Prediction of End-Stage Kidney Disease Using Estimated Glomerular Filtration Rate With and Without Race : A Prospective Cohort Study

Ann Intern Med. 2022 Mar;175(3):305-313. doi: 10.7326/M21-2928. Epub 2022 Jan 11.


Background: New estimated glomerular filtration rate (eGFR) equations removed race adjustment, but the impact of its removal on prediction of end-stage kidney disease (ESKD) is unknown.

Objective: To compare the ESKD prediction performance of different eGFR equations.

Design: Observational, prospective cohort study.

Setting: 7 U.S. clinical centers.

Participants: 3873 participants with chronic kidney disease (CKD) from the CRIC (Chronic Renal Insufficiency Cohort) Study contributing 13 902 two-year risk periods.

Measurements: ESKD was defined as initiation of dialysis or transplantation. eGFR was calculated using 5 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on serum creatinine and/or cystatin C, with or without race adjustment. The predicted 2-year risk for ESKD was calculated using the 4-variable Kidney Failure Risk Equation (KFRE). We evaluated the prediction performance of eGFR equations and the KFRE score using discrimination and calibration analyses.

Results: During a maximum 16 years of follow-up, 856 participants developed ESKD. Across all eGFR equations, the KFRE score was superior for predicting 2-year incidence of ESKD compared with eGFR alone (area under the curve ranges, 0.945 to 0.954 vs. 0.900 to 0.927). Prediction performance of KFRE scores using different eGFR equations was similar, but the creatinine equation without race adjustment improved calibration among Black participants. Among all participants, compared with an eGFR less than 20 mL/min/1.73 m2, a KFRE score greater than 20% had similar specificity for predicting 2-year ESKD risk (ranges, 0.94 to 0.97 vs. 0.95 to 0.98) but higher sensitivity (ranges, 0.68 to 0.78 vs. 0.42 to 0.66).

Limitation: Data are solely from the United States.

Conclusion: The KFRE score better predicts 2-year risk for ESKD compared with eGFR alone, regardless of race adjustment. The creatinine equation with age and sex may improve calibration among Black patients. A KFRE score greater than 20% showed high specificity and sensitivity for predicting 2-year risk for ESKD.

Primary funding source: National Institutes of Health.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Cohort Studies
  • Creatinine
  • Glomerular Filtration Rate
  • Humans
  • Kidney Failure, Chronic* / etiology
  • Kidney Function Tests / adverse effects
  • Prospective Studies
  • Renal Insufficiency, Chronic* / complications
  • Renal Insufficiency, Chronic* / epidemiology


  • Creatinine