
Clinical Cancer Research Vol. 6, 4733-4738, December 2000
© 2000 American Association for Cancer Research
Multi-Institutional Validation Study of Carboplatin Dosing Formula Using Adjusted Serum Creatinine Level1
Masahiko Ando,
Hironobu Minami,
Yuichi Ando,
Hideo Saka,
Shuzo Sakai,
Masashi Yamamoto,
Yasutsuna Sasaki,
Kaoru Shimokata and
Yoshinori Hasegawa2
Japanese Red Cross Nagoya First Hospital, Nagoya 453-8511 [M. A., S. S.]; National Nagoya Hospital, Nagoya 460-0001 [H. S.]; Nagoya Ekisaikai Hospital, Nagoya 454-8502 [M. Y.]; First Department of Internal Medicine [M. A., Y. A., Y. H.] and Clinical Preventive Services, Nagoya University School of Medicine, [K. S.], Nagoya 466-8550; and National Cancer Center Hospital East, Kashiwa 277-0882 [H. M., Y. S.], Japan
 |
ABSTRACT
|
|---|
Creatinine clearance (Ccr) is widely used as a practical substitute for
glomerular filtration rate (GFR) in the Calvert formula: carboplatin
dose (mg) = target area under the concentration
versus time curve (AUC, mg
ml-1 min) x [GFR (ml
min-1) + 25]. However, it causes systematic overdosing
when the creatinine levels are measured by an enzymatic
peroxidase-antiperoxidase method (PAP-Cr). We previously suggested an
amended dosing formula to adjust this overdosing: carboplatin dose
(mg) = AUC (mg ml-1 min) x
[adjusted Ccr (ml min-1) + 25], where the Ccr was
adjusted by adding 0.2 (mg dl-1) to serum PAP-Cr. In this
study, we prospectively validated this formula in 55 patients from six
institutions. Target AUC ranged from 3 to 7 mg ml-1 min,
and Ccr was measured by 24-h urine collection. Estimation of
carboplatin clearance with the amended formula was unbiased [mean
prediction error (MPE) ± SE = 2.9 ± 3.4%] and
acceptably precise [root mean squared error (RMSE) = 24.7%],
whereas the Calvert formula using nonadjusted Ccr overpredicted
carboplatin clearance systematically (MPE ± SE = 24.9 ± 4.9% and RMSE = 36.1%). The improvement in the bias and
precision of the estimation was seen in all of the participating
institutions as shown by decrease in the absolute value of MPE and RMSE
for each institution. The Chatelut formula also highly overestimated
carboplatin clearance when PAP-Cr was used, but the adjustment of
PAP-Cr yielded a decrease in MPE by 30.4% and in RMSE by 21.3%. These
results confirmed the necessity of adjusting the serum PAP-Cr in
carboplatin dosing formulas.
 |
INTRODUCTION
|
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Carboplatin, a second-generation platinum-containing compound, has
proven activity against a range of malignancies and is much less
nephrotoxic, neurotoxic, and emetogenic than its parent compound
cisplatin (1)
. Thrombocytopenia is the major dose-limiting
toxicity of carboplatin and is highly correlated with
AUC3
(2)
, which is the ratio of dose:clearance. Carboplatin
clearance depends on each patients renal function, and therefore
individualized carboplatin dosing is generally determined using the
following formula (the Calvert formula; Ref. 3
):
 |
A measurement of GFR in this formula primarily requires the
[51Cr]-EDTA method, which is not always
available in every clinical center or hospital. Thus, the use of Ccr as
a substitute for GFR in the formula is practical and is now widely
accepted in clinical practice (4, 5, 6)
. However, creatinine
is not an ideal filtration marker because it is both filtered by
glomeruli and secreted by renal tubules (7, 8, 9)
.
Accordingly, Ccr theoretically exceeds GFR by >12% in subjects with
normal renal function (9)
. Two methods are available for
measuring creatinine levels, a kinetic Jaffé method (7
, 10)
and an enzymatic PAP method (11
, 12)
. The
Jaffé method is known to cross-react with noncreatinine
chromogens in serum and overestimate creatinine level by 5 to 15% in
serum (7)
but not in urine (13)
. As a result,
the calculated Ccr can be accepted as a good approximation of GFR
because this error coincidentally offsets the excess of Ccr over GFR
(9
, 14)
. In contrast, the new enzymatic PAP method is more
specific and ensures better interlaboratory agreement than the
Jaffé method (11
, 12)
. Because the PAP method is not
influenced by chromogens, the serum creatinine level is lower than that
measured by the Jaffé method and the corresponding Ccr is
increased close to its true value, which is higher than GFR (11
, 12)
. Therefore, when serum creatinine level is measured by the
PAP method, the Calvert formula using Ccr instead of GFR causes
overestimation of carboplatin clearance, resulting in overdosing of the
drug (15)
. The majority of clinical laboratories use the
PAP method in Japan, whereas the Jaffé method has been widely
accepted in the United States (16)
.
We previously found that the observed carboplatin clearance is, as
expected, lower than that calculated by the Calvert formula in which
24-h urinary Ccr with the PAP method was directly substituted for GFR
(17)
. To adjust this overdosing, we proposed an amended
dosing formula in which the Ccr was adjusted by adding 0.2 (mg
dl-1) to the serum creatinine level measured by
the PAP method in its calculation (18)
. On the contrary,
investigators at another institution reported that the Calvert formula
using 24-h urinary Ccr, in which serum creatinine levels were
determined with the PAP method, predicted carboplatin clearance well
(19)
. We considered that it was necessary to investigate
whether or not there is any variability among different institutions in
the predictive accuracy of carboplatin dosing formulas.
In this study, we prospectively validated the adjusted carboplatin
dosing formula using the serum creatinine level that had been measured
by the PAP method and compared its predictive accuracy among
institutions. Additionally, the effect of this adjustment of the serum
creatinine levels measured by the PAP method was evaluated in the
Chatelut formula (20)
and the Cockcroft-Gault equation
(21)
. The former formula directly predicts carboplatin
clearance, and the latter equation estimates Ccr from the patients
demographic characteristics. Both require a single sampling for serum
creatinine measurement without urine collection and are frequently used
for outpatient chemotherapy in clinic (22, 23, 24)
.
 |
PATIENTS AND METHODS
|
|---|
Patients were eligible for entry if they met the following
criteria: (a) diagnosis of solid tumors;
(b) age, >20 years; (c) WHO performance
status, 02; (d) no chemotherapy with antineoplastic
agents within 4 weeks; and (e) adequate bone marrow function
(WBC, >3,000/µl; platelet count, >100,000/µl). Patients who
received cisplatin-containing chemotherapy within 12 weeks were
ineligible because Ccr does not give satisfactory estimates of renal
function during this period (25)
. This study was approved
by the ethics committee at each institution, and written informed
consent was obtained from all patients.
The participating institutions were National Cancer Center Hospital
East (Kashiwa, Japan), and National Nagoya Hospital, Nagoya Ekisaikai
Hospital, and Japanese Red Cross Nagoya First Hospital in Nagoya,
Japan. Two other institutions participated in the study, but the data
from these two were combined for analysis because of the small number
of patients (a total of four patients). In all of the institutions,
creatinine values were determined using the PAP method at their own
laboratories (11
, 12)
. The specific test kits were as
follows: Serotec CRE-L kit (Serotec Co., Sapporo) at institution A,
Kainos CRE-L kit (Kainos Co., Tokyo) at institutions B and D, and Wako
CRE-L kit (Wako Junyaku Co., Osaka) at institution C. All of the kits
are based on the enzyme catalytic sequence, where creatininase,
creatinase, and sarcosine oxidase are coupled to convert creatinine to
hydrogen peroxide, which is colorimetrically detectable. The different
quinone dye was measured in the colorimetric assay among the kits.
Carboplatin was given by 1-h infusion as a monotherapy or in
combination with other antineoplastic agents. The target AUC of
carboplatin was 7 mg ml-1 min with the
monotherapy and 3 to 6 mg ml-1 min with the
combination therapy. The dose of carboplatin was determined using the
formula (18)
:
 |
 |
Ccr was measured by 24-h urine collection. We used only the data
from >800 ml/day of urine to obtain an accurate estimation of Ccr. The
average of two measurements, which were obtained on separate days
within a week, was used for dosing.
 |
A pharmacokinetic study was performed during the first cycle of
the chemotherapy. Heparinized blood samples were obtained at the end of
infusion and at 0.25, 0.5, 1, 2, 4, 8, and 24 h after the end of
infusion. The plasma was immediately separated by centrifugation.
Ultrafiltrate of plasma was obtained using Amicon MPS micropartition
system with YMT membranes (Grace Japan KK, Amicon, Tokyo) and
stored at -20°C until analysis. The ultrafiltered platinum level was
measured by flameless atomic absorption spectrometry (26)
.
The lower limit of measurement was 25 ng ml-1.
The intra- and interassay coefficient of variation was 2.6 and
4.1%, respectively. The carboplatin level was calculated on the basis
of the molar ratio of platinum:carboplatin.
The observed AUC of carboplatin was calculated using the
trapezoidal method with extrapolation to infinity, using WINNONLIN
version 1.1 software (Scientific Consulting Inc., Apex, NC), and the
observed clearance was calculated as follows:
The observed clearance was compared with the estimated clearance,
which was calculated as follows: estimated clearance (ml
min-1) = adjusted Ccr (ml
min-1) + 25. Furthermore, estimations of
clearance by the various methods were evaluated for their accuracy,
which were calculated using the following formulas: (a) Ccr
+ 25 (the Calvert formula using nonadjusted Ccr); (b) the
Calvert formula using the Cockcroft-Gault equation; (c) the
Calvert formula using the Cockcroft-Gault equation with the adjustment
of serum creatinine by adding 0.2 mg dl-1;
(d) the Chatelut formula; and (e) the Chatelut
formula with adjustment of serum creatinine by adding 0.2 mg
dl-1. The Cockcroft-Gault equation was used to
estimate Ccr as follows (21)
:
where gender = 0 for male and 1 for female subjects.
The Chatelut formula was as follows (20)
:
where gender = 0 for male and 1 for female subjects.
The accuracy of the estimation was evaluated with MPE ± SE and
RMSE (27)
.
The MPE and its 95% confidence interval was calculated for the
overall population and for each institution separately. Whether the
adjustment of the serum creatinine level improved the estimation of the
carboplatin clearance was analyzed using Wilcoxon signed-rank test. An
ANOVA was used to analyze the difference in the MPE among institutions.
An analysis of covariance was used to evaluate the interinstitutional
difference in the MPE taking age, gender, body weight, history of
previous chemotherapy, adjusted Ccr, percentage range of the values of
adjusted Ccr derived from the two measurements, and time interval
between the two measurements into consideration. Demographic and
biological characteristics of patients were compared among the
institutions by the
2 test or Kruskal-Wallis
test. Statistical analyses were performed by SAS version 6.12 software
(SAS Institute Inc., Cary, NC).
 |
RESULTS
|
|---|
Fifty-five patients from the six institutions were entered into
the study (Table 1)
. The demographic characteristics of patients were similar among the
institutions except for age (P = 0.030), the value of
adjusted Ccr (P = 0.006), time interval between the two
measurements of adjusted Ccr (P = 0.015), and the
previous chemotherapy (P = 0.001). A total of five
patients had received cisplatin-containing chemotherapy before entry
into this study, with no difference in the distribution among
institutions. The percentage range of the two measurements of adjusted
Ccr was <25% in 48 of the 55 patients. No association was observed
between the time interval and the percentage range between the
measurements (r = 0.150; P = 0.274).
The Calvert formula with nonadjusted Ccr used as a substitute for GFR
overestimated the carboplatin clearance as shown by 24.9% of MPE. This
was improved to 2.9% by adjusting the serum creatinine level by adding
0.2 mg dl-1 (P < 0.001). The
adjustment of the serum creatinine level also improved the precision in
the estimation of carboplatin clearance (P = 0.003), so
that the prediction of carboplatin clearance with the amended formula
based on adjusted Ccr was unbiased and acceptably precise (Table 2
and Fig. 1
). The improvement in the estimation of carboplatin clearance was seen
in every participating institution; the absolute value of MPE was
decreased by a median of 11.8% (range, 0.126.3%) and RMSE decreased
by 6.1% (1.722.1%; Fig. 2
). The difference in the MPE was significant among the institutions
[P = 0.031 with and P = 0.009 without
the adjustment (Figs. 2, A and B
,
respectively)]. The interinstitutional difference remained
significant in the analysis of covariance (Table 3)
, with a significant overestimation of carboplatin clearance by 17% in
the patients treated at institution B (P = 0.025). The
differences in age, adjusted Ccr, the time interval between the two Ccr
measurements, and the previous chemotherapy did not explain the
interinstitutional difference in the MPE. The interinstitutional
difference in the MPE did not change after the exclusion of the seven
patients whose percentage range of adjusted Ccr exceeded 25%
(P = 0.031).

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Fig. 1. A, relationship between observed
carboplatin clearance and carboplatin clearance predicted by the
formula we proposed, where creatinine level was measured with the
enzymatic PAP method and adjusted by adding 0.2 mg dl-1 to
the serum creatinine level. Diagonal line, line of
identity. , 13 patients were entered from institution A; , 12
patients from B; , 10 patients from C; , 16 patients from D; +, 4
other patients. B, relationship between observed
carboplatin clearance and that predicted by the Calvert formula using
nonadjusted creatinine clearance, where creatinine level was measured
with the PAP method.
|
|

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Fig. 2. A, mean prediction error and the
95% confidence interval of estimated carboplatin clearance by the
formula we proposed, where creatinine level was measured with the PAP
method and adjusted by adding 0.2 mg dl-1 to the serum
creatinine level. The value in the overall population and that in the
participating institutions (institutions A,
B, C, D, and
others) are shown. Institution D,
institution at which the adjusted formula was originally developed in a
previous study (18)
. B, mean prediction
error and its 95% confidence interval of estimated carboplatin
clearance by the Calvert formula using nonadjusted creatinine
clearance, where the creatinine level was measured with the PAP
method.
|
|
The Chatelut formula also highly overestimated carboplatin clearance
when the serum creatinine level measured by the PAP method was used in
its calculation, and the adjustment by adding 0.2 mg
dl-1 to the serum creatinine level decreased MPE
and RMSE by 30.4 and 21.3%, respectively (Table 2)
. Similar results
were obtained when the Cockcroft-Gault equation was used in the Calvert
formula; the bias became nonsignificant after the adjustment of the
serum creatinine level, with an improvement in RMSE by 3.8%.
 |
DISCUSSION
|
|---|
We proved that the formula using Ccr calculated with the
creatinine level measured by the PAP method and adjusted by adding 0.2
mg dl-1 was reliable for carboplatin dosing in
this multi-institutional prospective evaluation. The amended formula
successfully corrected the systematic overestimation of carboplatin
clearance by the Calvert formula using nonadjusted Ccr with the PAP
method, so that the estimated carboplatin clearance by this formula was
unbiased and acceptably precise. The improvement in the bias and
precision of the estimation was discernible throughout the
participating institutions as shown by the reduction in the absolute
value of MPE and RMSE in every institution. These results reinforce the
usefulness of this carboplatin dosing formula and suggest its high
acceptability in clinical practice. It remains to be studied whether
more precise individualized dosing in carboplatin chemotherapy should
improve the therapeutic outcome of the drug.
This is the first study evaluating interinstitutional variability in
the validity of the estimated carboplatin clearance by uniform dosing
formula using serum creatinine levels measured by the PAP method. In
the analysis of covariance, we found a significant overestimation in
the patients treated at institution B. The demographic and biological
characteristics of the patients treated at this institution were
comparable with those in the other institutions. We had evaluated an
interinstitutional variability in measuring creatinine levels by
assaying identical serum samples of three different concentrations
among institutions B, C, and D. Each sample was measured in triplicate,
and we confirmed that there was no difference in measured creatinine
values among institutions. In the present study, the analysis of
covariance also found a significant difference in the MPE of
carboplatin clearance between institutions B and D, where the
same kit for creatinine measurement was used (P =
0.048). Therefore, we consider that the interinstitutional variability
in prediction of carboplatin clearance should not be caused by the
difference in the method of creatinine measurement.
Several pharmacokinetic studies have reported controversial results
about the predictive accuracy of the Calvert formula using 24-h urinary
Ccr (6
, 19
, 28)
. Some studies that underestimated the
carboplatin clearance provided little explanation about the
completeness of urine collection and the method of creatinine
measurement (6
, 28)
. Inadequate urine collections would
cause underestimation of carboplatin clearance. Other investigators in
Japan recently observed a good concordance of carboplatin clearance
with the corresponding predicted value in their study
(19)
. We consider that the discrepancy between their
result and ours might be caused by a low dose (25 mg
m-2) of carboplatin in about half of
their patients and by some technical problems concerning the
pharmacokinetic study, especially a lack of sampling shortly after the
infusion in their study. Indeed, their concentration versus
time data were fitted to a monoexponential curve, leading to
underestimation of AUC, whereas the pharmacokinetics of carboplatin are
usually fitted well by a two-compartment model (29)
. In
addition, the possibility of inadequate urine collections cannot be
ruled out.
The Chatelut formula overpredicted carboplatin clearance when serum
creatinine levels measured by the PAP method were used in the
calculation. The Ektachem method was used for serum creatinine
measurement in developing the formula, which generally gives higher
values than those measured by the PAP method (30
, 31)
. The
difference in the method of creatinine measurement, therefore, explains
the overestimation of carboplatin clearance by the Chatelut formula
with the PAP method (32)
. The present study showed that
the adjustment of the serum creatinine value is reasonable for the
Chatelut formula. In other studies, the Chatelut formula using the
serum creatinine value measured by the Jaffé method predicted
carboplatin clearance acceptably (24
, 33)
. These
observations were consistent with our results. The adjustment of serum
creatinine also improved the predictive accuracy of the Calvert formula
in which Ccr, as a substitute for GFR, was calculated using the
Cockcroft-Gault equation. Considering that the Cockcroft-Gault equation
was originally developed using serum creatinine measured by the
Jaffé method, it is reasonable to use the adjusted serum
creatinine in the Cockcroft-Gault equation (21
, 34)
.
We calculated the AUC of carboplatin on the basis of the trapezoidal
method in this analysis because the method was used in the development
of the original Calvert formula (3)
. Because the
trapezoidal method may overestimate the AUC after the end of the
infusion, we also calculated the AUC using the log-trapezoidal method.
Overall, the MPE was improved from 19.4 ± 4.3% without the
adjustment to -1.7 ± 3.2% with the adjustment, suggesting the
robustness of our conclusion.
We confirmed the necessity of adjusting Ccr by adding 0.2 mg
dl-1 to the serum creatinine level measured by
the enzymatic PAP method when Ccr was used as a surrogate for GFR in
the Calvert formula. This is true whether Ccr is measured by collecting
24-h urine or estimated by the Cockcroft-Gault equation. Likewise, when
the PAP method is used for creatinine measurement in the Chatelut
formula, the adjusted serum creatinine level should be used to avoid
overdosing of carboplatin. Considering moderate interinstitutional
variability in predicting carboplatin clearance, preliminary
pharmacokinetic examinations at each institution should be useful to
evaluate the predictive accuracy of carboplatin dosing formulas before
they are applied to clinical use.
 |
FOOTNOTES
|
|---|
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
1 Supported in part by a Grant-in-Aid for Cancer
Research (7-30) from the Ministry of Health and Welfare, Japan. 
2 To whom requests for reprints should be
addressed, at First Department of Internal Medicine, Nagoya University
School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
Phone: 81-52-744-1974; Fax: 81-52-744-2157; E-mail: yhasega{at}med.nagoya-u.ac.jp 
3 The abbreviations used are: AUC, area under the
concentration versus time curve; GFR, glomerular
filtration rate; Ccr, creatinine clearance; PAP,
peroxidase-antiperoxidase; MPE, mean prediction error; RMSE, root mean
squared error. 
Received 6/ 6/00;
revised 9/12/00;
accepted 9/15/00.
 |
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