Implications of the CKD-EPI GFR estimation equation in clinical practice

Estimated glomerular filtration rate and the risk of stroke in individuals with diabetes mellitus and atrial fibrillation insight from a large contemporary population study

BACKGROUND

Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Impaired renal function (IRF) increases the risk of stroke as well, but this finding is not consistent among all studies. Our aim was to assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels Among individuals with AF and DM.

METHODS

A prospective, historical cohort study using the Clalit Health Services electronic medical records database. Among patients with AF and DM, we compared three groups according to eGFR levels: eGFR ≥ 60, between 30 and 60, and ≤ 30 (mL/min/1.73m2).

RESULTS

A total of 17,567 cases were included in the final analysis; of them, 11,013 (62.7%) had eGFR ≥ 60, 4930 (28%) had eGFR between 30 and 60, and 1624 (9.24%) with eGFR ≤ 30. The incidence of stroke per 100 person-years in the three study groups was: 1.88, 2.69, and 3.34, respectively (p < 0.001). IRF was associated with increased risk of stroke in univariate analysis, but not after multivariate adjustment (Adjusted Hazard Ratio (AHR) 0.96 {95%CI; 0.74-1.25} for eGFR 30-60 and 0.96 {95%CI; 0.60-1.55} for eGFR ≤ 30). Mortality per 100 person-years was 10.78, 21.49, and 41.55, respectively (p < 0.001). IRF was associated with increased mortality risk in univariate analysis, as well as in multivariate analysis (AHR 1.08 {95%CI; 0.98-1.18} for eGFR 30-60, and 1.59 {95%CI; 1.37-1.85} for eGFR ≤ 30.

CONCLUSION

In patients with NVAF and DM, IRF was not associated with an increased risk of stroke, but severe IRF (eGFR ≤ 30) was associated with increased mortality risk.

Model-informed precision dosing in vancomycin treatment

Introduction: While vancomycin remains a widely prescribed antibiotic, it can cause ototoxicity and nephrotoxicity, both of which are concentration-associated. Overtreatment can occur when the treatment lasts for an unnecessarily long time. Using a model-informed precision dosing scheme, this study aims to develop a population pharmacokinetic (PK) and pharmacodynamic (PD) model for vancomycin to determine the optimal dosage regimen and treatment duration in order to avoid drug-induced toxicity. Methods: The data were obtained from electronic medical records of 542 patients, including 40 children, and were analyzed using NONMEM software. For PK, vancomycin concentrations were described with a two-compartment model incorporating allometry scaling. Results and discussion: This revealed that systemic clearance decreased with creatinine and blood urea nitrogen levels, history of diabetes and renal diseases, and further decreased in women. On the other hand, the central volume of distribution increased with age. For PD, C-reactive protein (CRP) plasma concentrations were described by transit compartments and were found to decrease with the presence of pneumonia. Simulations demonstrated that, given the model informed optimal doses, peak and trough concentrations as well as the area under the concentration-time curve remained within the therapeutic range, even at doses smaller than routine doses, for most patients. Additionally, CRP levels decreased more rapidly with the higher dose starting from 10 days after treatment initiation. The developed R Shiny application efficiently visualized the time courses of vancomycin and CRP concentrations, indicating its applicability in designing optimal treatment schemes simply based on visual inspection.

Using race in the estimation of glomerular filtration rates: time for a reversal?

PURPOSE OF REVIEW

Bedside estimates of renal function are essential for clinical practice in the modern era and have largely relied on serum creatinine concentrations despite the known drawbacks associated with this choice of biomarker, including the fact that creatinine clearance overestimates the glomerular filtration rate.

RECENT FINDINGS

Initial estimates relied primarily on equations that incorporated factors known to influence creatinine concentrations such as age, sex and anthropometric measures. More recent estimates of glomerular filtration rate have replaced the anthropometric measures with the social construct of race, suggesting that glomerular filtration rates for black individuals are higher at the same concentration of creatinine. This approach has led to large variations in the estimated differences in glomerular filtration rate between black and nonblack individuals in the United States that have not been reproducible, resulting in a plethora of population-specific formulae across the country.

SUMMARY

The introduction of race in estimated glomerular filtration rate equations may have potential unintended negative consequences for the very population with the greatest burden of kidney disease. These potential disadvantages underscore the need to perhaps return to the replacement of race with more objective anthropometric measures without the loss of precision.

The association between the severity of chronic kidney disease and medical costs among patients with type 2 diabetes

AIMS

Examine healthcare costs across chronic kidney disease (CKD) stages for US patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

IQVIA Real World Data Adjudicated Claims linked electronic medical records and insurance claims from January 1, 2012 through March 31, 2017 were used for this retrospective study. Adults diagnosed with T2D and comorbid CKD were included. General linear models incorporating splines were constructed, and information from these regressions were used to inform the relationship between medical costs and CKD. Multivariable analyses controlled for patient characteristics, vital signs, general health, prior medication use, prior visit to specialists, index A1c, and year of index date.

RESULTS

There were 6,645 individuals who met the study criteria. Results generally indicate sharp increases in annual total medical costs and non-drug medical costs in the 1 year post-period for patients with Stage 4 or 5 CKD (estimated glomerular filtration rate [eGFR] ≤ 30 mL/min/1.73 m²) with each 1 point reduction in eGFR from 30 associated with an increase of $1,870 in all-cause total medical costs (p < 0.0001) and $1,805 of all-cause non-drug medical costs (p < 0.0001). Similarly, each point decline below 30 mL/min was associated annual cost increases of $1,701 for CKD-related total medical costs, $1,695 for CKD-related non-drug medical costs, $173 for diabetes-related medical costs, and $187 for diabetes-related non-drug medical costs (all p < 0.0001).

LIMITATIONS

The investigation included only patients with medical insurance and laboratory test results, and results may not be generalizable to all T2D patients with CKD. The methodology allowed us to determine associations, not causation, and potential confounders, such as duration of diabetes, diet, exercise, or social support, could not be assessed.

CONCLUSIONS

Results indicate there are sharp and significant increases in medical costs among T2D patients with Stage 4 and 5 CKD compared to those with earlier stages of CKD.

Impact of a single eGFR and eGFR-estimating equation on chronic kidney disease reclassification: a cohort study in primary care

Background

Chronic kidney disease (CKD) is diagnosed using the estimated glomerular filtration rate (eGFR) and the urinary albumin:creatinine ratio (ACR). The eGFR is calculated from serum creatinine levels using the Modification of Diet in Renal Disease (MDRD) or Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations.

Aim

To compare the performance of one versus two eGFR/ACR measurements, and the impact of equation choice, on CKD diagnosis and classification.

Design and setting

Cohort study in primary care in the Thames Valley region of the UK.

Method

Data were from 485 participants aged >60 years in the Oxford Renal Cohort Study with at least two eGFR tests. The proportion of study participants diagnosed and classified into different CKD stages using one and two positive tests were compared. Prevalence of CKD diagnosis and classification by CKD stage were compared when eGFR was calculated using MDRD and CKD-EPI equations.

Results

Participants included in the analysis had a mean age of 72.1 (±6.8) years and 57.0% were female. Use of a single screening test overestimated the proportion of people with CKD by around 25% no matter which equation was used, compared with the use of two tests. The mean eGFR was 1.4 ml/min/1.73 m² (95% CI = 1.1 to 1.6) higher using the CKD-EPI equation compared with the MDRD equation. More patients were diagnosed with CKD when using the MDRD equation, compared with the CKD-EPI equation, once (64% versus 63%, respectively) and twice (39% versus 38%, respectively), and 16 individuals, all of who had CKD stages 2 or 3A with MDRD, were reclassified as having a normal urinary ACR when using the CKD-EPI equation.

Conclusion

Current guidance to use two eGFR measures to diagnose CKD remains appropriate in an older primary care population to avoid overdiagnosis. A change from MDRD to CKD-EPI equation could result in one in 12 patients with a CKD diagnosis with MDRD no longer having a diagnosis of CKD.

The Impact of Admission Serum Creatinine on Major Adverse Clinical Events in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

Background

Impaired renal function has been shown in previous studies to be an independent predictor of cardiovascular adverse events amongst patients admitted for percutaneous coronary intervention (PCI) following ST-segment elevation myocardial infarction (STEMI). This study investigates the impact of admission serum creatinine (SCr) on major cardiovascular outcomes among STEMI patients undergoing PCI.

Methods

A retrospective study of patients admitted for PCI following STEMI was conducted using the National Cardiovascular Database Action Registry (NCDR) at Cleveland Clinic Akron General (CCAG) Hospital. The primary outcome was a composite of major clinical events: cardiogenic shock, atrial fibrillation, ventricular tachycardia/fibrillation, heart failure, bleeding and mechanical ventilation. SCr was an independent and continuous variable.

Results

A total of 656 patients included in the study with the diagnosis of STEMI who subsequently underwent primary PCI. Patients with eGFR < 60 mL/min/1.73 m² on admission had an increased incidence of cardiogenic shock (P = 0.001), bleeding (P < 0.001), heart failure (P < 0.0005) and higher mortality rates (P = 0.0005). Furthermore, in the setting of STEMI, elevated SCr was also associated with an increased risk of developing major adverse events like cardiogenic shock (P = 0.05), bleeding (P = 0.05), and heart failure (P = 0.005).

Conclusions

In the setting of STEMI, elevated SCr and eGFR < 60 mL/min/1.73 m² was associated with an increased risk of developing major adverse events including cardiogenic shock, bleeding and heart failure.

Detection of relationships between SUDOSCAN with estimated glomerular filtration rate (eGFR) in Chinese patients with type 2 diabetes

OBJECTIVE

SUDOSCAN (Impeto Medical, Paris, France) has been proved to be a new and non-invasive method in detecting renal dysfunction in type 2 diabetes mellitus (T2DM) patients. In this study, we sought to compare the result of diabetic kidney dysfunction score (DKD-score) of SUDOSCAN with estimated glomerular filtration rate (eGFR) by using quantile regression analysis, which was completely different from previous studies.

METHODS

A total number of 223 Chinese T2DM patients were enrolled in the study. SUDOSCAN, renal function test (including blood urea nitrogen, creatinine and uric acid) and ⁹⁹mTc-diethylenetriamine pentaacetic acid (⁹⁹mTc-DTPA) renal dynamic imaging were performed in all T2DM patients. DKD-score of SUDOSCAN was compared with eGFR detected by ⁹⁹mTc-DTPA renal dynamic imaging through quantile regression analysis. Its validation and utility was further determined through bias and precision test.

RESULTS

The quantile regression analysis demonstrated the relationship with eGFR was inverse and significant for almost all percentiles of DKD-score. The coefficients decreased as the percentile of DKD-score increased. And in validation data set, both the bias and precision were increased with the eGFR (median difference, -21.2 ml/min/1.73 m² for all individuals vs. -4.6 ml/min/1.73 m² for eGFR between 0 and 59 ml/min/1.73 m²; interquartile range [IQR] for the difference, -25.4 ml/min/1.73 m² vs. -14.7 ml/min/1.73 m²). The eGFR category misclassification rate were 10% in eGFR 0-59 ml/min/1.73 m² group, 57.3% in 60-90 group, and 87.2% in eGFR > 90 ml/min/1.73 m² group.

CONCLUSION

DKD-score of SUDOSCAN could be used to detect renal dysfunction in T2DM patients. A higher prognostic value of DKD-score was detected when eGFR level was lower.

Clinical Update on Nursing Home Medicine: 2016

This is the tenth clinical update. It covers chronic kidney disease, dementia, hypotension, polypharmacy, rapid geriatric assessment, and transitional care.

SUDOSCAN, an effective tool for screening chronic kidney disease in patients with type 2 diabetes

SUDOSCAN is a non-invasive method of measuring peripheral small fiber and autonomic nerve activity by detection of abnormal sweat gland function through electrochemical skin conductance. It has been reported to be an effective screening tool in early detection of microvascular type 2 diabetes mellitus (T2DM) complications including diabetic neuropathy and nephropathy in recent studies. However, previous studies used estimated glomerular filtration rate (eGFR) as the golden standard, which has a 90% chance of being within 30% of the measured GFR at best. No relevant study has been performed in the Chinese population concerning SUDOSCAN in the screening of diabetic nephropathy (DN) in comparison with GFR. In this cross-sectional study, SUDOSCAN was performed in 176 Chinese patients with T2DM between September 2014 and September 2015. It was found that the SUDOSCAN test had a sensitivity of 57.8% and a specificity of 100% to detect chronic kidney disease at a cut-off SUDOSCAN-DN score of 59.5. The area under receiver operating characteristic curve for DN was 0.85 [95% confidence interval (CI), 0.76-0.93] compared with 0.84 for eGFR_MDRD (MDRD, modification of diet in renal disease; 95% CI, 0.71-0.98) and 0.77 for eGFR_EPI (EPI, epidemiology collaboration; 95% CI, 0.68-0.87). Patients with DN score <59.5 had a significantly lower GFR level (P<0.001) and significantly older age (P<0.001), longer duration of T2DM (P<0.001) and higher risk of diabetic complications, including diabetic neuropathy (P<0.001) and peripheral vascular disease (P<0.05). These results suggested that SUDOSCAN may be useful for detecting patients at risk of impaired renal function as part of a screening program in the Chinese population with T2DM.

Increased risk of cardiovascular events in end-stage renal disease patients with osteoporosis: a nationwide population-based cohort study

SUMMARY

We investigated the cardiovascular disease risk and mortality in end-stage renal disease (ESRD) patients. A total of 12,535 patients with ESRD undergoing incident dialysis were enrolled, 4,153 (33.13 %) of whom had osteoporosis. The osteoporosis group was associated with a significantly higher risk of coronary artery disease, congestive heart failure, stroke, and mortality.

INTRODUCTION

In this study, we aimed to investigate the risk of cardiovascular disease and mortality in a sample of end-stage renal disease patients with osteoporosis.

METHODS

We conducted this retrospective cohort study of incident dialysis patients with and without osteoporosis to evaluate the risk of overall mortality and cardiovascular complications including stroke, coronary heart disease, and congestive heart failure between the two groups. A total of 12,535 patients with ESRD undergoing incident dialysis were enrolled, 4,153 (33.13 %) of whom had osteoporosis, from the National Health Insurance Research Database of Taiwan for the years 1998 through 2011. The osteoporosis group had more comorbidities than the group without osteoporosis including hypertension, hyperlipidemia, mental disorders, and hepatitis C infection.

RESULTS

After adjusting for age, gender, and related comorbidities, the osteoporosis group was associated with a significantly higher risk of coronary artery disease (hazard ratio (HR)=1.32, 95 % confidence interval (CI)=1.20-1.45) which was significant in both genders (women, HR=1.35, 95% CI=1.20-1.50; men HR=1.27, 95% CI=1.06-1.52) and all age groups (≤49 years HR=1.41, 95% CI=1.16-1.70; >49 years HR=1.30, 95% CI=1.16-1.45). Similar results were observed for the outcomes of congestive heart failure, stroke, and mortality.

CONCLUSIONS

The results showed that osteoporosis was significantly associated with the subsequent risk of cardiovascular events in patients with ESRD. When encountering patients with ESRD and osteoporosis, physicians should be alert to the subsequent cardiovascular risk in incident dialysis patients to prevent the subsequent occurrence of these adverse events.

Chronic kidney disease in the elderly

Chronic kidney disease (CKD) is increasingly being recognized as a disease of elderly individuals. In recent years the definition and categorization of kidney disease has been standardized. There are concerns that this standardization has led to an increase in the number of older individuals labeled as having CKD. This article addresses the definitions of CKD, recently published revised CKD stages with risk stratifications, and limitations of using formulas to assess renal function in the elderly. Also discussed are management of common risk factors of progression CKD, nonrenal-related outcomes, prognosis of CKD in older individuals, and criteria for referral to nephrology.

Fragility fractures and osteoporosis in CKD: pathophysiology and diagnostic methods

Both chronic kidney disease (CKD) and osteoporosis are major public health problems associated with an aging population. Osteoporosis is characterized by reduced bone mineral density, while CKD results in qualitative changes in bone structure; both conditions increase the predisposition to fragility fractures. There is a significant coprevalence of osteoporotic fractures and CKD, particularly in the elderly population. Not only is the risk of fracture higher in the CKD population, but clinical outcomes are significantly worse, with substantial health care costs. Management of osteoporosis in the CKD population is particularly complex given the impact of renal osteodystrophy on bone quality and the limited safety and hard outcome data for current therapy in patients with severe CKD or on dialysis therapy. In this review, we discuss the pathophysiology of osteoporosis, the impact of CKD on bone strength, and the role of novel imaging techniques and biomarkers in predicting underlying renal osteodystrophy on bone histomorphometry in the context of CKD.

Impact on cardiovascular risk follow-up from a shift to the CKD-EPI formula for eGFR reporting: a cross-sectional population-based primary care study

OBJECTIVE

To assess the impact on cardiovascular risk factor management in primary care by the introduction of chronic kidney disease epidemiological collaboration (CKD-EPI) for estimated-glomerular filtration rate (eGFR) reporting.

DESIGN AND SETTING

Cross-sectional study of routine healthcare provision in 47 primary care practices in The Netherlands with Modification of Diet and Renal Disease Study eGFR reporting.

METHODS

eGFR values were recalculated using CKD-EPI in patients with available creatine tests. Patients reclassified from CKD stage 3a to CKD stage 2 eGFR range were compared to those who remained in stage 3a for differences in demographic variables, blood pressure, comorbidity, medication usage and laboratory results.

RESULTS

Among the 60 673 adult patients (37% of adult population) with creatine values, applying the CKD-EPI equation resulted in a 16% net reduction in patients with CKD stage 3 or worse. Patients reclassified from stage 3a to 2 had lower systolic blood pressure (139.7 vs 143.3 mm Hg p<0.0001), higher diastolic blood pressure (81.5 vs 78.4 mm Hg p<0.0001) and higher cholesterol (5.4 vs 5.1 mmol/L p<0.0001) compared to those who remained in stage 3a. Of those reclassified out of a CKD diagnosis 463 (32%) had no comorbidities that would qualify for annual CVD risk factor assessment and 20 (12% of those with sufficient data) had a EuroSCORE CVD risk >20% within 10 years.

CONCLUSIONS

Use of the CKD-EPI equation will result in many patients being removed from CKD registers and the associated follow-up. Current risk factor assessment in this group may be lacking from routine data and some patients within this group are at an increased risk for cardiovascular events.

Predicting residual renal function in peritoneal dialysis patients using an estimated glomerular filtration rate based on serum creatinine levels

BACKGROUND

The aim of this study was to evaluate regression equations correcting estimated glomerular filtration rate (eGFR) and the clinical significance of the corrected eGFRs calculated using these equations.

PATIENTS AND METHODS

The authors determined how well corrected eGFR values calculated using regression equations predict residual renal function (RRF).

RESULTS

RRF values were correlated with all eGFR values of nonanuric patients of both genders. Peritoneal creatinine clearance values were not correlated with eGFRs in anuric patients of either gender. In males, eGFR biases ranged from -5.66 to -3.25, and in females, from -5.96 to -3.21. However, these biases decreased when eGFR values were transformed to corrected eGFR values. The area under the curve of the corrected eGFR values was acceptable for a diagnosis of RRF loss.

CONCLUSION

Corrected eGFR values obtained using these methods may provide an alternative means of predicting RRF without 24-hour urine collection.

Electronic health records: a new tool to combat chronic kidney disease?

Electronic health records (EHRs) were first developed in the 1960s as clinical information systems for document storage and retrieval. Adoption of EHRs has increased in the developed world and is increasing in developing countries. Studies have shown that quality of patient care is improved among health centers with EHRs. In this article, we review the structure and function of EHRs along with an examination of its potential application in CKD care and research. Well-designed patient registries using EHRs data allow for improved aggregation of patient data for quality improvement and to facilitate clinical research. Preliminary data from the United States and other countries have demonstrated that CKD care might improve with use of EHRs-based programs. We recently developed a CKD registry derived from EHRs data at our institution and complimented the registry with other patient details from the United States Renal Data System and the Social Security Death Index. This registry allows us to conduct a EHRs-based clinical trial that examines whether empowering patients with a personal health record or patient navigators improves CKD care, along with identifying participants for other clinical trials and conducting health services research. EHRs use have shown promising results in some settings, but not in others, perhaps attributed to the differences in EHRs adoption rates and varying functionality. Thus, future studies should explore the optimal methods of using EHRs to improve CKD care and research at the individual patient level, health system and population levels.

Creatinine-or cystatin C-based equations to estimate glomerular filtration in the general population: impact on the epidemiology of chronic kidney disease

Background

Chronic kidney disease (CKD) is a major issue in public health. Its prevalence has been calculated using estimation of glomerular filtration rate (GFR) by the creatinine-based equations developed in the Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) study. Recently, new equations based either on cystatin C (CKD-EPI Cys) or both cystatin and creatinine (CKD-EPI mix) have been proposed by the CKD-EPI consortium. The aim of this study was to measure the difference in the prevalence of stage 3 CKD, defined as an estimated GFR less than 60 mL/min/1.73 m², in a population using these four equations.

Methods

CKD screening was performed in the Province of Liège, Belgium. On a voluntary basis, people aged over 50 years have been screened. GFR was estimated by the four equations. Stage 3 CKD was defined as a GFR less than 60 mL/min/1.73 m².

Results

The population screened consisted of 4189 people (47% were men, mean age 63 ± 7y). Their mean serum creatinine and plasma cystatin C levels were 0.88 ± 0.21 mg/dL and 0.85 ± 0.17 mg/L, respectively. The prevalence of CKD in this population using the MDRD, the CKD-EPI, the CKD-EPI Cys and the CKD-EPI mix equations was 13%, 9.8%, 4.7% and 5%, respectively. The prevalence of CKD was significantly higher with the creatinine-based (MDRD and the CKD-EPI) equations compared to the new cystatin C-based equations.

Conclusions

Prevalence of CKD varies strongly depending on the method used to estimate GFR. Such discrepancies are of importance and must be confirmed and explained by additional studies, notably by studies using GFR measured with a reference method.

Trial registration

B70720071509

Comparison of the MDRD Study and the CKD-EPI Study equations in evaluating trends of estimated kidney function at population level: findings from the National FINRISK Study

BACKGROUND

There are no data comparing the Modification of Diet in Renal Disease (MDRD) Study and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) Study equations in the evaluation of time-dependent trend of estimated glomerular filtration rate (eGFR) in the general population.

METHODS

Changes in eGFR and in the association of eGFR with kidney disease and cardiovascular disease (CVD) risk factors across age groups were estimated in two independent cross-sectional population surveys in Finland in 2002 and 2007 with 11 277 study participants, aged 25-74 years, using both the MDRD and the CKD-EPI equations.

RESULTS

A trend towards decreasing eGFRs between the study years was observed using both equations, but the trend was more substantial when using the MDRD equation. The MDRD equation yielded lower estimates of eGFR than the CKD-EPI equation, with small mean difference between the equations at low eGFR level but substantial at the level of only mildly decreased or near-normal to normal kidney function. Decrease of eGFR was associated with an increase in CKD and CVD risk factors. However, an increase of risk factors was not observed among those who had mildly decreased eGFR by only the MDRD equation but not by the CKD-EPI equation.

CONCLUSION

In comparison with the CKD-EPI equation, the MDRD equation augmented the trend of increasing prevalence of CKD, showed a weaker association with risk factors and tended to assign impaired renal function to individuals without an excess of cardiovascular risk factors.

Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO)

Drug dosage adjustment for patients with acute or chronic kidney disease is an accepted standard of practice. The challenge is how to accurately estimate a patient's kidney function in both acute and chronic kidney disease and determine the influence of renal replacement therapies on drug disposition. Kidney Disease: Improving Global Outcomes (KDIGO) held a conference to investigate these issues and propose recommendations for practitioners, researchers, and those involved in the drug development and regulatory arenas. The conference attendees discussed the major challenges facing drug dosage adjustment for patients with kidney disease. In particular, although glomerular filtration rate is the metric used to guide dose adjustment, kidney disease does affect nonrenal clearances, and this is not adequately considered in most pharmacokinetic studies. There are also inadequate studies in patients receiving all forms of renal replacement therapy and in the pediatric population. The conference generated 37 recommendations for clinical practice, 32 recommendations for future research directions, and 24 recommendations for regulatory agencies (US Food and Drug Administration and European Medicines Agency) to enhance the quality of pharmacokinetic and pharmacodynamic information available to clinicians. The KDIGO Conference highlighted the gaps and focused on crafting paths to the future that will stimulate research and improve the global outcomes of patients with acute and chronic kidney disease.

The prevalence of chronic kidney disease in the general population in Romania: a study on 60,000 persons

INTRODUCTION

Chronic kidney disease (CKD) is a major public health problem worldwide, due to its epidemic proportions and to its association with high cardiovascular risk. Therefore, screening for CKD is an increasingly important concept, aiming for early detection and prevention of progression and complications of this disease.

MATERIALS AND METHODS

We studied the prevalence of CKD in the adult population of Iaşi, the largest county in Romania, based on the results of a national general health screening program from 2007 to 2008. The patients were tested for CKD with serum creatinine and urinary dipstick. We used two different methods to estimate the glomerular filtration rate (eGFR): the simplified Modification of Diet in Renal Disease (MDRD) and the CKD Epidemiology Collaboration (CKD-EPI) equations. Based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, we defined CKD as the presence of either eGFR < 60 ml/min/1.73 m(2) and/or dipstick proteinuria. The classification of CKD by stage was also done according to the KDIGO criteria.

RESULTS

The study population included 60,969 people. The global prevalence of CKD was found to be 6.69% by the MDRD formula and 7.32% when using the CKD-EPI equation. The prevalence of CKD was much higher in women than in men: 9.09% versus 3.7%, by MDRD, and 9.32% versus 4.85%, by CKD-EPI. By age groups, the prevalence of CKD was 0.95% and 0.64% in persons aged 18-44 years old, 4.27% and 3.57% (45-64 years old), 13.36% and 15.34% (65-79 years old), and 23.59% and 34.56% (>80 years old), according to MDRD and CKD-EPI, respectively. By stages, the prevalence of CKD stage 3a (eGFR 59 to 45 ml/min/1.73 m(2)) was 5.72% by MDRD and 5.96% according to CKD-EPI, whereas the prevalence of stages 3b, 4, and 5 taken together (eGFR < 45 ml/min/1.73 m(2)) was 0.96% (MDRD) and 1.35% (CKD-EPI). Patients with CKD were significantly older (71.0 years versus 53.7 years) and had lower levels of serum Hb, total cholesterol, and glutamic pyruvic transaminase, and significantly higher serum creatinine and blood glucose, in comparison with the individuals without CKD. Impaired fasting glucose (106 mg/dl) was found in the CKD population, but not in non-CKD individuals.

CONCLUSIONS

Our study is one of the largest ever reported on the prevalence of CKD worldwide, the first one in Romania, and one of the very few of its kind in Europe (particularly in Eastern Europe). The study showed that the prevalence of CKD in our country is around 7%, which is lower than in other countries; however, this could be underestimated due to population selection bias. The prevalence is similar with the MDRD and the CKD-EPI equations; it increases with age and is much higher in women than in men. Impaired fasting glucose was detected in CKD patients, a finding that should probably raise the awareness of the high cardiovascular risk associated with CKD.