When kidneys get old: an essay on nephro-geriatrics

Glassock, Richard J.; Denic, Aleksandar; Rule, Andrew D.

doi:10.5935/0101-2800.20170010

Cited by 23 publications

(23 citation statements)

References 37 publications

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“…There is ongoing debate concerning the appropriateness of diagnosing CKD in older people with category G3a eGFR and no proteinuria [ 25 ]. In this analysis, we applied current guidelines to diagnosis of CKD in our cohort.…”

Section: Discussionmentioning

confidence: 99%

The clinical utility and cost impact of cystatin C measurement in the diagnosis and management of chronic kidney disease: A primary care cohort study

et al. 2017

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BackgroundTo reduce over-diagnosis of chronic kidney disease (CKD) resulting from the inaccuracy of creatinine-based estimates of glomerular filtration rate (GFR), UK and international guidelines recommend that cystatin-C-based estimates of GFR be used to confirm or exclude the diagnosis in people with GFR 45–59 ml/min/1.73 m2 and no albuminuria (CKD G3aA1). Whilst there is good evidence for cystatin C being a marker of GFR and risk in people with CKD, its use to define CKD in this manner has not been evaluated in primary care, the setting in which most people with GFR in this range are managed.Methods and findingsA total of 1,741 people with CKD G3a or G3b defined by 2 estimated GFR (eGFR) values more than 90 days apart were recruited to the Renal Risk in Derby study between June 2008 and March 2010. Using Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, we compared GFR estimated from creatinine (eGFRcreat), cystatin C (eGFRcys), and both (eGFRcreat-cys) at baseline and over 5 years of follow-up. We analysed the proportion of participants with CKD G3aA1 reclassified to ‘no CKD’ or more advanced CKD with the latter two equations. We further assessed the impact of using cystatin-C-based eGFR in risk prediction equations for CKD progression and all-cause mortality and investigated non-GFR determinants of eGFRcys. Finally, we estimated the cost implications of implementing National Institute for Health and Care Excellence (NICE) guidance to use eGFRcys to confirm the diagnosis in people classified as CKD G3aA1 by eGFRcreat. Mean eGFRcys was significantly lower than mean eGFRcreat (45.1 ml/min/1.73 m2, 95% CI 44.4 to 45.9, versus 53.6 ml/min/1.73 m2, 95% CI 53.0 to 54.1, P < 0.001). eGFRcys reclassified 7.7% (50 of 653) of those with CKD G3aA1 by eGFRcreat to eGFR ≥ 60 ml/min/1.73 m2. However, a much greater proportion (59.0%, 385 of 653) were classified to an eGFR category indicating more severe CKD. A similar pattern was seen using eGFRcreat-cys, but lower proportions were reclassified. Change in eGFRcreat and eGFRcys over 5 years were weakly correlated (r = 0.33, P < 0.001), but eGFRcys identified more people as having CKD progression (18.2% versus 10.5%). Multivariable analysis using eGFRcreat as an independent variable identified age, smoking status, body mass index, haemoglobin, serum uric acid, serum albumin, albuminuria, and C reactive protein as non-GFR determinants of eGFRcys. Use of eGFRcys or eGFRcreat-cys did not improve discrimination in risk prediction models for CKD progression and all-cause mortality compared to similar models with eGFRcreat. Application of the NICE guidance, which assumed cost savings, to participants with CKD G3aA1 increased the cost of monitoring by £23 per patient, which if extrapolated to be applied throughout England would increase the cost of testing and monitoring CKD by approximately £31 million per year. Limitations of this study include the lack of a measured GFR and the potential lack of ethnic diversity in the study cohort.ConclusionsImplementation ...

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Section: Discussionmentioning

confidence: 99%

The clinical utility and cost impact of cystatin C measurement in the diagnosis and management of chronic kidney disease: A primary care cohort study

et al. 2017

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“…This threshold is based on a mortality risk increase at an eGFR below 60 mL/min/1.73 m 2 , observed primarily among relatively young individuals aged 55-64 years. However, the association between mortality risk and kidney function might in part be age dependent, as demonstrated by the fact that at younger ages, even with an apparently adequate function (eGFR < 75 mL/min/1.73 m 2 , stages 2-5), mortality risk is increased [5][6][7]. Elderly individuals must have considerably more impaired function to have a similar magnitude of risk (eGFR <45 mL/min/1.73 m 2 , stages 3b-5) [8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Longitudinal Changes in Kidney Function Estimated from Cystatin C and Its Association with Mortality in Elderly Women

Malmgren

McGuigan

Christensson

et al. 2020

Nephron

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Background/Aims: Prospective data on age-related changes in kidney function are required, especially since the current Kidney Disease Improving Global Outcomes (KDIGO) definition has been suggested to classify a large number of elderly people with CKD. Objective: This study, a complement to our previous Cr-based study in the same cohort, is aimed at evaluating cystatin C (cysC)-based changes in kidney function during aging in older women and analyzing the association between CKD and mortality through 10 years of follow-up. Methods: cysC was available in 981 women from the Osteoporosis Prospective Risk Assessment (OPRA) cohort, all aged 75 years on entry. Reinvestigations were made after 5 (n = 685) and 10 years (n = 365). Kidney function was estimated (estimated glomerular filtration rate [eGFR]) using Chronic Kidney Disease Epidemiology Collaboration cysC and Caucasian, Asian, Pediatric, and Adult cysC equations and the change in function calculated. Women were staged equivalent to CKD stage 1, 2, 3a, or 3b-5 according to the KDIGO classification. Mortality risk was estimated for 5-year or 10-year follow-up time using Cox proportional hazard analyses (reference category, CKD stages 1 and 2). Results: Mortality risk for women with the worst kidney function (CKD stages 3b-5) increased during both 5-year follow-up times compared to that for women in stages 1 and 2 (age 75-80 years: adjusted Hazard Ratio [HR adj ] 3.9, 95% confidence interval [CI] 2.3-6.5; age 80-85 years: HR adj 1.7, 95% CI 1.0-2.7). In contrast, women in stage 3a had increased risk only in the first 5-year follow-up (HR adj 1.7, 95% CI 1.0-3.0, age 75-80 years). Change in kidney function amounted to a loss of 1.9 (±1.4) mL/min/1.73 m 2 per year during the 10-year follow-up, and at age 85 years, 4 of every 5 women had an eGFR equivalent to CKD. Conclusion: In the future, an ageadapted definition of CKD, lowering the threshold for CKD in the elderly, may be beneficial to avoid overdiagnosis of CKD.

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“…Their review article entitled "When kidneys get old: an essay on nephro-geriatrics", which was published in the Brazilian Journal of Nephrology (2017, 39:59-64), 1 raises an important discussion and, therefore, has great value. However, I would like to make some observations.…”

mentioning

confidence: 99%

Raised questions about the proposed adjustment in CKD classifcation in the elderly

Moura-Neto

2017

Jornal Brasileiro De Nefrologia

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When kidneys get old: an essay on nephro-geriatrics

Cited by 23 publications

References 37 publications

The clinical utility and cost impact of cystatin C measurement in the diagnosis and management of chronic kidney disease: A primary care cohort study

The clinical utility and cost impact of cystatin C measurement in the diagnosis and management of chronic kidney disease: A primary care cohort study

Longitudinal Changes in Kidney Function Estimated from Cystatin C and Its Association with Mortality in Elderly Women

Raised questions about the proposed adjustment in CKD classifcation in the elderly

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