Hermsen Elizabeth D, Maiefski Melissa, Florescu Marius C, Qiu Fang, Rupp Mark E
Department of Pharmaceutical and Nutrition Care, The Nebraska Medical Center, Omaha, Nebraska 68198-4031, USA.
Pharmacotherapy. 2009 Jun;29(6):649-55. doi: 10.1592/phco.29.6.649.
To determine the concordance between the Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault equations for glomerular filtration rate (GFR) estimation, the impact of using each equation on antimicrobial dosing, the difference in estimated GFR in patients with acute kidney disease (AKD) versus chronic kidney disease (CKD), and the correlation between the MDRD, Cockcroft-Gault equation, and expert medical opinion for estimating GFR in patients with AKD.
Retrospective cohort study.
A 689-bed academic medical center.
A total of 372 adults hospitalized with either AKD or CKD between January 1, 2007, and May 31, 2007, and who received at least one antimicrobial drug; patients with stage 1 or 2 CKD or those receiving dialysis were excluded.
Data were collected from electronic medical records on patient characteristics, laboratory values, antimicrobial drugs requiring dosage adjustment due to renal dysfunction, and estimated GFRs provided by the laboratory (MDRD estimation). In addition, estimated GFRs were calculated using the Cockcroft-Gault equation. For patients with AKD, a third GFR was estimated by a nephrologist. For all patients, the MDRD GFR was significantly higher than the Cockcroft-Gault GFR (p<0.001). Level of concordance for the need for dosage adjustment based on the two equations was moderate (kappa coefficient 0.57, 95% confidence interval 0.5-0.63); 99.1% of patients with discordant dose recommendations would receive a higher dose if the MDRD GFR was used. In the AKD versus CKD groups, mean MDRD GFR was significantly higher than the Cockcroft-Gault GFR in both groups (p<0.0001), but the difference was significantly greater in the CKD group (p<0.0001). In patients with AKD, the GFR estimated by expert opinion was greater than that estimated by the Cockcroft-Gault equation (p=0.04), but was similar to the MDRD equation (p=0.07).
The estimated GFR obtained with the MDRD equation was consistently higher than that from the Cockcroft-Gault equation in patients with AKD or CKD. In patients with AKD, the MDRD GFR more closely correlated with expert opinion than the Cockcroft-Gault, suggesting that the MDRD method may be applicable to this patient population. Moderate concordance between the two equations for the need for antimicrobial dosage adjustment due to renal dysfunction was found, but the specific dosage change was different for approximately 40% of patients, with 99% receiving higher doses when the MDRD GFR is used. These dosing differences may be significant, depending on drug safety profile, type of infection, and causative pathogen.
确定肾脏疾病饮食改良（MDRD）方程和Cockcroft-Gault方程在估算肾小球滤过率（GFR）方面的一致性，使用每个方程对抗菌药物剂量调整的影响，急性肾损伤（AKD）患者与慢性肾脏病（CKD）患者估算GFR的差异，以及MDRD方程、Cockcroft-Gault方程与专家医学意见在估算AKD患者GFR方面的相关性。
回顾性队列研究。
一家拥有689张床位的学术医疗中心。
2007年1月1日至2007年5月31日期间因AKD或CKD住院且至少接受过一种抗菌药物治疗的372名成年人；排除1或2期CKD患者或接受透析的患者。
从电子病历中收集患者特征、实验室值、因肾功能不全需要调整剂量的抗菌药物以及实验室提供的估算GFR（MDRD估算值）等数据。此外，使用Cockcroft-Gault方程计算估算GFR。对于AKD患者，由肾病科医生估算第三个GFR。对于所有患者，MDRD估算的GFR显著高于Cockcroft-Gault估算的GFR（p<0.001）。基于两个方程进行剂量调整需求的一致性水平为中等（kappa系数0.57，95%置信区间0.5 - 0.63）；如果使用MDRD估算的GFR，99.1%剂量建议不一致的患者将接受更高剂量。在AKD组与CKD组中，两组的平均MDRD估算的GFR均显著高于Cockcroft-Gault估算的GFR（p<0.0001），但CKD组的差异显著更大（p<0.0001）。在AKD患者中，专家意见估算的GFR大于Cockcroft-Gault方程估算的GFR（p = 0.04），但与MDRD方程估算的GFR相似（p = 0.07）。
在AKD或CKD患者中，使用MDRD方程获得的估算GFR始终高于Cockcroft-Gault方程估算的GFR。在AKD患者中，MDRD估算的GFR比Cockcroft-Gault估算的GFR与专家意见的相关性更强，这表明MDRD方法可能适用于该患者群体。发现因肾功能不全进行抗菌药物剂量调整需求的两个方程之间一致性为中等，但约40%患者的具体剂量变化不同，使用MDRD估算的GFR时99%的患者接受更高剂量。根据药物安全性、感染类型和致病病原体，这些剂量差异可能很显著。
Zotero 插件