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    1 Comment for this article
    Why not just do a real creatinine clearance test?
    Gordon Banks |
    Most patients are capable of collecting a 24 hour urine. Wouldn’t doing this settle the question of whether they really have kidney disease rather than relying on inaccurate formulae?
    Original Investigation
    April 29, 2019

    Diagnostic Performance of Creatinine-Based Equations for Estimating Glomerular Filtration Rate in Adults 65 Years and Older

    Author Affiliations
    • 1Service de Néphrologie, Dialyse, Hypertension et Exploration Fonctionnelle Rénale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
    • 2Programa de Pós-graduação em Ciências da Saúde Universidade de Caxias do Sul, Caxias do Sul, Brazil
    • 3CAPES Foundation, Ministry of Education of Brazil, Brasilia
    • 4Núcleo de Apoio à Pesquisa–COEDI, Hospital Geral de Caxias do Sul, Caxias do Sul, Brasil
    • 5Université Claude Bernard Lyon 1, Lyon, France
    • 6Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
    • 7CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne, France
    • 8Laboratoire CarMeN, Institution National de la Santé et de la Recherche Médicale 1060Université Lyon 1, Lyon, France
    • 9Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique (UMR 5305 CNRS/Université Claude Bernard, Lyon 1), Lyon, France
    JAMA Intern Med. 2019;179(6):796-804. doi:10.1001/jamainternmed.2019.0223
    Key Points

    Question  Are there differences in performance between equations that estimate glomerular filtration rate in adults 65 years and older?

    Findings  This single-center, cross-sectional study included 2247 French adults aged 65 to 90 years and older at a single referral center. When comparing 4 plasma creatinine–based glomerular filtration rate–estimating equations (Chronic Kidney Disease–Epidemiology Collaboration, Lund-Malmö Revised, full age spectrum, and Berlin Initiative Study) with the reference inulin-measuring method, there were no clinically significant differences in terms of bias, precision, or accuracy.

    Meaning  There do not appear to be performance advantages for the use of any of these equations in persons 65 years and older.


    Importance  Estimating glomerular filtration rate (GFR) is useful in many clinical conditions. However, very few studies have evaluated the performance of GFR-estimating equations in older adults at various degrees of kidney impairment.

    Objective  To determine the performance of plasma-creatinine-based equations Chronic Kidney Disease–Epidemiology Collaboration (CKD-EPI), Lund-Malmö Revised, (LMR), full age spectrum (FAS), and Berlin Initiative Study (BIS) 1 in older adults across a broad spectrum of GFRs.

    Design, Setting, and Participants  Single-center cross-sectional study performed in France including 2247 participants aged 65 to 90 years who underwent inulin GFR measurements from July 1, 2003, to July 30, 2017, for suspected or established renal dysfunction, for renal risk, before kidney donation, or after kidney transplant.

    Main Outcomes and Measures  The main outcome measure was GRF measured by inulin clearance. Equation performance criteria considered bias (difference between estimated and measured GFR), precision (interquartile range of the median difference), and accuracy P30 (percentage of estimated GFRs lying between [measured GFR – 30% of measured GFR] and [measured GFR + 30% of measured GFR]).

    Results  The mean (SD) age of the 2247 participants was 71.5 (5) years and 1192 (53.0%) were male. The difference in median (95% CI) bias was significant between CKD-EPI vs LMR (−4.0 [–4.0 to –3.5 mL/min/1.73 m2; P < .001]) and CKD-EPI vs FAS (–2.0 [–3.5 to –2.5] mL/min/1.73 m2, P < .001) but not significant between CKD-EPI vs BIS 1 (0.0 [–1.5 to 0.5], P = .07, Mood test). In patients aged 65 to 74 years with measured GFR<45 mL/min/1.73 m2, the difference in median P30 (95% CI) was not significant between CKD-EPI vs LMR (P = .08) and CKD-EPI vs FAS (P = .48) but significant vs BIS 1 (P = .004, McNemar test). In subjects 75 years and older, with measured GFR less than 45 mL/min/1.73 m2, LMR and BIS 1 were more accurate than CKD-EPI and FAS (P30 = 74.5 [70.0-79.5] and 73.0 [68.0-78.0] vs 69.0 [64.5-74.0] and 69.0 [65.5-72.0]). In all patients, despite small statistical differences, the performance of CKD-EPI equation was not clinically different from that of LMR, FAS, or BIS 1.

    Conclusions and Relevance  In a referral group of patients 65 years and older who had GFR estimated using CDK-EPI, LMR, BIS 1, and FAS equations, a comparison with renal inulin clearance found that none of the equations had a superior diagnostic performance. Each had limitations regarding accuracy.