Combination of pediatric and adult formulas yield valid glomerular filtration rate estimates in young adults with a history of pediatric chronic kidney disease

Abstract

As patients with chronic kidney disease (CKD) transition from pediatric nephrology care to adult care, their kidney function is clinically assessed by estimated glomerular filtration rate (eGFR) using both pediatric and adult equations, which may not be congruent. Here we evaluated commonly used eGFR equations and directly measured iohexol GFR (iGFR) among participants between ages 18 and 26 with a diagnosis of pediatric CKD in the Chronic Kidney Disease in Children (CKiD) cohort. The bedside serum creatinine (SCr)-only equation (CKiD_SCr), the SCr-only CKD-EPI (CKD-EPI_SCr), the cystatin C (Cys)-only CKD-EPI (CKD-EPI_Cys) and the combined SCr and Cys CKD-EPI (CKD-EPI_SCr-Cys) were compared with a) 279 measured iGFRs obtained from 187 participants and b) 548 eGFRs from the SCr and Cys-based CKiD equation (CKiD_SCr-Cys) obtained from 219 participants. Among emerging adults with a median iGFR of 49 ml/min/1.73m², the CKiD_SCr-Cys equation had low bias (+1.5 ml/min/1.73m²) and high correlation (0.94), while CKiD_SCr underestimated iGFR and CKiD_SCr-Cys (-5.6 and -7.4 ml/min/1.73m², respectively) and CKD-EPI_SCr had an overestimation bias (+8.2 and +6.1 ml/min/1.73m², respectively). However, the CKD-EPI_Cys and CKD-EPI_SCr-Cys exhibited strong agreement with both iGFR and CKiD_SCr-Cys. GFR may also be validly estimated in this population by taking the simple average of CKiD_SCr and CKD-EPI_SCr (average bias +1.3 compared to iGFR and -0.6 compared to CKiD_SCr-Cys). Clinicians should be aware that individually the pediatric and adult SCr-based estimates of GFR had large discrepancies among emerging adults with pediatric CKD. Thus, when cystatin C is not available, we recommend the average of pediatric and adult SCr-based eGFR as a valid tool for clinical use.

Keywords: chronic kidney disease; clinical nephrology; glomerular filtration rate; pediatric nephrology; young adults.

Figure 1

Agreement plot of CKiD eGFR based on serum creatinine and cystatin C (CKiDSCr-Cys) and directly measured iohexol GFR (iGFR) in the log scale among 279 person-visits from 187 young adults with a history of pediatric chronic kidney disease. The bolded grey line is a non-parametric spline based on 95% of the data; the ellipse region depicts the 90% confidence region of the data based on a bivariate normal distribution.

Figure 2

Agreement plot of the average of CKiD eGFR and CKD-EPI eGFR based on serum creatinine-only (CKiD_SCr and CKD-EPI_SCr eGFR) and directly measured iohexol GFR (iGFR) in the log scale among 279 person-visits from 187 young adults with a history of pediatric CKD. The bolded grey line is a nonparametric spline based on 95% of the data; the ellipse region depicts the 90% confidence region of the data based on a bivariate normal distribution.

Figure 3

Agreement plot of the average of CKiD eGFR and CKD-EPI eGFR based on serum creatinine-only (CKiD_SCr and CKD-EPI_SCr eGFR) and CKiDSCr-Cys in the log scale among 548 person-visits from 219 young adults with a history of pediatric CKD. The bolded grey line is a non-parametric spline based on 95% of the data; the ellipse region depicts the 90% confidence region of the data based on a bivariate normal distribution.