On 2025-11-30 17:00:32, user Cyril Burke wrote:
RESPONSE TO REVIEWER #2<br />
June 27, 2022<br />
Reviewer #2: Thank-you for the opportunity to review this work which highlights the importance of monitoring serum creatinine over time and how this can be a useful tool in detecting possible CKD. This is an important topic as the use of sCr on its own is certainly under-utilized and changes are often missed because they don’t fall into a predefined category.<br />
Thank you for considering our manuscript and for your detailed comments.
MAJOR CONCERNS
A. “Choi- rates of ESRD in Black and White Veterans” doesn’t fit with the rest of the paper including the title; the introduction and conclusion also don’t adequately address this portion of the paper. It feels disjointed from the main point of discussion which is the use of sCr in screening “pre-CKD”. This section and discussion should be removed and possibly considered for another type of publication.<br />
We have attempted to clarify this inclusion. This manuscript could be divided into three or four short papers, increasing the likelihood that any one of them would be read. However, different groups tend to read papers about screening for kidney impairment, racial disparities, cofactors in modeling physiologic parameters, or policy proposals to encourage best practices. Despite the appeal of perhaps three or four publications, we decided to tell a complete story in a single paper, but we are open to suggestions.
Black Americans suffer three times the kidney failure of White Americans. Other minority groups also have excessive rates of kidney disease. However, analysis of Veterans Administration interventions can bring that ratio close to one, similar interventions might also reduce to parity the risk for Hispanic, Asian, Native Americans, and others. Within-individual referencing should allow better monitoring of all patients and help to reveal the circumstances and novel kidney toxins that lead to progressive kidney decline. The ability to identify a healthy elderly cohort with essentially normal kidneys would help to calibrate expectations for all. Better modeling of GFR should help everyone, too.
Over eight decades, anthropologists have had little scholarly success in diminishing the inappropriate use of ‘race’. Keeping these parts together may be no more successful, but we feel compelled to try.
B. Cases 1 - 3, (lines 93 – 122): where are these cases from? There is no mention of ethics to publish these patient results, which appears to be a clear ethics violation. If so, these cases should be removed and patient consent and ethical approval obtained to publish them.<br />
The authors describe the reasons for not obtaining an ethics waiver for this secondary data analysis. Despite this, the relative ease of obtaining an ethics waiver for secondary data analysis usually means that this is done regardless.<br />
We take patient privacy seriously and have completely de-identified the Case data, as required by Privacy Act regulations. We understand that no authorization or waiver was necessary. We discussed the issues with an IRB representative, reviewed the relevant regulations, and confirmed no need for formal review of a secondary analysis of already publicly available IRB-approved data or of completely de-identified clinical data collected in the course of a treating relationship.
IRBs have a critical role to play, but many (including ours) are overworked. We understand the impulse authors feel to gain IRB approval even when the regulations clearly do not required it. As we discuss in the revision, there is a more significant matter that IRBs could help to resolve if they have the resources to do so. For all of these reasons, and even though we, too, felt the urge to obtain IRB approval, we resisted adding “just a little more” to their work.
C. The message of the article and data representation is unclear: do the authors wish to show that sCr is superior to eGFR in this “pre-CKD” stage, should both be used together? Do the authors wish to convey that a “creatinine blind range” does not exist? Or is the aim to demonstrate that continuous variables should not be interpreted in a categorical manner?<br />
Our interest is detection and prevention of progression of early kidney injury at GFRs above 60 mL/min – a range in which eGFR is especially unreliable. We have advanced the best argument we can to detect changes in sCr while kidney injury is still limited and perhaps reversible. If experience reveals that some avoidable exposure(s) begins the decline, then clinicians might alert patients and thereby reduce kidney disease. How best to use longitudinal sCr remains to be determined from experience. However, our message is that early changes in sCr can provide early warning of a decline in glomerular filtration. We are confident that clinicians can learn to separate other factors that may alter sCr, as we do for many other tests.
MINOR CONCERNS<br />
ABSTRACT<br />
A. Vague. Doesn’t give a clear picture of the study<br />
We have tried to clarify the title and abstract and are open to further suggestions.
INTRODUCTION<br />
B. 51 – 57: needs to state that these stats are from e.g. the US. The authors should consider adding international statistics to complement those from the US.<br />
We have updated the statistics on death rates from kidney disease to include US and global data.
C. 68: reference KDIGO guidelines, state year<br />
We now reference the KDIGO 2012 guidelines.
D. 75 – 77: is this reference of the New York Times the most appropriate?<br />
We have expanded this section with peer-reviewed, scholarly references. However, we found Hodge’s summary of the issue succinct and hence potentially more persuasive for some than decades of scholarly references that have had limited or no effect in the clinic.
E. 82: within-individual variation not changes (this is repetition of the point made in lines 425 – 427, but should match the language)<br />
We have matched the language.
F. 82 – 84: reference? If this is a question it should be presented as such<br />
We have attempted to clarify this statement.
G. 84: “normal GFR above 60” = guidelines (including KDIGO) do not refer to 60 as normal GFR, 60 – 89 is mildly decreased. (see line 126)<br />
We agree and have corrected the language.
H. 93: avoid the use of emotive words such as apparently (also in line 428)<br />
We wanted to emphasize appearance without proof and have made these changes.
I. 94: “Not meeting KDIGO guidelines”: KDIGO 2.1.3 includes a drop in category (including those with GFR >90). This would appear to include some of the cases listed. Additionally, albuminuria should have been measured for case 2 and 3.<br />
We have clarified that cases may or may not fit KDIGO categories, though that question will frequently arise in evaluating sCr changes. Where available, we have added urine protein and/or albumin results to the Cases.
J. 97: “progressive loss of nephrons equivalent to one kidney”: this is based on a single creatinine measurement.<br />
Since the original submission, we discovered for this Case (now Patient 3) early serum creatinine results and notes indicating a six-month period off thiazide diuretic. This data clarified the baseline and showed a remarkable effect of thiazide diuretic on sCr. We have added follow-up sCr results and details of thiazide use to the ASC chart.
K. 93 – 122: Could any of these shifts be explained by changes in creatinine methodology or standardization of assays, especially over 15 – 20 years (major differences between assays existed before standardization and arguably still exist with certain methods).<br />
It would be useful to see a comparison between serial sCr and eGFR measurements on the same figure. There appears to be significant (possibly more pronounced) changes when eGFR is used. As line 87 mentions changes in eGFR may be as useful (and in some situations more useful) than changes in sCr alone.
It would be helpful to have a chronology from each local laboratory with the date of every change in creatinine assay or standardization. However, any single shift draws attention but does not necessarily indicate significant change in glomerular filtration. After one or several incremental increases, over at least three months, the sCr pattern may meet the reference change value (RCV) that signals significant change. In the future, from age 20 or so, a patient’s medical record should retain the full range of the longitudinal sCr for true baseline comparison.
As noted in the revised manuscript, Rule et al showed that there is measurable nephrosclerosis even in the youngest kidney donors, suggesting that some injuries (perhaps exposure to dietary toxins) may begin in childhood and that early preventive counseling may be worthwhile. Experience will show whether this can slow progression to CKD. As we note, quoting Delanaye, sCr accounts for virtually 100% of the variability in eGFR equations based on sCr (eGFRcr), and these equations add their own uncertainties, so no, we do not believe that eGFR is more useful than sCr when GFR is above 60 mL/min and possibly much lower as well.
We have added eGFR results to the ASC charts (in blue), though availability was somewhat limited.
L. 127 – 142: should there be separate charts for males and females, the differences in creatinine between males and females needs to be discussed somewhere in the paper.
We do not think there should be separate charts for men and women based on size. The role of sex in eGFR equations is mainly based on the presumption that the average woman has less muscle mass than the average man. Clinicians care for individuals, not averages, and this sweeping generalization that increases agreement of the average of a population introduces unacceptable inaccuracy to individual care. Within-individual comparison eliminates the need for assumptions on relative size or muscle mass. Major changes in an individual’s muscle mass will usually be evident to the clinician who can adjust for them.
However, reports suggest significant influence of sex hormones on renal function, including effects of estrogen and estrogen receptors, such as reducing kidney fibrosis, increasing lupus nephritis, and increasing CKD after bilateral oophorectomy. The mechanism of these effects and how they might be incorporated into eGFR estimating equations is unclear, but the effort may benefit from a more individualized approach with focus on a measurand rather than matching population-based averages of a quantity value (calculated from measurands).
M. Similarly, is this suitable for all ages?<br />
We think so. Another sweeping generalization based on age merely introduces another inaccuracy which complicates the task of clinicians caring for individuals. Older persons have varying health, athleticism, muscle mass, dietary preferences, etc. Rule et al reported that biopsies of about 10% of older kidney donors had no nephrosclerosis. Within-individual comparison eliminates the need for assumptions on relative muscle mass or inevitable senescent decline in nephron number. We substitute the assumption that any change in an individual’s muscle mass will be evident and can be accounted for. A seemingly ubiquitous risk factor, or factors, starts injuring kidneys at a young age, which we may yet identify.
N. 162 – 163: rephrase<br />
Done.
METHODS<br />
O. 185 – 193: aim belongs in the introduction, can be adjusted to complement paragraph 178 – 182.<br />
Reorganized and rewritten.
P. 196 – 205: reference sources
References provided.
Q. 224 – 247: not in keeping with the rest of the article or title and conclusion
We have revised and restructured this section.
RESULTS<br />
R. If eGFR is treated as a continuous variable does inverted sCr still have higher accuracy?<br />
We believe so. Serum creatinine is a measurand and reflects the total sum of physiologic processes, known and unknown. In contrast, eGFR equations yield a quantity value, calculated from a measurand and dependent on the assumptions and approximations incorporated by their authors. The eGFR equations are thus necessarily less accurate than the measurands they are derived from, in this case, sCr. In a hyperbolic relationship, as the independent variable drops below one and approaches zero, the effect is to amplify the inaccuracy of the independent variable in the dependent variable. By avoiding the mathematical inverting, the data suggest that direct use of sCr is far more practical for pre-CKD.
S. As mentioned, the section on ESRD in black and white veterans doesn’t fit in with the rest of the article.<br />
We have revised, reorganized, and rewritten. We also outlined our rationale above.
DISCUSSION<br />
T. As mentioned, section 4.1 doesn’t fit in with the rest of the article. As the authors note the correlation between illiteracy and CKD is likely not causal.<br />
See above.
U. 387: erroneous creatinine blind range. The data presented does not show this is erroneous there is still a relative blind range. A distinction must be made between a population level “blind range” and an individual patient’s serial results. The data and figure 4 in particular demonstrate the lack of predictive ability of sCr above 40ml/min compared to below 40ml/min at a population level. For an individual patient this “blind range” is more relative, and a change in sCr even within the normal range may be predictive. (Note: the terminology “blind range” is problematic).<br />
We agree. On reading closer, Shemesh et al call attention to “subtle changes” in serum creatinine even though they had access only to the uncompensated Jaffe assay, so their recommendation to monitor sCr is even more forceful, today, due to more accurate and standardized creatinine assays. We have attempted to clarify this in the manuscript.
V. 399 – 400: “rose slowly at first and then more rapidly as mGFR decreased below 60” this refers to a relative blind range. Whether these slow initial changes can be distinguished from analytical and intra-individual variation is the question that needs to be answered before we can say a “blind-range” doesn’t exist for an individual patient.
We appreciate this observation. We believe longitudinal sCr is worth adopting to gain insights into individual sCr patterns, which may reveal early changes in GFR, among other influences on sCr. This is a low-cost, potentially high-impact population health measure, and there seems little risk in trying it because many clinicians already use components of the process.
W. 425 - 432: sCr is indeed very useful when baseline measurements are available. eGFR remains useful when baseline sCr is not available or when large intervals between measurements are found.<br />
As Delanaye et al noted, virtually 100% of the variability in longitudinal eGFR is due to sCr, so we understand that the errors in eGFR can be (and usually are) greater than but cannot be less than those in sCr.
X. 425: low analytical variation- if enzymatic methods are used<br />
Lee et al suggest that even the compensated Jaffe method provides some accuracy and reproducibility, which may allow longitudinal tracking of sCr even where more modern assays are as yet unavailable.
Y. 428: avoid the use of “apparently”<br />
Done.
Z. 430: reference 56 compares sCr and sCysC with creatinine clearance NOT with mGFR, this does not prove that mGFR has greater physiologic variability. Creatinine clearance is known to be highly variable (partially due to two sources of variability in the measurements of creatinine: serum and urine).<br />
The creatinine clearance is another form of mGFR, and our understanding of it begins with the units: if the clearance or removal of creatinine were being measured, the units should be umoles/minute, but they are mL/min. “Clearance” is an old concept coined by physiologists to describe many substances, such as urea, glucose, amino acids, and other metabolites. Since creatinine is mostly not reabsorbed and is only slightly secreted in the tubules, the “creatinine clearance” became a measure of GFR. The ratio of urine Creatinine to serum Creatinine is simply a factor for how much the original glomerular filtrate then gets concentrated (typically about 100-fold) by the kidney. Since the assumption is that the timed urine was once the rate of glomerular filtrate production, the creatinine clearance is a measure of the GFR.
Creatinine clearance has some inaccuracies based on tubular secretion, but also has some advantages: blood concentrations are essentially constant during urine collection, no need for exogenous administration, and reliable measurements in serum and urine. The methods that we often call mGFR also have problems, including unverifiable assumptions about distributions, dilutional effects, and others we cite in the text. None of these are direct measures of GFR. Due to changes in remaining nephrons, even true GFR itself is not strictly proportional to the lost number of functional nephrons, which seems the ultimate measure of CKD that Rule et al estimated from biopsy material.
AA. The limitations of sCr for screening should also be discussed: differences in performance and acceptability between enzymatic and Jaffe methods (still widely used in certain parts of the world), the effect of standardizing creatinine assays (an important initiative but one that could also produce shifts in results around the time of standardization- see cases), low InIx means that once-off values are exceedingly difficult to interpret, is a single raised creatinine value predictive (or should there be evidence of chronicity): similarly are there effects from protein rich meals, etc (The influence of a cooked-meat meal on estimated glomerular filtration rate. Annals of Clinical Biochemistry. 2007;44(1):35-42. doi:10.1258/000456307779595995)<br />
We have added discussion of additional references on reproducibility of sCr assays and discuss dietary meat and, in Part Three, possible dietary kidney toxins.
CONCLUSION<br />
BB. The discussion recommends using SCr above eGFR while the conclusion recommends the NKF-ASN eGFR for use in pre-CKD and ASC charts. While the use of both together in a complementary fashion is understandable- this needs to be congruent with the discussion, aims and results.<br />
We have rewritten this section. We would welcome any further recommendations.
Cyril O. Burke III, MD, FACP