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. 2006 Aug;20(8):521-6.
doi: 10.1155/2006/858053.

Serum creatinine in patients with advanced liver disease is of limited value for identification of moderate renal dysfunction: are the equations for estimating renal function better?

Jillian MacAulay  1 , Kara Thompson, Bryce A Kiberd, David C Barnes, Kevork M Peltekian
Affiliations

Serum creatinine in patients with advanced liver disease is of limited value for identification of moderate renal dysfunction: are the equations for estimating renal function better?

Jillian MacAulay et al. Can J Gastroenterol. 2006 Aug.

Abstract
in English, French

Background: The Cockcroft-Gault formula (CGF) is used to estimate the glomerular filtration rate (GFR) based on serum creatinine (Cr) levels, age and sex. A new formula developed by the Modification of Diet in Renal Disease (MDRD) Study Group, based on the patient's Cr levels, age, sex, race and serum urea nitrogen and serum albumin levels, has shown to be more accurate. However, the best formula to identify patients with advanced liver disease (ALD) and moderate renal dysfunction (GFR 60 mL/min/1.73 m2 or less) is not known. The aim of the present study was to compare calculations of GFR, using published formulas (excluding those requiring urine collections) with standard radionuclide measurement of GFR in patients with ALD.

Methods: Fifty-seven consecutive subjects (40% women) with a mean age of 50 years (range 16 to 67 years) underwent 99m-technetium-diethylenetriamine pentaacetic acid (99mTc-DTPA) (single injection) radionuclide measurement of GFR. To calculate GFR, three formulas were used: the reciprocal of Cr multiplied by 100 (100/Cr), the CGF and the MDRD formulas. Pearson's correlation coefficient (r) and Bland-Altman analyses of agreement were used to analyze the association between 99mTc-DTPA clearance and the three equations for GFR.

Results: The mean 99mTc-DTPA clearance was 83 mL/min/1.73 m2 (range 28 mL/min/1.73 m2 to 173 mL/min/1.73 m2). Mean calculated GFRs by 100/Cr, the CGF and the MDRD formula were 106 mL/min/1.73 m2, 98 mL/min/1.73 m2 and 86 mL/min/1.73 m2, respectively. Regression analysis showed good correlation between radionuclide GFR and calculated GFR with r(100/Cr)=0.74, r(CGF)=0.80, r(MDRD)=0.87, all at P > or = 0.0001. The MDRD formula provided the least bias. The Bland-Altman plot showed best agreement between GFR calculated by the MDRD formula and 99mTc-DTPA clearance, with only 3 mL/min/1.73 m2 overestimation. There was higher variability between radionuclide GFR and calculated GFR by the CGF and by 100/Cr. Although there was no difference in precision, GFR calculated by the MDRD formula had the best overall accuracy. The sensitivity and specificity for detection of moderate renal dysfunction by the MDRD formulas were 73% and 87%, respectively.

Conclusions: Among the Cr-based GFR formulas, the MDRD formula showed a larger proportion of agreement with radionuclide GFR in patients with ALD. In clinical practice, the MDRD is the best formula for detection of moderate renal dysfunction among those with ALD.

HISTORIQUE :: La formule de Cockcroft-Gault (FCG) sert à évaluer le taux de filtration glomérulaire (TFG) d’après les taux de créatinine (Cr) sérique, l’âge et le sexe. Une nouvelle formule, mise au point par le groupe d’étude sur la modification du régime en cas de maladie rénale (MRMR), fondée sur le taux de Cr, l’âge, le sexe, la race et les taux d’azote uréique sérique et d’albumine sérique du patient, s’est révélée plus exacte. Cependant, on ne connaît pas la meilleure formule pour repérer les patients atteints d’une maladie hépatique avancée (MHA) et d’une dysfonction rénale modérée (TFG 60 mL/min/1,73 m2). La présente étude visait à comparer les calculs de TFG au moyen des formules publiées (à l’exception de celles exigeant un prélèvement d’urine) à la mesure radionucléide normalisée du TFG chez les patients atteints d’une MHA.

MÉTHODOLOGIE :: Cinquante-sept sujets consécutifs (40 % de femmes) d’un âge moyen de 50 ans (fourchette de 16 à 67 ans) ont subi une mesure radionucléide du TGF au technétium 99m d’acide diéthylène triamino-pentaacétique (99mTc DTPA) (une seule injection). Pour calculer le TFG, trois formules ont été utilisées, soit la réciproque de la Cr multipliée par 100 (100/Cr), la FCG et la formule MRMR. Le coefficient de corrélation de Pearson (r) et les analyses de concordance de Bland-Altman ont été utilisés pour analyser le lien entre la clairance du 99mTc DTPA et les trois équations du TGF.

RÉSULTATS :: La clairance moyenne de 99mTc DTPA était de 83/mL/min/1,73 m2 (fourchette de 28/mL/min/1,73 m2 à 173/mL/min/1,73 m2). Le TFG moyen calculé par 100/Cr, la FCG et la formule MRMR étaient de 106 mL/min/1,73 m2, de 98 mL/min/1,73 m2 et de 86 mL/min/1,73 m2, respectivement. L’analyse de régression a démontré une bonne corrélation entre le TFG radionucléide et le TFG calculé par r(100/Cr)=0,74, r(FCG)=0,80, r(MRMR)=0,87, tous à P≤0,0001. La formule MRMR était la moins biaisée. La courbe de Bland-Altman révélait la meilleure concordance entre le TFG calculé par la formule MRMR et la clairance 99mTc DTPA, avec une surestimation de seulement 3 mL/min/1,73 m2. On constatait une plus grande variabilité entre le TFG radionucléide et le TFG calculé par la FCG et le 100/Cr. Même s’il n’y avait aucune différence de précision, le TFG calculé par la formule MRMR était la plus précise. La sensibilité et la spécificité de détection d’une dysfonction rénale modérée par la formule MRMR étaient de 73 % et de 87 %, respectivement.

CONCLUSIONS :: Parmi les formules pour calculer le TFG fondées sur la Cr, la formule MRMR démontrait la meilleure concordance avec le TFG radionucléide chez les patients atteints d’une MHA. En pratique clinique, la formule MRMR est la meilleure pour déceler une dysfonction rénale modérée chez les personnes atteintes d’une MHA.

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Figures

Figure 1)
Figure 1)
Relationship of glomerular filtration rate (GFR) measured by 99m-technetium-diethylenetriamine pentaacetic acid clearance to GFR estimation using 100/creatinine (Cr), the Cockcroft-Gault formula (CGF) and the Modification of Diet in Renal Disease (MDRD) formula. The lines represent the regression line of best fit with Pearson’s correlation coefficient r(100/Cr)=0.74, r(CGF)=0.80 and r(MDRD)=0.87, P≤0.0001
Figure 2)
Figure 2)
Accuracy of different creatinine (Cr)-based glomerular filtration rate (GFR) calculations expressed as the percentage of estimates with 10%, 30% and 50% of the reference GFR as measured by 99m-technetium-diethylenetriamine pentaacetic acid clearance. The highest accuracy within 10% was found for the Modification of Diet in Renal Disease (MDRD) formula at 26%. CGF Cockcroft-Gault formula
Figure 3)
Figure 3)
Bland-Altman comparison plots, which measure the agreement between glomerular filtration rate (GFR) measured by 99m-technetium-diethylenetriamine pentaacetic acid clearance, and A 100/creatinine (Cr), B the Cockcroft-Gault formula (CGF) and the C Modification of Diet in Renal Disease (MDRD) formula. The mean difference is indicated by the centre line; 95% limits of agreement are indicated by the upper and lower lines. The MDRD formula shows the highest level of agreement with 99m-technetium-diethylenetriamine pentaacetic acid clearance, overestimating renal function by 3 mL/min/1.73 m2 (P=0.414), while the CGF and 100/Cr overestimated renal function with significant difference (P<0.001)
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