Estimating glomerular filtration rate in cirrhosis using creatinine- and cystatin C- based equations: systematic review and meta-analysis.
Sumeet K. Asrani M.D.
Singapura, P., Ma, T.W., Sarmast, N., Gonzalez, S., Durand, F., Maiwall, R., Nadim, M.K., Fullinwider, J., Saracino, G., Francoz, C., Sartin, R., Trotter, J. and Asrani, S.K. (2021). “Estimating glomerular filtration rate in cirrhosis using creatinine- and cystatin C- based equations: systematic review and meta-analysis.” Liver Transpl Jun 18. [Epub ahead of print].
BACKGROUND AND AIMS: Accurate estimation of kidney function in cirrhosis is crucial for prognosis and decisions regarding dual organ transplantation. Several estimating glomerular filtration rate (GFR) equations are used, however, most overestimate kidney function. APPROACH AND RESULTS: We performed a systematic review/meta-analysis to assess the performance of creatinine and cystatin C-based GFR estimating (eGFR) equations as compared to measured GFR (mGFR) in patients with cirrhosis. Standardized mean difference (SMD) of each eGFR equation was compared to mGFR. Twenty-five studies (n= 4,565, 52.0years, 37.0% female) comprising 18 equations met the inclusion criteria. All GFR: Creatinine-based equations overestimated GFR (SMD 0.51, 95% CI0.31-0.71) and cystatin C-based equations underestimated GFR (SMD -0.3, 95% CI-0.6- -0.02). Equations based on both creatinine and cystatin C were the least biased (SMD -0.14, 95% CI -0.46-0.18). CKD-Epi-sCr-CysC was the least biased but had low precision and underestimated GFR by -3.6 ml/min/1.73m(2) (95% CI -17.4-10.3). GFR<60ml/min/1.73m(2) : All equations significantly overestimated GFR (+21.7 ml/min/1.73m(2) , 95% CI17.7-25.7); of these, CKD-Epi-CysC (10.3 ml/min/1.73m(2) , 95% CI2.1-18.4) and GFR Assessment in Liver disease (GRAIL) (12.6 ml/min/1.73m(2) , 95%CI 7.2-18.0) were the least biased followed by Royal Free Hospital (RFH) (15 ml/min/1.73m(2) , 95%CI 5.5-24.6) and MDRD-6 (15.7 ml/min/1.73m(2) , 95%CI 10.6-20.8).; however there was overlap in the precision of estimates and studies were limited. Ascites: Overestimation of GFR was common (+8.3 ml/min/1.73m(2) , 95%CI -3.1-19.7). CONCLUSION: CKD-Epi-sCr-CysC may be acceptable across the spectrum of GFR. However, overestimation of GFR by 10-20 ml/min/1.73m(2) is common in patients with cirrhosis with most equations, especially in conjunction with ascites and/or kidney dysfunction. There is wide overlap in confidence intervals/precision. A tailored approach is required based on clinical scenario, especially for decisions regarding dual organ transplantation.