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The importance of standardization of creatinine in the implementation of guidelines and recommendations for CKD:
Wim Van Biesen1, Raymond Vanholder, Nic Veys
1Department of Internal Medicine, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium. wim.vanbiesen@ugent.be
Insights
Implementing current chronic kidney disease (CKD) referral guidelines would overwhelm nephrology services. Differences in creatinine assays lead to varied GFR estimates, impacting CKD classification and patient management. Standardization is crucial.
Area of Science:
- Nephrology
- Clinical Chemistry
- Public Health
Background:
- Current guidelines recommend nephrologist referral for chronic kidney disease (CKD) patients with estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73 m2, and mandatory referral below 30 ml/min/1.73 m2.
- The abbreviated Modification of Diet in Renal Disease (MDRD) equation is commonly used for eGFR estimation, but its accuracy is affected by creatinine assay methodology.
- The impact of these guidelines on nephrology practice and the reliability of routine eGFR estimations have not been adequately evaluated.
Purpose of the Study:
- To assess the prevalence of CKD in a defined population.
- To simulate the impact of 100% guideline implementation on nephrology workload.
- To evaluate the validity of routinely provided eGFR using the abbreviated MDRD formula.
Main Methods:
- Serum creatinine values from hospital and private laboratories were collected for one week.
- Lowest creatinine values were retained for patients with multiple determinations; those already known to nephrology were excluded.
- eGFR was calculated using the abbreviated MDRD formula with reported creatinine values and after correction to an MDRD-standard.
Main Results:
- Over 20,000 patients had serum creatinine measured; significant percentages of males and females were classified as CKD stage 3, 4, or 5.
- eGFR classifications varied substantially based on different creatinine correction formulas.
- Full guideline implementation could necessitate referral of 4100-15360 CKD stage 3 and 1650-2400 CKD stage 4 patients per 100,000 inhabitants.
Conclusions:
- Implementing current CKD referral guidelines would likely overload nephrology services.
- Discrepancies in eGFR estimations due to creatinine assay variability lead to significant CKD classification differences.
- Standardization of serum creatinine assays is essential before routine implementation of eGFR-based CKD guidelines.
Background:
In an attempt to reduce late referral and to improve the care of patients with chronic kidney disease (CKD), different organizations have issued guidelines on when to refer patients to the nephrologist. Most suggest referral of patients with a GFR below 60 ml/min/1.73 m2, and demand referral if the GFR is below 30 ml/min/1.73 m2. It is recommended to use the abbreviated MDRD equation to estimate GFR. This formula is, however, sensitive to the creatinine assay methodology. In addition, the impact of the implementation of such guidelines on the nephrology practice has never been evaluated. This study (i) identifies the true burden of CKD in a population and simulates the effects of a 100% implementation of the guidelines on the nephrology work load, and (ii) evaluates the validity of the estimated GFR using the abbreviated MDRD formula when routinely provided.
Methods:
Different laboratories (both hospital and private) in our region were asked to report on all the serum creatinine values performed during the first week of December 2004. If patients had more than one determination, only the lowest serum creatinine value was retained. Patients already known to a nephrology unit were not included. GFR was calculated using the abbreviated MDRD, using the serum creatinine as reported by these laboratories, or after correction to the MDRD-standard using different published equations.
Results:
20,108 patients, with a mean age of 53.4+/-16.2 years, 48% females, had at least one serum creatinine determination in the observation period. According to the K/DOQI CKD classification, 20.2, 1.6 and 0.8% of females and 13.3, 1.6 and 0.6% of males were in stage 3, 4 and 5, respectively, when the abbreviated MDRD formula was used with the serum creatinine value as reported by the laboratories. Important differences in classifications were obtained when the different correction formulae for creatinine were applied. According to the current recommendations, this would lead to a mandatory referral of 1650-2400 CKD stage 4 patients per 100 000 inhabitants and a suggested referral of another 4100-15 360 CKD stage 3 patients per 100,000 inhabitants to a nephrology unit.
Conclusion:
Implementation of the current guidelines for referral of CKD patients to nephrologists would lead to an overload of the nephrology care capacities. Large differences in estimated GFRs with different corrections for serum creatinine are observed, resulting in important CKD classification differences. Standardization of serum creatinine assays is mandatory before guidelines, and especially the routine provision of the estimated GFR by the abbreviated MDRD formula, can be implemented in clinical practice.
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