Race-agnostic eGFR for Medication-related Decisions

Since 1976, the Cockcroft-Gault estimated creatinine clearance (C-G eCrCL) equation has informed most dosing decisions for medications excreted by the kidneys and requiring adjustment in persons with impaired kidney function. However, since its introduction, more accurate kidney filtration estimating equations have been developed and other important factors call for a transition from C-G eCrCL to contemporary CKD-EPI estimated glomerular filtration rate (eGFR) equations. These include:  

• NKF and American Society of Nephrology (ASN) Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease recommended use of CKD-EPI race-agnostic eGFR equations for medical and medication-related decisions; 
• 2024 U.S. Food and Drug Administration (FDA) guidance for industry recommended use of eGFR to determine kidney function in pharmacokinetic (PK) studies over C-G eCrCL;
• Development and subsequent widespread use of standardized serum creatinine assay methods in clinical laboratories; and 
• Increasing availability and use of cystatin C for eGFR assessment. 

In addition, limitations in the development of the C-G eCrCL equation itself and accommodations to mitigate those limitations also make its continued use unsuitable. Among these are:

• Development using data from 249 white males;
• Use of an estimated (not scientifically quantified) 15% adjustment for females;
• Lack of validation in broader, more diverse patient populations;
• Inconsistent application of body weight parameters and adaptations for older age using highly variable criteria across clinicians and practices;
• Development before serum creatinine assays were standardized. Furthermore, when most serum creatinine assays were standardized by ~2011, this created an average 12% decrease in serum creatinine values when compared to pre-standardization, yielding eCrCL values that are higher (on average) than those obtained during the pharmacokinetic studies used to create dosing recommendations prior to 2011.

The consensus statement, U.S. Pharmacy Organizations Endorse Transition from C-G eCrCL to the 2021 CKD-EPI Equation for eGFR to Improve Medication-related Decision-making in Adults Across Healthcare Settings reflects support for moving from the C-G eCrCL equation to the 2021 CKD-EPIcr eGFR equation (with results adjusted for body surface area) as the preferred equation for estimating kidney function for medication-related decisions. This transition provides a consistent, accurate, and equitable foundation for medication decisions in people living with reduced kidney function across practice settings and patient populations.

Moving forward from C-G eCrCL to race-free eGFR to improve medication-related decision-making in adults across healthcare settings: A consensus of the NKF Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions frames out the limitations of the C-G eCrCL equation in today’s healthcare environment and provides evidence-based support for the transition to race-agnostic eGFR equations adjusted for individual body surface area. In doing so, the paper also reflects the expertise and experience of pharmacists, primary care clinicians, nephrologists, patients, and representatives from hospitals/health systems, clinical laboratories, electronic health record systems, and compendia and data vendors.

Transitioning from C-G eCrCL to the 2021 CKD-EPI eGFR with results adjusted for body surface area is being met with considerable interest and enthusiasm. However, this is only the beginning of the change. Advancing change successfully requires proven implementation strategies with contributions from all stakeholders: pharmacists, informaticists, pathologists, clinical laboratory specialists, prescribing clinicians, student pharmacists, compendia vendors, electronic health record (EHR) vendors, quality improvement specialists, and others.

The Implementing Medication Decisions with eGFR (IMeD-eGFR) Community offers a forum for teams leading the transition to eGFR_BSAadj to regularly convene and share knowledge on effective implementation strategies.

Leading the Change

• A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. 2022;79(2):268-288.
• Time to rethink the current paradigm for assessing kidney function in drug development and beyond. Clin Pharmacol Ther. 2022;112(5):946-958.
• Pharmacokinetics in patients with impaired renal function – study design, data analysis, and impact on dosing: FDA guidance for industry. March 2024. 
• KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease [Chapter 4]. Kidney Int. 2024;105(4S):S246-S254. 
• KDOQI US commentary on the KDIGO 2024 clinical practice guideline for the evaluation and management of CKD. Am J Kidney Dis. 2025;85(2):135-176. 
• Moving forward from Cockcroft-Gault creatinine clearance to race-free estimated glomerular filtration rate to improve medication-related decision-making in adults across healthcare settings: A consensus of the National Kidney Foundation Workgroup for Implementation of Race-Free eGFR-Based Medication-Related Decisions. Am J Health-Syst Pharm. 2025;82:644-659.
• A call to action: Transitioning from Cockcroft–Gault estimated creatinine clearance to race-free estimated glomerular filtration rate. J Am Coll Clin Pharm. 2025;8:324-326.
• Optimizing estimation: Perspective on drug dosing using new CKD-EPI equations. Clin Chem. 2025;71(10):1014-1017.
• Current practices in estimating kidney function: Insights from a cross-sectional survey. J Am Coll Clin Pharm. 2025;8(11):1136-1142.
• Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy. J Am Coll Clin Pharm. 2026;9(2):e70153. 
• Analysis of current industry practices for informing dosing recommendations for patients with renal impairment. Clin Transl Sci. 2026;19(1):e70457.

Medication-specific Studies

• Removing race and body surface area indexation for estimated kidney function based drug dosing: aminoglycosides as justification of these principles. Pharmacotherapy. 2023;43(1):35-42. 
• Estimated glomerular filtration rate with and without race for drug dosing: cystatin C vs. serum creatinine. Br J Clin Pharmacol. 2023;89(3):1207-1210.
• Impact of various estimated glomerular filtration rate equations on the pharmacokinetics of meropenem in critically ill adults. Crit Care Explor. 2023;5(12):e1011. 
• Population pharmacokinetic model of cefepime for critically ill adults: a comparative assessment of eGFR equations. Antimicrob Agents Chemother. 2023;67(11):e0081023. 
• Performance of estimated kidney function equations for predicting aminoglycosides clearance in Thai population. J Clin Pharm. 2026;66(1):e70150.
• Use of a cystatin C-based GFR equation in a population pharmacokinetic model of methotrexate clearance in adult patients with lymphoma. Clin Pharmacokinet. 2026;65:465-477.
• Impact of cystatin C on bivalirudin dosing and monitoring. Thromb Res. 2026:260:109644.