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CLINICAL RESEARCH: RENAL FUNCTION IN ACUTE CORONARY SYNDROME

Cockcroft-Gault Versus Modification of Diet in Renal Disease

Importance of Glomerular Filtration Rate Formula for Classification of Chronic Kidney Disease in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

Chiara Melloni, MD, MHS^_*, Eric D. Peterson, MD, MPH^_*, Anita Y. Chen, MS^_*, Lynda A. Szczech, MD, MSCE^_*, L. Kristin Newby, MD, MHS^_*, Robert A. Harrington, MD^_*, W. Brian Gibler, MD, E. Magnus Ohman, MD^_*, Sarah A. Spinler, PharmD, FCCP, Matthew T. Roe, MD, MHS^_* and Karen P. Alexander, MD^_*,_*

^_* Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Philadelphia, Pennsylvania.

Manuscript received May 29, 2007; revised manuscript received October 5, 2007, accepted November 8, 2007.

^_* Reprint requests and correspondence: Dr. Karen P. Alexander, 2400 Pratt Street, Duke Clinical Research Institute, Durham, North Carolina 27705. (Email: alexa019{at}mc.duke.edu).

Objectives: Our purpose was to compare formulae for estimating glomerular filtration rate (GFR) in non–ST-segment elevation acute coronary syndromes (NSTE ACS) patients.

Background: Assessment of GFR is important for antithrombotic dose adjustment in NSTE ACS patients.

Methods: We assessed estimated glomerular filtration rate (eGFR) with Cockcroft-Gault (C-G) and Modification of Diet in Renal Disease (MDRD) formulae in 46,942 NSTE ACS patients from 408 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) hospitals. Formula agreement was shown continuously and by chronic kidney disease (CKD) stages. We determined in-hospital outcomes and the association between antithrombotic dose adjustment and bleeding for moderate CKD as determined by each formula.

Results: The median (interquartile range [IQR]) eGFR was 53.2 ml/min (34.7, 75.1 ml/min) by C-G and 65.8 ml/min (47.6, 83.5 ml/min) by MDRD. The mean eGFR was higher with MDRD (9.1 ml/min), but this difference was greater in age, weight, and gender subgroups. Chronic kidney disease classification differed in 20% of the population and altered when antithrombotic dose adjustment was required by C-G versus MDRD (eptifibatide: 45.7% vs. 27.3%; enoxaparin: 19.0% vs. 9.6%).

Conclusions: Important CKD disagreements occur in 20% of acute coronary syndrome patients, affecting dosing adjustments in those already susceptible to bleeding. Dosing based on C-G formula is preferable, particularly in the small, female, or elderly patient.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   BMI = body mass index   CI = confidence interval   CKD = chronic kidney disease   C-G = Cockcroft-Gault   eGFR = estimated glomerular filtration rate   GFR = glomerular filtration rate   GP = glycoprotein   MDRD = Modification of Diet in Renal Disease   NSTE ACS = non–ST-segment elevation acute coronary syndromes   OR = odds ratio

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