GFR and Drug Dosage Adaptation: Are We still in the Mist?
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- Russell Jefferson
- 5 years ago
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1 GFR and Drug Dosage Adaptation: Are We still in the Mist? Pierre Delanaye, MD, PhD Nephrology, Dialysis, Transplantation CHU Sart Tilman University of Liège BELGIUM
2 I have no conflict of interest to declare
3 Renal function (GFR) is important Especially for renal excreted drugs Especially for renal excreted drugs potentially nephrotoxic Especially for renal excreted drugs potentially nephrotoxic with a narrow therapeutic window But not Only CKD can influence: Bioavailability (ex: propanolol: +300%) Drug Distribution (increased for water soluble drugs if edema) Plasma binding to protein (nephrotic syndrome, uremic toxins) Decreased extra-renal clearance
4 Dreisbach AW, Drug Metabolism and Chronic Kidney Disease, in Chronic Renal Disease, Kimmel and Rosenberg, 2015 A pharmacokinetic study is required for every drug according to different stages of CKD
5 Inappropriately drug prescription: Is it Is it frequent? VA MDRD frequent? Is it relevant? Is it relevant? 2-10% of drug-related hospitalization (9-31% in the elderly) Salvi F, Drug Saf, 2012, p29 Oscanoa TJ, Eur J Clin Pharmcol, 2017, p759 10% of these hospitalizations are related to CKD Leendertse AJ, Ann Pharmacother, 2012, p625 Elderly: Hellden A, Drugs Aging, 2009, p595 14% and 32% related to CKD 17,5% Chang F, J Am Soc Geriar, 2015, 2015, p2290
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7 Drug Dosage Adaptation is personalized medicine
8 GFR is usually indexed by BSA (1.73m²) BSA indexation is questionable per se (Eriksen BO, JASN, 2001, p1517) Why? To make comparison between people/patients of different body size (ex: gender) But for a given patient in term drug of dosage, we must know his «true» GFR.not the GFR he would have if BSA was 1.73m² It is recommended (FDA/EMA/KDIGO) to use GFR not indexed for BSA (measured GFR and Cockcroft) OR «desindexed» for BSA (MDRD/CKD-EPI)
9 BSA desindexation Is it relevant? Delanaye P, Nephrol Dial Transplant, 2005, p2024 Is it problematic? Few studies (purely theoretical) The desindexation is mathematically questionable Skip one major advantage of recent equations: the automatic report by the lab One more step for the clinicians
10 Serum creatinine: Analytical limitations Jaffe: Pseudochromogen: glucose, fructose, ascorbate, proteins, urate, acetoacetate, acetone, pyruvate => false «high» Bilirubins: false «low» Few (fewer) interferences with enzymatic methods Different Jaffe-Enzymatic methods, different calibration by different manufacturers IDMS-traceability (enzymatic methods)
11 Serum creatinine: Physiological limitations Production (relatively) constant but muscular production => serum creatinine is dependent of muscualr mass, not only GFR gender age ethnicity Muscular mass(creatine) Tubular secretion of creatinine 10 to 40% Increase with decreased GFR Unpredictable at the individual level Perrone RD, Clin Chem, 1992, p1933
12 egfr equations
13 Statistics Good correlation: a sine qua non condition but insufficient Bias: mean difference between two values = the systematic error Precision: SD around the bias = the random error Accuracy 30% = % of egfr between ± 30% of measured GFR GFR method 1 unbiased/ precise -30% +30% biased/ precise -30% +30% unbiased/ unprecise -30% +30% GFR True method GFR2 True GFR True GFR
14 Creatinine clearance Not recommended by guidelines Creatinine tubular secretion Lack of precision: errors in urine collection 22 to 27% for «trained» patients 50 to 70 % for others large intra-individual variability for creatinine excretion Less performant (less precision) than all modern estimating equations
15 Cockcroft versus MDRD Cockcroft MDRD Population Canada 1976 USA 1999 N Mean GFR Measured GFR Creatinine Clearance Iothalamate Assay Jaffe Jaffe % women 4 40 % black 0 (?) 12 Mean age Mean weight Indexation for BSA No yes Internal validation no yes
16
17
18 The new CKD-EPI equation
19 CKD-EPI Development dataset: n=5504 Internal validation: n=2750 External validation: n=3896 Creatinine calibrated Median GFR in the development = 68 ml/min/1.73 m²
20
21 Cockcroft/MDRD/CKDEPI: limitations = creatinine Specific population: egfr is not If creatinine is especially «bad» for reflecting GFR (most of time because abnormal magic!! muscular mass), your creatininebased egfr result won t be accurate Keep our clinical feeling!! Anorexia Nervosa (Delanaye P, Clin Nephrol, 2009, 71, 482) Cirrhotic (Skluzacek PA, Am J Kidney Dis, 2003, 42, 1169) Intensive Care (Delanaye P, BMC Nephrology, 2014, 15, 9) Severely ill (Poggio ED, Am J Kidney Dis, 2005, 46, 242) Heart transplanted (Delanaye P, Clin Transplant, 2006, 20, 596) Kidney transplantation (Masson I, Transplantation, 2013, 95, 1211) Obese (Bouquegneau A, NDT, 2013, 28, iv122) Elderly (Schaeffner E, Ann Intern Med, 2012, 157, 471)
22 MDRD/CKDEPI are better to estimate GFR than Cockcroft Methodologically more solid Estimate «true» GFR (not clearance creatinine) Precision, bias, accuracy are better especially in the relevant range of GFR for drug adaptation (<45 ml/min) Can be used with IDMS-traceable creatinine Weight CKDEPI against Cockcroft: The debate is closed in the Nephrological community
23 But Cockcroft is still used in the context of drug dosage adaptation The historical perspective The weight Safety in geriatric
24 Between , 44 new medications with recommendations according to CKD status 42 are based on creatinine clearance 11 used Cockcroft MDRD recommended (with Cockcroft) since 2008 by the FDA
25 The weight The weight is an estimation of volume of distribution Dufour B, J Nutrit Health Aging, 2012
26 Safety in geriatry Cockcroft MDRD
27
28
29 N=9535 serum creatinine from two different labs, in patients over 60y (hospital and private)
30 Conclusions Several studies illustrate the discrepancies between Cockcroft and MDRD/CKDEPI and between these equations and measured GFR Calvert: Target AUC x (GFR + 25) N=115 GFR = CrEDTA Target AUC: 7 mg/ml/min Same dose = +/- 10%
31 Conclusions Several studies illustrate the discrepancies between Cockcroft and MDRD/CKDEPI and between these equations and measured GFR Many methodological limitations NO prospective trial having compared the impact of using measured GFR, Cockcroft or CKDEPI in the efficacy/safety profile (carboplatin, aminosides etc) So, yes we are still in the mist
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33 No improvement? Yes, A great one
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35 Some (personal) advices but always a personalized approach Nephrotoxic agent with narrow therapeutic window and/or extreme age or body size I still recommend measuring GFR (iohexol plasma clearance) Cystatin C: maybe Frazee E, Am J Kidney Dis, 2017, p658 I would recommend to calculate both Cockcroft and CKDEPI (desindexed) If no significant difference => dosage adaptation if needed If differences: consider THE PATIENT (age, body size, frailty) and the DRUG (balance between efficacy and safety) CKD is always a good reason for drug monitoring (direct or indirect)
36 Thank you for your attention
37 Age 80 Length 170 BSA W/Scr 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 1,9 2 2,1 2,2 2,3 2,4 2,5 2,6 2,7 2,8 2,9 3 1, ,1-25,4-26,7-27,4-27,8-24,0-21,0-18,6-16,6-15,0-13,6-12,4-11,3-10,4-9,7-9,0-8,4-7,8-7,3-6,9-6,5-6,1-5,8-5,5-5,2-4,9 1, ,8-23,1-25,0-26,3-27,0-23,2-20,3-17,9-15,9-14,3-12,9-11,7-10,7-9,8-9,0-8,4-7,8-7,2-6,8-6,3-5,9-5,6-5,3-5,0-4,7-4,4 1, ,9-20,3-23,0-24,8-25,9-22,2-19,3-16,9-15,0-13,4-12,0-10,9-9,9-9,0-8,3-7,6-7,1-6,5-6,1-5,7-5,3-5,0-4,7-4,4-4,1-3,9 1, ,7-17,2-20,7-23,0-24,5-20,9-18,0-15,7-13,8-12,3-11,0-9,9-8,9-8,1-7,4-6,8-6,2-5,7-5,3-4,9-4,6-4,3-4,0-3,7-3,5-3,3 1, ,2-13,8-18,0-20,9-22,9-19,4-16,6-14,4-12,6-11,1-9,8-8,8-7,9-7,1-6,4-5,8-5,3-4,9-4,5-4,1-3,8-3,5-3,2-3,0-2,8-2,6 1, ,5-10,2-15,2-18,7-21,1-17,7-15,0-12,9-11,2-9,7-8,6-7,6-6,7-6,0-5,4-4,8-4,4-3,9-3,6-3,2-2,9-2,7-2,4-2,2-2,0-1,8 1, ,5-6,4-12,2-16,2-19,1-15,8-13,3-11,3-9,7-8,3-7,2-6,3-5,5-4,8-4,3-3,8-3,3-2,9-2,6-2,3-2,0-1,8-1,6-1,4-1,2-1,1 1, ,6-2,4-9,0-13,7-17,0-13,9-11,5-9,6-8,1-6,8-5,8-4,9-4,2-3,6-3,1-2,6-2,2-1,9-1,6-1,3-1,1-0,9-0,7-0,5-0,4-0,3 1, ,9 1,7-5,7-11,0-14,8-11,8-9,6-7,8-6,4-5,2-4,3-3,5-2,9-2,3-1,9-1,5-1,1-0,8-0,6-0,3-0,1 0,0 0,2 0,3 0,5 0,6 1, ,3 6,0-2,3-8,2-12,4-9,7-7,6-5,9-4,6-3,6-2,8-2,1-1,5-1,0-0,6-0,2 0,0 0,3 0,5 0,7 0,9 1,0 1,1 1,3 1,3 1,4 1, ,9 10,3 1,2-5,2-10,0-7,4-5,5-4,0-2,8-1,9-1,2-0,6 0,0 0,4 0,7 1,0 1,2 1,5 1,6 1,8 1,9 2,0 2,1 2,2 2,3 2,3 1, ,5 14,8 4,8-2,2-7,5-5,1-3,4-2,0-1,0-0,2 0,5 1,0 1,4 1,8 2,1 2,3 2,5 2,6 2,8 2,9 3,0 3,0 3,1 3,1 3,2 3,2 1, ,3 19,3 8,5 0,8-4,9-2,7-1,2 0,0 0,9 1,6 2,2 2,6 2,9 3,2 3,4 3,6 3,7 3,8 3,9 4,0 4,0 4,1 4,1 4,1 4,1 4,1 1, ,1 24,0 12,3 4,0-2,2-0,3 1,1 2,1 2,9 3,4 3,9 4,2 4,5 4,7 4,8 4,9 5,0 5,1 5,1 5,1 5,1 5,1 5,1 5,1 5,1 5,1 1, ,0 28,7 16,2 7,2 0,6 2,2 3,4 4,2 4,9 5,3 5,6 5,9 6,1 6,2 6,3 6,3 6,3 6,3 6,3 6,3 6,3 6,2 6,2 6,1 6,1 6,0 1, ,0 33,5 20,1 10,5 3,4 4,8 5,7 6,4 6,9 7,2 7,4 7,6 7,7 7,7 7,7 7,7 7,6 7,6 7,5 7,5 7,4 7,3 7,2 7,1 7,0 7,0 1, ,1 38,3 24,1 13,8 6,2 7,4 8,1 8,6 9,0 9,1 9,3 9,3 9,3 9,2 9,2 9,1 9,0 8,9 8,8 8,7 8,5 8,4 8,3 8,2 8,1 7,9 2, ,2 43,2 28,1 17,2 9,1 10,0 10,6 10,9 11,1 11,1 11,1 11,0 10,9 10,8 10,7 10,5 10,4 10,2 10,0 9,9 9,7 9,5 9,4 9,2 9,1 8,9 2, ,4 48,2 32,2 20,7 12,0 12,7 13,0 13,2 13,2 13,1 13,0 12,8 12,6 12,4 12,2 12,0 11,7 11,5 11,3 11,1 10,9 10,7 10,5 10,3 10,1 9,9 2, ,7 53,2 36,3 24,2 15,0 15,4 15,5 15,5 15,3 15,1 14,9 14,6 14,3 14,0 13,7 13,4 13,1 12,8 12,6 12,3 12,1 11,8 11,6 11,4 11,1 10,9 2, ,0 58,2 40,5 27,7 18,1 18,2 18,1 17,8 17,5 17,1 16,8 16,4 16,0 15,6 15,2 14,9 14,5 14,2 13,9 13,6 13,3 13,0 12,7 12,4 12,2 11,9 80 y Age 70 Length 170 BSA W/Scr 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 1,9 2 2,1 2,2 2,3 2,4 2,5 2,6 2,7 2,8 2,9 3 1, ,9-24,0-25,8-26,9-27,6-23,8-20,7-18,3-16,3-14,6-13,2-12,0-11,0-10,1-9,3-8,6-8,0-7,5-7,0-6,6-6,2-5,8-5,5-5,2-4,9-4,6 1, ,5-20,8-23,5-25,2-26,4-22,6-19,6-17,2-15,3-13,6-12,3-11,1-10,1-9,2-8,5-7,8-7,2-6,7-6,2-5,8-5,4-5,1-4,8-4,5-4,2-4,0 1, ,6-17,2-20,8-23,1-24,8-21,1-18,2-15,8-13,9-12,4-11,1-9,9-9,0-8,2-7,4-6,8-6,3-5,8-5,3-4,9-4,6-4,3-4,0-3,7-3,5-3,3 1, ,3-13,2-17,7-20,7-22,8-19,3-16,5-14,2-12,4-10,9-9,7-8,6-7,7-7,0-6,3-5,7-5,2-4,7-4,3-4,0-3,7-3,4-3,1-2,9-2,6-2,4 1, ,7-8,9-14,3-18,0-20,7-17,2-14,6-12,5-10,8-9,4-8,2-7,2-6,4-5,7-5,0-4,5-4,0-3,6-3,3-2,9-2,6-2,4-2,2-1,9-1,8-1,6 1, ,2-4,4-10,7-15,1-18,3-15,0-12,5-10,6-9,0-7,7-6,6-5,7-4,9-4,3-3,7-3,2-2,8-2,4-2,1-1,8-1,6-1,4-1,2-1,0-0,8-0,7 1, ,3 0,3-6,9-12,0-15,7-12,7-10,3-8,5-7,0-5,9-4,9-4,1-3,4-2,8-2,3-1,9-1,5-1,2-0,9-0,7-0,5-0,3-0,1 0,0 0,2 0,3 1, ,6 5,3-3,0-8,8-13,0-10,2-8,0-6,4-5,0-4,0-3,1-2,4-1,8-1,3-0,8-0,5-0,2 0,1 0,3 0,5 0,7 0,8 1,0 1,1 1,2 1,3 1, ,0 10,3 1,1-5,4-10,2-7,6-5,6-4,1-2,9-2,0-1,2-0,6-0,1 0,3 0,7 1,0 1,2 1,4 1,6 1,8 1,9 2,0 2,1 2,2 2,3 2,3 1, ,6 15,5 5,3-1,9-7,2-4,9-3,1-1,8-0,8 0,0 0,7 1,2 1,6 2,0 2,2 2,5 2,7 2,8 2,9 3,0 3,1 3,2 3,3 3,3 3,3 3,4 1, ,3 20,9 9,7 1,7-4,2-2,1-0,6 0,6 1,5 2,1 2,7 3,1 3,4 3,7 3,9 4,0 4,1 4,2 4,3 4,4 4,4 4,4 4,4 4,4 4,4 4,4 1, ,2 26,3 14,1 5,4-1,0 0,8 2,1 3,0 3,8 4,3 4,7 5,0 5,2 5,4 5,5 5,6 5,6 5,7 5,7 5,7 5,7 5,7 5,6 5,6 5,6 5,5 1, ,1 31,8 18,7 9,2 2,2 3,7 4,8 5,6 6,1 6,5 6,8 6,9 7,1 7,1 7,2 7,2 7,2 7,1 7,1 7,0 7,0 6,9 6,9 6,8 6,7 6,6 1, ,2 37,5 23,3 13,1 5,5 6,7 7,6 8,1 8,5 8,7 8,9 8,9 9,0 8,9 8,9 8,8 8,7 8,6 8,5 8,4 8,3 8,2 8,1 8,0 7,9 7,8 1, ,3 43,2 28,0 17,0 8,9 9,8 10,4 10,7 10,9 11,0 11,0 11,0 10,9 10,8 10,6 10,5 10,3 10,2 10,0 9,8 9,7 9,5 9,4 9,2 9,1 8,9 1, ,6 48,9 32,7 21,0 12,3 12,9 13,3 13,4 13,4 13,3 13,2 13,0 12,8 12,6 12,4 12,2 11,9 11,7 11,5 11,3 11,1 10,8 10,6 10,4 10,3 10,1 1, ,8 54,8 37,6 25,1 15,8 16,1 16,2 16,1 15,9 15,7 15,4 15,1 14,8 14,5 14,2 13,9 13,6 13,3 13,0 12,7 12,4 12,2 11,9 11,7 11,5 11,3 2, ,2 60,7 42,5 29,2 19,3 19,3 19,2 18,8 18,5 18,1 17,6 17,2 16,8 16,4 16,0 15,6 15,2 14,8 14,5 14,2 13,8 13,5 13,2 13,0 12,7 12,4 2, ,6 66,7 47,4 33,4 22,9 22,6 22,2 21,6 21,1 20,5 19,9 19,3 18,8 18,3 17,8 17,3 16,9 16,4 16,0 15,6 15,3 14,9 14,6 14,2 13,9 13,6 2, ,1 72,7 52,4 37,7 26,6 25,9 25,2 24,4 23,7 22,9 22,2 21,5 20,9 20,2 19,6 19,1 18,6 18,1 17,6 17,1 16,7 16,3 15,9 15,5 15,2 14,8 2, ,6 78,8 57,4 41,9 30,2 29,3 28,3 27,3 26,3 25,4 24,5 23,7 22,9 22,2 21,5 20,9 20,2 19,7 19,1 18,6 18,1 17,7 17,2 16,8 16,4 16,1 70 y Age 60 Length 170 BSA W/Scr 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 1,9 2 2,1 2,2 2,3 2,4 2,5 2,6 2,7 2,8 2,9 3 1, ,0-22,9-25,3-26,8-27,7-23,8-20,7-18,2-16,2-14,5-13,1-11,9-10,8-9,9-9,1-8,4-7,8-7,3-6,8-6,3-5,9-5,6-5,2-4,9-4,7-4,4 1, ,6-18,9-22,3-24,5-26,0-22,2-19,2-16,8-14,8-13,2-11,8-10,6-9,6-8,8-8,0-7,4-6,8-6,3-5,8-5,4-5,0-4,7-4,4-4,1-3,8-3,6 1, ,7-14,5-18,9-21,8-23,9-20,2-17,3-15,0-13,1-11,6-10,3-9,2-8,2-7,4-6,7-6,1-5,6-5,1-4,7-4,3-4,0-3,7-3,4-3,1-2,9-2,7 1, ,3-9,6-15,1-18,8-21,5-17,9-15,2-13,0-11,2-9,8-8,6-7,6-6,7-6,0-5,3-4,8-4,3-3,8-3,5-3,1-2,8-2,6-2,3-2,1-1,9-1,7 1, ,4-4,5-11,0-15,5-18,8-15,4-12,9-10,8-9,2-7,9-6,7-5,8-5,0-4,4-3,8-3,3-2,9-2,5-2,2-1,9-1,6-1,4-1,2-1,0-0,8-0,7 1, ,4 1,0-6,6-12,0-15,8-12,7-10,3-8,5-7,0-5,8-4,8-4,0-3,3-2,7-2,2-1,8-1,4-1,1-0,8-0,5-0,3-0,1 0,0 0,2 0,3 0,4 1, ,6 6,6-2,1-8,2-12,7-9,9-7,7-6,0-4,7-3,6-2,7-2,0-1,4-0,9-0,5-0,1 0,2 0,4 0,6 0,8 1,0 1,1 1,3 1,4 1,5 1,6 1, ,0 12,5 2,6-4,3-9,4-6,9-4,9-3,4-2,3-1,3-0,6 0,0 0,5 0,9 1,3 1,5 1,8 2,0 2,1 2,3 2,4 2,5 2,6 2,6 2,7 2,7 1, ,6 18,5 7,5-0,3-6,0-3,7-2,0-0,7 0,3 1,0 1,6 2,1 2,5 2,8 3,1 3,3 3,4 3,6 3,7 3,7 3,8 3,9 3,9 3,9 3,9 4,0 1, ,4 24,6 12,6 3,9-2,5-0,5 1,0 2,0 2,8 3,5 3,9 4,3 4,6 4,8 4,9 5,0 5,1 5,2 5,2 5,3 5,3 5,3 5,3 5,2 5,2 5,2 1, ,3 30,9 17,7 8,2 1,2 2,9 4,0 4,9 5,5 5,9 6,3 6,5 6,7 6,8 6,8 6,9 6,9 6,9 6,8 6,8 6,8 6,7 6,6 6,6 6,5 6,5 1, ,3 37,3 22,9 12,6 4,9 6,3 7,2 7,8 8,2 8,5 8,7 8,8 8,8 8,8 8,8 8,7 8,6 8,6 8,5 8,4 8,3 8,2 8,1 8,0 7,8 7,7 1, ,5 43,8 28,3 17,1 8,8 9,8 10,4 10,8 11,0 11,1 11,1 11,1 11,0 10,9 10,7 10,6 10,5 10,3 10,1 10,0 9,8 9,7 9,5 9,3 9,2 9,1 1, ,7 50,4 33,7 21,7 12,7 13,4 13,7 13,8 13,8 13,7 13,6 13,4 13,2 13,0 12,8 12,5 12,3 12,1 11,8 11,6 11,4 11,2 11,0 10,8 10,6 10,4 1, ,0 57,1 39,3 26,4 16,7 17,0 17,0 16,9 16,7 16,4 16,1 15,8 15,5 15,1 14,8 14,5 14,2 13,8 13,5 13,3 13,0 12,7 12,4 12,2 12,0 11,7 1, ,5 63,9 44,9 31,1 20,8 20,7 20,4 20,1 19,6 19,2 18,7 18,2 17,8 17,3 16,9 16,4 16,0 15,7 15,3 14,9 14,6 14,3 13,9 13,6 13,4 13,1 1, ,0 70,7 50,5 35,9 24,9 24,4 23,9 23,2 22,6 21,9 21,3 20,7 20,1 19,5 19,0 18,4 17,9 17,5 17,0 16,6 16,2 15,8 15,5 15,1 14,8 14,5 2, ,5 77,6 56,2 40,7 29,1 28,2 27,4 26,5 25,6 24,7 23,9 23,1 22,4 21,7 21,1 20,5 19,9 19,3 18,8 18,3 17,9 17,4 17,0 16,6 16,2 15,8 2, ,2 84,6 62,0 45,7 33,3 32,1 30,9 29,7 28,6 27,6 26,6 25,7 24,8 24,0 23,2 22,5 21,8 21,2 20,6 20,0 19,5 19,0 18,5 18,1 17,6 17,2 2, ,9 91,6 67,9 50,6 37,6 36,0 34,5 33,0 31,7 30,4 29,3 28,2 27,2 26,2 25,4 24,6 23,8 23,1 22,4 21,8 21,2 20,6 20,1 19,6 19,1 18,7 2, ,6 98,7 73,8 55,6 41,9 39,9 38,1 36,4 34,8 33,3 32,0 30,7 29,6 28,5 27,5 26,6 25,8 25,0 24,2 23,5 22,9 22,2 21,7 21,1 20,6 20,1 60 y Age 50 Length 170 BSA W/Scr 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 1,9 2 2,1 2,2 2,3 2,4 2,5 2,6 2,7 2,8 2,9 3 1, ,5-22,2-25,0-26,9-28,1-24,1-20,9-18,3-16,2-14,5-13,1-11,8-10,7-9,8-9,0-8,3-7,7-7,1-6,6-6,2-5,8-5,4-5,1-4,8-4,5-4,2 1, ,1-17,4-21,4-24,1-26,0-22,1-19,0-16,5-14,5-12,9-11,5-10,3-9,3-8,4-7,7-7,0-6,4-5,9-5,5-5,0-4,7-4,3-4,0-3,8-3,5-3,3 1, ,2-12,2-17,4-20,9-23,4-19,7-16,7-14,4-12,5-11,0-9,7-8,6-7,6-6,8-6,2-5,6-5,0-4,6-4,1-3,8-3,4-3,1-2,9-2,6-2,4-2,2 1, ,2-6,5-12,9-17,3-20,5-16,9-14,2-12,0-10,3-8,8-7,7-6,7-5,8-5,1-4,5-3,9-3,5-3,1-2,7-2,4-2,1-1,9-1,6-1,4-1,2-1,1 1, ,0-0,4-8,0-13,4-17,2-13,9-11,4-9,4-7,8-6,6-5,5-4,6-3,9-3,2-2,7-2,2-1,8-1,5-1,2-0,9-0,7-0,5-0,3-0,1 0,0 0,2 1, ,1 5,9-3,0-9,2-13,8-10,8-8,5-6,7-5,3-4,1-3,2-2,4-1,8-1,3-0,8-0,4-0,1 0,2 0,4 0,6 0,8 1,0 1,1 1,2 1,3 1,4 1, ,4 12,4 2,3-4,8-10,1-7,4-5,4-3,8-2,6-1,6-0,8-0,2 0,4 0,8 1,1 1,4 1,7 1,9 2,1 2,2 2,4 2,5 2,5 2,6 2,7 2,7 1, ,9 19,2 7,8-0,3-6,3-3,9-2,1-0,8 0,3 1,1 1,7 2,2 2,6 2,9 3,2 3,4 3,6 3,7 3,8 3,9 4,0 4,0 4,0 4,1 4,1 4,1 1, ,7 26,1 13,5 4,4-2,3-0,2 1,3 2,4 3,2 3,8 4,3 4,6 4,9 5,1 5,3 5,4 5,5 5,5 5,6 5,6 5,6 5,6 5,6 5,6 5,5 5,5 1, ,6 33,2 19,3 9,3 1,9 3,5 4,7 5,6 6,2 6,6 6,9 7,1 7,3 7,4 7,4 7,4 7,4 7,4 7,4 7,3 7,3 7,2 7,1 7,1 7,0 6,9 1, ,6 40,4 25,2 14,3 6,1 7,4 8,3 8,9 9,3 9,5 9,6 9,7 9,7 9,7 9,6 9,5 9,4 9,3 9,2 9,1 9,0 8,9 8,7 8,6 8,5 8,4 1, ,8 47,8 31,3 19,4 10,5 11,4 11,9 12,2 12,4 12,4 12,4 12,3 12,2 12,0 11,8 11,7 11,5 11,3 11,1 10,9 10,7 10,5 10,4 10,2 10,0 9,9 1, ,2 55,2 37,4 24,5 14,9 15,4 15,7 15,7 15,6 15,4 15,2 15,0 14,7 14,4 14,1 13,8 13,6 13,3 13,0 12,8 12,5 12,3 12,0 11,8 11,6 11,4 1, ,6 62,8 43,7 29,8 19,4 19,6 19,4 19,2 18,9 18,5 18,1 17,7 17,2 16,8 16,4 16,0 15,7 15,3 15,0 14,6 14,3 14,0 13,7 13,4 13,1 12,9 1, ,1 70,4 50,0 35,2 24,0 23,7 23,3 22,7 22,2 21,6 21,0 20,4 19,8 19,3 18,8 18,3 17,8 17,4 16,9 16,5 16,1 15,7 15,4 15,1 14,7 14,4 1, ,7 78,2 56,4 40,6 28,7 28,0 27,2 26,4 25,5 24,7 23,9 23,2 22,5 21,8 21,1 20,5 20,0 19,4 18,9 18,4 18,0 17,5 17,1 16,7 16,3 16,0 1, ,4 86,0 62,9 46,1 33,5 32,3 31,2 30,0 28,9 27,9 26,9 26,0 25,1 24,3 23,5 22,8 22,2 21,5 20,9 20,4 19,8 19,3 18,8 18,4 18,0 17,5 2, ,2 93,9 69,5 51,7 38,3 36,7 35,2 33,7 32,4 31,1 29,9 28,8 27,8 26,9 26,0 25,1 24,4 23,6 23,0 22,3 21,7 21,1 20,6 20,1 19,6 19,1 2, ,1 101,9 76,1 57,3 43,1 41,1 39,2 37,5 35,8 34,3 33,0 31,7 30,5 29,4 28,4 27,5 26,6 25,8 25,0 24,3 23,6 23,0 22,4 21,8 21,2 20,7 2, ,0 109,9 82,8 63,0 48,1 45,6 43,3 41,2 39,3 37,6 36,0 34,6 33,3 32,0 30,9 29,8 28,8 27,9 27,1 26,3 25,5 24,8 24,1 23,5 22,9 22,3 Age 40 Length 170 2, ,0 118,0 89,5 68,7 53,0 50,1 47,4 45,0 42,9 40,9 39,1 37,5 36,0 34,6 33,4 32,2 31,1 30,1 29,1 28,3 27,4 26,7 25,9 25,2 24,6 24,0 BSA W/Scr 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6 1,7 1,8 1,9 2 2,1 2,2 2,3 2,4 2,5 2,6 2,7 2,8 2, y 1, ,4-21,8-25,1-27,4-28,8-24,6-21,3-18,7-16,5-14,7-13,2-11,9-10,8-9,9-9,0-8,3-7,7-7,1-6,6-6,1-5,7-5,3-5,0-4,7-4,4-4,2 1, ,1-16,3-21,0-24,1-26,3-22,2-19,1-16,5-14,5-12,8-11,4-10,2-9,1-8,2-7,5-6,8-6,2-5,7-5,2-4,8-4,4-4,1-3,8-3,5-3,3-3,0 1, ,1-10,2-16,2-20,3-23,2-19,4-16,4-14,1-12,1-10,6-9,3-8,2-7,2-6,4-5,7-5,1-4,6-4,1-3,7-3,3-3,0-2,7-2,5-2,2-2,0-1,8 1, ,3-3,7-11,1-16,1-19,8-16,2-13,5-11,3-9,5-8,1-6,9-6,0-5,1-4,4-3,8-3,3-2,8-2,4-2,1-1,8-1,5-1,2-1,0-0,8-0,7-0,5 1, ,1 3,1-5,6-11,7-16,1-12,8-10,3-8,3-6,8-5,5-4,5-3,6-2,9-2,3-1,8-1,3-0,9-0,6-0,3-0,1 0,1 0,3 0,5 0,6 0,8 0,9 1, ,2 10,3 0,2-6,9-12,1-9,1-6,9-5,2-3,8-2,7-1,8-1,1-0,5 0,0 0,4 0,7 1,0 1,3 1,5 1,7 1,8 2,0 2,1 2,2 2,3 2,3 1, ,7 17,7 6,3-1,9-7,9-5,3-3,3-1,9-0,7 0,2 0,9 1,5 1,9 2,3 2,6 2,9 3,1 3,2 3,4 3,5 3,6 3,7 3,7 3,8 3,8 3,8 1, ,3 25,4 12,5 3,3-3,5-1,3 0,4 1,6 2,5 3,2 3,7 4,2 4,5 4,7 4,9 5,1 5,2 5,3 5,3 5,4 5,4 5,4 5,4 5,4 5,4 5,4 1, ,2 33,2 18,9 8,7 1,0 2,9 4,2 5,1 5,8 6,3 6,7 6,9 7,1 7,2 7,3 7,3 7,3 7,3 7,3 7,3 7,2 7,2 7,1 7,1 7,0 6,9 1, ,2 41,2 25,5 14,2 5,7 7,2 8,1 8,8 9,2 9,5 9,7 9,7 9,8 9,8 9,7 9,7 9,6 9,5 9,4 9,3 9,1 9,0 8,9 8,8 8,7 8,5 1, ,4 49,3 32,2 19,8 10,5 11,6 12,2 12,5 12,7 12,7 12,7 12,6 12,5 12,4 12,2 12,0 11,8 11,6 11,5 11,3 11,1 10,9 10,7 10,5 10,4 10,2 1, ,7 57,6 39,0 25,6 15,5 16,0 16,3 16,3 16,2 16,1 15,8 15,6 15,3 15,0 14,7 14,4 14,1 13,9 13,6 13,3 13,0 12,8 12,5 12,3 12,1 11,9 1, ,2 66,0 45,9 31,4 20,5 20,6 20,5 20,2 19,9 19,5 19,0 18,6 18,2 17,7 17,3 16,9 16,5 16,1 15,7 15,4 15,0 14,7 14,4 14,1 13,8 13,5 1, ,8 74,5 53,0 37,4 25,6 25,3 24,8 24,2 23,5 22,9 22,3 21,6 21,0 20,5 19,9 19,4 18,9 18,4 17,9 17,5 17,1 16,7 16,3 15,9 15,6 15,2 1, ,5 83,2 60,1 43,4 30,8 30,0 29,1 28,2 27,3 26,4 25,5 24,7 24,0 23,2 22,5 21,9 21,3 20,7 20,1 19,6 19,1 18,6 18,2 17,8 17,4 17,0 1, ,3 91,9 67,4 49,6 36,1 34,8 33,5 32,3 31,1 29,9 28,9 27,9 26,9 26,0 25,2 24,4 23,7 23,0 22,4 21,8 21,2 20,6 20,1 19,6 19,2 18,7 1, ,2 100,6 74,7 55,8 41,5 39,7 38,0 36,4 34,9 33,5 32,2 31,0 29,9 28,9 27,9 27,0 26,2 25,4 24,6 23,9 23,3 22,7 22,1 21,5 21,0 20,5 2, ,1 109,5 82,0 62,0 46,9 44,6 42,5 40,6 38,8 37,1 35,6 34,2 32,9 31,7 30,6 29,6 28,6 27,8 26,9 26,1 25,4 24,7 24,0 23,4 22,8 22,3 2, ,2 118,4 89,5 68,4 52,4 49,6 47,1 44,8 42,7 40,8 39,0 37,4 36,0 34,6 33,4 32,2 31,2 30,2 29,2 28,3 27,5 26,7 26,0 25,3 24,7 24,1 2, ,3 127,5 97,0 74,8 57,9 54,6 51,7 49,0 46,6 44,5 42,5 40,7 39,1 37,5 36,2 34,9 33,7 32,6 31,5 30,6 29,7 28,8 28,0 27,3 26,5 25,9 2, ,5 136,5 104,6 81,2 63,5 59,7 56,3 53,3 50,6 48,2 46,0 44,0 42,2 40,5 39,0 37,5 36,2 35,0 33,9 32,8 31,8 30,9 30,0 29,2 28,4 27,7 40 y
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