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Marco U. Martínez-Martínez et al. Renal function and SLE originales Table 1. Equations for estimating GFR Author Cystatin C based equations Rule, et al. 66.8 * Cys C -1.3 MacIsaac, et al. (84.6/Cys C) -3.2 Larsson, et al. 77.24 * (Cys C) -1.2623 Stevens, et al. 177.6 * (Scr) -0.65 * (Cys C) -0.57 * (age) -0.20 * (0.82 if woman) Stevens 2 76.7 * Cys C -1.19 Ma et al. 169 * Scr -0.608 * Cys C -0.63 * edad -0.157 * 0.83 if woman) Equation Creatinine-based equations CKD-EPI a) For female, Scr 0.7: 144 * (Scr/0.7) -1.209 * (0.993) Age c) For male, Scr 0.9: 141 * (Scr/0.9) -1.209 * (0.993) Age sMDRD 175*Scr -1.154 * age (year) -0.203 * (0.742 if female). None of our patients were Afro-American. CG [140-age (year)] * weight (kilogram)/(72 * Scr] * (0.85, if female). The CG was then normalized to a standard BSI of 1.73m 2 . CGi [140-age (year)] * (ideal body weight)/[72 * Scr] * (0.85, if female). The CG was then normalized to a standard BSI of 1.73m 2 . MCQ exp[ 1.911 + (5.249/Scr) - (2.114/Scr2) - 0.00686 x Age (- 0.205 (if female))], if Scr
originales Marco U. Martínez-Martínez et al. Renal function and SLE RESULTS In the first phase we included 14 patients; their median age was 32.5 years old, and 61.5 months of mean SLE evolution time (Table 2). Table 3 shows the results of the first phase which highlights the fact that the equation based on creatinine and cystatin C developed by Stevens and colleagues 11 (Stevens’ equation) had the best bias and the most accuracy. Because our patients were selected for their low disease activity and drug doses, and because of the interference of these factors may have on cystatin C levels, for the clinician, the better setting is to have a creatinine-based equation than a cystatin-based equation, so we performed a second phase with more patients to determine the best creatinine-based equation to estimate GFR in patients with SLE (Table 1). Table 4 shows how the bias, precision and accuracy are better with the CKD-EPI equation than with the others. In this phase, 55 patients were included; median age was 36 years old and SLE evolution time was 60 months (Table 2). Figure 1 shows the difference between measured and estimated versus estimated GFR in phase 2. A smoothed regression line is shown with the 95% CI, using quantile regression. Notice how the CKD-EPI equation has a good performance both at high and low GFR. Table 5 shows sensitivity and specificity of each equations to detect GFR less than 60ml/min/1.73. Eleven patients had GFR less than 60ml/min/1.73 according to Stevens’ equation, CKD-EPI misclassified 1 patient (1.8%), sMDRD 2 (3.6%), CG 4 (7.3%), CGi 6 (10.9%), MCQ 5 (9.1) and CrCl 4 (7.3%). DISCUSSION The GFR should be determined as accurately as possible, ideally with an accessible and inexpensive method which does not cause harm to the patient. Several factors affect serum creatinine level other than GFR, including its generation from muscle metabolism; these factors compromise the generalization of the equations in patients with SLE. Cystatin-based equations has no dependence on muscle mass, but previous studies showed evidence for non- GFR determinants of cystatin C (inflammation, glucocorticoids, thyroid disease and cytotoxic drugs); variation in these factors can restrict the use of this protein for measuring GFR in patients with SLE. 31 Even though we reported previously that Cystatin C does not correlate with disease activity and drug doses, 32 we selected our patients avoiding these factors. Because there are multiple equations to estimate GFR, the management guidelines of patients with SLE are based on studies in other different diseases from SLE and we think that the results on these diseases cannot be extrapolated to SLE. 8 National Kidney Foundation (NKF) guidelines suggest using the GFR estimating equations (not the CrCl) to achieve a better assessment of renal function. 6,7 In spite of these recommendations, 24 h urine collection to determine CrCl is a widely used method for assessing GRF in patients with SLE (including clinical trials). 16,33-35 Our study identifies several important findings: 1) The equation developed by Stevens and colleagues based on creatinine and cystatin C is the best equation to estimate renal function for our specifically selected SLE patients (with low disease activity, low doses of glucocorticoids, no smoking, no hypothyroidism). 2) Because of all those factors that the clinicians must take into account when Table 2. Clinical and demographic characteristics Phase 1 Phase 2 n 14 55 Female (%) 100 94.5 Age a 32.5 (21-61) 36 (18-67) SLE evolution (months) 61.5 (9-216) 60 (0-300) Weight (kg) 60.3 (45-95) 62.5 (39.5-95) BMI 23.6 (16.9-34.4) 24.6 (16.9-36.4) MEX-SLEDAI 4 (0-8) 2 (0-8) a : mean ± standard deviation; BMI: body mass index (kg/m 2 ); MEX-SLEDAI: Mexican systemic lupus erythematosus disease activity index; SLE: Systemic lupus erythematosus. 102 Nefrologia 2013;33(1):99-106
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