Abstract
OBJECTIVES: Accurate glomerular filtration rate (GFR) assessment is essential in critically ill patients. GFR is often estimated using creatinine-based equations, which require surrogates for muscle mass such as age and sex. Race has also been included in GFR equations, based on the assumption that Black individuals have genetically determined higher muscle mass. However, race-based GFR estimation has been questioned with the recognition that race is a poor surrogate for genetic ancestry, and racial health disparities are driven largely by socioeconomic factors. The American Society of Nephrology and the National Kidney Foundation (ASN/NKF) recommend widespread adoption of new "race-free" creatinine equations, and increased use of cystatin C as a race-agnostic GFR biomarker. DATA SOURCES: Literature review and expert consensus. STUDY SELECTION: English language publications evaluating GFR assessment and racial disparities. DATA EXTRACTION: We provide an overview of the ASN/NKF recommendations. We then apply an Implementation science methodology to identify facilitators and barriers to implementation of the ASN/NKF recommendations into critical care settings and identify evidence-based implementation strategies. Last, we highlight research priorities for advancing GFR estimation in critically ill patients. DATA SYNTHESIS: Implementation of the new creatinine-based GFR equation is facilitated by low cost and relative ease of incorporation into electronic health records. The key barrier to implementation is a lack of direct evidence in critically ill patients. Additional barriers to implementing cystatin C-based GFR estimation include higher cost and lack of test availability in most laboratories. Further, cystatin C concentrations are influenced by inflammation, which complicates interpretation. CONCLUSIONS: The lack of direct evidence in critically ill patients is a key barrier to broad implementation of newly developed "race-free" GFR equations. Additional research evaluating GFR equations in critically ill patients and novel approaches to dynamic kidney function estimation is required to advance equitable GFR assessment in this vulnerable population.
Original language | English (US) |
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Pages (from-to) | 951-962 |
Number of pages | 12 |
Journal | Critical care medicine |
Volume | 52 |
Issue number | 6 |
DOIs | |
State | Published - Jun 1 2024 |
Funding
Supported by the Society of Critical Care Medicine Drs. Miano, Sakhuja, and Barreto received funding from the National Institutes of Health (NIH) (K08DK124658 to Dr. Miano); (K08KD 131286 to Dr. Sakhuja); and (K23AI143882 to Dr. Barreto). Dr. Barreto received funding from Wolters Kluwer. Dr. Martin received funding from Astra Zeneca, Nestle, and FloBio. Dr. Sakhuja\u2019s institution received funding from the National Institute of Diabetes and Digestive and Kidney Diseases (1K08DK131286-01A1). Dr. Basu received funding from BioPorto Diagnostics, Biomerieux, Potrero, and Seastar Therapeutics; he received support for article research from NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.
Keywords
- creatinine
- critical care medicine
- cystatin C
- implementation science
- kidney function estimation
- race
ASJC Scopus subject areas
- Critical Care and Intensive Care Medicine