significant predictor of mortality. CONCLUSIONS Serum cystatin C has an important role in enhancing accuracy of GFR estimation and predicting mortality in LT recipients.
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Tarantini L, McAlister FA, Barbati G, Ezekowitz JA, Cioffi G, Faggiano P, Pulignano G, Cherubini A, Grisolia Franceschini E, Di Lenarda A. Chronic kidney disease and prognosis in elderly patients with cardiovascular disease: Comparison between CKD-EPI and Berlin Initiative Study-1 formulas. Eur J Prev Cardiol 2016; 23:1504-13. [PMID: 26988974 DOI: 10.1177/2047487316638454] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 02/20/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) is frequent in patients with cardiovascular (CV) disease and impacts prognosis in these subjects. While current guidelines recommend the CKD-EPI equation for the estimated glomerular filtration rate (eGFR) and recognizing CKD, a new creatinine-based equation - the Berlin Initiative Study-1 (BIS-1) - was generated for elders with a high prevalence of CV disease. We assessed whether BIS-1 provided more accurate risk stratification than the CKD-EPI equation in unselected aged patients with CV disease. METHODS Patients aged ≥70 years who were seen consecutively at the Cardiovascular Centre of Trieste (Italy) between November 2009 and October 2013 were recruited into this study. The correlation and agreement between the BIS-1 and CKD-EPI formulas were evaluated and intra-class correlation coefficients (ICCs) were computed in order to estimate the correlation between the two formulas. Patients were followed for all-cause death, composite outcomes of all-cause death/all-cause hospitalization and all-cause death/CV hospitalization. RESULTS A total of 7845 subjects met the inclusion criteria for this study. GFR as estimated with the BIS-1 and the CKD-EPI equation was highly correlated (ICC: 0.81; 95% confidence interval [CI]: 0.79-0.82; p < 0.0001). When allocating patients in Kidney Disease Improving Global Outcomes classes of eGFR, compared to CKD-EPI, the BIS-1 formula reclassified 2720 (34.7%) patients: 53 (1.9%) were placed in a better class and 2667 (98.1%) were placed in a worse class. Multivariable Cox models showed that BIS-1 compared to CKD-EPI had a significantly better accuracy for predicting death (NRI: 0.12; 95% CI: 0.03-0.19; p = 0.001), death/CV hospitalization (net reclassification improvement [NRI]: 0.34; 95% CI: 0.27-0.38; p < 0.001) and death/all-cause hospitalization (NRI: 0.14; 95% CI: 0.06-0.21; p = 0.001). CONCLUSIONS The BIS-1 formula is better than the CKD-EPI formula for risk stratification of CKD in elderly people with CV disease.
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Affiliation(s)
| | | | | | - Justin Adrian Ezekowitz
- Division of General Internal Medicine, University of Alberta, Edmonton, AB, Canada Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada
| | - Giovanni Cioffi
- Department of Cardiology, Villa Bianca Hospital, Trento, Italy
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Tuot DS, Scherzer R, Leong H, Hung AM, Grunfeld C, Shlipak MG. Use of cystatin C to inform metformin eligibility among adult veterans with diabetes. J Clin Transl Endocrinol 2016; 3:1-6. [PMID: 28603691 PMCID: PMC5464411 DOI: 10.1016/j.jcte.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/16/2015] [Accepted: 10/21/2015] [Indexed: 12/11/2022] Open
Abstract
AIMS Recommendations for metformin use are dependent on eGFR category: eGFR >45 ml/min/1.73 m2 - "first-line agent"; eGFR 30-44 - "use with caution"; eGFR<30 - "do not use". Misclassification of metformin eligibility by creatinine-based MDRD GFR estimates (eGFRcr) may contribute to its misuse. We investigated the impact of cystatin c estimates of GFR (eGFRcys) on metformin eligibility. METHODS In a consecutive cohort of 550 Veterans with diabetes, metformin use and eligibility were assessed by eGFR category, using eGFRcr and eGFRcys. Discrepancy in eligibility was defined as cases where eGFRcr and eGFRcys categories (<30, 30-44, 45-60, and >60 ml/min/1.73 m2) differed with an absolute difference in eGFR of >5 ml/min/1.73 m2. We modeled predictors of metformin use and eGFR category discrepancy with multivariable relative risk regression and multinomial logistic regression. RESULTS Subjects were 95% male, median age 68, and racially diverse (45% White, 22% Black, 11% Asian, 22% unknown). Metformin use decreased with severity of eGFRcr category, from 63% in eGFRcr >60 to 3% in eGFRcr <30. eGFRcys reclassified 20% of Veterans into different eGFR categories. Factors associated with a more severe eGFRcys category compared to eGFRcr were older age (aOR = 2.21 per decade, 1.44-1.82), higher BMI (aOR = 1.04 per kg/m2, 1.01-1.08) and albuminuria >30 mg/g (aOR = 1.81, 1.20-2.73). CONCLUSIONS Metformin use is low among Veterans with CKD. eGFRcys may serve as a confirmatory estimate of kidney function to allow safe use of metformin among patients with CKD, particularly among older individuals and those with albuminuria.
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Affiliation(s)
- Delphine S. Tuot
- Division of Nephrology, University of California, San Francisco, CA, USA
| | - Rebecca Scherzer
- Department of Medicine, University of California, San Francisco, CA, USA
- Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Howard Leong
- Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Adriana M. Hung
- Division of Nephrology and Hypertension, Vanderbilt University and Veterans Affairs Medical Center, Nashville, TN, USA
| | - Carl Grunfeld
- Department of Medicine, University of California, San Francisco, CA, USA
- Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Michael G. Shlipak
- Department of Medicine, University of California, San Francisco, CA, USA
- Veterans Affairs Medical Center, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
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Denic A, Alexander MP, Kaushik V, Lerman LO, Lieske JC, Stegall MD, Larson JJ, Kremers WK, Vrtiska TJ, Chakkera HA, Poggio ED, Rule AD. Detection and Clinical Patterns of Nephron Hypertrophy and Nephrosclerosis Among Apparently Healthy Adults. Am J Kidney Dis 2016; 68:58-67. [PMID: 26857648 DOI: 10.1053/j.ajkd.2015.12.029] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 12/28/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Even among ostensibly healthy adults, there is often mild pathology in the kidney. The detection of kidney microstructural variation and pathology by imaging and the clinical pattern associated with these structural findings is unclear. STUDY DESIGN Cross-sectional (clinical-pathologic correlation). SETTING & PARTICIPANTS Living kidney donors at Mayo Clinic (Minnesota and Arizona sites) and Cleveland Clinic 2000 to 2011. PREDICTORS Predonation kidney function, risk factors, and contrast computed tomographic scan of the kidneys. These scans were segmented for cortical volume and medullary volume, reviewed for parenchymal cysts, and scored for kidney surface roughness. OUTCOMES Nephrosclerosis (glomerulosclerosis, interstitial fibrosis/tubular atrophy, and arteriosclerosis) and nephron size (glomerular volume, mean profile tubular area, and cortical volume per glomerulus) determined from an implantation biopsy of the kidney cortex at donation. RESULTS Among 1,520 living kidney donors, nephrosclerosis associated with increased kidney surface roughness, cysts, and smaller cortical to medullary volume ratio. Larger nephron size (nephron hypertrophy) associated with larger cortical volume. Nephron hypertrophy and larger cortical volume associated with higher systolic blood pressure, glomerular filtration rate, and urine albumin excretion; larger body mass index; higher serum uric acid level; and family history of end-stage renal disease. Both nephron hypertrophy and nephrosclerosis associated with older age and mild hypertension. The net effect of both nephron hypertrophy and nephrosclerosis associating with cortical volume was that nephron hypertrophy diminished volume loss with age-related nephrosclerosis and fully negated volume loss with mild hypertension-related nephrosclerosis. LIMITATIONS Kidney donors are selected on health, restricting the spectrum of pathologic findings. Kidney biopsies in living donors are a small tissue sample leading to imprecise estimates of structural findings. CONCLUSIONS Among apparently healthy adults, the microstructural findings of nephron hypertrophy and nephrosclerosis differ in their associations with kidney function, macrostructure, and risk factors.
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Affiliation(s)
- Aleksandar Denic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Vidhu Kaushik
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Mark D Stegall
- Division of Transplant Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph J Larson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Walter K Kremers
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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Delanaye P, Glassock RJ, Pottel H, Rule AD. An Age-Calibrated Definition of Chronic Kidney Disease: Rationale and Benefits. Clin Biochem Rev 2016; 37:17-26. [PMID: 27057075 PMCID: PMC4810758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Defining chronic kidney disease (CKD) is the subject of intense debate in the current nephrology literature. The debate concerns the threshold value of estimated glomerular filtration rate (eGFR) used to make the diagnosis of CKD. Current recommendations argue that a universal threshold of 60 mL/min/1.73m(2) should be used. This threshold has been defended by epidemiological studies showing that the risk of mortality or end-stage renal disease increases with an eGFR below 60 mL/min/1.73m(2). However, a universal threshold does not take into account the physiologic decline in GFR with ageing nor does it account for the risk of mortality and end-stage renal disease being trivial with isolated eGFR levels just below 60 mL/min/1.73m(2) in older subjects and significantly increased with eGFR levels just above 60 mL/min/1.73m(2) among younger patients. Overestimation of the CKD prevalence in the elderly (medicalisation of senescence) and underestimation of CKD (potentially from treatable primary nephrologic diseases) in younger patients is of primary concern. An age-calibrated definition of CKD has been proposed to distinguish age-related from disease-related changes in eGFR. For patients younger than 40 years, CKD is defined by eGFR below 75 mL/min/1.73m(2). For patients with ages between 40 and 65 years, CKD is defined by 60 mL/min/1.73m(2). For subjects older than 65 years without albuminuria or proteinuria, CKD is defined by eGFR below 45 mL/min/1.73m(2).
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Affiliation(s)
- Pierre Delanaye
- Department of Nephrology, Dialysis, Transplantation, University of Liège (ULg CHU), Liège, Belgium
| | - Richard J. Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Hans Pottel
- Department of Public Health and Primary Care, KU, Leuven Kulak, Kortrijk, Belgium
| | - Andrew D. Rule
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Denic A, Glassock RJ, Rule AD. Structural and Functional Changes With the Aging Kidney. Adv Chronic Kidney Dis 2016; 23:19-28. [PMID: 26709059 DOI: 10.1053/j.ackd.2015.08.004] [Citation(s) in RCA: 408] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 07/07/2015] [Accepted: 08/19/2015] [Indexed: 01/08/2023]
Abstract
Senescence or normal physiologic aging portrays the expected age-related changes in the kidney as compared to a disease that occurs in some but not all individuals. The microanatomical structural changes of the kidney with older age include a decreased number of functional glomeruli from an increased prevalence of nephrosclerosis (arteriosclerosis, glomerulosclerosis, and tubular atrophy with interstitial fibrosis), and to some extent, compensatory hypertrophy of remaining nephrons. Among the macroanatomical structural changes, older age associates with smaller cortical volume, larger medullary volume until middle age, and larger and more numerous kidney cysts. Among carefully screened healthy kidney donors, glomerular filtration rate (GFR) declines at a rate of 6.3 mL/min/1.73 m(2) per decade. There is reason to be concerned that the elderly are being misdiagnosed with CKD. Besides this expected kidney function decline, the lowest risk of mortality is at a GFR of ≥75 mL/min/1.73 m(2) for age <55 years but at a lower GFR of 45 to 104 mL/min/1.73 m(2) for age ≥65 years. Changes with normal aging are still of clinical significance. The elderly have less kidney functional reserve when they do actually develop CKD, and they are at higher risk for acute kidney injury.
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Ku E, Xie D, Shlipak M, Hyre Anderson A, Chen J, Go AS, He J, Horwitz EJ, Rahman M, Ricardo AC, Sondheimer JH, Townsend RR, Hsu CY. Change in Measured GFR Versus eGFR and CKD Outcomes. J Am Soc Nephrol 2015; 27:2196-204. [PMID: 26604213 DOI: 10.1681/asn.2015040341] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 10/14/2015] [Indexed: 01/13/2023] Open
Abstract
Measured GFR (mGFR) has long been considered the gold standard measure of kidney function, but recent studies have shown that mGFR is not consistently superior to eGFR in explaining CKD-related comorbidities. The associations between longitudinal changes in mGFR versus eGFR and adverse outcomes have not been examined. We analyzed a subset of 942 participants with CKD in the Chronic Renal Insufficiency Cohort Study who had at least two mGFRs and two eGFRs determined concurrently by iothalamate and creatinine (eGFRcr) or cystatin C, respectively. We compared the associations between longitudinal changes in each measure of kidney function over 2 years and risks of ESRD, nonfatal cardiovascular events, and all-cause mortality using univariate Cox proportional hazards models. The associations for all outcomes except all-cause mortality associated most strongly with longitudinal decline in eGFRcr. Every 5-ml/min per 1.73 m(2) decline in eGFRcr over 2 years associated with 1.54 (95% confidence interval, 1.44 to 1.66; P<0.001) times higher risk of ESRD and 1.23 (95% confidence interval, 1.12 to 1.34; P<0.001) times higher risk for cardiovascular events. All-cause mortality did not associate with longitudinal decline in mGFR or eGFR. When analyzed by tertiles of renal function decline, mGFR did not outperform eGFRcr in the association with any outcome. In conclusion, compared with declines in eGFR, declines in mGFR over a 2-year period, analyzed either as a continuous variable or in tertiles, did not consistently show enhanced association with risk of ESRD, cardiovascular events, or death.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology, Department of Medicine, Division of Pediatric Nephrology, Department of Pediatrics, and
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics and
| | - Michael Shlipak
- Division of General Internal Medicine, San Francisco Veterans Affair Medical Center, Departments of Medicine, Epidemiology, and Biostatistics, University of California, San Francisco, San Francisco, California
| | | | - Jing Chen
- Division of Nephrology and Hypertension, Department of Medicine, Tulane University New Orleans, Louisiana
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jiang He
- Departments of Epidemiology and Medicine, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Edward J Horwitz
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center Cleveland, Ohio
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, Department of Medicine, University Hospitals Case Medical Center Cleveland, Ohio; Division of Nephrology, Department of Medicine, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio; Division of Nephrology and Hypertension, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Ana C Ricardo
- Department of Medicine, Division of Nephrology, University of Illinois, Chicago, Illinois; and
| | - James H Sondheimer
- Division of Nephrology and Hypertension, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chi-Yuan Hsu
- Division of Nephrology, Department of Medicine, Division of Research, Kaiser Permanente Northern California, Oakland, California
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Tuot DS, Lin F, Shlipak MG, Grubbs V, Hsu CY, Yee J, Shahinian V, Saran R, Saydah S, Williams DE, Powe NR. Potential Impact of Prescribing Metformin According to eGFR Rather Than Serum Creatinine. Diabetes Care 2015; 38:2059-67. [PMID: 26307607 PMCID: PMC4613912 DOI: 10.2337/dc15-0542] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/24/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Many societies recommend using estimated glomerular filtration rate (eGFR) rather than serum creatinine (sCr) to determine metformin eligibility. We examined the potential impact of these recommendations on metformin eligibility among U.S. adults. RESEARCH DESIGN AND METHODS Metformin eligibility was assessed among 3,902 adults with diabetes who participated in the 1999-2010 National Health and Nutrition Examination Surveys and reported routine access to health care, using conventional sCr thresholds (eligible if <1.4 mg/dL for women and <1.5 mg/dL for men) and eGFR categories: likely safe, ≥45 mL/min/1.73 m(2); contraindicated, <30 mL/min/1.73 m(2); and indeterminate, 30-44 mL/min/1.73 m(2)). Different eGFR equations were used: four-variable MDRD, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine (CKD-EPIcr), and CKD-EPI cystatin C, as well as Cockcroft-Gault (CG) to estimate creatinine clearance (CrCl). Diabetes was defined by self-report or A1C ≥6.5% (48 mmol/mol). We used logistic regression to identify populations for whom metformin was likely safe adjusted for age, race/ethnicity, and sex. Results were weighted to the U.S. adult population. RESULTS Among adults with sCr above conventional cutoffs, MDRD eGFR ≥45 mL/min/1.73 m(2) was most common among men (adjusted odds ratio [aOR] 33.3 [95% CI 7.4-151.5] vs. women) and non-Hispanic Blacks (aOR vs. whites 14.8 [4.27-51.7]). No individuals with sCr below conventional cutoffs had an MDRD eGFR <30 mL/min/1.73 m(2). All estimating equations expanded the population of individuals for whom metformin is likely safe, ranging from 86,900 (CKD-EPIcr) to 834,800 (CG). All equations identified larger populations with eGFR 30-44 mL/min/1.73 m(2), for whom metformin safety is indeterminate, ranging from 784,700 (CKD-EPIcr) to 1,636,000 (CG). CONCLUSIONS The use of eGFR or CrCl to determine metformin eligibility instead of sCr can expand the adult population with diabetes for whom metformin is likely safe, particularly among non-Hispanic blacks and men.
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Affiliation(s)
- Delphine S Tuot
- Division of Nephrology, University of California, San Francisco, San Francisco, CA Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA
| | - Feng Lin
- Department of Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Michael G Shlipak
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Vanessa Grubbs
- Division of Nephrology, University of California, San Francisco, San Francisco, CA Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA
| | - Chi-yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI
| | - Vahakn Shahinian
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Sharon Saydah
- Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Neil R Powe
- Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA Department of Medicine, University of California, San Francisco, San Francisco, CA
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Meeusen JW, Rule AD, Voskoboev N, Baumann NA, Lieske JC. Performance of cystatin C- and creatinine-based estimated glomerular filtration rate equations depends on patient characteristics. Clin Chem 2015; 61:1265-72. [PMID: 26240296 DOI: 10.1373/clinchem.2015.243030] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/29/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends use of a cystatin C-based estimated glomerular filtration rate (eGFR) to confirm creatinine-based eGFR between 45 and 59 mL · min(-1) · (1.73 m(2))(-1). Prior studies have demonstrated that comorbidities such as solid-organ transplant strongly influence the relationship between measured GFR, creatinine, and cystatin C. Our objective was to evaluate the performance of cystatin C-based eGFR equations compared with creatinine-based eGFR and measured GFR across different clinical presentations. METHODS We compared the performance of the CKD-EPI 2009 creatinine-based estimated GFR equation (eGFRCr) and the newer CKD-EPI 2012 cystatin C-based equations (eGFRCys and eGFRCr-Cys) with measured GFR (iothalamate renal clearance) across defined patient populations. Patients (n = 1652) were categorized as transplant recipients (n = 568 kidney; n = 319 other organ), known chronic kidney disease (CKD) patients (n = 618), or potential kidney donors (n = 147). RESULTS eGFRCr-Cys showed the most consistent performance across different clinical populations. Among potential kidney donors without CKD [stage 2 or higher; eGFR >60 mL · min(-1) · (1.73 m(2))(-1)], eGFRCys and eGFRCr-Cys demonstrated significantly less bias than eGFRCr; however, all 3 equations substantially underestimated GFR when eGFR was <60 mL · min(-1) · (1.73 m(2))(-1). Among transplant recipients with CKD stage 3B or greater [eGFR <45 mL · min(-1) · (1.73 m(2))(-1)], eGFRCys was significantly more biased than eGFRCr. No clear differences in eGFR bias between equations were observed among known CKD patients regardless of eGFR range or in any patient group with a GFR between 45 and 59 mL · min(-1) · (1.73 m(2))(-1). CONCLUSIONS The performance of eGFR equations depends on patient characteristics that are readily apparent on presentation. Among the 3 CKD-EPI equations, eGFRCr-Cys performed most consistently across the studied patient populations.
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Affiliation(s)
| | - Andrew D Rule
- Department of Internal Medicine, Division of Nephrology and Hypertension, and Department of Health Sciences Research Division of Epidemiology, Mayo Clinic, Rochester, MN
| | | | | | - John C Lieske
- Department of Laboratory Medicine and Pathology, Department of Internal Medicine, Division of Nephrology and Hypertension, and
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Lenders M, Canaan-Kühl S, Krämer J, Duning T, Reiermann S, Sommer C, Stypmann J, Blaschke D, Üçeyler N, Hense HW, Brand SM, Wanner C, Weidemann F, Brand E. Patients with Fabry Disease after Enzyme Replacement Therapy Dose Reduction and Switch-2-Year Follow-Up. J Am Soc Nephrol 2015; 27:952-62. [PMID: 26185201 DOI: 10.1681/asn.2015030337] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/10/2015] [Indexed: 02/05/2023] Open
Abstract
Because of the shortage of agalsidase-β supply between 2009 and 2012, patients with Fabry disease either were treated with reduced doses or were switched to agalsidase-α. In this observational study, we assessed end organ damage and clinical symptoms with special focus on renal outcome after 2 years of dose-reduction and/or switch to agalsidase-α. A total of 89 adult patients with Fabry disease who had received agalsidase-β (1.0 mg/kg body wt) for >1 year were nonrandomly assigned to continue this treatment regimen (regular-dose group, n=24), to receive a reduced dose of 0.3-0.5 mg/kg and a subsequent switch to 0.2 mg/kg agalsidase-α (dose-reduction-switch group, n=28), or to directly switch to 0.2 mg/kg agalsidase-α (switch group, n=37) and were followed-up for 2 years. We assessed clinical events (death, myocardial infarction, severe arrhythmia, stroke, progression to ESRD), changes in cardiac and renal function, Fabry-related symptoms (pain, hypohidrosis, diarrhea), and disease severity scores. Determination of renal function by creatinine and cystatin C-based eGFR revealed decreasing eGFRs in the dose-reduction-switch group and the switch group. The Mainz Severity Score Index increased significantly in these two groups (P=0.02 and P<0.001, respectively), and higher frequencies of gastrointestinal pain occurred during follow-up. In conclusion, after 2 years of observation, all groups showed a stable clinical disease course with respect to serious clinical events. However, patients under agalsidase-β dose-reduction and switch or a direct switch to agalsidase-α showed a decline of renal function independent of the eGFR formula used.
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Affiliation(s)
- Malte Lenders
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster
| | | | - Johannes Krämer
- Department of Pediatrics and Adolescent Medicine, University of Ulm, Ulm, Germany; Department of Medicine, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center, Fabry Center for Interdisciplinary Therapy and
| | | | - Stefanie Reiermann
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster
| | - Claudia Sommer
- Department of Medicine, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center, Fabry Center for Interdisciplinary Therapy and Department of Neurology, University of Würzburg, Würzburg, Germany
| | - Jörg Stypmann
- Department of Cardiovascular Medicine, Division of Cardiology
| | - Daniela Blaschke
- Department of Medicine, Division of Cardiology, Charité, Campus Virchow-Klinikum, Berlin, Germany
| | - Nurcan Üçeyler
- Department of Medicine, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center, Fabry Center for Interdisciplinary Therapy and Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Stefan-Martin Brand
- Institute of Sports Medicine, Molecular Genetics of Cardiovascular Disease, University Hospital Münster, Münster, Germany
| | - Christoph Wanner
- Department of Medicine, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center, Fabry Center for Interdisciplinary Therapy and
| | - Frank Weidemann
- Department of Medicine, Divisions of Cardiology and Nephrology, Comprehensive Heart Failure Center, Fabry Center for Interdisciplinary Therapy and Katharinen-Hospital Unna, Unna, Germany
| | - Eva Brand
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, Interdisciplinary Fabry Center Münster,
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Berns JS. Clinical Decision Making in a Patient with Stage 5 CKD--Is eGFR Good Enough? Clin J Am Soc Nephrol 2015; 10:2065-72. [PMID: 25883071 DOI: 10.2215/cjn.00340115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The development and widespread use of serum creatinine concentration-based prediction equations to calculate eGFR have been major advances for detection of patients with CKD and the epidemiologic study of CKD and its outcomes. However, these equations as well as those that also incorporate serum cystatin C concentration provide GFR estimates that, although reasonably precise on average, can differ markedly and in clinically important ways from actual GFR. Thus, it is important that clinicians who use these equations for clinical decision-making be familiar with their strengths and weaknesses and have an appreciation of their potential for error. More precise knowledge of actual GFR is important in certain clinical circumstances, including, as presented in this Attending Rounds, patients with stage 5 CKD, in whom decisions regarding dialysis initiation are necessary. Nephrologists should have the ability to accurately determine GFR when needed if clinical circumstances suggest inaccuracy of the calculated eGFR reported by the clinical laboratory.
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Affiliation(s)
- Jeffrey S Berns
- Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Fraser SDS, Aitken G, Taal MW, Mindell JS, Moon G, Day J, O’Donoghue D, Roderick PJ. Exploration of chronic kidney disease prevalence estimates using new measures of kidney function in the health survey for England. PLoS One 2015; 10:e0118676. [PMID: 25700182 PMCID: PMC4336286 DOI: 10.1371/journal.pone.0118676] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 10/02/2014] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) diagnosis relies on glomerular filtration rate (eGFR) estimation, traditionally using the creatinine-based Modification of Diet in Renal Disease (MDRD) equation. The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) equation performs better in estimating eGFR and predicting mortality and CKD progression risk. Cystatin C is an alternative glomerular filtration marker less influenced by muscle mass. CKD risk stratification is improved by combining creatinine eGFR with cystatin C and urinary albumin to creatinine ratio (uACR). We aimed to identify the impact of introducing CKDEPI and cystatin C on the estimated prevalence and risk stratification of CKD in England and to describe prevalence and associations of cystatin C. METHODS AND FINDINGS Cross sectional study of 5799 people in the nationally representative 2009 and 2010 Health Surveys for England. PRIMARY OUTCOME MEASURES prevalence of MDRD, CKDEPI and cystatin C-defined eGFR<60 ml/min/1.73 m(2); prevalence of CKD biomarker combinations (creatinine, cystatin C, uACR). Using CKDEPI instead of MDRD reduced the prevalence of eGFR<60 ml/min/1.73 m(2) from 6.0% (95% CI 5.4-6.6%) to 5.2% (4.7-5.8%) equivalent to around 340,000 fewer individuals in England. Those reclassified as not having CKD evidenced a lower risk profile. Prevalence of cystatin C eGFR<60 ml/min/1.73 m(2) was 7.7% and independently associated with age, lack of qualifications, being an ex-smoker, BMI, hypertension, and albuminuria. Measuring cystatin C in the 3.9% people with CKDEPI-defined eGFR<60 ml/min/1.73 m(2) without albuminuria (CKD Category G3a A1) reclassified about a third into a lower risk group with one of three biomarkers and two thirds into a group with two of three. Measuring cystatin C in the 6.7% people with CKDEPI eGFR >60 ml/min/1.73 m(2) with albuminuria (CKD Category G1-2) reclassified almost a tenth into a higher risk group. LIMITATIONS Cross sectional study, single eGFR measure, no measured ('true') GFR. CONCLUSIONS Introducing the CKDEPI equation and targeted cystatin C measurement reduces estimated CKD prevalence and improves risk stratification.
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Affiliation(s)
- Simon D. S. Fraser
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
| | - Grant Aitken
- Geography & Environment, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO171BJ, United Kingdom
| | - Maarten W. Taal
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Derby, DE22 3DT, United Kingdom
| | - Jennifer S. Mindell
- Research Department of Epidemiology and Public Health, UCL (University College London), London, WC1E 6BT, United Kingdom
| | - Graham Moon
- Geography & Environment, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO171BJ, United Kingdom
| | - Julie Day
- Department of Clinical Biochemistry, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, United Kingdom
| | - Donal O’Donoghue
- Renal Unit, Salford Royal NHS Foundation Trust, Salford, M6 8HD, United Kingdom
| | - Paul J. Roderick
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, United Kingdom
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Sood MM, Akbari A, Hiebert B, Hiremath S, Komenda P, Rigatto C, Zimmerman D, Tangri N. Trends in Arteriovenous Fistula Use at Dialysis Initiation After Automated eGFR Reporting. Semin Dial 2015; 28:439-45. [PMID: 25583047 DOI: 10.1111/sdi.12344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this study was to examine trends in the presence of an arteriovenous fistula (AVF) at dialysis initiation before and after eGFR reporting. All incident dialysis patients from four Canadian provinces that implemented province-wide, automated laboratory reporting of eGFR with known vascular access at dialysis initiation were included in the study (N = 25,201) from 2001 to 2010. The primary outcome was the change in proportion of patients with an AVF at dialysis initiation using an interrupted time series and adjusted multilevel logistic regression models. AVF usage at dialysis initiation decreased gradually over the study period from 19.0% to 14.6%. After implementation of automated eGFR reporting, there was attenuation in the decline in AVF usage in models adjusted for case-mix, facility, and the downward trajectory in AVF use over time. The adjusted odds ratio for initiating dialysis with an AVF 1 year post-eGFR reporting compared to pre-eGFR reporting was more pronounced in older patients (age tertile >73; OR: 1.40; 95% CI: 1.04-1.90). Laboratory-based eGFR reporting was associated with a possible attenuation in the decline of AVF at dialysis initiation and this was more pronounced in older patients.
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Affiliation(s)
- Manish M Sood
- Department of Medicine/Section of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ayub Akbari
- Department of Medicine/Section of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Brett Hiebert
- Section of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Swapnil Hiremath
- Department of Medicine/Section of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Komenda
- Department of Medicine/Section of Nephrology, Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Claudio Rigatto
- Department of Medicine/Section of Nephrology, Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Deborah Zimmerman
- Department of Medicine/Section of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Navdeep Tangri
- Department of Medicine/Section of Nephrology, Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
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Is a decline in estimated GFR an appropriate surrogate end point for renoprotection drug trials? Kidney Int 2014; 85:723-7. [PMID: 24682115 DOI: 10.1038/ki.2013.506] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Pavkov ME, Nelson RG. Improved early risk stratification with cystatin C-based estimated GFR. Am J Kidney Dis 2014; 63:745-8. [PMID: 24602780 DOI: 10.1053/j.ajkd.2014.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 02/04/2014] [Indexed: 01/29/2023]
Affiliation(s)
- Meda E Pavkov
- Centers for Disease Control and Prevention, Atlanta, Georgia
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