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Clin Chem Lab Med. 2018 Feb 23;56(3):422-435. doi: 10.1515/cclm-2017-0563.

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

Author information

Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden.
Department of Clinical Chemistry, Skåne University Hospital, Lund, Sweden.
Division of Nephrology and Intensive Care Medicine, Charite´ Campus Virchow, Berlin, Germany.
Department of Clinical Sciences Intervention and Technology, Karolinska Institute and Karolinska University Hospital Huddinge, Stockholm, Sweden.
Department of Clinical Chemistry, Karolinska Institute and Karolinska University Hospital Huddinge, Stockholm, Sweden.
Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
Clinical Biochemistry, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK.
Institute of Medical Biostatistics, Eberhard Karls University Tübingen, Tübingen, Germany.
Department of Translational Medicine, Division of Medical Radiology, Lund University, Malmö, Sweden, Phone: +46-733-842244.



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.


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

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