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Does a standardization of GFR estimation increase the accuracy of cardiovascular risk assessment?

Journal of Human Hypertension volume 25, pages 467–468 (2011)Cite this article

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Thorough detection of risk factors is a crucial prerequisite for efficient prevention strategies of arterial hypertension. Impairment of renal function is one of these risk factors. Several trials have consistently shown that the estimated glomerular filtration rate (eGFR) is highly associated with the prevalence of hypertension.1, 2 Individuals with eGFR ⩽60 ml min−1 run a significantly higher risk of being hypertensive than those with normal eGFR. Moreover, eGFR is inversely correlated with arterial stiffness and cardiovascular mortality.3, 4, 5, 6, 7 In all these reports, eGFR was calculated by using the Modification of Diet in Renal Disease (MDRD) formula.8, 9 The accuracy of serum creatinine, however, may differ depending on the various measurement assays. Therefore, the National Kidney Disease Education Program (NKDEP) has initiated a serum creatinine standardization programme aiming at a uniform reference method for creatinine assessment in all laboratories.10, 11 To date, the clinical benefit of this standardization procedure remains elusive. Is this standardization procedure ‘epidemiological nitpicking’ or does it indeed reveal further insight into the cardiovascular risk of a subject? In the present issue of the Journal of Human Hypertension Liu et al. shed some light on this important question.12

The authors examine the association of regular vs standardized eGFR with hypertension. They utilize the NHANES database to provide data of >20 000 subjects. Standardized eGFR was derived from standardized serum creatinine, age, gender and race according to the NKDEP study formula re-expressed in 2005.10 Non-standardized eGFR was calculated by using the MDRD equation derived in 1999 using non-standardized creatinine.8 Liu et al.12 found the same qualitative association of standardized eGFR with hypertension as former studies using the MDRD formula and non-standardized serum creatinine values: Standardized eGFR was highly associated with the prevalence of hypertension and subjects with a standardized eGFR ⩽60 ml min−1 had a significantly higher chance of being hypertensive than those with eGFR >60 ml min−1. Interestingly, compared with non-standardized eGFR, the participants were significantly more often claimed to have low eGFR (eGFR⩽60 ml min−1) when using standardized eGFR. If standardized eGFR indeed provided a more accurate measure of renal function, one might intuitively expect a higher rate of hypertensives in the group of subjects with standardized eGFR ⩽60 ml min−1 compared with the assignment by regular eGFR. In fact, however, the prevalence of hypertension under standardized eGFR was not significantly different from that under non-standardized eGFR in both groups of participants. How to explain this dilemma? The NKDEP claim that standardized eGFR represents the true glomerular filtration rate (GFR) more accurately than regular eGFR. The most probable reason is that subjects with an eGFR close to the cut-off value of 60 ml min−1 were more frequently assigned to >60 ml min−1 using regular GFR assessment and <60 ml min−1 using standardized assessment. This assignment led to a significant difference in the number of subjects in the two groups. The difference in the prevalence of hypertension between participants with values slightly lower or higher than 60 ml min−1, however, was too low to evoke a significant difference in the prevalence between the two groups. Therefore, standardized eGFR failed to increase the ‘sensitivity’ to predict hypertension. Interestingly, the difference in assignment rates decreased continuously in the observation period. Whereas the proportion of subjects with an eGFR <60 ml min−1 was 2.5% by regular assessment and 7.6% by standardized assessment in 1999–2000, the rates were quite similar in 2005–2006 (7.3 vs 7.8%). Thus, it may be speculated that serum creatinine assays have gained accuracy in the course of time, leading to a lower inter-assay variation.

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References

  1. Mokwe E, Ohmit SE, Nasser SA, Shafi T, Saunders E, Crook E et al. Determinants of blood pressure response to quinapril in black and white hypertensive patients: the Quinapril Titration Interval Management Evaluation trial. Hypertension 2004; 43 (6): 1202–1207.

    Article  CAS  Google Scholar 

  2. Flack JM, Duncan K, Ohmit SE, Quah R, Liu X, Ramappa P et al. Influence of albuminuria and glomerular filtration rate on blood pressure response to antihypertensive drug therapy. Vasc Health Risk Manag 2007; 3 (6): 1029–1037.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. Kawamoto R, Kohara K, Tabara Y, Miki T, Ohtsuka N, Kusunoki T et al. An association between decreased estimated glomerular filtration rate and arterial stiffness. Intern Med 2008; 47 (7): 593–598.

    Article  Google Scholar 

  4. Kubozono T, Miyata M, Ueyama K, Nagaki A, Hamasaki S, Kusano K et al. Association between arterial stiffness and estimated glomerular filtration rate in the Japanese general population. J Atheroscler Thromb 2009; 16 (6): 840–845.

    Article  Google Scholar 

  5. Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY . Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004; 351 (13): 1296–1305.

    Article  CAS  Google Scholar 

  6. Anavekar NS, McMurray JJ, Velazquez EJ, Solomon SD, Kober L, Rouleau JL et al. Relation between renal dysfunction and cardiovascular outcomes after myocardial infarction. N Engl J Med 2004; 351 (13): 1285–1295.

    Article  CAS  Google Scholar 

  7. Vanholder R, Massy Z, Argiles A, Spasovski G, Verbeke F, Lameire N . Chronic kidney disease as cause of cardiovascular morbidity and mortality. Nephrol Dial Transplant 2005; 20 (6): 1048–1056.

    Article  CAS  Google Scholar 

  8. 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 (6): 461–470.

    Article  CAS  Google Scholar 

  9. Hallan S, Asberg A, Lindberg M, Johnsen H . Validation of the Modification of Diet in Renal Disease formula for estimating GFR with special emphasis on calibration of the serum creatinine assay. Am J Kidney Dis 2004; 44 (1): 84–93.

    Article  Google Scholar 

  10. Myers GL, Miller WG, Coresh J, Coresh J, Fleming J, Greenberg N et al. Recommendations for improving serum creatinine measurement: a report from the Laboratory Working Group of the National Kidney Disease Education Program. Clin Chem 2006; 52 (1): 5–18.

    Article  CAS  Google Scholar 

  11. Narva AS, Briggs M . The National Kidney Disease Education Program: improving understanding, detection, and management of CKD. Am J Kidney Dis 2009; 53 (3 Suppl 3): S115–S120.

    Article  Google Scholar 

  12. Liu X, Wang K, Lee K . Association of standardised estimated glomerular filtration rate with the prevalence of hypertension amoung adults in the United States. J Hum Hypertens 2011; 25: 469–475.

    Article  CAS  Google Scholar 

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  1. Department of Nephrology, Charité—Campus Benjamin Franklin, Berlin, Germany

    T Westhoff & W Zidek

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Correspondence to T Westhoff.

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Westhoff, T., Zidek, W. Does a standardization of GFR estimation increase the accuracy of cardiovascular risk assessment?. J Hum Hypertens 25, 467–468 (2011). https://doi.org/10.1038/jhh.2011.20

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