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American Journal of Kidney Diseases

Clinical Risk Implications of the CKD Epidemiology Collaboration (CKD-EPI) Equation Compared With the Modification of Diet in Renal Disease (MDRD) Study Equation for Estimated GFR

      Background

      The CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) creatinine-based equation for estimated glomerular filtration rate (eGFR) is more accurate than the MDRD (Modification of Diet in Renal Disease) Study equation. However, it has not been determined whether the improvement in risk categorization applies to all segments of the population.

      Study Design

      Population-based cohort study.

      Setting & Participants

      Adults (aged ≥18 years) who did not have kidney failure at baseline and had at least one serum creatinine measurement and dipstick proteinuria evaluation in a province-wide laboratory registry from Alberta, Canada, in 2002-2007 (N = 1,010,988).

      Predictor

      eGFR categories of ≥90, 60-89, 45-59, 30-44, and 15-29 mL/min/1.73 m2.

      Outcomes

      All-cause mortality, acute myocardial infarction, end-stage renal disease, and doubling of serum creatinine level.

      Measurements

      GFR was estimated by the CKD-EPI and MDRD Study equations.

      Results

      The CKD-EPI equation reclassified 22.6% and 1.2% of participants to a higher and lower eGFR category, respectively, and decreased the prevalence of CKD stages 3 and 4 from 9.2% to 7.3%. Of 70,071 participants with eGFRMDRD of 45-59 mL/min/1.73 m2, 30.8% were reclassified to eGFRCKD-EPI of 60-89 mL/min/1.73 m2, and after adjusting for potential confounders, participants reclassified had a lower risk of all-cause mortality (incidence rate ratio [IRR], 0.77; 95% CI, 0.69-0.86), acute myocardial infarction (IRR, 0.73; 95% CI, 0.60-0.88), end-stage renal disease (IRR, 0.55; 95% CI, 0.32-0.94), and doubling of creatinine level (IRR, 0.78; 95% CI, 0.59-1.04) compared with those not reclassified. Similar findings were observed for those reclassified to a higher eGFR category from other eGFRMDRD categories. Net reclassification improvements based on eGFR categories were positive for all outcomes (range, 0.146-0.256; all P < 0.001).

      Limitations

      Relatively short follow-up (median, 2.8 years), lack of data for some potential confounders (eg, smoking), and mainly white participants.

      Conclusions

      These results suggest that the CKD-EPI equation more accurately categorizes individuals regarding clinical risk than the MDRD Study equation.

      Index Words

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      References

        • Crowe E.
        • Halpin D.
        • Stevens P.
        • Guideline Development Group
        Early identification and management of chronic kidney disease: summary of NICE guidance.
        BMJ. 2008; 337: a1530
        • National Kidney Foundation
        K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: evaluation, classification, and stratification.
        Am J Kidney Dis. 2002; 39: S1-S266
        • Levey A.S.
        • Bosch J.P.
        • Lewis J.B.
        • Greene T.
        • Rogers N.
        • Roth D.
        A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation.
        Ann Intern Med. 1999; 130: 461-470
        • Levey A.S.
        • Coresh J.
        • Greene T.
        • et al.
        Using standardized serum creatinine values in the Modification of Diet in Renal Disease Study equation for estimating glomerular filtration rate.
        Ann Intern Med. 2006; 145: 247-254
        • Rule A.D.
        • Gussak H.M.
        • Pond G.R.
        • et al.
        Measured and estimated GFR in healthy potential kidney donors.
        Am J Kidney Dis. 2004; 43: 112-119
        • Rule A.D.
        • Larson T.S.
        • Bergstralh E.J.
        • Slezak J.M.
        • Jacobsen S.J.
        • Cosio F.G.
        Using serum creatinine to estimate glomerular filtration rate: accuracy in good health and in chronic kidney disease.
        Ann Intern Med. 2004; 141: 929-937
        • Stevens L.A.
        • Coresh J.
        • Greene T.
        • Levey A.S.
        Assessing kidney function—measured and estimated glomerular filtration rate.
        N Engl J Med. 2006; 354: 2473-2483
        • Stevens L.A.
        • Coresh J.
        • Feldman H.I.
        • et al.
        Evaluation of the Modification of Diet in Renal Disease Study equation in a large diverse population.
        J Am Soc Nephrol. 2007; 18: 2749-2757
        • Levey A.S.
        • Stevens L.A.
        • Schmid C.H.
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Matsushita K.
        • Selvin E.
        • Bash L.D.
        • Astor B.C.
        • Coresh J.
        Risk implications of the new CKD-EPI equation as compared to the MDRD study equation for estimated glomerular filtration rate: the Atherosclerosis Risk in Communities (ARIC) Study.
        Am J Kidney Dis. 2010; 55: 648-659
        • White S.L.
        • Polkinghorne K.R.
        • Atkins R.C.
        • Chadban S.J.
        Comparison of the prevalence and mortality risk of CKD in Australia using the CKD Epidemiology Collaboration (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) Study GFR estimating equations: The AusDiab (Australian Diabetes, Obesity and Lifestyle) Study.
        Am J Kidney Dis. 2010; 55: 660-670
        • Matsushita K.
        • van der Velde M.
        • Astor B.C.
        • et al.
        Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis.
        Lancet. 2010; 375: 2073-2081
        • Hemmelgarn B.R.
        • Clement F.
        • Manns B.J.
        • et al.
        Overview of the Alberta Kidney Disease Network.
        BMC Nephrol. 2009; 10: 30
        • Hemmelgarn B.R.
        • Manns B.J.
        • Lloyd A.
        • et al.
        • Alberta Kidney Disease Network
        Relation between kidney function, proteinuria, and adverse outcomes.
        JAMA. 2010; 303: 423-429
        • Sin D.D.
        • Svenson L.W.
        • Cowie R.L.
        • Man S.F.
        Can universal access to health care eliminate health inequities between children of poor and nonpoor families?.
        Chest. 2003; 124: 51-56
        • Hux J.E.
        • Ivis F.
        • Flintoft V.
        • Bica A.
        Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.
        Diabetes Care. 2002; 25: 512-516
        • Quan H.
        • Khan N.
        • Hemmelgarn B.R.
        • et al.
        Validation of a case definition to define hypertension using administrative data.
        Hypertension. 2009; 54: 1423-1428
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • Austin P.C.
        • Daly P.A.
        • Tu J.V.
        A multicenter study of the coding accuracy of hospital discharge administrative data for patients admitted to cardiac care units in Ontario.
        Am Heart J. 2002; 144: 290-296
        • Manns B.J.
        • Mortis G.P.
        • Taub K.J.
        • McLaughlin K.
        • Donaldson C.
        • Ghali W.A.
        The Southern Alberta Renal Program Database: a prototype for patient management and research initiatives.
        Clin Invest Med. 2001; 24: 164-170
        • Tonelli M.
        • Klarenbach S.W.
        • Lloyd A.M.
        • et al.
        Higher estimated glomerular filtration rates may be associated with increased risk of adverse outcomes, especially with concomitant proteinuria.
        Kidney Int. 2011; 80: 1306-1314
        • Pencina M.J.
        • D'Agostino Sr, R.B.
        • D'Agostino Jr, R.B.
        • Vasan R.S.
        Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
        Stat Med. 2008; 27: 157-172
        • Stevens L.A.
        • Li S.
        • Kurella Tamura M.
        • et al.
        Comparison of the CKD Epidemiology Collaboration (CKD-EPi) and Modification of Diet in Renal Disease (MDRD) Study equations: risk factors for and complications of CKD and mortality in the Kidney Early Evaluation Program (KEEP).
        Am J Kidney Dis. 2011; 57: S9-S16
        • Shlipak M.G.
        • Praught M.L.
        • Sarnak M.J.
        Update on cystatin C: new insights into the importance of mild kidney dysfunction.
        Curr Opin Nephrol Hypertens. 2006; 15: 270-275
        • Astor B.C.
        • Levey A.S.
        • Stevens L.A.
        • Van Lente F.
        • Selvin E.
        • Coresh J.
        Method of glomerular filtration rate estimation affects prediction of mortality risk.
        J Am Soc Nephrol. 2009; 20: 2214-2222