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Chronic kidney disease (CKD) is a major issue in public health. Its prevalence has been calculated using estimation of glomerular filtration rate (GFR) by the creatinine-based equations developed in the Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) study. Recently, new equations based either on cystatin C (CKD-EPI Cys) or both cystatin and creatinine (CKD-EPI mix) have been proposed by the CKD-EPI consortium. The aim of this study was to measure the difference in the prevalence of stage 3 CKD, defined as an estimated GFR less than 60 mL/min/1.73 m2, in a population using these four equations.
CKD screening was performed in the Province of Liège, Belgium. On a voluntary basis, people aged over 50 years have been screened. GFR was estimated by the four equations. Stage 3 CKD was defined as a GFR less than 60 mL/min/1.73 m2.
The population screened consisted of 4189 people (47% were men, mean age 63 ± 7y). Their mean serum creatinine and plasma cystatin C levels were 0.88 ± 0.21 mg/dL and 0.85 ± 0.17 mg/L, respectively. The prevalence of CKD in this population using the MDRD, the CKD-EPI, the CKD-EPI Cys and the CKD-EPI mix equations was 13%, 9.8%, 4.7% and 5%, respectively. The prevalence of CKD was significantly higher with the creatinine-based (MDRD and the CKD-EPI) equations compared to the new cystatin C-based equations.
Prevalence of CKD varies strongly depending on the method used to estimate GFR. Such discrepancies are of importance and must be confirmed and explained by additional studies, notably by studies using GFR measured with a reference method.
Trial registration
Keywords:Creatinine; Cystatin C; Chronic kidney disease; Glomerular filtration rate
Chronic kidney disease (CKD) is frequently presented as a major public health issue, because a prevalence as high as 10% has been described in the general population of Western Countries [1,2]. In addition, CKD is associated with a high mortality risk [3-5]. In this context, prevention and screening of CKD could be of importance, even if definitive proof of the benefits of such CKD screening is still lacking [6-8]. Disease screening requires the use of a diagnostic tool with high sensitivity and specificity. Measuring both glomerular filtration rate (GFR) and proteinuria are key elements to estimate the global function of the kidneys [9]. In this article, we will focus on the determination of GFR. Because measuring GFR may be costly and cumbersome, several authors have proposed creatinine-based equations to improve GFR estimation. The Modified Diet in Renal Disease (MDRD) study and the Chronic Kidney Disease Epidemiology Collaboration study (CKD-EPI) equations are used to estimate CKD prevalence in epidemiological studies [10,11]. For example, according to the National Health and Nutrition Examination Survey (NHANES) performed in the USA, the prevalence of stage 3 CKD (defined as an estimated GFR (eGFR) less than 60 mL/min/1.73 m2) was 6.3% and 7.8% using either the CKD-EPI or MDRD study equation, respectively [1,11]. However, there are several limitations to the use of serum creatinine-based equations. There are reasons to believe that both equations overestimate the real prevalence of CKD because they underestimate the measured GFR (mGFR) [12].
Plasma cystatin C is a relatively new marker of GFR. Cystatin C seems to have most of the characteristics of a good biomarker of GFR [13-15]. Several equations based on plasma cystatin C level have been created to estimate GFR [16]. However, these equations have been developed by the use of a limited sample of test subjects and have been poorly validated [13,15]. There is also concern because of the lack of standardized calibration for the measurement of the plasma level of cystatin C [17-21]. Now, a standardized calibration is available [22] and the CKD-EPI consortium has recently proposed equations (based on cystatin C alone or combined with creatinine) to better estimate GFR [23]. It is thus now possible to compare the prevalence of stage 3 CKD with the MDRD and CKD-EPI study equations to its prevalence based on the new cystatin C-based equations, namely the CKD-EPI based on cystatin C alone (CKD-EPI Cys) and CKD-EPI based on creatinine and cystatin C (CKD-EPI mix).
This study was approved by the Ethics Committee of our University Hospital (Comité d'Ethique Hospitalo-Facultaire Universitaire de Liège). The Belgian registration number is B70720071509. This prospective study was performed in the context of the CKD screening program organized by the Department of Health of the Province of Liège. This province is one of the ten provinces in Belgium. Its area is 3862 km2 and its population in 2005 was 1,037,161 inhabitants. The CKD screening is enabled by a medical bus that travels through the 84 communes of the province. Between June 2008 and March 2010, 112,000 subjects without any other restriction that being aged between 40 and 75 years were invited through a personal letter to participate in a CKD screening. All individuals wanting to voluntary participate had to register and make an appointment by giving a phone call to the Department of Health of the Province of Liège. The time slot to visit the screening bus was from 9 am to 7.45 pm so that active working people could participate. We arbitrary limited our analysis to subjects older than 50 years. All patients have signed informed consent. Blood samples and anthropometric data were collected and a short interview was done. Between June 2008 and March 2010, frozen blood samples were sent to the Clinical Chemistry laboratory of the University of Liège where they were immediately thawed and assayed. Serum creatinine was measured by the IDMS traceable compensated Jaffe method (Roche Diagnostics, Mannheim, Germany) on Modular apparatus. Cystatin C was measured by a particle-enhanced nephelometric immunoassay (PENIA) on the BNII nephelometer (Siemens Healthcare Diagnostics, Marburg, Germany). The assay was not calibrated against the international certified reference material ERM-DA471/IFCC for cystatin C but values were multiplied by 1.11 as recommended by the manufacturer (customer notification November 18, 2010) to convert them to ERM-DA471/IFCC–equivalent concentrations [22,24]. Our university laboratory is currently accredited for the ISO 15189 Standard.
Diabetes mellitus was defined as glycosylated hemoglobin greater than 48 mmoL/moL or self-reported diabetes. Hypertension was defined as measured systolic blood pressure by oscillometric method of 140 mm Hg or greater, diastolic blood pressure of 90 mm Hg or greater or self-reported hypertension. Smoking status was self-reported.
The four equations analyzed in the study are shown in (Additional file 1: Table S1). Stage 3 CKD was defined as eGFR less than 60 mL/min/1.73 m2[9].
Additional files 1: Table S1. Creatinine and cystatin C-based equations for glomerular filtration rate (GFR) estimation. Serum creatinine: SCr in mg/dL, serum cystatin C: SCys in mg/L. Table S2. Prevalence of CKD according to gender (in %).
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The data were anonymously analyzed. All results are expressed as mean ± SD. The percentage of CKD patients obtained with the four equations was compared with the McNemar test (paired samples). Agreement or reliability between GFR estimations was assessed by Cohen's kappa statistics to discriminate GFR greater and less than 60 mL/min/1.73 m2 (only two possible categories) [25]. A kappa value of 0.20 or less was considered slight agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; and 0.81–1.00, almost perfect agreement. We compared the results of the four GFR estimations by paired sample t-test. The validity between eGFR was studied with estimation of the bias, SD (i.e. precision) and with a graphical approach (i.e. Bland et Altman) [26]. In these analyses, we have arbitrarily chosen the creatinine-based equation results as the reference value. Because no equation can be considered as the perfect reference, we have only considered the absolute bias (with neither positive nor negative sign). Bias between equations has been defined as the absolute mean of the differences. The SD around the mean reflect the dispersion of the equations.
Because performance of the equations and epidemiology of CKD are well known to be influenced by age, we performed analyses according to 10 years age bracket. We also repeated the analyses according to gender and diabetes status.
In subgroup analyses, we focused on discrepant results between the equations regarding the stage 3 CKD diagnosis (i.e. eGFR < 60 mL/min/1.73 m2). Clinical characteristics of discrepant subjects were compared by t-test and Chi square test. In all statistical data, we used p < 0.05 to determine statistical significance. All analyses were performed using MedCalc® (MedCalc Software, Mariakerke, Belgium).
During the study period, 4189 people were screened (47% male and 53% women). Anthropometric, clinical and biological characteristics of the population are shown in Table 1. By the paired samples t-test, four equations were all different from each other (p < 0.0001). Prevalence of different CKD stages is shown in Table 2. Prevalence of stage 3 CKD (defined as eGFR < 60 mL/min/1.73 m2) when GFR was estimated by the MDRD equation study was 13.1%. This prevalence was significantly higher than the prevalence obtained with the CKD-EPI (9.8%, p < 0.0001), the CKD Cys (4.7%, n = 198, p < 0.0001) and the CKD-EPI mix (5%, n = 210, p < 0.0001) equations. Differences between the CKD-EPI equations on one hand and the two other cystatin C-based equations on the other hand were also very significant (p < 0.0001). On the contrary, no significant difference was found between the CKD-EPI Cys and the CKD-EPI mix equations.
Table 1. Anthropometrical and biological description of the population
Table 2. Prevalence (%) of CKD stages according to the equations used
Concordance analyses
Kappa statistics showed good agreement between the MDRD and CKD-EPI equations to detect stage 3 CKD (κ = 0.84). They also showed good agreement between the CKD-EPI Cys and the CKD-EPI mix equations (κ = 0.71). On the contrary, the kappa agreement range was only moderate or fair between the two creatinine-based equations and the two cystatin C-based equations (κ between 0.32 and 0.59). All kappa results between equations are summarized in Table 3.
Table 3. Kappa coefficients between the equations. 95% confidence intervals are shown between brackets
The Bland and Altman analyses are given in Figure 1. Once again, because no equation can be considered as the perfect reference, we only considered the absolute bias. In Table 4, the bias (mean difference) and the SD around the bias are summarized. The larger differences are observed between the creatinine- and the cystatin C-based equations although differences between the MDRD and the CKD-EPI and between the CKD-EPI Cys and CKD-EPI mix are lower.
Figure 1. Bland and Altman analysis between the MDRD study, the CKD-EPI, the CKD-EPI Cys and the CKD-EPI mix equations. The continuous line represents the mean difference between measured and estimated GFR, whereas the dashed lines represent the limits of agreement (mean difference ± 2 SD). All values are expressed in mL/min/1.73 m2.
Table 4. Absolute bias (mean difference) (bold) and precision (SD around the bias) (italic) between the equations
Subgroups analyses according to gender, diabetic status and age
No difference was observed between stage 3 CKD prevalence according to gender when either CKD-EPI Cys or CKD-EPI mix were used (Additional file 1: Table S2). On the contrary, the prevalence of stage 3 CKD was significantly higher in women when the CKD-EPI equation was used and even more when the MDRD study equation was considered.
We also calculated the prevalence of stage 3 CKD in diabetic patients. In these patients, the prevalence with the MDRD, CKD-EPI, CKD-EPI Cys and CKD-EPI mix were 17.1%, 14.5%, 10.2% and 10.4%, respectively.
In Table 5 and Figure 2, we summarized the prevalence of stage 3 CKD according to age. As expected, the prevalence of CKD increased with age, regardless of the equation used. The prevalence of CKD showed a significant difference between the two creatinine-based equations and the two cystatin C-based equations for all age ranges, except for those older than 80 years. Whatever the age range, we observed no difference between the CKD-EPI Cys and the CKD-EPI mix equations. On the contrary, difference of prevalence between the MDRD and CKD-EPI equations was not significant in those older than 70 years.
Table 5. Prevalence of CKD according to age (age ranges of 10 years) (in %)
Figure 2. Prevalence (in % with the 95% confidence interval) of CKD according to age (X axis: 10 years age range) (Y axis: percentage).
Analysis of discrepant results
In Table 6, we showed the percentage of patients with discrepant results (eGFR > or < 60 mL/min/1.73 m2) according to the equation used. Discrepant results (3.3%, n = 140) were observed between the MDRD and the CKD-EPI equations. In these subjects, the MDRD-based results were systematically indicating CKD whereas the CKD-EPI equation results were greater than 60 mL/min/1.73 m2. Comparable percentage of discrepancy (2.7%, n = 114) was observed between the CKD-EPI Cys and the CKD-EPI mix but with these equations, the differences between positive and negative screening were not uniform. Indeed, in 45% of cases, the CKD-EPI Cys indicated stage 3 CKD whereas the CKD-EPI mix result was greater than 60 mL/min/1.73 m2 and the opposite was observed in 55% of cases. The highest percentage of discrepant results was observed between the MDRD and the CKD-EPI Cys equations (11.3%, n = 473). An 8% discrepancy was observed between the CKD-EPI and the CKD-EPI Cys and between the MDRD and the CKD-EPI mix. The percentage of discrepancies between CKD-EPI and CKD-EPI mix was intermediate at 5.5%. Regarding these last comparisons, creatinine-based equations gave positive result although cystatin-C based equations were reassuring for stage 3 CKD diagnosis in a majority of patients.
Table 6. Percentage of discordant patients according to the two equations considered
Table 7 summarized the possible combination of screening results. Some combinations were not or very rarely (n < 10) found. For example, a positive screening with the two cystatin C-based equations, but not with the creatinine-based equations was found only in 11 subjects. The four equations yielded the same results (positive or negative screening) in 3702 cases (89%). In 131 subjects, only the MDRD equation gave a positive screening result, although the three other equations indicated an eGFR greater than 60 mL/min/1.73 m2. Compared to the whole population, these patients were more often women (23.7% versus 46.8%, respectively) and were lighter and shorter. In 218 subjects, both MDRD and CKD-EPI equations gave a positive screening result although the results were negative for CKD when using the CKD-EPI Cys and CKD-EPI mix equations. The mean age of these discrepant subjects was significantly higher compared to the whole population (67 ± 7 versus 63 ± 7 years old, respectively). Similarly, patients with positive screening for all equations except CKD-EPI Cys (n = 63) were older (68 ± 5 versus 63 ± 7 years old, respectively) and more frequently women (28.6% versus 46.8%, respectively). Inversely, patients with a positive screening only for CKD-EPI Cys (n = 49) were older (68 ± 7 versus 63 ± 7 years old, respectively) and heavier (BMI at 30 ± 6 versus 27 ± 5 kg/m2, respectively).
Table 7. Characteristics of the subjects in the different subgroups
Epidemiologic studies in Western countries have shown that prevalence of stage 3 CKD, defined as a GFR less than 60 mL/min/1.73 m2, is about 10% in the general population [1,2,11,27]. But there are large differences between studies regarding the prevalence of CKD which can be explained not only by the population characteristics, but also by the difference in the method used to estimate GFR [2]. Most of the recent data have been obtained with the MDRD study equation using a well calibrated serum creatinine [2,28,29]. However, the use of this equation is not free from criticisms. We and others, have demonstrated that this equation tends to strongly underestimate GFR in healthy populations and, more generally, in patients with normal or near normal creatinine values [12,30,31]. Thus, the Levey's group has recently proposed a new equation, the CKD-EPI equation, which is expected to be better especially in the higher GFR range (over 60 ml/min/1.73 m2). Indeed, the CKD prevalence is significantly lower according to the CKD-EPI equations for the present population cohort than if the MDRD equation is used (9.8% versus 13%). Among the patients screened, 140 (3.3%) were classified as having stage 3 CKD with the MDRD study equation but not with the CKD-EPI equation. This is important from an epidemiological point of view. We have thus confirmed that a higher prevalence of stage 3 CKD when the MDRD equation is used [11,32-36]. The higher prevalence of stage 3 CKD found with the MDRD study equation compared to the prevalence observed with the newer CKD-EPI equation may be explained by the systematic underestimation of GFR obtained with this first equation, especially in women [12,30,35,37]. Interestingly, we confirmed that difference between the MDRD and the CKD-EPI equations seems to decrease with age, notably in subjects older than 70 years [34-38]. These results may be explained by the performances of the two equations which have been showed to be very similar (or at least less different) in elderly patients [39]. Indeed, it has been shown that the MDRD equation yields systematically lower eGFR results (for a given age and creatinine level) than the CKD-EPI equation except in the very old patient [35]. This is confirmed by our own data showing that all patients presenting discrepant results between MDRD and CKD-EPI equations are actually positively screened only by the MDRD equation, except in one patient who was the oldest of the sample (96 years old).
In their initial CKD-EPI article [11], Levey et al. have also compared prevalence of CKD in the NHANES study. If we consider the same definition of CKD (only based on eGFR), these authors have found that prevalence of CKD in the NHANES study was 10.06% with the CKD-EPI equation and 14.9% with the MDRD study equation (Appendix Table 9 in [11]) in subjects aged between 60 and 69 years. The discrepancies observed between the two equations are comparable to discrepancies observed in our study.
One can conclude that the performance of the CKD-EPI equation to determine the prevalence of CKD in epidemiological studies is better than the MDRD study equation [11,32]. However, this equation is not free from criticism. The CKD-EPI notably remains dependent on the limitations of serum creatinine and its precision is imperfect. Cystatin C is often presented as a better marker of kidney function, especially because its concentration is less influenced by muscular mass than serum creatinine [15]. New equations based on standardized cystatin C have been recently proposed by the CKD-EPI consortium. These equations have been built and internally validated from an impressive sample (5592 subjects in the developing dataset and 1119 in the validation dataset). The authors demonstrated better performance of the equations combining creatinine and cystatin C compared to the CKD-EPI equation [23]. Recent studies confirmed the good performances of the two cystatin C-based equations in specific populations [24,40]. This better performance is also supported by the studies that show a better estimate of mortality risk when using cystatin C compared to creatinine-based equations [41,42].
In our population of volunteers, the prevalence of stage 3 CKD is strongly discordant using creatinine- or cystatin C-based equations. Indeed, if the prevalence of CKD is as high as 13% and 9.8% using the MDRD or the CKD-EPI study equations, the prevalence will decrease to 5%, for the equations based on cystatin C only or on cystatin C and creatinine. Interestingly, the seminal study on the cystatin C-based equations published by Inker et al. showed a better performance of the CKD-EPI mix equation to estimate GFR [23]. In our study, we found however no difference in the prevalence of stage 3 CKD results between the CKD-EPI Cys or the CKD-EPI mix. This may be related to the way the authors calibrated the cystatin C measurement, which was not unquestionable. Also, the bias of the equations influences the epidemiologic results and we note that in the CKD-EPI study (Table 3 in [43]), bias of the CKD-EPI Cys is similar to the bias of the CKD-EPI mix equation in the range of interest for the CKD screening (i.e. around 60 mL/min/1.73 m2).
In our cohort, when we considered the ability of each equation to detect CKD, kappa statistics showed very good agreement (κ = 0.84) between the CKD-EPI and the MDRD equations. Agreement is still acceptable, even if lower (κ = 0.71), between the CKD-EPI Cys and the CKD-EPI mix. However, agreement between CKD-EPI (or MDRD) and CKD-EPI Cys is low (0.39 and 0.32, respectively) although agreement is slightly better between CKD-EPI (and MDRD) and the CKD-EPI mix equations (0.59 and 0.48, respectively). These results underlined the powerful value of each biomarker in the equations: more concordant results between equations based exclusively on creatinine (MDRD versus CKD-EPI), poor concordant results between equations based on creatinine and on cystatin C only (CKD-EPI or MDRD versus CKD-EPI Cys), and intermediate concordance results when the mix equation is compared to others. Better concordance between the CKD-EPI and the two new cystatin C-based equations compared to the MDRD study equation is also probably explained by the mathematical construction of the equation (different exponent applied to creatinine according to creatinine level) and by the fact that the MDRD study equation has been developed on a very different sample [44] although the three other equations have been developed from comparable cohorts [11,23].
Bias and precision results must be interpreted with caution in our study. Indeed, the systematic difference between the MDRD and the CKD-EPI equations seems low (3 mL/min/1.73 m2). It can be suggested from Figure 1 that this bias is however very dependent on the GFR level. The systematic difference between the MDRD and the CKD-EPI equations increases with increasing GFR values especially at high values. Comparing the three CKD-EPI equations, we also found a positive correlation between the difference in equations and the mean of the two equations, which means that the differences between equations slightly increase with eGFR levels. This correlation is however low (r2 between 0.02 and 0.04, p < 0.001) and linear although a clear non linear relationship with a knot join-point around X = 80 mL/min/1.73 m2 does exist when MDRD is compared to CKD-EPI and CKD-EPI Mix. This fact also means that discrepancies between the MDRD and the CKD-EPI are systematic and almost in the same direction, i.e. MDRD giving a positive screening result and CKD-EPI giving a negative one. Such a systematic deduction cannot be done when discrepancies are found between the CKD-EPI Cys and the CKD-EPI mix equations.
The prevalence of stage 3 CKD may be higher in women if the CKD-EPI, and especially if the MDRD study equation is used [2,11]. Contrary to the CKD-EPI and the MDRD study equations, the prevalence of stage 3 CKD with the cystatin C-based equations is the same in both men and women. In the absence of mGFR, this discrepancy in results according to gender cannot be explained. Regarding the underestimation of women's GFR by the MDRD equation [30], the higher prevalence of stage 3 CKD in women must be interpreted with caution. Differences in prevalence of CKD according to gender observed between the three CKD-EPI equations deserve further studies.
Diabetes is a well-known risk factor associated with CKD. As expected, CKD prevalence was higher in diabetic patients than in non-diabetic patients. Interestingly, the difference between the prevalences with creatinine-based versus the cystatin C-based equations appears less important than in the general population. Once again, in the absence of measured GFR, we can only describe such differences. Moreover, we must be careful in our interpretation of this result, as diabetic patients have also different clinical characteristics than non-diabetics, like a higher mean BMI.
CKD prevalence is also greatly influenced by age. As expected, we observed an increasing prevalence of stage 3 CKD according to age [2,23,37,45,46]. At every age range, the prevalence of stage 3 CKD remains significantly lower with the CKD-EPI Cys and the CKD-EPI mix, except in the higher age category but results must be interpreted with caution due to the low sample number.
It is useful to analyze the characteristics of patients with discrepant results. Generally, concordant results for the 4 equations were found in 3702 subjects (88%). If we based our CKD definition on eGFR less than 60 mL/min/1.73 m2 with all four equations, the prevalence of stage 3 CKD would be 3.1%. Our first comment must be emphasized: a perfect concordance between all four equations does not necessarily mean that the results of these equations are correct. Indeed, in the absence of mGFR, it remains possible that all four equations misclassified the patients. The same argument must be applied in the following discussion on discrepant subjects. In 131 subjects, the discrepant result is the positive screening with the MDRD study equation. As already discussed, there is little doubt that the MDRD effectively underestimates GFR and thus yields a substantial proportion of false positive screening results. The most numerous discrepant patients are those with a positive screening result with the creatinine-based equations (MDRD and CKD-EPI) but with a negative screening result with the two cystatin C-based equations. These 218 patients are slightly older compared to the general population (67 ± 7 y versus 63 ± 7 y). Because mGFR is not really known, such a discrepancy remains difficult to explain. However, this last result could be interpreted in the light of recent studies suggesting that the combined creatinine and cystatin-C based equations better estimate GFR in the elderly subject [24,45]. Moreover, it must be underlined that the proportion of diabetic and hypertensive subjects was the same in the whole population. The positive screening result using cystatin C-based equations could thus be the most accurate, especially in the elderly [46]. In 63 patients, the CKD-EPI Cys was the only one to give a negative screening result. These subjects were slightly older and more often women (71.4%). On the contrary, the CKD-EPI Cys is the only equation to give a positive screening result in 49 subjects. These subjects were older and had a higher BMI. Once again, in the absence of mGFR, we can only note the discrepancies without asserting which equation actually gives the better results. The possible influence of body mass index on cystatin C levels deserves future study [47]. Further studies are actually important in these discrepant patients who are also more frequently hypertensive and diabetic.
There are several limitations to our study. First, the main limitation is linked to the fact that we have not measured GFR with a reference method. Therefore, even if we have indirect arguments to affirm that the CKD-EPI and MDRD equations overestimate the prevalence of CKD, such an assertion is conclusive only if a reference method to measure GFR is used. In our cohort, we can only identify clinical characteristics of discrepant patients. In the same vein, our Jaffe assay has lesser precision than enzymatic assays, although IDMS traceable. Second, our population may not be representative of the Belgian population because only volunteers were included. We actually noted a higher proportion of hypertension and diabetes than expected in the general population. Therefore, our results are not generally applicable for epidemiological considerations but more of an illustration of potential discrepancies in the CKD epidemiology due to difference in estimating GFR [21,32]. Third, we have no data on the ethnicity. As the ethnicity factor for each equation is different, this could be source of bias. But in the Province of Liège, Caucasians are by far the dominant ethnic group. Therefore, it is doubtful that the differences observed in our study are due to ethnic factors. Fourth, as in several epidemiological studies, our subjects have been tested only one time. A strict definition of CKD requires that two or three samples confirm the first result after at least three months [9]. With this correct definition, CKD prevalence would likely still be lower [48-52]. Last, we have defined stage 3 CKD as a GFR less than 60 mL/min/1.73 m2. The definition of CKD is however subject to debate and we have recently questioned this definition, notably in elderly population [31,37,46].
The present study has illustrated large discrepancies for the prevalence of stage 3 CKD according to the biomarker used to estimate the GFR. Moving from strictly creatinine-based equations (MDRD or CKD-EPI) to cystatin C-based or combined equations will decrease prevalence of stage 3 CKD by half, which is highly significant from an epidemiological point of view. Additional studies are thus necessary before asserting we know the true prevalence of CKD in the general population.
BMI: Body mass index; CKD: Chronic kidney disease; CKD-EPI: Chronic Kidney disease epidemiology collaboration study; CKD-EPI Cys: CKD-EPI equation based on cystatin C alone; CKD-EPI mix: CKD-EPI equation based on creatinine and cystatin C; eGFR: Estimated glomerular filtration rate; GFR: Glomerular filtration rate; MDRD: Modified diet in renal disease; mGFR: Measured glomerular filtration rate; NHANES: National health and nutrition examination survey; PENIA: Particle-enhanced nephelometric immunoassay.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
PD is the principal investigator and the first author of this manuscript. EC is the Biochemist who measured serum creatinine. LL measured cystatin C. OM and OB performed statistical analyses. J-MK, EC, OM and OB have critically corrected the manuscript as Chief of the Department of Nephrology, Clinical Chemistry and Public Health, Epidemiology and Health Economics, respectively. All authors read and approved the final manuscript.
We want to thank Dr Eric Cohen from Milwaukee, Mrs Fabienne Damblon and Mrs Rosalie Bonmariage for their help in the redaction of the manuscript. We want to thank Mr G. Pire, Deputy of the Health Department of the Province of Liège, and Dr Ph. Maasen. We also thank our data nurses Michèle Focan and Arnaud Borsu for their contribution.
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From The Collaborative International Dictionary of English v.0.48 [gcide]:
Unconditional \Un'con*di"tion*al\, adjective Not conditional, limited, or conditioned; made without condition; absolute; unreserved; as, an unconditional surrender.
O, pass not, Lord, an absolute decree, Or bind thy sentence unconditional. --Dryden. -- {Un'con*di"tion*al*ly}, adverb
From WordNet (r) 3.0 (2006) [wn]:
1: not conditional; "unconditional surrender" [syn: {unconditional}, {unconditioned}] [ant: {conditional}]
2: not modified or restricted by reservations; "a categorical denial"; "a flat refusal" [syn: {categoric}, {categorical}, {flat}, {unconditional}]
3: not contingent; not determined or influenced by someone or something else
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Appartamento Aternia C is an elegant and welcoming apartment. It sleeps two people. From Appartamento Aternia C you will enjoy a marvelous view of the sea and of the coast of Amalfi . Appartamento Aternia C is 40 square meters (430 square feet). It features a panoramic private terrace, air conditioning (please read description below to check in which rooms the units are installed) and WI-FI Internet access.
You will be in the center of Ravello , where you will find restaurants and shops. You will find the stop for the SITA bus Amalfi - Ravello line at 300 meters (990 feet) and the closest beach ( Castiglione di Ravello beach ) at 5.5 km (roughly ...Read more
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Keurig Extends Vue Single-Serve Brewer Line
Friday March 1st, 2013 - 5:36PM
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Keurig has introduced new Vue single-serve brewer model, giving the company a good, better, best Vue assortment for the home market. The new Vue V500 represents the opening pricepoint of the Vue line, carrying a suggested retail of $169.99, compared to the original Vue V700, which has been repositioned at $199.99 from its original $229 pricepoint, and the Vue V600, which has a $189.99 suggested retail.
With the filling out of the Vue assortment Keurig now offers single serve brewers in K-cup format from $99.99 to $179.99 and Vue brewers from $169.99 to $199.99.
The new Vue V500 features a black and white touchscreen display, removable drip tray, adjustable plate and a choice of 10 cup sizes. In keeping with the "Bigger, Stronger, Hotter" positioning of the Vue systems, the V500 is fully programmable and offers both strength and temperature control as well as cup size selection. It also has an energy saver mode and a 60-ounce water reservoir. Both of the step-up Vues have 74-ounce water reservoirs.
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Resolution: standard / high
Figure 2.
Standard curves of CADM1 and MAL in a multiplex qMSP with ACTB* tested on a serial dilution series of methylation positive SiHa DNA in methylation negative DNA of primary keratinocytes. Standard curve of CADM1 (A) and MAL (B) with the previously described primers 9. CADM1 (C) and MAL (D) primers with nearly identical annealing temperatures as ACTB primers. For the dilution series the PCR efficiencies were calculated by E=(10(−1/Slope)-1)×100%. The qPCR efficiencies increased from 76% to 87% for CADM1 and 52% to 105% for MAL.*) Multiplex qMSP was performed with an ACTB primer concentration of 200 nM.
Snellenberg et al. BMC Cancer 2012 12:551 doi:10.1186/1471-2407-12-551


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Dr. Dennis Rosen.
(photo credit:Courtesy)
'It is the providence of knowledge to speak," said 19th-century American physician Oliver Wendell Holmes Sr., "and it the privilege of wisdom to listen." However, a recent published study of US medical students specializing in internal medicine found that they spent as little as 12 percent of their time examining patients and even less talking to them – compared to 40% in front of their computer screens.With such a seeming disconnect between doctors pressed by patient quotas and sick people worried about their lives and health, an English-language book advocating better doctor-patient communications, to be published by Columbia University Press, is quite timely. Titled Vital Conversations: Improving Communication Between Doctors and Patients, the 240-page volume was written by a Canadian- born Israeli who currently lives in Massachusetts.An assistant professor of pediatrics at Harvard Medical School and a pediatric lung and sleep specialist at Children's Hospital Boston, Dr. Dennis Rosen made aliya with his family to Jerusalem in 1982. There, he attended Rene Cassin High School, served in the Israel Defense Forces' Nahal Brigade, graduated from the Hebrew University Faculty of Medicine and completed his pediatrics residency at Rehovot's Kaplan Medical Center. Moving to Boston for his fellowship, he remained for his career.FULL OF personal anecdotes, selected research in biomedicine, sociology and anthropology and lots of footnotes (but reader friendly), Rosen's book should be read by physicians and students of medicine and nursing, as well as laymen interested in our medical system.Israeli medicine – still the majority of it public and much more efficient than America's private system – would also benefit from improved communication between doctor and patient.Rosen maintains that such improved two-way communication actually reduces the cost and raises the level of medical care, improves patient compliance and minimizes medical complications and hospital readmissions.He begins with his first and only experience of being hospitalized, at 18 with dehydration a few days after developing a relapse of mononucleosis. Taken to a hospital in Haifa after developing painful, bleeding ulcers in his mouth, he was unable to drink or eat anything. Nearly a dozen different people stuck their gloved fingers into his mouth, but none ever explained what his problem was. "Doctor," he called after a senior-looking doctor, Rosen's numbed-up tongue and lips making the words difficult to articulate. "What's wrong with me?" "Gingivitis," the physician said while going out the door.The teen had never hear d of the inflamedgum condition before and thought he was dying."I certainly didn't like the way [the word] sounded. All of a sudden, I was very frightened and felt small and inexplicably ashamed, unworthy even. Instead of asking what gingivitis was and why I had gotten it, I asked about its treatment.""Keep on rinsing your mouth with salt water and use the lidocaine gel for pain," the doctor said in a hurry."How long will it take until I'm better?" Rosen asked in desperation.The doctor "shrugged his shoulders silently and turned away," Rosen recalled in his book. During his week of hospitalization, no one bothered to tell him that it was a self-limiting periodontal infection that goes away.GOOD DOCTOR-PATIENT communication, he continues, is good for medical professionals, the healthcare system and society as a whole. It "establishes the trust necessary for patients to open up to their physicians and to commit themselves to the healing process." The onus of improving the communications, he says, lies with the doctor.This may be clear to ill people, but not always to the physician, Rosen notes.A large US survey of patients found that a quarter complained their doctors did not encourage them to ask questions, while 30% complained that they weren't given clear instructions regarding what symptoms to watch for or when to seek further care. Two-fifths said their doctors didn't always discuss different treatment options or involve them in medical decision making, even though the practice of medicine has long ceased to be paternalistic.Many low-income US patients avoid getting prescribed medication because they can't afford copayments, and their doctors don't bother telling them the cheaper generic version is just as good. Instead, the patient will go without. A recent review of over 700,000 patients being treated for any of seven chronic diseases found that non-adherence ranged from 32% to 63%, often because of copayments. This occurs in Israel as well, but it is less common, as copayments are cheaper.Rosen writes that because some doctors do not explain exactly how to take medication, the drugs are less effective. In any case, doctors rarely ask about non-adherence. Another study, this by the US Veterans Administration, found that a fifth of those in smoking cessation courses claimed to kick the habit but lied, and their doctors didn't check to find out if they were still smoking.Patients whose doctors do not persuade patients effectively or at all about the need for preventative tests such as cancer screening or vaccination are less likely to undergo them and thus more likely to get sick.Poor communication with patients has been shown even to increase "burn out" among doctors and raise the risk of malpractice suits. Many physicians are also very reluctant to speak to patients and their families about end-of-life care.The need before discharge to explain carefully to patients and their families what to expect, how to take medications and what signs of problems to look for.Communications would also benefit from better surroundings when patients and doctors meet. The typical "hospital smell" of chemicals, sanitizers and bodily fluids can cause dread, unease and stress, Rose notes.Improved lighting, noise control and even essential oils for scents can reduce anxiety during these encounters.In an outpatient clinic waiting room, presenting patients with relevant videos to explain conditions and answering questionnaires that would save time in the encounter with the doctor would be welcome.Recommendations to patients include taking notes, bringing someone along with you, speaking up to the doctor if something is not clear and preparing a list of questions in advance.Doctors, he advises, should shake hands with their patients; smile; maintain eye contact instead of constantly looking at the computer screen; face the patient squarely, leaning forward or in a relaxed body position; avoid technical jargon; ask open-ended questions; and follow up patient's comments or questions.ROSEN DOES not present himself as a know-it-all doctor, and he also discusses his failures to communicate properly. He recalls the case at Kaplan of a three-week-old daughter of an Ethiopian immigrant couple who brought her to the pediatric ward severely ill. It took some time for him to discover that the infant had had her uvula (the dangling piece of flesh at the back of the throat) removed at the hands of a traditional healer, which almost killed her.He urges that physicians familiarize themselves with cultural, ethnic and religious influences so they can learn how to deal better with their patients.The author also differentiates among disease, illness and sickness. They are not variations on the same theme. "Disease" is a malfunctioning of biological and/or psychological processes, while "illness" refers to the psychosocial meaning and experience of perceived disease and includes personal and social responses to disease, he notes. "Illness is a human event" and larger and more complicated than disease."Sickness" relates to how society defines the unhealthy and assigns them roles within it, even when the patient doesn't regard himself/herself as being unhealthy. "Societal attitudes toward disease weigh heavily upon how patients interpret their symptoms and construct the narratives of their illnesses. They also directly influence the way patients are treated by their physicians and by larger society."Communications-skills training, including how to break bad news, has begun in both American and Israeli medical schools after having been neglected for too long.Examples for these subjective terms include ultra-Orthodox parents of a child with epilepsy who refused to describe seizures because they worried that when others learned of the diagnosis, the child and even his siblings would have problems finding a marriage partner.When going on a medical mission to Haiti, the author encountered a new mother in a Port-au-Prince facility for earthquake survivors who refused to nurse her premature baby. As formula based on unsanitary water supplies could have killed the baby, but Rosen couldn't get through to her the importance of breastfeeding him. It seemed a "frivolous and reckless endangerment of her son's life." But after a lot of digging, the medical team learned that the woman had a previous child who died in infancy and had been told by a voodoo priest that it was because her milk was "bad." If she breastfed subsequent babies, the priest said, they too would die. Haitian women abused by their husbands are frequently accused of having "spoiled milk."Finally, they persuaded the woman's mother that her daughter's milk was not tainted. The grandmother "gave her blessing for the mother to express a small quality of milk into a bottle for her baby. Once the mother saw that no harm befell him, she began to nurse him fully, and within a few days we were able to send him home safely, thriving and gaining weight," Rosen recalled.He still carries with him the lesson of one case during his pediatric residency at Kaplan. Rosen was in charge of Tomer, a three-month-old boy with seizures due to an incurable disease. He did his best medically for the infant, but he had failed to communicate with the parents regarding what to do when his end was near. Rosen was unable to move as the child's heart rate slowed.Sigal, a somewhat more experienced doctor, took over. She walked to the crib, stroked the baby's face softly, put her arms around both parents and drew them toward her."It's time," she whispered softly. Then Sigal suggested they say their final goodbyes. "Several minutes later, the door opened, and the parents stepped into the hallway. They were tearful and clearly distraught, but they also had a certain inner peace that I'd not seen since we'd first met," Rosen confessed."I became aware, suddenly, of just how poorly I actually had connected with Tomer's parents and how little I had allowed myself really to understand what it was that they had been feeling and struggling with."
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anyone try the cabbage diet?
Well I am going to start this as of today. The soup actually tastes quite yummy. I am just glad I am working the late shift.I need to lose 10-15 pounds. I also do the eliptical in the morning and some kind of stomach crunches. Wish me luck for I usually bomb. Hope everyone has a set goal for themselves and all the best to you.
I've tried it but never last long - too much 'gas' for me but I do like the soup. I just can't take the cramps. I need a slow, balanced diet. I too have about the same amount to shed. I'm in your corner and hope to see you post often. Keep us posted - good, bad or ugly - we are all in the same boat and rowing together.
If this doesn't work for you don't give up, just move on to something that works for you. There is no failure - I have to take it ounce by ounce, pound by pound.
You go girl!
Day 2 of Cabbage diet and yes gassy and alittle crampy but managed the day yesterday. Today I get to eat as much vegetables and the soup as I want. We will see where the craving takes me. I try to controll other craving with water. Well I hope today works good as long as no one is around hehehe and did the eleptical for 1/2 and on my supper break I will use the hoolo hoop for 15 minutes. Take care I just need to get rid of this muffin top
Day 3 and I feel pretty good. That starchy food is creeping on me I love chips and that is my huge downfall. I did really well for day 2 but I had a handfull of chips YIKES!!!! I hope that was ok today is all the fruit and veges i want and some soup. SO I pack all that in until I am full. I did the eleptical this am and now going to do the hoola hoop at break time for its extremely cold here and I work evenings and should not go out.I feel ok and yes still gassy and a few cramping but I want to try this and stick to it and see how it works. If anything I know I'm not full of crap or gas anymore. I will keep you posted. Enjoy! Remeber the hoola hoop does wonders on your hips and tummy.
Day 5 and things are going pretty good. Last night I cheated with some popcorn but other than that I did what the diet called for. Today though I suppose to eat tomoatoes and have a piece of chicken breat or beef. I will have chicken breast today for supper and some soup but I will not eat any tomatoes. Those just kill me! I break out and i get loads of pimples. I am not going to eat that. WE will see. My weigh in day is monday. So we will see:)
Weekend coming around the corner I hope I can stick to it. Soup is almost gone. Hubby was eating it too. Good luck to anyone elses diet and if it worked for you please let us know, Thanks
Here's what WebMD says about the cabbage soup diet.
What the Experts Say
There is little debate as to whether this is a sound diet plan. Indeed, it has all the components of a diet disaster.
"It is a monotonous, short-term fix, severely lacking in nutrients, which will result in a weight loss that is primarily water and not the essential fat loss that is so important to improving health," says Connie Diekman, MEd, RD, president-elect of the American Dietetic Association.
Here is a link that might be useful: WebMD cabbage soup


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£475,000 Offers Over
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7 bedroom detached house for sale St Clement's, 97 Glamis Road, Forfar, Angus, DD8Outstanding late Victorian townhouse More details ›
£450,000 Offers in Region of
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3 bedroom detached house for sale Drumshade Farmhouse, Roundyhill, Forfar, Angus, DD8Charming farmhouse with traditional steading set in 4.6 acres of land More details ›
4 bedroom detached house for sale Forfar, AngusSituated on a private road shared with just one other property, but only about 2 miles from Forfar, this is a very comfortable, easily run family home in a plot of approximately half an acre of well-tended gardens with lovely views of open countryside, the Sidlaws, and the Grampians. More details ›
Added on 27/04/2014 by eMoov.co.uk, National. Call: 03331 214950 Local call rate
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5 bedroom detached bungalow for sale 15 BALMASHANNER PLACE, Forfar, DD8 1PEImmaculately presented, individually designed, detached bungalow situated in a superb position at the end of a sought after cul-de-sac. The property offers extremely spacious accommodation throughout and enjoys desirable features such as natural wood and quality finishings. Beautiful open outlook. More details ›
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4 bedroom detached villa for sale 16 Balmashanner Place, Forfar, Angus, DD8 1PEWell proportioned detached four double bedroom house - Stunning views over the open countryside More details ›
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5 bedroom bungalow for sale 53 Charleston Village, Forfar, Angus, DD8 1UGDetached five bedroom chalet bungalow with swimming pool with refitted bathrooms and kitchen and far fetching views to the rear More details ›
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3 bedroom detached house for sale Lochmill Farmhouse & Steading, Forfar, Angus, DD8CLOSING DATE SET FOR WEDNESDAY, 15 APRIL 2015 AT 12 NOON. Traditional farmhouse requiring upgrading with stone steading set in 2.8 acres of land More details ›
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Suburban Extended Stay
2727 Watson Blvd
Warner Robins, GA 31093
Phone: (478) 953-5100
Fax: (478) 953-5255
Practical Information
»Anita Clark Realtor LLC
Residential Warner Robins Realtor providing quality services to both buyers and sellers.
»Vernon Jones Photography
A full service photography studio that offers timeless photography services for all of your special events such as weddings and anniversaries.
»Century 21 Homes & Investments
This full service real estate company offers a wide range of beautiful homes and properties in the Warner Robins, Centerville, Perry, Byron, and Houston County areas.
»GoMinis Mobile Storage
They deliver the container to you. You load it. Keep it on your site or call them and they can move it to your new location or to their clean, secure warehouse. Serving Macon, Warner Robins and all of Middle Georgia.
»Houston Medical Center
A state-of-the-art medical center that offers the latest in medical technology with departments including a pain treatment center, behavioral science and psychiatry, a women's center, and imaging services.
»Warner Robins Area Chamber of Commerce
Promotes and supports local businesses and industries in the Warner Robins area plus provides relocation information.
»Enterprise Rent-A-Car
Nationally known car rental company that provides a wide range of high quality vehicles plus offers free pickup and delivery services.
»Davis Dental Care
Dr. Ryan Davis is a dentist offering services as a family, sedation, & cosmetic dentist providing oral surgery, teeth whitening, dentures, and dental implants.
»City of Warner Robins
Provides information on local city services and local government offices in the Warner Robins area.
»Coldwell Banker Robbins & Free Realty
A team of highly trained professionals with this full service real estate company offer a wide range of residential properties, acreage and land, community information, commercial properties, residential lots, and relocation services in the Warner Robins area.
»The Telegraph (Daily Sun)
A daily newspaper that provides feature articles on local and national news, sports, lifestyles, weather, and classifieds.
»Ready to Move
A licensed and insured moving company. They are members of the BBB and have been serving the area for seven-years. They are a full service moving company and can move everything in your home or can provide smaller services such as moving a treadmill upstairs.


text:
But on the plus side, truffles are getting cheaper!http://www.clusterstock.com/2008/11/oh-no-white-truffle-prices-collapse
Reader comments are listed below. Comments are currently closed and new comments are no longer being accepted.
But on the plus side, truffles are getting cheaper!http://www.clusterstock.com/2008/11/oh-no-white-truffle-prices-collapse
goudreau: Whatever. You obviously got my point. (You must also be from Detroit).
this is a pretty interesting article from greenfaucet. while a large percentage of their information is republican in nature this article seems to make some really great points.
Super. Bowl. Two words, not one. Not "Superbowl", not even "Super-Bowl", but "Super Bowl".
The Detroit Lions have been around since 1934 and have never won a Superbowl. General Motors is smart to pull their advertising ... it would just remind everyone how dumb that that town is.
Our economics correspondents consider the fluctuations in the world economy and the policies intended to produce more booms than busts
The Economist explains: What is going on in Yemen?
The Economist explains
Politics in New Zealand: A Winston win
Containing Iran: The Sunnis strike back
Middle East and Africa
The Amanda Knox verdict: Innocente
Harry Reid's retirement: Republicans get their wish
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The week ahead: Open to investigation
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text: Images Franklin Pierce. Key events in the life of Franklin Pierce. Birthplace of President Franklin Pierce, Hillsboro, New Hampshire. Franklin Pierce during the Mexican-American War, steel engraving by W.L. Ormsby, c. 1852. Results of the American presidential election, 1852Presidential CandidatePolitical PartyElectoral VotesPopular VotesFranklin PierceDemocratic2541,601,274Winfield ScottWhig421,386,580John Parker HaleFree Soil155,210Sources: Electoral and popular vote totals based on data from the United States Office of the Federal Register and Congressional Quarterly's Guide to U.S. Elections, 4th ed. (2001). Silk ribbon depicting Franklin Pierce, c. 1852.


text:
9 spring-y things to enjoy way past break
4 ways to keep it cool around your crush
Dear Carol: How can I turn my attitude around?
GL is hitting up the Nickelodeon Kids' Choice Awards
Feel Good Friday: Adorable photo series helps local dogs from a Utah shelter get adopted
How to make a pretty (and inspiring) mason jar terrarium
4 steps to perfectly thick 'n' long lashes
5 strappy sports bras you need in your life
Share your thoughts on our April/May 2015 music issue! What did YOU love?
Nfinity Champions League 2: The Biggest Night in Cheerleading
More Friends = More Fun
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text:
Locked-out Love headed to beach volleyball court
By Brian Mahoney, AP Basketball Writer
NEW YORK -- Locked out of NBA arenas, Kevin Love is headed to the beach.
Beach volleyball, that is.
The NBA's leading rebounder plans to play in next month's Manhattan Beach Open on the pro volleyball tour, finding himself a paycheck while he's not earning one on the basketball court.
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Uncover up-to-date details on Jackie Phelps by searching PeopleFinders.com. There are several methods you can employ to search within our extensive database of public records, which includes their age, year of birth, prior addresses, aliases, and more. Jackie Phelps is 60 of age and born on 1955.
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THE DRAMATIC, across-the-board victory engineered by Republicans in the Nov. 4 elections would seem to bode well for the party's chance to capture the White House in 2016. The GOP took full control of Congress, flipped at least four governor's offices from blue to red, and prompted much talk of a resurgent Republican movement.
Not so fast. A more careful look at the returns significantly complicates the narrative that an American electorate, which recently tilted Democratic, has since shifted back to the Republican fold.


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St Mary's Primary School
May 13, 2012
Tim Short
November 26, 2010
Tag Rugby Team Success
The children are at the heart of everything we do.
Congratulations to the Tag Rugby Team who were joint champions of the Eastern District Competition. They will now play the winners of the other 3 regions in the Final on 1st December 2010 from 1pm to 3pm at the National Sports Centre.
Congratulations are also in order for all the Year 3 / 4 Football Team who came 3rd in the Douglas Primary Schools Competition.
Well done to all the pupils who met in Peel for the Fell Race, Connor Cooke from Year 4 had a particularly good run and came a close 2nd in his age group.
After Christmas Years 3 and 4 will be able to take part in a Hockey Club more details are available from Mrs Quinn.
St Mary's Community Choir
The next Community Choir Practice will be 3.30 to 4.30 on Wednesday 1st December 2010 in the school Hall
St Mary's School Choir
Monday 29th November 2010 choir members from Years 4, 5 and 6 will be singing at Nobles Hospital to promote a new hand hygiene initiative singing a specially composed rap song. This perform- ance will be recorded by Manx Radio.
The Choir will also be singing Christmas Carols outside Marks and Spencer on the 9th December from 5pm - 6pm. Please come along and put money in our charity collection buckets!
Sickness Bugs and Vomiting
Please remember that if your child has been vomiting it is recommended that they do not return to school for 48 hours after they have last vomited. This will help to prevent the spread of illness amongst the other pupils.
Congestion Problems
At 3.30 to avoid congestion please can arrangements be made to meet children either in the school yard or outside by the kitchen. The smaller children are finding it increasingly difficult to get through the crush at the foot of the stairs in the Lower Key Stage 2 area where parents appear to be gathering.
Sadly we do not seem to have seen any improvement in the traffic congestion at the end of the school day. PLEASE do not drive into St Mary's Road to collect your child. Parents are parking on double yellow lines, double parked, stopped on corners, stopped in the bus stop lane, parked on the zebra crossing zig zags and this really does need to improve. We have a new Police Liaison Officer who has been working with the children selected to be our Road Safety Officers highlighting the dangers and problems of parking and speeding. Gabe and Jamie appeal to all drivers to please take more care around the school.
November 28th, 2010
Christmas Fair Sunday 2-4pm
November 29th, 2010
Shoe Box Appeal Ends - all donations by this date please
December 6th, 2010
KS2 Concert Dress Rehearsal
December 7th, 2010
KS2 Christmas Concert 2pm and 7pm
December 8th, 2010
KS1 Nativity Dress Rehearsal KS2 Final Performance 7pm December 9th, 2010 KS1 Nativity 10am and 2pm
December 10th, 2010
Carol Concert and Tombola Night 7pm to 9pm
December 16th, 2010
Junior Disco 7pm to 8.30pm
Please note earlier finish time December 17th, 2010
Mass 10am St Mary's Church.Whole School Mass - all welcome.
We need Volunteers to help us walk the children there and back please.
December 17th, 2010
Children finish school on 17th December and return on Tuesday 4th January 2011
Christmas Cards
Congratulations to Cyreline, Joshua, Olivia,Tom and Scott for their Christmas Card designs now printed on our School cards.
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