Discrepancies between the use of MDRD-4 IDMS and CKD-EPI equations, instead of the Cockcroft–Gault equation, in the determination of the dosage of direct oral anticoagulants in patients with non-valvular atrial fibrillation

Cabeza, Alejandro Isidoro Pérez; Capote, Pedro Antonio Chinchurreta; Correa, José Antonio González; Mateas, Francisco Ruíz; Cervantes, Gabriel Rosas; Rivas-Ruiz, Francisco; Alberca, Almudena Valle; Marqués, Rafael Bravo

doi:10.1016/j.medcle.2017.12.005

Cited by 12 publications

(14 citation statements)

References 28 publications

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“…28 Other recent analyses have shed light on how the use of different estimating equations can lead to dosing variations in high-risk medications, such as direct oral anticoagulants. 29,30 The methodology of these studies is similar to that used in other dosing discordance studies.…”

Section: Discussionmentioning

confidence: 99%

Clearance Confusion: An Exploratory Analysis of Inpatient Dosing Discordances Between Renal Estimating Equations

2020

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Background: Numerous equations exist for estimating renal clearance for drug dosing, and discordance rates may be as high as 40% in certain populations. However, the populations and types of equations used in these studies may not be generalizable to broader pharmacy practice. Objectives: To determine the dosing discordance rate between Cockcroft-Gault (C-G), Chronic Kidney Disease Epidemiology (CKD-EPI), and Modification of Diet in Renal Disease (MDRD) equations in a community hospital population. Methods: This was a cross-sectional analysis of inpatients who had documented renal function assessment over a 6-month period. Renal estimation was calculated using 5 equations (MDRD, CKD-EPI, and 3 C-G variants). Differences between equations were assessed using mean bias, dosing discordance, and agreement (κ statistic). Patients with acute kidney injury and those requiring renal replacement therapy were excluded. Results: A total of 466 patients were eligible for inclusion. Dosing discordance was evident between C-G variants and both MDRD and CKD-EPI equations in greater than 20% of patients. Agreement was highest between MDRD and CKD-EPI (κ = 0.93) and lowest between MDRD and C-G calculated using ideal body weight (κ = 0.33). The majority of discordant instances led to higher dosing recommendations when using MDRD and CKD-EPI equations compared with C-G variants. Dosing discordance exceeded 18% between the different C-G variants, with the highest discordance (36%) observed between total body weight and ideal body weight variants. Conclusion and Relevance: Dosing discordance between renal estimating equations is widespread. Practitioners and institutions should be aware of these differences when dosing medications and implementing renal dosing policies.

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Section: Discussionmentioning

confidence: 99%

Clearance Confusion: An Exploratory Analysis of Inpatient Dosing Discordances Between Renal Estimating Equations

2020

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“…22 This explanation, confounding one clearance estimate for another, has been hypothesized to underlie some of the inappropriate dosing of DOAC medications in retrospective studies. 16,26 However, the research underlying this hypothesis in DOACs has been based primarily on dosing discordances between GFR and CrCl estimates. 26 In this study, MDRD and CKD-EPI estimates, although discordant from the least-biased C-G estimate in cases 1, 2, and 3, did not appear to affect dosing deviation as clearly as C-G estimates (which were only discordant in the 2 cases in which dosing deviation was statistically significant).…”

Section: Discussionmentioning

confidence: 99%

“…16,26 However, the research underlying this hypothesis in DOACs has been based primarily on dosing discordances between GFR and CrCl estimates. 26 In this study, MDRD and CKD-EPI estimates, although discordant from the least-biased C-G estimate in cases 1, 2, and 3, did not appear to affect dosing deviation as clearly as C-G estimates (which were only discordant in the 2 cases in which dosing deviation was statistically significant). This finding may be explained by recent surveys that demonstrate that the vast majority of pharmacists use variants of the C-G equation for drug dosing purposes instead of either the MDRD or CKD-EPI.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Multiple Renal Estimates on Pharmacist Dosing Recommendations: A Randomized Trial

et al. 2020

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Background: Numerous equations are used for estimation of renal function, and many electronic medical records report multiple clearance estimates to assist with drug dosing. It is unknown whether the presence of multiple clearance estimates affects clinical decision-making. Objective: To determine whether the presence of multiple renal clearance estimates affects pharmacist drug dosing decisions. Methods: A randomized trial in the form of an electronic survey including 4 clinical vignettes was delivered to hospital pharmacists. Vignettes consisted of a patient presenting with an acute pulmonary embolism requiring enoxaparin therapy. Pharmacists were randomized to receive a single estimate of renal function or multiple estimates for all vignettes. The primary outcome was deviation from approved recommendations on at least 1 vignette. The χ2 test was used to detect differences in deviation rates between groups. Logistic regression was performed to adjust for the effects of potentially confounding variables. Results: A total of 154 studies were completed (73 in the multiple-estimate group and 81 in the single-estimate group). Pharmacists presented with multiple renal estimates were significantly more likely to deviate from recommended dosing regimens than pharmacists presented with a single estimate (54.7% vs 38.2%; P = 0.04). The results were driven primarily by the 2 vignettes that included discordance among Cockcroft-Gault equation creatinine clearance estimates. Logistic regression identified multiple estimates as the only independent predictor of deviation ( P = 0.04). Conclusion and Relevance: Pharmacists provided with a single renal clearance estimate were more likely to adhere to approved dosing recommendations than pharmacists provided with multiple estimates.

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“…Chronic kidney disease (CKD) alters the concentrations and effects of various drugs and, as a result, may increase the risks of toxicity as well as treatment failure. 1–6 In response, clinicians use multiple equations to estimate renal function and select doses of medications in such patients. 2–4 Previous studies, however, show that up to 77% of medicines prescribed in this population were unadjusted.…”

Section: Introductionmentioning

confidence: 99%

“…1–6 In response, clinicians use multiple equations to estimate renal function and select doses of medications in such patients. 2–4 Previous studies, however, show that up to 77% of medicines prescribed in this population were unadjusted. 7–16 Almost two–thirds of these improper amounts potentially bear adverse consequences and about 3% may, in fact, result in severe outcomes and even death.…”

Section: Introductionmentioning

confidence: 99%

Concordance Among Methods for Empiric Renal Drug Dosing: Meropenem as a Role Model for Clinical Superiority of Cockroft–Gault or Modification of Diet in Renal Disease

Jasmi

Khan

Saadah

et al. 2018

Clinical Medicine Insights: Therapeutics

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The objectives of this study are, first, to measure concordance between 5 different renal function estimates (methods) in terms of recommended drug doses, and, subsequently, to establish the potential for significant clinical differences between Cockroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations in dosing a specific medication, namely, meropenem. DESiGn AnD SETTinG: This study used a Monte Carlo simulation, and this is a computer-based study with no actual patient data. PATiEnTS: A total of 1200 and 8701 simulated cases to study the concordance for the 5 methods and the potential clinical significance of discordance between CG and MDRD, respectively, were chosen for the study. METhODS: Simulated factors were age, sex, height, weight, serum creatinine, ethnicity, and albumin. We estimated the renal function using 5 formulas (ie, 10 combinations) including CG, MDRD, and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI). Next, the team evaluated concordance for each combination in dosing 22 drugs. Finally, our researchers reviewed and simulated data from the literature to show how CG versus MDRD use can result in clinically significant differences for meropenem. RESulTS: Pairwise combinations yielded statistically significant differences (P < .0001) except for CG and MDRD (P < .5147). In addition, the highest concordance was for MDRD and CKD-EPI. Average discordance is in the range of 25% to 30% with the lowest being between CG and albumin-based estimates. Both CG and MDRD were largely discordant which can reach up to 40% with a drug like meropenem and may be associated with significant adverse outcomes. COnCluSiOnS: Both CG and MDRD in our simulation are statistically comparable. Clinically, nonetheless, they are significantly inconsistent in terms of recommended drug dosing. We encourage practical comparisons of outcomes for individual or groups of medications (eg, meropenem and antibiotics) empirically dosed in renal patients on the basis of equations used in distinct populations.

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Discrepancies between the use of MDRD-4 IDMS and CKD-EPI equations, instead of the Cockcroft–Gault equation, in the determination of the dosage of direct oral anticoagulants in patients with non-valvular atrial fibrillation

Cited by 12 publications

References 28 publications

Clearance Confusion: An Exploratory Analysis of Inpatient Dosing Discordances Between Renal Estimating Equations

Clearance Confusion: An Exploratory Analysis of Inpatient Dosing Discordances Between Renal Estimating Equations

The Impact of Multiple Renal Estimates on Pharmacist Dosing Recommendations: A Randomized Trial

Concordance Among Methods for Empiric Renal Drug Dosing: Meropenem as a Role Model for Clinical Superiority of Cockroft–Gault or Modification of Diet in Renal Disease

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