Acute Crit Care.  2022 May;37(2):185-192. 10.4266/acc.2021.01256.

Measured versus estimated creatinine clearance in critically ill patients with acute kidney injury: an observational study

• Kadivarian S
• Heydarpour F
• Karimpour H
• Shahbazi F

• KMID: 2531675
• DOI: http://doi.org/10.4266/acc.2021.01256

Abstract

Background
Acute kidney injury (AKI) commonly occurs in critically ill patients. Estimation of renal function and antibiotics dose adjustment in patients with AKI is a challenging issue.
Methods
Urinary creatinine clearance was measured in a 6-hour urine collection from patients with acute kidney injuries. The correlations between different formulas including the modified Cockcroft-Gault, modification of diet in renal disease, chronic kidney disease-epidemiology collaboration, Jelliffe, kinetic-glomerular filtration rate (GFR), Brater, and Chiou formulas were considered. The pattern of the prescribed antimicrobial agents was also compared with the patterns in the available resources.
Results
Ninety-five patients with acute kidney injuries were included in the research. The mean age of the participants was 63.11±17.58 years old. The most patients (77.89%) were in stage 1 of AKI according to the Acute Kidney Injury Network criteria, followed by stage 2 (14.73%) and stage 3 (7.36), respectively. None of the formulations had a high or very high correlation with the measured creatinine clearance. In stage 1, Chiou (r=0.26), and in stage 2 and 3, kinetic-GFR (r=0.76 and r=0.37) had the highest correlation coefficient. Antibiotic over- and under-dosing were frequently observed in the study.
Conclusions
The results showed that none of the static methods can predict the measured creatinine clearance in the critically ill patients. The dynamic methods such as kinetic-GFR can be helpful for patients who do not receive diuretics and vasopressors. Further studies are needed to confirm our results.

Keyword

correlations; estimated glomerular filtration rate; measured creatinine clearance

Figure

• 

  Figure 1. Flowchart of included patients. GFR: glomerular filtration rate; AKI: acute kidney injury.

Reference

1. Singbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012; 81:819–25.

2. Susantitaphong P, Cruz DN, Cerda J, Abulfaraj M, Alqahtani F, Koulouridis I, et al. World incidence of AKI: a meta-analysis. Clin J Am Soc Nephrol. 2013; 8:1482–93.

3. Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. Am J Kidney Dis. 2013; 61:649–72.

4. Mohammadi Kebar S, Hosseini Nia S, Maleki N, Sharghi A, Sheshgelani A. The incidence rate, risk factors and clinical outcome of acute kidney injury in critical patients. Iran J Public Health. 2018; 47:1717–24.

5. Blanco VE, Hernandorena CV, Scibona P, Belloso W, Musso CG. Acute kidney injury pharmacokinetic changes and its impact on drug prescription. Healthcare (Basel). 2019; 7:10.

6. Zamoner W, de Freitas FM, Garms DS, de Oliveira MG, Balbi AL, Ponce D. Pharmacokinetics and pharmacodynamics of antibiotics in critically ill acute kidney injury patients. Pharmacol Res Perspect. 2016; 4:e00280.

7. Veiga RP, Paiva JA. Pharmacokinetics-pharmacodynamics issues relevant for the clinical use of beta-lactam antibiotics in critically ill patients. Crit Care. 2018; 22:233.

8. Matzke GR, Aronoff GR, Atkinson AJ Jr, Bennett WM, Decker BS, Eckardt KU, et al. Drug dosing consideration in patients with acute and chronic kidney disease-a clinical update from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011; 80:1122–37.

9. Levey AS, Inker LA. GFR as the "gold standard": estimated, measured, and true. Am J Kidney Dis. 2016; 67:9–12.

10. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004; 8:R204–12.

11. Al-Dorzi HM, Alsadhan AA, Almozaini AS, M Alamri A, Tamim H, Sadat M, et al. The performance of equations that estimate glomerular filtration rate against measured urinary creatinine clearance in critically ill patients. Crit Care Res Pract. 2021; 2021:5520653.

12. Hahn T, Yao S, Dunford LM, Thomas J, Lohr J, Arora P, et al. A comparison of measured creatinine clearance versus calculated glomerular filtration rate for assessment of renal function before autologous and allogeneic BMT. Biol Blood Marrow Transplant. 2009; 15:574–9.

13. Tsai D, Udy AA, Stewart PC, Gourley S, Morick NM, Lipman J, et al. Prevalence of augmented renal clearance and performance of glomerular filtration estimates in Indigenous Australian patients requiring intensive care admission. Anaesth Intensive Care. 2018; 46:42–50.

14. Chen S. Retooling the creatinine clearance equation to estimate kinetic GFR when the plasma creatinine is changing acutely. J Am Soc Nephrol. 2013; 24:877–88.

15. Xiong L, Lu ZK, Quidley AM, Alford BS, Bookstaver PB. Evaluation of renal function estimation formulas specific to dynamic renal function for drug dosing in critically ill patients. South Med J. 2018; 111:299–306.

16. Guilhaumou R, Benaboud S, Bennis Y, Dahyot-Fizelier C, Dailly E, Gandia P, et al. Optimization of the treatment with beta-lactam antibiotics in critically ill patients-guidelines from the French Society of Pharmacology and Therapeutics (Société Française de Pharmacologie et Thérapeutique-SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation-SFAR). Crit Care. 2019; 23:104.

17. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007; 11:R31.

18. Shahrami B, Najmeddin F, Mousavi S, Ahmadi A, Rouini MR, Mojtahedzadeh M. CP-184 correlations of vancomycin clearance during intermittent infusion with measured and estimated creatinine clearance in critically ill patients: 6 hour urine collection may be beneficial. Eur J Hosp Pharm. 2017; 24(Suppl 1):A82.

19. Carson JS, Goverman J, Fagan SP. 31 - acute renal failure in association with thermal injury. In: Herndon DN, editor. Total burn care. 5th ed. Amsterdam: Elsevier; 2018. p. 318-27.

20. Kane-Gill SL, Sileanu FE, Murugan R, Trietley GS, Handler SM, Kellum JA. Risk factors for acute kidney injury in older adults with critical illness: a retrospective cohort study. Am J Kidney Dis. 2015; 65:860–9.

21. Williams P, Beall G, Cotta MO, Roberts JA. Antimicrobial dosing in critical care: a pragmatic adult dosing nomogram. Int J Antimicrob Agents. 2020; 55:105837.

22. Baptista JP, Udy AA, Sousa E, Pimentel J, Wang L, Roberts JA, et al. A comparison of estimates of glomerular filtration in critically ill patients with augmented renal clearance. Crit Care. 2011; 15:R139.

23. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med. 1993; 21:1487–95.

24. Bouchard J, Macedo E, Soroko S, Chertow GM, Himmelfarb J, Ikizler TA, et al. Comparison of methods for estimating glomerular filtration rate in critically ill patients with acute kidney injury. Nephrol Dial Transplant. 2010; 25:102–7.

25. Jelliffe R. Estimation of creatinine clearance in patients with unstable renal function, without a urine specimen. Am J Nephrol. 2002; 22:320–4.

26. Pelletier K, Lafrance JP, Roy L, Charest M, Bélanger MC, Cailhier JF, et al. Estimating glomerular filtration rate in patients with acute kidney injury: a prospective multicenter study of diagnostic accuracy. Nephrol Dial Transplant. 2020; 35:1886–1893.

27. Carlier M, Dumoulin A, Janssen A, Picavet S, Vanthuyne S, Van Eynde R, et al. Comparison of different equations to assess glomerular filtration in critically ill patients. Intensive Care Med. 2015; 41:427–35.

28. Delanaye P, Cavalier E, Pottel H. Serum creatinine: not so simple! Nephron. 2017; 136:302–8.

29. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012; 120:c179–84.

30. Crass RL, Rodvold KA, Mueller BA, Pai MP. Renal dosing of antibiotics: are we jumping the gun? Clin Infect Dis. 2019; 68:1596–602.

31. Macedo E, Bouchard J, Soroko SH, Chertow GM, Himmelfarb J, Ikizler TA, et al. Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients. Crit Care. 2010; 14:R82.

32. Sunder S, Jayaraman R, Mahapatra HS, Sathi S, Ramanan V, Kanchi P, et al. Estimation of renal function in the intensive care unit: the covert concepts brought to light. J Intensive Care. 2014; 2:31.

33. Sangla F, Marti PE, Verissimo T, Pugin J, de Seigneux S, Legouis D. Measured and estimated glomerular filtration rate in the ICU: a prospective study. Crit Care Med. 2020; 48:e1232–41.

34. Tomasa-Irriguible TM, Sabater-Riera J, Pérez-Carrasco M, Ortiz-Ballujera P, Díaz-Buendía Y, Navas-Pérez A, et al. Augmented renal clearance: an unnoticed relevant event. Sci Prog. 2021; 104:368504211018580.

35. Schortgen F, Schetz M. Does this critically ill patient with oliguria need more fluids, a vasopressor, or neither? Intensive Care Med. 2017; 43:907–10.

36. Albanèse J, Leone M, Delmas A, Martin C. Terlipressin or norepinephrine in hyperdynamic septic shock: a prospective, randomized study. Crit Care Med. 2005; 33:1897–902.

37. Chen S. Kinetic glomerular filtration rate in routine clinical practice-applications and possibilities. Adv Chronic Kidney Dis. 2018; 25:105–14.

38. Hoste EA, Damen J, Vanholder RC, Lameire NH, Delanghe JR, Van den Hauwe K, et al. Assessment of renal function in recently admitted critically ill patients with normal serum creatinine. Nephrol Dial Transplant. 2005; 20:747–53.

39. Kwong YD, Chen S, Bouajram R, Li F, Matthay MA, Mehta KM, et al. The value of kinetic glomerular filtration rate estimation on medication dosing in acute kidney injury. PLoS One. 2019; 14:e0225601.

40. Seelhammer TG, Maile MD, Heung M, Haft JW, Jewell ES, Engoren M. Kinetic estimated glomerular filtration rate and acute kidney injury in cardiac surgery patients. J Crit Care. 2016; 31:249–54.

41. Bairy M, See FH, Lim RS. Using the kinetic estimating glomerular filtration rate equation for estimating glomerular filtration rate and detecting acute kidney injury: a pilot study. Nephron. 2018; 140:231–9.