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Clinical Chemistry and Laboratory Medicine (CCLM)

Published in Association with the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM)

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Ed. by Gillery, Philippe / Greaves, Ronda / Lackner, Karl J. / Lippi, Giuseppe / Melichar, Bohuslav / Payne, Deborah A. / Schlattmann, Peter

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Volume 56, Issue 3


GFR estimation based on standardized creatinine and cystatin C: a European multicenter analysis in older adults

Jonas Björk
  • Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden
  • Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
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/ Sten Erik Bäck / Natalie Ebert / Marie Evans
  • Department of Clinical Sciences Intervention and Technology, Karolinska Institute and Karolinska University Hospital Huddinge, Stockholm, Sweden
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/ Anders Grubb / Magnus Hansson
  • Department of Clinical Chemistry, Karolinska Institute and Karolinska University Hospital Huddinge, Stockholm, Sweden
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/ Ian Jones / Edmund J. Lamb
  • Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK
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/ Peter Martus / Elke Schaeffner / Per Sjöström / Ulf Nyman
  • Corresponding author
  • Department of Translational Medicine, Division of Medical Radiology, Lund University, Malmö, Sweden, Phone: +46-733-842244
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Published Online: 2017-10-06 | DOI: https://doi.org/10.1515/cclm-2017-0563



Although recommended by the Kidney Disease Improving Global Outcomes, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPICR) creatinine equation was not targeted to estimate glomerular filtration rate (eGFR) among older adults. The Berlin Initiative Study (BIS1CR) equation was specifically developed in older adults, and the Lund-Malmö revised (LMRCR) and the Full Age Spectrum (FASCR) equations have shown promising results in older adults. Our aim was to validate these four creatinine equations, including addition of cystatin C in a large multicenter cohort of Europeans ≥70 years.


A total of 3226 individuals (2638 with cystatin C) underwent GFR measurement (mGFR; median, 44 mL/min/1.73 m2) using plasma iohexol clearance. Bias, precision (interquartile range [IQR]), accuracy (percent of estimates ±30% of mGFR, P30), eGFR accuracy diagrams and probability diagrams to classify mGFR<45 mL/min/1.73 m2 were compared.


The overall results of BIS1CR/CKD-EPICR/FASCR/LMRCR were as follows: median bias, 1.7/3.6/0.6/−0.7 mL/min/1.73 m2; IQR, 11.6/12.3/11.1/10.5 mL/min/1.73 m2; and P30, 77.5%/76.4%/80.9%/83.5% (significantly higher for LMR, p<0.001). Substandard P30 (<75%) was noted for all equations at mGFR<30 mL/min/1.73 m2, and at body mass index values <20 and ≥35 kg/m2. LMRCR had the most stable performance across mGFR subgroups. Only LMRCR and FASCR had a relatively constant small bias across eGFR levels. Probability diagrams exhibited wide eGFR intervals for all equations where mGFR<45 could not be confidently ruled in or out. Adding cystatin C improved P30 accuracy to 85.7/86.8/85.7/88.7 for BIS2CR+CYS/CKD-EPICR+CYS/FASCR+CYS/MEANLMR+CAPA.


LMRCR and FASCR seem to be attractive alternatives to CKD-EPICR in estimating GFR by creatinine-based equations in older Europeans. Addition of cystatin C leads to important improvement in estimation performance.

This article offers supplementary material which is provided at the end of the article.

Keywords: chronic kidney disease; creatinine; cystatin C; glomerular filtration rate; kidney function tests; renal failure


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About the article

Received: 2017-06-28

Accepted: 2017-08-17

Published Online: 2017-10-06

Published in Print: 2018-02-23

Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: UN and JB receive reimbursement for letting GE Healthcare AB, Danderyd, Sweden, distribute the computer program OmniVis in radiology departments for GFR estimation based on various creatinine- and cystatin C-based equations. UN receives lecture fees from GE Healthcare AB, Danderyd, Sweden. None declared by the remaining authors (SEB, NE, ME, AG, MH, IJ, EJL, PM, ES and PS).

Employment or leadership: None declared.

Honorarium: None declared.

Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.

Citation Information: Clinical Chemistry and Laboratory Medicine (CCLM), Volume 56, Issue 3, Pages 422–435, ISSN (Online) 1437-4331, ISSN (Print) 1434-6621, DOI: https://doi.org/10.1515/cclm-2017-0563.

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