Occult kidney disease determined using glomerular filtration rate equations in Primary Care
Enfermedad renal oculta a través de las ecuaciones de filtrado glomerular en Atención Primaria
Francisco T. Pérez-Durilloa, Ana B. Villarejo-Villarb, Josefa Pérez-Durilloc, Ana I. Ribes-Bautistad, Carmen Macías-Ortiz de Galisteoe
a Licenciado en Medicina. Especialista en Medicina Familiar y Comunitaria. C.S. Bailén. Área de Gestión Sanitaria Norte de Jaén, Jaén,
b Licenciada en Farmacia, Departamento de Fisiología. Universidad de Jaén, Jaén,
c Diplomada Universitaria en Enfermería, Diputación Provincial de Jaén, Jaén,
d Doctora en Medicina. Especialista en Medicina Familiar y Comunitaria, C.S. San Felipe. Distrito Sanitario de Jaén, Jaén,
e Médico Interno Residente de 4º año de Medicina Familiar y Comunitaria, C.S. San Felipe. Distrito Sanitario de Jaén, Jaén,
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Universidad de Jaén, Jaén, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Diplomada Universitaria en Enfermería, Diputación Provincial de Jaén, Jaén, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Doctora en Medicina. Especialista en Medicina Familiar y Comunitaria, C.S. San Felipe. Distrito Sanitario de Jaén, Jaén, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 4 => array:3 [ "entidad" => "Médico Interno Residente de 4º año de Medicina Familiar y Comunitaria, C.S. San Felipe. Distrito Sanitario de Jaén, Jaén, " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Enfermedad renal oculta a través de las ecuaciones de filtrado glomerular en Atención Primaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12604_16025_61476_en_t112604.jpg" "Alto" => 618 "Ancho" => 1419 "Tamanyo" => 231617 ] ] "descripcion" => array:1 [ "en" => "Stratification of the glomerular filtration rate according to the values of the Cockcroft-Gault and MDRD-4 equations" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor,</span></p><p class="elsevierStylePara">In Spain, around 11% of the adult population suffers from some degree of chronic kidney disease<span class="elsevierStyleSup">1</span>, a figure that will progressively grow due to an ageing population and the increase in the prevalence of other chronic diseases such as diabetes mellitus, high blood pressure, dyslipidaemia and obesity.</p><p class="elsevierStylePara">We carried out this study with the objective of determining the percentage of patients with occult kidney disease using the Cockcroft-Gault (C-G) and/or the 4-variable MDRD (Modification of Diet in Renal Disease) equations as an indirect measurement of renal function, analysing the potential error made by exclusively assessing serum creatinine.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">We performed a cross-sectional descriptive study with adult patients older than 18 years of age, whose serum creatinine had been requested on at least two occasions in a one-year period in their health centre, excluding those whose tests showed high variability (greater than 0.5mg/dl of creatinine between the two tests).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">A total of 183 patients were included with a mean age of 59.1±18.2 years, with 64.5% being female (mean age: 58.7 years vs. 60.0 years in males).</p><p class="elsevierStylePara">With regard to pathologies, 51.4% had high blood pressure, 27.9% were diabetic, 40.4% had dyslipidaemia and 11.5% suffered from some type of heart disease. 6.6% of patients had hyperuricemia (13.8% males, 2.5% females, <span class="elsevierStyleItalic">p</span><.01). 5.5% were diagnosed with chronic kidney disease.</p><p class="elsevierStylePara">5.5% had kidney disease according to serum creatinine values (9.2% of the males and 3.4% of the females, <span class="elsevierStyleItalic">p</span>=.10). Using the C-G equation, 29.1% had a glomerular filtration rate (GFR) <60ml/min/1.73m² (25.0% of the males, 31.4% of the females, <span class="elsevierStyleItalic">p</span>=.37) and 25.7% using the 4-variable MDRD equation (24.6% of the males, 26.3% of the females, <span class="elsevierStyleItalic">p</span>=.81). Table 1 compares the percentages of patients in accordance with their GFR using both equations.</p><p class="elsevierStylePara">21.4% of patients according to the 4-variable MDRD equation and 25.0% according to the C-G equation had occult kidney disease.</p><p class="elsevierStylePara">With regard to drugs that are potentially dangerous for patients with a low GFR, it has been demonstrated that 40.0%-44.4% (depending on the equation used) of patients with stage 3-4 chronic kidney disease were being treated with non-steroidal anti-inflammatory drugs, 15.6%-18.0% with metformin, 15.6%-16.0% with oral anti-diabetic drugs and 6.0%-6.7% with allopurinol.</p><p class="elsevierStylePara">If we analyse the level of concordance obtained between the two equations, C-G<span class="elsevierStyleSup">2</span> and 4-variable MDRD<span class="elsevierStyleSup">3</span>, we observe a level of concordance classified as very good (index κ 0.81±0.05, <span class="elsevierStyleItalic">p</span><.001, χ<span class="elsevierStyleSup">2</span> test) (Table 2). In a more detailed manner, upon analysing the specific level of concordance of each stage of chronic kidney disease, similar results were obtained mainly in advanced stages. Thus, for stage 1, the level of concordance is weak (κ 0.39±0.09; <span class="elsevierStyleItalic">p</span><.001; χ<span class="elsevierStyleSup">2</span> test), for stage 2, it is moderate (κ 0.56±0.06; <span class="elsevierStyleItalic">p</span><.001; χ<span class="elsevierStyleSup">2</span> test) and for stage 3, it is very good (κ 0.84±0.05; <span class="elsevierStyleItalic">p</span><.001; χ<span class="elsevierStyleSup">2</span> test).</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">Approximately one in every four patients in our study had a GFR <60ml/min/1.73m<span class="elsevierStyleSup">2 </span>despite having creatinine values within the appropriate range. In similar studies, the percentage of patients with occult kidney disease varies between 10.4% and 43.5%, according to the study population<span class="elsevierStyleSup">4-6</span>. We observed a more prevalent decrease in GFR in females, similarly to the aforementioned studies, although in our study, the differences observed were not statistically significant.</p><p class="elsevierStylePara">Most patients assessed had a slightly decreased GFR. The patients who had more marked GFR involvement were elderly patients with more cardiovascular risk factors, similarly to studies of similar characteristics carried out in Primary Care<span class="elsevierStyleSup">7</span>.</p><p class="elsevierStylePara">In our study, high blood pressure, hyperuricemia and heart disease were the pathologies most associated with moderate-severe GFR involvement. Controlling these pathologies, as well as diabetes mellitus, must be one of our priorities, not only in order to slow down progression, but also to reduce cardiovascular risk, which is significantly associated with chronic kidney disease<span class="elsevierStyleSup">8-10</span>.</p><p class="elsevierStylePara">The concordance found between the two equations (C-G and 4-variable MDRD) improves as the degree of GFR involvement increases, being very good in patients in stage 3.</p><p class="elsevierStylePara">In conclusion, the data show the ever increasing incidence of individuals with kidney disease in Primary Care clinics, probably due to an ageing population, concomitant diseases and the increase in medication use in general, and mainly medications that can affect renal function. We also noted the high percentage of individuals who had a decreased GFR despite maintaining normal plasma creatinine and who usually are undetected since their GFR is not estimated using a more reliable method.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/12604_16025_61476_en_t112604.jpg" class="elsevierStyleCrossRefs"><img src="12604_16025_61476_en_t112604.jpg" alt="Stratification of the glomerular filtration rate according to the values of the Cockcroft-Gault and MDRD-4 equations"></img></a></p><p class="elsevierStylePara">Table 1. Stratification of the glomerular filtration rate according to the values of the Cockcroft-Gault and MDRD-4 equations</p><p class="elsevierStylePara"><a href="grande/12604_16025_61477_en_t212604.jpg" class="elsevierStyleCrossRefs"><img src="12604_16025_61477_en_t212604.jpg" alt="Concordance between the two equations used to determine the glomerular filtration rate"></img></a></p><p class="elsevierStylePara">Table 2. Concordance between the two equations used to determine the glomerular filtration rate</p>" "pdfFichero" => "P1-E574-S4716-A12604-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12604_16025_61476_en_t112604.jpg" "Alto" => 618 "Ancho" => 1419 "Tamanyo" => 231617 ] ] "descripcion" => array:1 [ "en" => "Stratification of the glomerular filtration rate according to the values of the Cockcroft-Gault and MDRD-4 equations" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12604_16025_61477_en_t212604.jpg" "Alto" => 390 "Ancho" => 2161 "Tamanyo" => 156809 ] ] "descripcion" => array:1 [ "en" => "Concordance between the two equations used to determine the glomerular filtration rate" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Otero A, Gayoso P, García F, de Francisco AL. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 3 | 6 |
| 2024 October | 46 | 32 | 78 |
| 2024 September | 52 | 20 | 72 |
| 2024 August | 69 | 50 | 119 |
| 2024 July | 48 | 35 | 83 |
| 2024 June | 58 | 40 | 98 |
| 2024 May | 74 | 43 | 117 |
| 2024 April | 47 | 32 | 79 |
| 2024 March | 50 | 24 | 74 |
| 2024 February | 35 | 30 | 65 |
| 2024 January | 31 | 26 | 57 |
| 2023 December | 39 | 36 | 75 |
| 2023 November | 36 | 37 | 73 |
| 2023 October | 65 | 35 | 100 |
| 2023 September | 68 | 17 | 85 |
| 2023 August | 95 | 42 | 137 |
| 2023 July | 86 | 47 | 133 |
| 2023 June | 50 | 17 | 67 |
| 2023 May | 57 | 36 | 93 |
| 2023 April | 26 | 15 | 41 |
| 2023 March | 57 | 18 | 75 |
| 2023 February | 33 | 26 | 59 |
| 2023 January | 53 | 22 | 75 |
| 2022 December | 48 | 24 | 72 |
| 2022 November | 60 | 31 | 91 |
| 2022 October | 49 | 40 | 89 |
| 2022 September | 40 | 35 | 75 |
| 2022 August | 47 | 53 | 100 |
| 2022 July | 42 | 43 | 85 |
| 2022 June | 41 | 21 | 62 |
| 2022 May | 37 | 37 | 74 |
| 2022 April | 52 | 42 | 94 |
| 2022 March | 45 | 54 | 99 |
| 2022 February | 43 | 38 | 81 |
| 2022 January | 68 | 38 | 106 |
| 2021 December | 37 | 33 | 70 |
| 2021 November | 39 | 40 | 79 |
| 2021 October | 50 | 41 | 91 |
| 2021 September | 29 | 40 | 69 |
| 2021 August | 35 | 30 | 65 |
| 2021 July | 54 | 38 | 92 |
| 2021 June | 47 | 19 | 66 |
| 2021 May | 66 | 30 | 96 |
| 2021 April | 98 | 43 | 141 |
| 2021 March | 83 | 34 | 117 |
| 2021 February | 81 | 23 | 104 |
| 2021 January | 48 | 13 | 61 |
| 2020 December | 46 | 15 | 61 |
| 2020 November | 55 | 14 | 69 |
| 2020 October | 51 | 11 | 62 |
| 2020 September | 83 | 9 | 92 |
| 2020 August | 51 | 9 | 60 |
| 2020 July | 66 | 11 | 77 |
| 2020 June | 51 | 10 | 61 |
| 2020 May | 49 | 24 | 73 |
| 2020 April | 51 | 17 | 68 |
| 2020 March | 60 | 14 | 74 |
| 2020 February | 70 | 16 | 86 |
| 2020 January | 73 | 16 | 89 |
| 2019 December | 62 | 18 | 80 |
| 2019 November | 52 | 27 | 79 |
| 2019 October | 28 | 12 | 40 |
| 2019 September | 66 | 14 | 80 |
| 2019 August | 27 | 16 | 43 |
| 2019 July | 51 | 16 | 67 |
| 2019 June | 50 | 11 | 61 |
| 2019 May | 83 | 12 | 95 |
| 2019 April | 126 | 39 | 165 |
| 2019 March | 52 | 22 | 74 |
| 2019 February | 45 | 27 | 72 |
| 2019 January | 67 | 22 | 89 |
| 2018 December | 279 | 38 | 317 |
| 2018 November | 241 | 17 | 258 |
| 2018 October | 265 | 19 | 284 |
| 2018 September | 279 | 10 | 289 |
| 2018 August | 181 | 13 | 194 |
| 2018 July | 138 | 17 | 155 |
| 2018 June | 111 | 16 | 127 |
| 2018 May | 117 | 16 | 133 |
| 2018 April | 82 | 6 | 88 |
| 2018 March | 71 | 11 | 82 |
| 2018 February | 66 | 9 | 75 |
| 2018 January | 58 | 5 | 63 |
| 2017 December | 59 | 8 | 67 |
| 2017 November | 56 | 7 | 63 |
| 2017 October | 49 | 7 | 56 |
| 2017 September | 56 | 9 | 65 |
| 2017 August | 57 | 11 | 68 |
| 2017 July | 71 | 17 | 88 |
| 2017 June | 70 | 30 | 100 |
| 2017 May | 90 | 16 | 106 |
| 2017 April | 61 | 12 | 73 |
| 2017 March | 57 | 11 | 68 |
| 2017 February | 106 | 16 | 122 |
| 2017 January | 49 | 11 | 60 |
| 2016 December | 63 | 11 | 74 |
| 2016 November | 76 | 6 | 82 |
| 2016 October | 134 | 12 | 146 |
| 2016 September | 181 | 2 | 183 |
| 2016 August | 178 | 4 | 182 |
| 2016 July | 188 | 3 | 191 |
| 2016 June | 126 | 0 | 126 |
| 2016 May | 167 | 0 | 167 |
| 2016 April | 116 | 0 | 116 |
| 2016 March | 112 | 0 | 112 |
| 2016 February | 143 | 0 | 143 |
| 2016 January | 138 | 0 | 138 |
| 2015 December | 132 | 0 | 132 |
| 2015 November | 97 | 0 | 97 |
| 2015 October | 113 | 0 | 113 |
| 2015 September | 86 | 0 | 86 |
| 2015 August | 78 | 0 | 78 |
| 2015 July | 97 | 0 | 97 |
| 2015 June | 34 | 0 | 34 |
| 2015 May | 59 | 0 | 59 |
| 2015 April | 11 | 0 | 11 |
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