Estimated GFR in Diabetes

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Presentation transcript:

Estimated GFR in Diabetes Baskar V, Holland MR, Singh BM

Introduction Diabetic nephropathy triad Abnormal serum creatinine Albuminuria rise BP rise GFR fall Abnormal serum creatinine Relative late stage in natural history Strategies to identify individuals at risk Dipstick proteinuria Microalbuminuria BP

Introduction Diabetic nephropathy Abnormal serum creatinine Albuminuria rise BP rise GFR fall Abnormal serum creatinine Relative late stage in natural history Strategies to identify individuals at risk Dipstick proteinuria Microalbuminuria BP

MA based strategies - pitfalls Uncertain predictive value 20-30% progression (cf. 85-100% in 1980’s) Other causes of albuminuria Non-albuminuric renal impairment Non-diabetic renal disease in diabetes ≈ 25% proven DN & normoalbuminuria

GFR True GFR measurements unsuitable for mass screening Estimated GFR (eGFR) From serum creatinine, age, gender, ethnicity… Reliable indicators of renal reserve Supported by organisations National Kidney Foundation Renal NSF ADA (DUK, ABCD)

CKD staging

CKD staging eGFR equation – C&G or MDRD

Aims To evaluate renal disease burden in diabetes using eGFR – either by C&G or MDRD estimate To study the clinical utility of eGFR (over and above current markers)

Methods Study design Study period MA screening cross sectional from district diabetes register Study period Jan 2002 to June 2003 MA screening spot morning urine ACR (3.5mg/mmol threshold) SPSS 11.5 for statistical analysis

eGFR equations MDRD Cockcroft’s and Gault’s equation 186 x [Serum Cr (μmol/l)/88.4]-1.154 x [Age]-0.203 x [0.742 if female] x [1.210 if Black] Cockcroft’s and Gault’s equation (140 - age in years) x body weight (kg) x K Serum creatinine (μmol/l) K = 1.23 for men or 1.04 for women Correction for BSA of 1.73m2

Whites/Asians/AfroCarib Results Total N = 4548; N with eGFR = 4173 Age 60+14y Duration 12+9y BMI 31+6Kg/m2 Males 57% Type 2 DM 78% Whites/Asians/AfroCarib 68%/23%/9% Serum Creatinine 101+44µmol/l Urine ACR 1.75mg/mmol

Frequency distribution

C&G and MDRD correlation >90, 60-90, 30-60 & <30 C&G 25%, 46%, 27% & 2% MDRD 9%, 62%, 27% & 2%

Concordance & Discordance C&G >90 C&G 90-60 C&G 60-30 C&G <30 Total MDRD >90 316 (87%) 49 (13%) (0%) 0 (0%) 365 MDRD 90-60 722 (28%) 1557 (61%) 295 (11%) 2574 MDRD 60-30 10 (1%) 315 (28%) 795 (70%) 22 (2%) 1142 MDRD <30 33 (36%) 59 (64%) 92

Concordance & Discordance C&G >90 C&G 90-60 C&G 60-30 C&G <30 Total MDRD >90 316 (87%) 49 (13%) (0%) 0 (0%) 365 MDRD 90-60 722 (28%) 1557 (61%) 295 (11%) 2574 MDRD 60-30 10 (1%) 315 (28%) 795 (70%) 22 (2%) 1142 MDRD <30 33 (36%) 59 (64%) 92 65% Green

Concordance & Discordance C&G >90 C&G 90-60 C&G 60-30 C&G <30 Total MDRD >90 316 (87%) 49 (13%) (0%) 0 (0%) 365 MDRD 90-60 722 (28%) 1557 (61%) 295 (11%) 2574 MDRD 60-30 10 (1%) 315 (28%) 795 (70%) 22 (2%) 1142 MDRD <30 33 (36%) 59 (64%) 92 65% Green; 20% Amber

Concordance & Discordance C&G >90 C&G 90-60 C&G 60-30 C&G <30 Total MDRD >90 316 (87%) 49 (13%) (0%) 0 (0%) 365 MDRD 90-60 722 (28%) 1557 (61%) 295 (11%) 2574 MDRD 60-30 10 (1%) 315 (28%) 795 (70%) 22 (2%) 1142 MDRD <30 33 (36%) 59 (64%) 92 65% Green; 20% Amber & 15% Red

Renal risk markers in those with serious discordance C&G<60 MDRD>60 N=295 MDRD<60 C&G>60 N=325 Abnormal serum Creatinine 28 (10%) 51 (16%) Abnormal urine ACR 90 (31%) 112 (35%) Abnormal creatinine or ACR 107 (36%) 136 (42%)

Study summary Renal disease burden was different depending on the eGFR equation used Full concordance observed in 65% Serious discordance in 15% The majority with serious discordance had normal levels of other renal markers Relying entirely on eGFR to flag their risk

Discussion What does low eGFR really mean?

eGFR, RRT & Mortality Keith et al, Arch Intern Med 2004

eGFR, mortality & CVS events Go et al, NEJM, 2004

Discussion – role of eGFR Renal progression indicator Predictor of mortality & CVS events Role in predicting safety of Metformin? Early and inexpensive identification of risk individuals No data to support intervention solely based on eGFR Lack of standardization of creatinine across labs Validation in diabetes lacking Exaggerates risk in the very old?

Conclusion eGFR may have an additional role in renal and vascular risk prediction Need for a single equation of choice Clarity Uniformity of practice