NDT Advance Access originally published online on April 26, 2005
Nephrology Dialysis Transplantation 2005 20(8):1617-1622; doi:10.1093/ndt/gfh839
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Measured creatinine clearance from timed urine collections substantially overestimates glomerular filtration rate in patients with liver cirrhosis: a systematic review and individual patient meta-analysis
1 Department of Medicine and 2 Department of Epidemiology and Biostatistics, University of Western Ontario, London, 3 Depatment of Medicine University of Ottawa, Ottawa, 4 Department of Medicine, Ottawa Health Research Institute and 5 Department of Medicine, Kidney Research Center, Ottawa, Ontario, Canada
Correspondence and offprint requests to: Normand L. Proulx, MD, London Kidney Clinical Research Unit, Room A01, Westminster Tower, London Health Sciences Centre, 800 Commissioners Road East, London, Ontario N6A 4G5, Canada. Email: nproulx{at}uwo.ca
Background. Accurate glomerular filtration rate (GFR) assessment in patients with liver cirrhosis is important for prognostication, chronic kidney disease staging, drug dosing and identifying combined liver–kidney transplantation candidates. The objective of this study was to review the accuracy of measured creatinine clearance (MCrCl) from timed urine collections for estimating true GFR.
Methods. A systematic review and individual patient meta-analysis was performed. MEDLINE, old MEDLINE, Index Medicus and Cochrane library bibliographic databases and conference proceedings were searched up to June 2004. Reference lists of relevant studies were searched and experts were contacted. Comparative diagnostic studies describing stable adult patients with cirrhosis categorized according to the Child–Pugh classification were included if a gold standard GFR measurement was performed within 3 days of MCrCl. Individual patient data were abstracted from graphs of primary articles to allow a pooled analysis of agreement between renal measures.
Results. Seven studies of 193 patients from 1974 to 2002 were summarized. MCrCl overestimated inulin clearance (CIn) by a mean of +13 ml/min/1.73 m2 and the limits of agreement (mean of the differences±2 SD) were +60 ml/min/1.73 m2 and –34 ml/min/1.73 m2. This overestimation was highest in patients with lower GFR. The mean clearance ratios [95% confidence interval (CI)] between MCrCl and CIn in the high (
60 ml/min/1.73 m2) and low (<60 ml/min/1.73 m2) GFR subgroups were 1.18 (1.12–1.23) and 1.49 (1.33–1.66), respectively (P<0.0001). Fourteen percent of patients with a MCrCl 60 ml/min/1.73 m2 had a CIn of <30 ml/min/1.73 m2.
Conclusions. For patients with liver cirrhosis, MCrCl from timed urine collections consistently overestimates the true GFR. For patients requiring complete clinical evaluation, GFR assessment by CIn is justified.
Keywords: cirrhosis; creatinine; glomerular filtration rate (GFR); inulin; liver diseases; meta-analysis
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