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Clinical Research

The estimation of GFR and the adjustment for BSA in overweight and obesity: a dreadful combination of two errors

International Journal of Obesity volume 44, pages 1129–1140 (2020)Cite this article

Subjects

Abstract

Background

Obesity is an established risk factor for renal disease and for disease progression. Therefore, an accurate determination of renal function is necessary in this population. Renal function is currently evaluated by estimated glomerular filtration rate (GFR) by formulas, a procedure with a proven high variability. Moreover, the adjustment of GFR by body surface area (BSA) confounds the evaluation of renal function. However, the error of using estimated GFR adjusted by BSA has not been properly evaluated in overweight and obese subjects.

Methods

We evaluated the error of 56 creatinine- and/or cystatin-C-based equations and the adjustment of GFR by BSA in 944 subjects with overweight or obesity with or without chronic kidney disease (CKD). The error between estimated (eGFR) and measured GFR (mGFR) was evaluated with statistics of agreement: the total deviation index (TDI), the concordance correlation coefficient (CCC) and the coverage probability (cp).

Results

The error of eGFR by any equation was common and wide: TDI averaged 55%, meaning that 90% of estimations ranged from −55 to 55% of mGFR. CCC and cp averaged 0.8 and 26, respectively. This error was comparable between creatinine and cystatin-C-based formulas both in obese or overweight subjects. The error of eGFR was larger in formulas that included weight or height. The adjustment of mGFR or eGFR led to a relevant underestimation of renal function, reaching at least 10 mL/min in 25% of the cases.

Conclusions

In overweight and obese patients, formulas failed in reflecting real renal function. In addition, the adjustment for BSA led to a relevant underestimation of GFR. Both errors may have important clinical consequences. Thus, whenever possible, the use of a gold standard method to measure renal function is recommended. Moreover, the sense of indexing for BSA should be re-considered and probably abandoned.

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Acknowledgements

We thank the Instituto de Tecnologías Biomédicas (ITB), the DISA Foundation, the Spanish Society of Nephrology (SENEFRO) and the IMBRAIN project for support (FP7-RE6-POT-2012-CT2012-31637-IMBRAIN) funded under the 7th Frameworks Programme capacities.

Funding

SLL is a researcher of the Juan Rodés Contract (Grant number: JR18/00027) of the Instituto de Salud Carlos III (Spain). EP is a researcher of the Programme Ramón y Cajal (Grant number: RYC-2014-16573) of the Ministerio de Ciencia, Innovación y Universidades (Spain). This study was supported by grants from the Instituto de Salud Carlos III (Grant numbers: PI13/00342 and PI16/01814) and Red de Investigación Renal (REDinREN) (Grant number: RD16/0009/0031).

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Authors and Affiliations

  1. Department of Nephrology, Hospital Universitario Germans Trias i Pujol, Badalona, Spain

    Marina López-Martínez & Maruja Navarro-Díaz

  2. Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz, Madrid, Spain

    Sergio Luis-Lima, Natalia Negrín-Mena, Laura Díaz-Martín, Alejandro Jiménez-Sosa & Federico González-Rinne

  3. Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain

    Enrique Morales

  4. Department of Endocrinology, Hospital Universitario de Canarias, Tenerife, Spain

    Tomás Folgueras

  5. Department of Nephrology, Hospital Universitario de Canarias, Tenerife, Spain

    Beatriz Escamilla, Sara Estupiñán, Patricia Delgado-Mallén, Domingo Marrero-Miranda, Ana González-Rinne, Rosa María Miquel-Rodríguez, Maria Angeles Cobo-Caso & Armando Torres

  6. Internal Medicine Department, Universidad de La Laguna, Instituto de Tecnologías Biomédicas, Tenerife, Spain

    Armando Torres & Esteban Porrini

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  1. Marina López-Martínez
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Contributions

MLM, SLL and EP had the idea of the study. EM, MND, TF, BE, SE, PDM, DMM, AGR, RMMR, MACC and AT helped in the performance of the study. LDM and NNM performed the plasma clearance of iohexol. SLL evaluated the GFR determination. FGR design the figures and AJS performed the statistical analysis.

Corresponding author

Correspondence to Esteban Porrini.

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López-Martínez, M., Luis-Lima, S., Morales, E. et al. The estimation of GFR and the adjustment for BSA in overweight and obesity: a dreadful combination of two errors. Int J Obes 44, 1129–1140 (2020). https://doi.org/10.1038/s41366-019-0476-z

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