Obtaining an accurate estimation of renal function is germane to optimizing care in critically ill patients. However, there is no consensus on the most accurate renal function assessment to utilize in this patient population, particularly in aneurysmal subarachnoid hemorrhage (aSAH) patients. Thus, the objective of this observational study was to determine the comparability of renal function equations to body surface area (BSA)-adjusted 8-h creatinine clearance (CrCl) in aSAH patients.
A PubMed search investigated the applicability of various renal function equations in critically ill patient populations. A subset of these equations was compared to BSA-adjusted 8-h CrCl from a previous study with aSAH patients with no evidence of renal dysfunction (admission serum creatinine < 1.5 mg/dL) and no history of chronic kidney disease. Area-under-the-curve (AUC) calculations were completed using serial laboratory measurements to validate preliminary findings.
A total of 14 renal function equations were identified with seven carried forward for further analysis based upon a priori criteria. Seven equations were excluded for various reasons, including lack of available clinical data, redundancy with other equations, and dissimilar patient populations to this study. When directly compared to the BSA-adjusted 8-h CrCl, only the Cockcroft–Gault and BSA-adjusted Cockcroft–Gault equations were not statistically significantly different (P = 0.0886 and P = 0.4805, respectively); all other equations were statistically significantly different (P < 0.0001). Additionally, only 52% and 44% of patients had average values within 20% of the BSA-adjusted 8-h CrCl using the Cockcroft–Gault and BSA-adjusted Cockcroft–Gault equations, respectively. Finally, the AUC calculations corroborated the preliminary findings with similar results in statistical testing for the Cockcroft–Gault and BSA-adjusted Cockcroft–Gault (P = 0.6300 and P = 0.1513, respectively).
The Cockcroft–Gault equation may be the best renal function equation to assess in critically ill patients diagnosed with aSAH. However, accuracy and consistency in assessing renal function when compared to the BSA-adjusted 8-h CrCl were lacking. Thus, this study suggests the BSA-adjusted 8-h CrCl may be the most appropriate assessment of renal function in patients with aSAH.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
May CC, Arora S, Parli SE, et al. Augmented renal clearance in patients with subarachnoid hemorrhage. Neurocrit Care. 2015;23(3):374–9.
Martin SM, Balestracci A, Aprea V, et al. Acute kidney injury in critically ill children: incidence and risk factors for mortality. Arch Argent Pediatr. 2013;111(5):411–6.
Sanchez-pinto LN, Goldstein SL, Schneider JB, Khemani RG. Association between progression and improvement of acute kidney injury and mortality in critically ill children. Pediatr Crit Care Med. 2015;16(8):703–10.
Hobbs AL, Shea KM, Roberts KM, Daley MJ. Implications of augmented renal clearance on drug dosing in critically ill patients: a focus on antibiotics. Pharmacotherapy. 2015;35(11):1063–75.
Sunder S, Jayaraman R, Mahapatra HS, et al. Estimation of renal function in the intensive care unit: the covert concepts brought to light. J Intensive Care. 2014;2(1):31.
Pea F, Viale P, Furlanut M. Antimicrobial therapy in critically ill patients: a review of pathophysiological conditions responsible for altered disposition and pharmacokinetic variability. Clin Pharmacokinet. 2005;44(10):1009–34.
Lantigua H, Ortega-gutierrez S, Schmidt JM, et al. Subarachnoid hemorrhage: Who dies, and why? Crit Care. 2015;19:309.
Lin HL, Soo KM, Chen CW, et al. Incidence, national trend, and outcome of nontraumatic subarachnoid haemorrhage in Taiwan: initial lower mortality, poor long-term outcome. Biomed Res Int. 2014;2014:274572.
Wartenberg KE, Mayer SA. Medical complications after subarachnoid hemorrhage. Neurosurg Clin N Am. 2010;21:325–38.
Wartenberg KE, Mayer SA. Medical complications after subarachnoid hemorrhage: new strategies for prevention and management. Curr Opin Crit Care. 2006;12:78–84.
Naidech AM, Bendok BR, Tamul P, et al. Medical complications drive length of stay after brain hemorrhage: a cohort study. Neurocrit Care. 2009;10:11–9.
Liotta EM, Singh M, Kosteva AR, et al. Predictors of 30-day readmission after intracerebral hemorrhage: a single-center approach for identifying potentially modifiable associations with readmission. Crit Care Med. 2013;41:2762–9.
Solenski NJ, Haley EC Jr, Kassell NF, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the multicenter cooperative aneurysm study. Crit Care Med. 1995;23:1007–17.
Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol. 2012;11:101–18.
Tujjar O, Belloni I, Hougardy JM, et al. Acute kidney injury after subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2017;29(2):140–9.
Rumalla K, Mittal MK. Acute renal failure in aneurysmal subarachnoid hemorrhage: nationwide analysis of hospitalizations in the United States. World Neurosurg. 2016;91(542–547):e6.
Morbitzer KA, Jordan JD, Dehne KA, Durr EA, Olm-Shipman CM, Rhoney DH. Enhanced renal clearance in patients with hemorrhagic stroke. Crit Care Med. 2019;47(6):800–8.
Udy AA, Baptista JP, Lim NL, et al. Augmented renal cleaeance in the ICU: results of a multicenter observational study of renal function in critically ill patients with normal plasma concentrations. Crit Care Med. 2014;42:520–7.
Devine BJ. Gentamicin therapy. DICP. 1974;8:650–5.
DuBois D, DuBois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Int Med. 1916;17:863–71.
Michels WM, Grootendorst DC, Verduijn M, Elliott EG, Dekker FW, Krediet RT. Performance of the Cockcroft–Gault, MDRD, and new CKD-EPI formulas in relation to GFR, age, and body size. Clin J Am Soc Nephrol. 2010;5(6):1003–9.
Rostoker G, Andrivet P, Pham I, Griuncelli M, Adnot S. Accuracy and limitations of equations for predicting the glomerular filtration rate during follow-up of patients with non-diabetic nephropathies. BMC Nephrol. 2009;10:16.
Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31–41.
Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med. 1993;21(10):1487–95.
Botev R, Mallié JP, Couchoud C, et al. Estimating glomerular filtration rate: Cockcroft–Gault and Modification of Diet in Renal Disease formulas compared to renal inulin clearance. Clin J Am Soc Nephrol. 2009;4(5):899–906.
Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Intern Med. 2006;145:247–54.
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of diet in renal disease study group. Ann Intern Med. 1999;130(6):461–70.
Jelliffe R. Estimation of creatinine clearance in patients with unstable renal function, without a urine specimen. Am J Nephrol. 2002;22(4):320–4.
Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–12.
Kirkpatrick CM, Duffull SB, Begg EJ. Pharmacokinetics of gentamicin in 957 patients with varying renal function dosed once daily. Br J Clin Pharmacol. 1999;47(6):637–43.
Mawer GE, Lucas SB, Knowles BR, Stirland RM. Computer-assisted prescribing of kanamycin for patients with renal insufficiency. Lancet. 1972;1(7740):12–5.
Hull JH, Hak LJ, Koch GG, Wargin WA, Chi SL, Mattocks AM. Influence of range of renal function and liver disease on predictability of creatinine clearance. Clin Pharmacol Ther. 1981;29(4):516–21.
Morbitzer KA, Jordan JD, Sullivan KA, Durr EA, Olm-shipman CM, Rhoney DH. Vancomycin pharmacokinetic parameters in patients with hemorrhagic stroke. Neurocrit Care. 2016;25(2):250–7.
De Waele JJ, Dumoulin A, Janssen A, Hoste EA. Epidemiology of augmented renal clearance in mixed ICU patients. Minerva Anestesiol. 2015;81(10):1079–85.
Udy AA, De Waele JJ, Lipman J. Augmented renal clearance and therapeutic monitoring of β-lactams. Int J Antimicrob Agents. 2015;45(4):331–3.
Udy AA, Roberts JA, Lipman J. Implications of augmented renal clearance in critically ill patients. Nat Rev Nephrol. 2011;7(9):539–43.
Claus BO, Hoste EA, Colpaert K, Robays H, Decruyenaere J, De Waele JJ. Augmented renal clearance is a common finding with worse clinical outcome in critically ill patients receiving antimicrobial therapy. J Crit Care. 2013;28(5):695–700.
Udy AA, Varghese JM, Altukroni M, et al. Subtherapeutic initial B-lactam concentrations in select critically ill patients: association between augmented renal clearance and low trough drug concentrations. Chest. 2012;142(1):30–9.
Cojutti PG, Barbarino C, De monte A, Hope W, Pea F. Higher than standard meroperem and linezolid dosages needed for appropriate treatment of an intracerebral hemorrhage patient with augmented renal clearance. Eur J Clin Pharmacol. 2018;74(8):1091–2.
Zacharia BE, Ducruet AF, Hickman ZL, et al. Renal dysfunction as an independent predictor of outcome after aneurysmal subarachnoid hemorrhage: a single-center cohort study. Stroke. 2009;40(7):2375–81.
Sweileh WM. Predictors of in-hospital mortality after acute stroke: impact of renal dysfunction. Int J Clin Pharmacol Ther. 2008;46(12):637–43.
Ruiz S, Minville V, Asehnoune K, et al. Screening of patients with augmented renal clearance in ICU: taking into account the CKD-EPI equation, the age, and the cause of admission. Ann Intensive Care. 2015;5(1):49.
Grootaert V, Willems L, Debaveye Y, Meyfroidt G, Spriet I. Augmented renal clearance in the critically ill: how to assess kidney function. Ann Pharmacother. 2012;46(7–8):952–9.
Baptista JP, Neves M, Rodrigues L, Teixeira L, Pinho J, Pimentel J. Accuracy of the estimation of glomerular filtration rate within a population of critically ill patients. J Nephrol. 2014;27(4):403–10.
Lee JP, Dang AT. Evaluation of methods to estimate glomerular filtration rate versus actual drug clearance in patients with chronic spinal cord. Spinal Cord. 2011;49(12):1158–63.
Conil JM, Georges B, Fourcade O, et al. Assessment of renal function in clinical practice at the bedside of burn patients. Br J Clin Pharmacol. 2007;63(5):583–94.
Barraclough K, Er L, Ng F, Harris M, Montaner J, Levin A. A comparison of the predictive performance of different methods of kidney function estimation in a well-characterized HIV-infected population. Nephron Clin Pract. 2009;111(1):c39–48.
Baptista JP, Udy AA, Sousa E, et al. A comparison of estimates of glomerular filtration in critically ill patients with augmented renal clearance. Crit Care. 2011;15(3):R139.
Udy AA, Boots R, Senthuran S, et al. Augmented creatinine clearance in traumatic bran injury. Anesth Analg. 2010;111:1505–10.
Hao Z, Wu B, Lin S, et al. Association between renal function and clinical outcome in patients with acute stroke. Eur Neurol. 2010;63(4):237–42.
Tsagalis G, Akrivos T, Alevizaki M, et al. Renal dysfunction in acute stroke: an independent predictor of long-term all combined vascular events and overall mortality. Nephrol Dial Transplant. 2009;24(1):194–200.
Auriel E, Kliper E, Shenhar-Tsarfaty S, et al. Impaired renal function is associated with brain atrophy and poststroke cognitive decline. Neurology. 2016;86(21):1996–2005.
Miyagi T, Koga M, Yamagami H, et al. Reduced estimated glomerular filtration rate affects outcomes 3 months after intracerebral hemorrhage: the stroke acute management with urgent risk-factor assessment and improvement-intracerebral hemorrhage study. J Stroke Cerebrovasc Dis. 2015;24(1):176–82.
Steinke T, Moritz S, Beck S, Gnewuch C, Kees MG. Estimation of creatinine clearance using plasma creatinine or cystatin C: a secondary analysis of two pharmacokinetic studies in surgical ICU patients. BMC Anesthesiol. 2015;15:62.
Dowling TC, Matzke GR, Murphy JE. Estimated GFR vs creatinine clearance for drug dosing. Am J Kidney Dis. 2009;54(5):984–5.
Baumann TJ, Staddon JE, Horst HM, Bivins BA. Minimum urine collection periods for accurate determination of creatinine clearance in critically ill patients. Clin Pharm. 1987;6(5):393–8.
Cherry RA, Eachempati SR, Hydo L, Barie PS. Accuracy of short-duration creatinine clearance determinations in predicting 24-hour creatinine clearance in critically ill and injured patients. J Trauma. 2002;53(2):267–71.
The original study was funded through the Department of Neurology at the University of North Carolina School of Medicine.
This study was approved by the University of North Carolina Institutional Review Board. Drs. Morbitzer and Rhoney report a grant from University of North Carolina School of Medicine, during the conduct of the study; the remaining author has nothing to disclose.
Ethical approval/Informed consent
This study protocol was approved by the UNC Institutional Review Board.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Wells, M.A., Morbitzer, K. & Rhoney, D.H. Evaluation of the Accuracy of Standard Renal Function Equations in Critically Ill Patients with Subarachnoid Hemorrhage. Neurocrit Care (2019). https://doi.org/10.1007/s12028-019-00854-w
- Critical care
- Subarachnoid hemorrhage