Obesity, Underweight, and Accuracy of eGFR Using Cystatin C and Creatinine in a Northern European Population

Background: The presence of a low or high body mass index (BMI) in patients may influence the accuracy of estimated glomerular filtration rate (eGFR). This study evaluates the performance of eGFR equations across the range of BMI. Methods: This is an observational study of 4,707 adults (7,503 repeated observations) referred for measured GFR (mGFR) in Stockholm, Sweden. We calculated indexed eGFR (in mL/min/1.73 m 2 ) and non-indexed eGFR (in mL/min) with validated equations that use creatinine (eGFR cr ), cystatin C (eGFR cys ), or both (eGFR cr-cys ). We assessed equation performance against indexed and non-indexed mGFR across categories of BMI with median bias, P 30 (the percentage of estimated values within 30% of mGFR), and classification of GFR categories, and modelled the implications of choice of filtration marker and indexing on clinical decisions regarding dose-adjustment or eligibility for treatment. Results: Mean age(SD)was 57(16) years (39% female), and median(IQR) indexed and non-indexed mGFR were 59(39-79) and 65(42-87), respectively. In total, 9% of participants were underweight (BMI <20 kg/m 2 ) and 18% were obese (BMI ≥ 30 kg/m 2 ). For indexed and non-indexed eGFR for all equations, eGFR cr overestimated mGFR at BMI <20 kg/m 2 and ≥30 kg/m 2 , and eGFR cys underestimated mGFR at BMI ≥30 kg/m 2 . eGFR cr-cys had the least bias, acceptable P 30 , and highest correct classification throughout the BMI range. In theoretical modelling, using indexed eGFR cr-cys vs. eGFR cr would allow more accurate clinical decisions across all BMI categories. Using non-indexed vs. indexed eGFR cr-cys would lead to further but smaller improvement that was not consistently related to BMI category for these decisions. Conclusions: In a clinical population of northern European individuals referred for GFR measurement, indexed eGFR cr-cys was more accurate than indexed eGFR cr across the BMI spectrum and may improve classification accuracy for treatment decisions. Using non-indexed eGFR cr-cys further improved accuracy for some treatment decisions.