#3248 Adjustment of glomerular filtration rate by BSA: an unnecesary error in estimating renal function
Abstract Background and Aims Glomerular filtration rate (GFR) is the main index of renal function in clinical practice and research. GFR is used to assess renal function at fixed points and to check the evolution of renal disease evolution over time, the response of the kidneys to diverse treatments, to adjust potentially toxic drugs and to establish risk for cardiovascular events and disease progression. Renal function is usually adjusted for body surface area (BSA) by Dubois-Dubois formula, a rudimentary and inexact method to estimate BSA. Also, the indexation of GFR for BSA was based on the hypothesis of the proportionality between metabolic rate and BSA, published at the end of 19th century. This assumption has no scientific basis since metabolic rate is linked to nutritional and maintenance fluid requirements rather that weight or BSA. Later, GFR started to be reported adjusted to a “standard” body surface area of 1.73 m2. Despite these limitations, indexing GFR by the Dubois–Dubois formula is widely used. Additionally, adjusting renal function for BSA has very little impact on GFR in individuals of normal body size, but a large impact by artificially adding or subtracting renal function in patients with extreme body surface areas very different (higher or lower) from 1.73 m2. Furthermore, the adjustment for BSA does not take gender into account, thus ignoring the differences between men and women in this regard. However, the difference between adjusted and unadjusted GFR by gender has been seldom evaluated in a wide cohort. The present study aimed to evaluate the impact of the adjustment of GFR by BSA in our whole cohort of patients with and without CKD. Method We evaluated renal function by the plasma clearance of iohexol using dried blood spot technique (iohexol-DBS) at the Renal Function Laboratory of the University of La Laguna in 2389 patients with CKD of diverse aetiologies. We reported measured GFR at Hospital Universitario de Canarias as unadjusted in ml/min. Then, we adjusted the result by applying the formula (GFR unadjusted = GFR adjusted × BSA/1.73). BSA was calculated by DuBois and DuBois formula (BSA = 0.007184 × Weight0.425 × Height0.725). We then analyzed the difference in adjusted GFR compared to the unadjusted GFR by gender. We analyzed the number of cases with a percent difference between both values using a cut-off of 15%. In addition, we analyzed subgroups of men and women with extreme BSAs far from the 1.73 m2 standard: >2.00 and <1.50, to evaluate how adjustment of GFR by BSA affects this subpopulation of patients. Results Of the total of 2389 patients, 1561 (65%) were men and 827 (35%) women: 20% had advanced CKD (pre-dialysis), 27% CKD of diverse causes, 19% diabetes, 9% were living kidney donors and 15% kidney transplant recipients and 10% had other causes i.e. non-renal transplantation, cirrhosis, heart failure, etc. In men the mean unadjusted GFR was 61 ± xx ml/min in men, while the BSA-adjusted GFR was 53 ± xx ml/min/1.73 m2. However, in women the adjusted and unadjusted GFR were similar 59 ± xx ml/min or ml/min/1.73 m2. Around half of the men (n = 743, 47%) while only 10% of women (80 of 827) BSA adjustment led to a reduction in GFR with differences < −15% between unadjusted and BSA-adjusted GFR. In men, the average reduction of GFR with BSA adjustment was –24%, distributed as follows: 34% from −15 to −20%; 45% from −20 to −30% and 21% greater than −30%. Only 5 of 1561 male while 53 of 827 women (6%) had an increment > 15%. Conclusion The BSA adjustment differentially penalizes male subjects with and without CKD, particularly in those with larger height and/or weight, both variables of the Dobois-Dubois formula used to adjust the GFR, with a false mean reduction of 24% of GFR observed in almost half of the cases. However, this does not occur in women because the latter's body surface area is more similar to the 1.73 m2 standard. Adjustment for renal function should be abandoned because there is no scientific basis for it, and it may overestimate the degree of renal function in almost half of male patients.
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