Discordance in Estimated GFR Among Hospitalized Older Adults

KIDNEY MEDICINE(2023)

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Wang et al. evaluated discordances in eGFR based on creatinine (eGFRcr), cystatin C (eGFRcys), or their combination (eGFRcr-cys).1Wang Y, Adingwupu OM, Shlipak MG, et al. Discordance Between Creatinine and Cystatin C-Based Estimated GFR: Interpretation According to Performance Compared to Measured GFR. Kidney Med. Published online August 9, 2023:100710. doi:10.1016/j.xkme.2023.100710Google Scholar They used data from the 2021 CKD-EPI external validation cohort, which included 4,050 ambulatory participants (mean age 57.0 years, mean mGFR 76.4 mL/min/1.73m2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar).2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar Defining eGFRdiff as a discordance between eGFRcys and eGFRcr larger than ±15 mL/min/1.73m2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar, the authors found that 21% of patients had a negative discordance (eGFRcr higher) and 10% had a positive discordance (eGFRcys higher). In both groups, eGFRcr-cys yielded the best performance relative to mGFR according to bias and P30. The authors acknowledge that their study is limited by the lack of multimorbid or hospitalized patients. Our research focuses on hospitalized older adults, who are characterized by high rates of multimorbidity, frailty, malnutrition, and polypharmacy.3Andersen A.L. Nielsen R.L. Houlind M.B. et al.Risk of Malnutrition upon Admission and after Discharge in Acutely Admitted Older Medical Patients: A Prospective Observational Study.Nutrients. 2021; 13: 2757https://doi.org/10.3390/nu13082757Crossref PubMed Scopus (9) Google Scholar,4Iversen E. Bodilsen A.C. Klausen H.H. et al.Kidney function estimates using cystatin C versus creatinine: Impact on medication prescribing in acutely hospitalized elderly patients.Basic Clin Pharmacol Toxicol. 2019; 124: 466-478https://doi.org/10.1111/bcpt.13156Crossref PubMed Scopus (18) Google Scholar Given the unique patient population, we performed a similar analysis to Wang et al. for a previously described cohort of 106 hospitalized older adults with a mean age of 79.0 years and mGFR of 62.7 mL/min/1.73m2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar (Table 1).5Iversen E. Bengaard A.K. Andersen A.L. et al.Performance of Panel-Estimated GFR Among Hospitalized Older Adults.Am J Kidney Dis. 2023; 0https://doi.org/10.1053/j.ajkd.2023.05.004Abstract Full Text Full Text PDF Scopus (0) Google Scholar Using the 2009 eGFRcr equation (Danish standard), we found that 51% of patients had a negative discordance (67% when using 2021 eGFRcr), which is more than double that of Wang et al. and likely reflects differences in non-GFR determinants between cohorts. Like Wang et al., however, we found that eGFRcr-cys outperformed both eGFRcr and eGFRcys in patients with a negative discordance.Table 1Patient characteristics and performance of GFR estimating equations compared with measured GFR in hospitalized older adults, stratified by groups based on eGFRdiff (eGFRcys – eGFRcr).OveralleGFRdiff group (eGFRcys – eGFRcr)Negative (< –15)(eGFRcr higher)Concordant (–15 to 15)Positive (≥ 15)(eGFRcys higher)Patient characteristicsNumber106 (100%)51 (48%)54 (51%)1 (1%)Age (years)79.0 ± 7.280.1 ± 8.277.9 ± 6.080.3 ± NAFemale61 (58%)29 (57%)32 (59%)0 (0%)BMI (kg/m2)27.0 ± 6.526.2 ± 7.227.7 ± 5.831.4 ± NAmGFR (mL/min/1.73m2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar)62.7 ± 19.865.8 ± 18.759.3 ± 20.385.9 ± NAPerformance metricseGFRcrBias–2.6 (–4.7 to 1.3)–7.2 (–9.6 to –3.4)2.6 (–0.6 to 4.0)21.0 (NA)P3092 (86 to 96)84 (75 to 94)98 (94 to 100)100 (NA)eGFRcysBias11.2 (9.8 to 12.9)16.6 (12.9 to 21.4)8.3 (6.8 to 10.0)–1.4 (NA)P3078 (70 to 86)61 (47 to 75)94 (87 to 100)100 (NA)eGFRcr-cysBias1.9 (0.8 to 3.5)3.5 (0.9 to 6.4)1.1 (–0.2 to 3.2)0.9 (NA)P3096 (93 to 99)94 (86 to 100)98 (94 to 100)100 (NA)Patient characteristics are presented as N (percent) or mean ± standard deviation. Performance metrics are presented with 95% confidence intervals calculated by bootstrapping with 10,000 iterations. Bias is defined as the median difference between mGFR and eGFR in units of mL/min/1.73m2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar, where negative values indicate overestimation and positive values indicate underestimation. P30 is defined as the percent of eGFR values within 30% of mGFR, where values closer to 100 indicate better performance. mGFR was determined by plasma clearance of 99mTc-DTPA with 4- or 5-point sampling. BMI, body mass index; cr, creatinine; cys, cystatin C; eGFR, estimated glomerular filtration rate; mGFR, measured glomerular filtration rate; NA, not applicable. Open table in a new tab Patient characteristics are presented as N (percent) or mean ± standard deviation. Performance metrics are presented with 95% confidence intervals calculated by bootstrapping with 10,000 iterations. Bias is defined as the median difference between mGFR and eGFR in units of mL/min/1.73m2Inker L.A. Eneanya N.D. Coresh J. et al.New Creatinine- and Cystatin C–Based Equations to Estimate GFR without Race.N Engl J Med. 2021; 385: 1737-1749https://doi.org/10.1056/NEJMoa2102953Crossref PubMed Scopus (773) Google Scholar, where negative values indicate overestimation and positive values indicate underestimation. P30 is defined as the percent of eGFR values within 30% of mGFR, where values closer to 100 indicate better performance. mGFR was determined by plasma clearance of 99mTc-DTPA with 4- or 5-point sampling. BMI, body mass index; cr, creatinine; cys, cystatin C; eGFR, estimated glomerular filtration rate; mGFR, measured glomerular filtration rate; NA, not applicable. These findings corroborate the results of Wang et al. and emphasize the potential clinical value of eGFRcr-cys. The authors note that cystatin C is already part of routine clinical practice in Sweden, and we agree that cystatin C should be routinely measured in patient populations with a high risk of eGFR discordance.
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estimated gfr,hospitalized,older adults
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