Estimation of creatinine clearance in elderly persons in long-term care facilities.

Nearly 25% of patients over the age of 85 years reside in nursing homes (1). Prescribing for the older patient presents several challenges, partly because of the presence of comorbid illness (2) and ageassociated decline in renal function (3,4). The clearance of renally excreted drugs and their metabolites is reduced by renal insufficiency, increasing the risk of adverse events (5). For example, renal impairment increases the likelihood of antibiotic drug toxicity (6,7), as well as toxicity due to amantadine (8), nonsteroidal anti-inflammatory drugs (9), angiotensin-converting enzyme inhibitors (10), and digoxin (11). It is recommended that both the dose and dosing interval of these drugs be adjusted for the decreased renal function (6,7,12). Knowledge about the decrease in renal function among the older population is limited. Previous studies have included fewer than 50 participants, with even fewer adults over the age of 80 years or living in institutions being considered. Larger studies have focused on serum creatinine levels rather than on estimated creatinine clearance (13). Accordingly, we conducted a large study of elderly long-term care residents to describe the prevalence of renal impairment in this population, as well as the changes in serum creatinine level and creatinine clearance with advancing age.

[1]  B. Zarowitz,et al.  Predictability of creatinine clearance estimates in critically ill patients , 1993, Critical care medicine.

[2]  D. Levy,et al.  Prevalence and correlates of elevated serum creatinine levels: the Framingham Heart Study. , 1999, Archives of internal medicine.

[3]  C. Weinberg,et al.  Nonsteroidal anti-inflammatory drugs and the risk for chronic renal disease. , 1991, Annals of internal medicine.

[4]  M. Young,et al.  Measured versus Estimated Creatinine Clearance in the Elderly as an Index of Renal Function , 1980, Journal of the American Geriatrics Society.

[5]  M Wolfson,et al.  Drug prescribing in renal failure: dosing guidelines for adults. , 1983, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[6]  L. Sokoll,et al.  Establishment of creatinine clearance reference values for older women. , 1994, Clinical chemistry.

[7]  M. Finkelstein,et al.  Difficulties in estimating glomerular filtration rate in the elderly. , 1987, Archives of internal medicine.

[8]  M. O’Connell,et al.  Predictive Performance of Equations to Estimate Creatinine Clearance in Hospitalized Elderly Patients , 1992, The Annals of pharmacotherapy.

[9]  D. Platt,et al.  Age-Dependent Changes of the Kidneys: Pharmacological Implications , 1999, Gerontology.

[10]  G. Drusano,et al.  Commonly Used Methods of Estimating Creatinine Clearance Are Inadequate for Elderly Debilitated Nursing Home Patients , 1988, Journal of the American Geriatrics Society.

[11]  D. Forman,et al.  Evaluating the Use of Angiotensin‐Converting Enzyme Inhibitors For Older Nursing Home Residents with Chronic Heart Failure , 1998, Journal of the American Geriatrics Society.

[12]  C. Frampton,et al.  Assessment of creatinine clearance in healthy subjects over 65 years of age. , 1991, Nephron.

[13]  Z. Duraković.  Creatinine clearance in the elderly: a comparison of direct measurement and calculation from serum creatinine. , 1986, Nephron.

[14]  Cockcroft Dw,et al.  Prediction of Creatinine Clearance from Serum Creatinine , 1976 .

[15]  M. Bédard,et al.  Assessment of Adherence to Renal Dosing Guidelines in Long‐Term Care Facilities , 2000, Journal of the American Geriatrics Society.

[16]  W. Stone,et al.  Adverse antibiotic effects associated with renal insufficiency. , 1990, Reviews of infectious diseases.

[17]  D. Guay,et al.  Comparison of Pharmacokinetic and Safety Profiles of Amantadine 50‐ and 100‐mg Daily Doses in Elderly Nursing Home Residents , 1991, Pharmacotherapy.

[18]  D. Fliser,et al.  Renal handling of drugs in the healthy elderly Creatinine clearance underestimates renal function and pharmacokinetics remain virtually unchanged , 1999, European Journal of Clinical Pharmacology.

[19]  A. Egberts,et al.  Adverse drug events in hospitalized patients A comparison of doctors, nurses and patients as sources of reports , 1999, European Journal of Clinical Pharmacology.

[20]  J. Avorn,et al.  Drug Use in the Nursing Home , 1996, Annals of Internal Medicine.

[21]  P. Drinka.  Estimating creatinine clearance from serum creatinine in chronically immobilized nursing home residents. , 1987, Nephron.

[22]  J. Guralnik,et al.  Serum creatinine levels in older adults: relationship with health status and medications. , 1995, Age and ageing.

[23]  A. H. Norris,et al.  The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study. , 1976, Journal of gerontology.

[24]  W. Aronow.  Prevalence of Appropriate and Inappropriate Indications for Use of Digoxin in Older Patients at the Time of Admission to a Nursing Home , 1996, Journal of the American Geriatrics Society.

[25]  H. Jick.  Adverse drug effects in relation to renal function. , 1977, The American journal of medicine.

[26]  A. Levey,et al.  A More Accurate Method To Estimate Glomerular Filtration Rate from Serum Creatinine: A New Prediction Equation , 1999, Annals of Internal Medicine.

[27]  W. S. St. Peter,et al.  Clinical Pharmacokinetics of Antibiotics in Patients with Impaired Renal Function , 1992, Clinical pharmacokinetics.

[28]  M. Labeeuw,et al.  Screening early renal failure: cut-off values for serum creatinine as an indicator of renal impairment. , 1999, Kidney international.

[29]  D. Norman,et al.  Correlation of Estimated Renal Function Parameters Versus 24‐Hour Creatinine Clearance in Ambulatory Elderly , 1989, Journal of the American Geriatrics Society.

[30]  D. Classen,et al.  Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. , 1997, JAMA.

[31]  N W Shock,et al.  Longitudinal Studies on the Rate of Decline in Renal Function with Age , 1985, Journal of the American Geriatrics Society.

[32]  J. Coresh,et al.  Serum creatinine levels in the US population: third National Health and Nutrition Examination Survey. , 1998, American journal of kidney diseases : the official journal of the National Kidney Foundation.