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High Prevalence of Stage 3 Chronic Kidney Disease in Older Adults Despite Normal Serum Creatinine

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Abstract

BACKGROUND

Serum creatinine is commonly used to diagnose chronic kidney disease (CKD), but may underestimate CKD in older adults when compared with using glomerular filtration rates (eGFR). The magnitude of this underestimation is not clearly defined.

OBJECTIVE

Using the Modification of Diet in Renal Disease (MDRD) equation, to describe both the prevalence and the magnitude of underestimation of stage 3 CKD (GFR 30–59 ml/min/1.73 m2), as well as ideal serum creatinine cutoff values to diagnose stage 3 CKD among Americans ≥65 years of age.

DESIGN

Cross-sectional.

PARTICIPANTS

A total of 3,406 participants ≥65 years of age from the 1999–2004 National Health and Nutrition Examination Surveys (NHANES).

MEASUREMENTS

Serum creatinine levels were used to determine eGFR from the MDRD equation. Information on clinical conditions was self-reported.

RESULTS

Overall, 36.1% of older adults in the US have stage 3 or greater CKD as defined by eGFR values. Among older adults with stage 3 CKD, 80.6% had creatinine values ≤1.5 mg/dl, and 38.6% had creatinine values ≤1.2 mg/dl. Optimal cutoff values for serum creatinine in the diagnosis of stage 3 CKD in older adults were ≥1.3 mg/dl for men and ≥1.0 mg/dl for women, regardless of the presence or absence of hypertension, diabetes, or congestive heart failure.

CONCLUSION

Use of serum creatinine underestimates the presence of advanced (stage 3 or greater) CKD among older adults in the US. Automated eGFR reporting may improve the accuracy of risk stratification for older adults with CKD.

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References

  1. McCullough P, Wolyn R, Rocher LL, et al. Acute renal failure after coronary intervention: Incidence, risk factors, and relationship to mortality. Am J Med. 1997;103:368–375.

    Article  PubMed  CAS  Google Scholar 

  2. Mangano CM, Diamondstone LS, Ramsay JG, et al. Renal dysfunction after myocardial revascularization: Risk factors, adverse outcomes, and hospital resource utilization. The Multicenter Study of Postoperative Ischemia Group. Ann Intern Med. 1998;128:194–203.

    PubMed  CAS  Google Scholar 

  3. Rahman M, Pressel S, Davis BR, et al. Cardiovascular outcomes in high-risk hypertensive patients stratified by baseline glomerular filtration rate. Ann Intern Med. 2006;144:172–180.

    PubMed  Google Scholar 

  4. Anavekar NS, McMurray JJ, Velazquez EJ, et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med. 2004;351:1285–1295.

    Article  PubMed  CAS  Google Scholar 

  5. Smith GL, Lichtman JH, Bracken MB, et al. Renal impairment and outcomes in heart failure: systematic review and meta-analysis. J Am Coll Cardiol. 2006;47:1987–1996.

    Article  PubMed  Google Scholar 

  6. Wattanakit K, Coresh J, Muntner P, Marsh J, Folsom AR. Cardiovascular risk among adults with chronic kidney disease, with or without prior myocardial infarction. J Am Coll Cardiol. 2006;48:1183–1189.

    Article  PubMed  Google Scholar 

  7. Tonelli M, Wiebe N, Culleton B, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006;17:2034–2047.

    Article  PubMed  Google Scholar 

  8. Keith DS, Nichols GA, Gullion CM, Brown JB, Smith DH. Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization. Arch Intern Med. 2004;1646659–663.

    Article  PubMed  Google Scholar 

  9. Miller WG. Reporting estimated GFR from serum creatinine: Recommendations from the laboratory working group of the National Kidney Diabetes Education Program. Oral presentation from the 2006 annual meeting of the American Association of Clinical Chemistry. Available at: http://www.aacc.org/events/expert_access/2006/kidneydisease/Pages/default.aspx. Accessed August 1, 2008.

  10. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 2003;41:1–12.

    Article  PubMed  Google Scholar 

  11. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med. 1999;130:461–470.

    PubMed  CAS  Google Scholar 

  12. Perrone RD, Madias NE, Levey AS. Serum creatinine as an index of renal function: new insights into old concepts. Clin Chem. 1992;38:1933–1953.

    PubMed  CAS  Google Scholar 

  13. Duncan L, Heathcote J, Djurdjev O, Levin A. Screening for renal disease using serum creatinine: who are we missing? Nephrol Dial Transplant. 2001;16:1042–1046.

    Article  PubMed  CAS  Google Scholar 

  14. Swedko PJ, Clark HD, Paramsothy K, Akbari A. Serum creatinine is an inadequate screening test for renal failure in older patients. Arch Intern Med. 2003;163:356–360.

    Article  PubMed  CAS  Google Scholar 

  15. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139:137–147.

    PubMed  Google Scholar 

  16. http://www1.va.gov/kidney; United States Department of Veterans Affairs website, accessed August 1, 2008.

  17. Levey AS, Stevens LA, Hostetter T. Automatic reporting of estimated glomerular filtration rate–just what the doctor ordered. Clin Chem. 2006;52:2188–2193.

    Article  PubMed  CAS  Google Scholar 

  18. Giannelli SV, Patel KV, Windham BG, Pizzarelli F, Ferrucci L, Guralnik JM. Magnitude of underascertainment of impaired kidney function in older adults with normal serum creatinine. J Am Geriatr Soc. 2007;55:816–823.

    Article  PubMed  Google Scholar 

  19. The National Health and Nutrition Examination Survey Analytic and Reporting Guidelines. Hyattsville, MD: Centers for Disease Control and Prevention (CDC). National Center for Health Statistics (NCHS). 2004. Available at: http://www.cdc.gov/nchs/about/major/nhanes/nhanes2003–2004/analytical_guidelines.htm. Accessed August 1, 2008.

  20. Levey AS, 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.

    PubMed  CAS  Google Scholar 

  21. Coresh J, Astor BC, McQuillan G, et al. Calibration and random variation of the serum creatinine assay as critical elements of using equations to estimate glomerular filtration rate. Am J Kidney Dis. 2002;39:920–929.

    Article  PubMed  CAS  Google Scholar 

  22. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–266.

    Google Scholar 

  23. Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet. 2005;365:1500–1505.

    Article  PubMed  Google Scholar 

  24. Medical Technology Today Newsmagazine. Vol 37: American Society for Clinical Pathology; 2006:394–95.

  25. Mehran R, Aymong ED, Nikolsky E, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention. J Am Coll Cardiol. 2004;44:1393–1399.

    PubMed  Google Scholar 

  26. Lin J, Knight EL, Hogan ML, Singh AK. A comparison of prediction equations for estimating glomerular filtration rate in adults without kidney disease. J Am Soc Nephrol. 2003;14:2573–2580.

    Article  PubMed  Google Scholar 

  27. Rule AD, Larson TS, Bergstralh EJ, Slezak JM, Jacobsen SJ, Cosio FG. Using serum creatinine to estimate glomerular filtration rate: accuracy in good health and in chronic kidney disease. Ann Intern Med. 2004;141:929–937.

    PubMed  CAS  Google Scholar 

  28. Poggio ED, Wang X, Greene T, Van Lente F, Hall PM. Performance of the modification of diet in renal disease and Cockcroft-Gault equations in the estimation of GFR in health and in chronic kidney disease. J Am Soc Nephrol. 2005;16:459–466.

    Article  PubMed  Google Scholar 

  29. Verhave JC, Fesler P, Ribstein J, du Cailar G, Mimran A. Estimation of renal function in subjects with normal serum creatinine levels: influence of age and body mass index. Am J Kidney Dis. 2005;46:233–241.

    Article  PubMed  CAS  Google Scholar 

  30. Froissart M, Rossert J, Jacquot C, Paillard M, Houillier P. Predictive performance of the modification of diet in renal disease and Cockcroft-Gault equations for estimating renal function. J Am Soc Nephrol. 2005;16:763–773.

    Article  PubMed  Google Scholar 

  31. Stevens LA, Levey AS. Chronic kidney disease in the elderly–how to assess risk. N Engl J Med. 2005;352:2122–2124.

    Article  PubMed  CAS  Google Scholar 

  32. Ibrahim H, Mondress M, Tello A, et al. An alternative formula to the Cockroft-Gault and the modification of diet in renal diseases formulas in predicting GFR in individuals with type 1 diabetes. J Am Soc Nephrol. 2005;16:1051–1060.

    Article  PubMed  Google Scholar 

  33. Kasitanon N, Fine DM, Haas M, Magder LS, Petri M. Estimating renal function in lupus nephritis: comparison on the Modification of Diet in Renal Disease and Cockroft Gault equations. Lupus. 2007;16:887–895.

    Article  PubMed  CAS  Google Scholar 

  34. Rigalleau V, Lasseur C, Raffaitin C, et al. The Mayo Clinic quadratic equation improves the prediction of glomerular filtration rate in diabetic subjects. Nephrol Dial Transplant. 2007;22:813–818.

    Article  PubMed  Google Scholar 

  35. Smilde TD, van Veldhuisen DJ, Navis G, Voors AA, Hillege HL. Drawbacks and prognostic value of formulas estimating renal function in patients with chronic heart failure and systolic dysfunction. Circulation. 2006;114:1572–1580.

    Article  PubMed  Google Scholar 

  36. MacAulay J, Thompson K, Kiberd BA, Barnes DC, Peltekian KM. 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? Can J Gastroenterol. 2006;20:521–526.

    PubMed  Google Scholar 

  37. Stevens LA, Fares G, Fleming J, et al. Low rates of testing and diagnostic codes usage in a commercial clinical laboratory: evidence for lack of physician awareness of chronic kidney disease. J Am Soc Nephrol. 2005;16:2439–2448.

    Article  PubMed  Google Scholar 

  38. Akbari A, Swedko PJ, Clark HD, et al. Detection of chronic kidney disease with laboratory reporting of estimated glomerular filtration rate and an educational program. Arch Intern Med. 2004;164:1788–1792.

    Article  PubMed  Google Scholar 

  39. Coresh J, Astor BC, Greene T, Eknoyan G, Levey AS. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis. 2003;41:1–12.

    Article  PubMed  Google Scholar 

  40. Gansevoort RT, Lambers H, Witte C. Methodology of screening for albuminuria. 2007;22:2194–200.

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Acknowledgements

This publication was made possible by grant no. U54RR019234 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH). Dr. Duru received support from the UCLA Center for the Health Improvement of Minority Elders/Resource Center for Minority Aging Research, NIH/National Institute on Aging, under grant AG02004. Dr. Vargas was supported by NIH grants RR019234 and MD00148; Ms. Kermah was supported by NIH grants RR03026, RR011145, and RR014616; Dr. Norris received support from NIH grants RR011145, RR014616, RR019234, P30AG21684 and MD000182.

Drs. Norris, Nissenson and Vargas obtained funding to support this study. Drs. Duru and Norris conceived and designed the study, and Dr. Duru drafted the manuscript. Ms. Kermah conducted data analyses. All authors reviewed the manuscript critically for revision of intellectual content.

Dr. Duru had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Funding agencies were not directly involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, and approval of the manuscript.

Conflict of Interest

None of the study authors have any conflicts with for-profit companies that relate directly to this manuscript.

Dr. Nissenson has served as a consultant for Amgen, OBI, Roche, Affymax, Medgenics, Fibrogen, Prometic, Advanced Magnetics, Watson and DaVita, as well as received honoraria from Amgen, Roche and Watson. Over the past 3 years, Dr. Nissenson has also received grants from Amgen, OBI, and Roche. He owns stock in Advanced Magnetics.

Dr. Norris has served as a consultant for Abbott, Amgen, Merck and King-Monarch, received honoraria from Abbott, Amgen and Merck, and received grants from Abbott, Pfizer and King-Monarch.

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Correspondence to O. Kenrik Duru MD, MSHS.

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Duru, O.K., Vargas, R.B., Kermah, D. et al. High Prevalence of Stage 3 Chronic Kidney Disease in Older Adults Despite Normal Serum Creatinine. J GEN INTERN MED 24, 86–92 (2009). https://doi.org/10.1007/s11606-008-0850-3

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  • DOI: https://doi.org/10.1007/s11606-008-0850-3

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