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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Estimation of Glomerular Filtration Rate and Predicting Diagnostic Accuracy of Cystatin C and Creatinine in Detection of Renal Function among Longstanding Type-2 Diabetics
Correspondence Address :
Dr. Ranakishor Pelluri,
Assistant Professor, Department of Pharmacy Practice, Vignan Pharmacy College, Vadlamudi, Guntur-52213, Andhra Pradesh, India.
E-mail: ranampharm@gmail.com
Introduction: Estimation of Glomerular Filtration Rate (GFR) is dependent on Serum Creatinine (SCr). Though, a sudden decrease in GFR would not result in rapid rise in concentrations of SCr, as they are imprecise but it leads to the over diagnosis of Chronic Kidney Disease (CKD).
Aim: To calculate GFR using Cystatin-C (Cys-C) based formulas to contrast its accuracy with SCr based formulas and to predict the diagnostic accuracy of Cys-C in patients with diabetes.
Materials and Methods: A total 48 type-2 diabetic patients were diagnosed with CKD and their GFR was assessed using the Cys-C and SCr. GFR was measured and estimated using three equations (Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CDK-EPI), that are based on SCr and three equations (LeBricon, Grubb and Hoek) based on Cys-C among the 48 CKD patients. The filtration rate was measured using labelled diethylenetriaminepentaacetic acid (99mTc-DTPA) renal scan method as the standard for comparison. The Receiver Operating Characteristics (ROC) analysis was used to evaluate the diagnostic accuracy of the filtration rate.
Results: A significant association was observed (p=0.0001) among both the estimates which were equivocal when compared with measured iGFR, SCr and Cys-C based GFR estimate. A greater difference of Area Under the Curve (AUC) was observed between SCr (0.765±0.07) and Cys-C (0.569±0.09) (p=0.04) in the ROC analysis at a creatinine clearance <60 mL/min/m2.
Conclusion: The SCr and Cys-C based formulae has equivocal performance in estimating GFR. SCr could be a better marker to estimate GFR among patients with Cr clearance <60 mL/min/m2.
Chronic kidney disease, Diabetes mellitus, Receiver operating characteristic curve
Chronic kidney disease is a significant public health issue and is also associated with poor outcome and indulges high treatment costs (1). GFR is studied with high precision by determining the plasma clearance rate of substances that are excreted exclusively through glomerular filtration. Some key substances that are injected to assess the GFR include inulin, 99mTc-diethylenetripentaaceticacid, 51Cr-EDTA or radiographic contrast media like iohexol and 125I-Iothalamate. These methods are time consuming and the patient is not completely risk-free. Therefore, for more than a century, the SCr has been used as a marker to estimate the filtration rate, respectively.
However, creatinine concentration is not an ideal marker for GFR because in addition to GFR other parameters such as muscle mass, diet, gender, age and tubular secretion significantly affect its concentration (2),(3). There are several successful attempts to develop GFR prediction equations, which include additional parameters to compensate for creatinine concentration’s deficiencies as a GFR marker (4).
In the traditional clinical procedures, SCr has been commonly used as the marker of kidney function, but SCr concentration is indicated as a GFR biomarker and it may not be a perfect diagnostic marker to assess renal function. The reason is that creatinine in the blood does not increase until 50% of kidney function is damaged (5), though it is the conventional marker and it has frailty to perceive early stage of CKD (3),(6),(7). The Cys-C is a probable alternative marker for the estimation of GFR in Type-2 diabetics (6). There several commercial automated procedures are available for determining Cys-C (8),(9),(10),(11).
However, prediction of decline of renal function with these markers are uncertain (12),(13),(14),(15) in chronic diabetics. Hence, the present study aimed to evaluate eGFR using Cys-C and SCr based formula and compare with iGFR and to predict the diagnostic power of Cys-C and SCr in longstanding diabetics.
This was a hospital-based, cohort study, conducted from November 2020 to December 2020. It constituted patients of longstanding type-2 diabetes that visited the health camp conducted at Endo-life hospital, Department of Endocrinology and Metabolism. Written informed consent was receved from all patients. The study procedure was approved by Institutional Ethical Committee (IEC No: ECR/647/INST/AP/2014), Endo-life Specialty Hospital, Guntur, India.
Inclusion criteria: The subjects with chronic diabetes with or without co-morbidities were included in the study.
Exclusion criteria: Subjects with known history of renal failure were excluded from the study.
Study Procedure
Creatinine and Cystatin C assay: All creatinine measurements were performed in the central laboratory of Endo-life hospital. The obtained samples were subjected to ROCHE COBAS c311 (auto analyser) to measure the SCr, adopting Jaffe’s method (16).
Creatinine based estimation of GFR: The Cockcroft-Gault and MDRD formula (11),(17) were used to predict GFR using SCr.
GFR-CG = {(140-age) multiply with weight (kg)}/72 × SCr (mg/dL) (for women, multiply with 0.8)
GFR-MDRD = 186 × (SCr in mg/dL) minus1.54 × age-0.203 (for women, multiply with 0.742)
CKD-EPI Formula (18):
GFR=141 × min (Scr/κ, 1)α × max(Scr/κ, 1)-1.209 × 0.993Age × 1.018 (if female) × 1.159 (if African American)
where:
Scr is serum creatinine in mg/dL, κ is 0.7 for females and 0.9 for males, α is -0.329 for females and -0.411 for males, min indicates the minimum of Scr/κ or 1, and max indicates the maximum of Scr/κ or 1.
A correction for Body Surface Area (BSA) is essential for the CG formula. This was done with estimated BSA from Haycock’s equation (10).
Cystatin C based estimation of GFR: GFR was estimated using three equations based on serum cystatin C that were proposed by Hoek, Lebricon and Grubb (19),(20),(21):
GFR-Hoek=-4.32+(80.35×1/cystatin C)
GFR-LeBricon={(78)×(1/cystatin C)}+4
GFR-Grubb=89.12×cystatin C (mg/L)-1.1675
Statistical Analysis
The t-test was employed to compare the two means between creatinine clearance <60 and ≥60 mL/min/m2. The medcalc 8.1 statistical software (Belgium) was used as a statistical tool. Correlation coefficients (r) and stepwise regression analysis was applied to compare measured and estimated GFRs among SCr and Cys-C formulas. A p-value <0.05 was considered statistically significant.
A total of 48 patients (38 men and 10 women) with mean age of 59±7.2 years and age range from 41-74 years, with the mean±SD of SCr, Cys-C and measured GFR were 1.4±0.2, 1.9±0.5, and 47.7±9.5 (Table/Fig 1). Based on the GFR levels, the patients were divided into two categories:
(1) GFR 30-59 mL/min/1.73 m2 (47.7±9.5; n=34), according to National Kidney Foundation Stage-III CKD (22).
(2) GFR 60-89 mL/min/1.73 m2 (61.7±3.75; n=14), stage-II CKD.
The SCr levels showed statistically significant association (p=0.002) among the patients with creatinine clearance <60 mL/min/1.73m2 and less than 60 mL/min/1.73m2 (Table/Fig 2). The correlation between spot Albumin Creatinine Ratios (ACR) is illustrated in (Table/Fig 3). The urine micro-albumin, Cys-C and duration of diabetes were significantly (r: 0.517, p=0.001; r: 0.314, p=0.029 and r: 0.296, p=0.040) correlated with ACR (Table/Fig 4), (Table/Fig 5), (Table/Fig 6). ACR is also correlated with duration of hypertension (p=0.005). This represents, that these patients are at higher risk for kidney disease. Measuring of these parameters also helps to diagnose the disease in early stage and also assist to prevent further progression of disease. In this study, SCr and hs-CRP did not correlated with ACR (p<0.05).
In stage-III and II of CKD (Table/Fig 7), (Table/Fig 8), the measured filtration rate was compared to creatinine-based formulae and Cys-C based formulae. Of these formulae, both Cys-C and creatinine-based estimated GFRs showed significant correlation (p=0.0001). In the stage-II of CKD, only Cys-C based estimated formulae (p=0.0001) showed significant correlation. A significant direct correlation was established between stage-III CKD and measured SCr (p=0.0001), whereas there was an inverse correlation with measured Cys-C (p=0.09). The AUC showed a greater difference between SCr (0.765±0.07) and Cys-C (0.569±0.09).
In the ROC analysis (Table/Fig 9), (Table/Fig 10), the mean (0.765±0.07) AUC of SCr was more as compared to Cys-C (0.569±0.09) AUC, when the cut-off value of GFR <60 mL/min/m2. Hence, it indicates SCr showed better predictor than Cys-C.
Measurement of renal function is important in diabetic patients and early structural and functional changes in diabetic nephropathy must be identified using markers. SCr was considered specific but less sensitive because its level does not increase significantly until the GFR is reduced to <50% of normal (23). Furthermore, many factors have a significant impact on SCr concentrations and which can interfere with assay. The factors includes, age, gender, muscle mass, dietary intake, changes in tubular secretions, various drugs and endogenous substances as well. However, serum Cys-C may be affected to a lesser extent by these factors and which may explain the possible superiority of serum CysC to SCr for predicting GFR (24).
Hence, this study assessed the eGFR using Cys-C and SCr based formula and compared with iGFR to predict the diagnostic power of Cys-C and SCr. The equations proposed by Filler G and Lepage N (25) and Le Bricon T colleagues and Grubby A et al., (20),(21) provide a more accurate estimate of GFR among the different methods for Cys-C based GFR stimulations. The measured Cys-C was not statistically significant in relation to inulin clearance. Additionally, there was no correlation observed between measured SCr and estimated GFR with CG formulae (p<0.09). The results are supported by Mysliwic P et al., that conducted a study on morbidly obese subjects 26].
In the index study, no significant differences were shown between Cys-C based equations (p<0.09) and significant correlation was observed with SCr-based formulae, when compared with iGFR. This is because the amount of creatinine varies, because of muscle mass and tubular secretion, As a result, the test is susceptible to certain limitations. The Cys-C is produced endogenously at a constant rate and which was freely filtered completely through glomeruli and reabsorbed. Later, it was consolidated in renal tubules with the presence of renal cells and is not affected by severe disease, age, sex, height and obesity. There are many studies that support and undermine the results. The study conducted among a Korean population showed that Cys-C is more accurate than SCr in evaluating prognostic stage of diabetic nephropathy (12). Another study reveals, SCr is a better indicator for assessing renal function than Cys-C. In addition, SCr based CKD-EPI is the best one for estimation of GFR among patients with type-2 diabetes having normal renal function (13). Overall, a significant correlation was observed among all the formula based on both markers, when the CrCl value was 30-59 <60 mL/min/m2. Moreover, there was no correlation with SCr based CG formula, when the CrCl value was 60-89 <60 mL/min/m2. Hence, nearly all SCr and Cys-C based equations significantly correlated to each other.
In the ROC analysis, Cys-C was unable to predict renal function, at CrCl 60-89 <60 mL/min/m2. Similarly, another study expressed that Cys-C may be an surrogate marker for early detection of renal function in subjects with slight reduction of GFR and also it may be a marker for early glomerular dysfunction in type 2 diabetes mellitus (6). Hence, it is a reliable measure of kidney function. In kidney transplant recipients, the MDRD equation may provide a more accurate estimate of GFR than cystatin C-based equations or other creatinine-based GFR calculations (27). In type-2 diabetes patients with GFR renal failure, Cys-C was observed to be better alternative than Scr and CG, when comparing the GFR < 80 mL/min per 1.73 m2 and > 80 mL/min per 1.73 m2 (28).
The ROC analysis demonstrates that SCr levels rise rapidly during the moderate renal damage (<60 mL/min/m2). The predictive accuracy of SCr for individuals was shown in early stage of CKD as a better diagnostic biomarker, {AUC (0.765), (p<0.04)}. The mean of SCr levels was significantly increased in patients with renal impairment in comparison to Cys-C and ACR among those with CrCl <60 mL/min/m2.
Limitation(s)
It was a pilot study with a limited sample size. The study was conducted among patients with only type-2 diabetes and with or without hypertension. It is better to include a larger population with different co-morbidities to predict the best marker in order to estimate GFR.
The present study indicates that SCr is better than Cys-C. Therefore, SCr could be a better marker to estimate GFR among patients with CrCl <60 mL/min/m2.
The authors are obedient to Endo-life health camp team for providing extensive support to acquire the specific data of screened subjects. The authors also extend their appreciation to chairman of Endo-life hospital, Guntur. The author would like to thank Ms. Geethika Rayapati. Her contirubution part in statistical analysis of this research article.
10.7860/JCDR/2021/48764.15091
Date of Submission: Jan 29, 2021
Date of Peer Review: Mar 19, 2021
Date of Acceptance: May 04, 2021
Date of Publishing: Jul 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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