Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low.
BACKGROUND
UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).


METHODS
Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).


RESULTS
Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.


CONCLUSIONS
The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.
Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, DG1 4AP, UK. alison.almond@nhs.net
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A
Almond
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Siddiqui
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Robertson
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Norrie
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C
Isles
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003404:Creatinine / Q000378:metabolism*; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000503:physiopathology* / Q000628:therapy; D007677:Kidney Function Tests / Q000379:methods; D008297:Male; D008875:Middle Aged; D009752:Nutritional Status / Q000502:physiology*; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D012372:ROC Curve; D006435:Renal Dialysis / Q000295:instrumentation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013997:Time Factors; D014508:Urea / Q000378:metabolism*
D014508:Urea; D003404:Creatinine