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glomerular filtration rate (GFR)

Estimated from creatinine clearance Reference interval: - 75-130 mL/min/1.73 m2 Clinical significance: - < 60 mL/min/1.73 m2 consistent with chronic kidney disease - < 15 mL/min/1.73 m2 consistent with renal failure - glomerular filtration begins to decline in the 4th decade of life - like chronic kidney disease, increased GFR is associated with increased risk of mortality [5] - obesity is associated with excess risk for GFR decline & end-stage renal disease [11] - eGFR can be affected by muscle mass, cooked meat, & obesity [16] - at higher GFR, small changes in serum creatinine may indicate larger changes in GFR [1] - at lower GFR, large changes in serum creatinine may indicate smaller changes in GFR [1] Methods: - radionuclide kidney clearance scanning is the gold standard for estimation of glomerular filtration rate [1] - clearance of inulin, iothalamate, DPTA & creatinine are measures of glomerular filtration rate - creatinine clearance is most commonly used to estimate glomerular filtration rate - the creatinine clearance is determined by a 24 hour urine for creatinine along with serum creatinine according to the following equation: Creatinine [urine] (mg/dL) x volume (mL) / Creatinine [serum] (mg/dL) x minutes - creatinine clearance overestimates glomerular filtration because of tubular secretion of creatinine - the creatinine clearance is often estimated using a patient's age, weight & sex according to the Cockcroft-Gault equation. The Cockcroft-Gault estimate formula for males is: GFR = (140 - age in years) x lean body weight in kg / serum creatinine in mg/dL x 72 for females, use the above formula & multiply by 0.85 other methods include - Modification of Diet in Renal Disease formula (MDRD formula) - method for calculating GFR used by most clinical labs [1] - most accurate when eGFR is 15-60 mL/min/1.73 m2 [1] - Chronic Kidney Disease Epidemiology Collaboration formula (CKD-EPI formula) [4] - allegedly better than the MDRD when eGFR >60 mL/min/1.73 m2 [1] - this would include patients with serum creatinine of 1.8 mg/dL [12] - CKD-EPI gives accurate results in older patients - no better or worse than Lund-Malmo Revised, the Full Age Spectrum, or the Berlin Initiative Study methods [13] - recommended by the National Kidney Foundation (NKF) & the American Society of Nephrology (ASN) [14] without adjustment for ethnicity - serum cystatin C is less influenced than serum creatinine by age, sex, muscle mass & body weight & is more sensitive in identifying smaller changes in GFR [1] - for some patients cystatin C-based measures of GFR may be more accurate than creatinine-based measures [17] - cystatin C-based measures may have prognostic value - adverse outcomes, including ESRD, cardiovacular events & mortality, are more common when cystatin C-based measurements of GFR are signficantly lower than creatinine-based measures [17] Clinical trials: [16] - with eGFR of 60 mL/minute, 20% of measured GFR values were < 45 or > 76 mL/minute - with eGFR of 30 mL/minute, 20% of measured GFR values were < 23 or > 44 mL/minute Notes: - also see: - National Kidney Foundation's renal function calculator [4] - ref [15] reclassifies threshold for chronic renal failure in the elderly as 45 mL/min/1.73 m2

Related

creatinine clearance

Specific

glomerular filtration rate blacks glomerular filtration rate females

General

laboratory analysis

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 620
  3. Prescriber's Letter 12(7): 2005 Calculating Renal Function Detail-Document#: 210704 (subscription needed) http://www.prescribersletter.com
  4. Matsushita K et al. Comparison of risk prediction using the CKD-EPI equation and the MDRD study equation for estimated glomerular filtration rate. JAMA 2012 May 9; 307:1941 PMID: 22570462 - Kalantar-Zadeh K and Amin AN. Toward more accurate detection and risk stratification of chronic kidney disease. JAMA 2012 May 9; 307:1976. PMID: 22570467
  5. Hallan SI et al Age and Association of Kidney Measures With Mortality and End-stage Renal Disease JAMA. Oct 30, 2012 PMID: 23111824 http://jama.jamanetwork.com/article.aspx?articleid=1387683 - de Boer IH Chronic Kidney Disease--A Challenge for All Ages JAMA. Oct 30, 2012 PMID: 23111858 http://jama.jamanetwork.com/article.aspx?articleid=1387684
  6. Levey AS, Stevens LA, Schmid CH et al A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009 May 5;150(9):604-12. PMID: 19414839
  7. Melamed ML, Bauer C, Hostetter TH. eGFR: is it ready for early identification of CKD? Clin J Am Soc Nephrol. 2008 Sep;3(5):1569-72 PMID: 18667739
  8. Stevens LA, Schmid CH, Greene T et al Comparative performance of the CKD Epidemiology Collaboration (CKD-EPI) and the Modification of Diet in Renal Disease (MDRD) Study equations for estimating GFR levels above 60 mL/min/1.73 m2. Am J Kidney Dis. 2010 Sep;56(3):486-95 PMID: 20557989
  9. Levey AS, Fan L, Eckfeldt JH, Inker LA. Cystatin C for glomerular filtration rate estimation: coming of age. Clin Chem. 2014 Jul;60(7):916-9. PMID: 24871681 Free Article
  10. Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function--measured and estimated glomerular filtration rate. N Engl J Med. 2006 Jun 8;354(23):2473-83. PMID: 16760447
  11. Chang AR, Grams ME, Ballew SH, et al. Adiposity and risk of decline in glomerular filtration rate: Meta-analysis of individual participant data in a global consortium. BMJ 2019 Jan 10; 364:k5301. PMID: 30630856 Free Article https://www.bmj.com/content/364/bmj.k5301
  12. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  13. da Silva Selistre L, Rech DL, de Souza V et al Diagnostic Performance of Creatinine-Based Equations for Estimating Glomerular Filtration Rate in Adults 65 Years and Older. JAMA Intern Med. Published online April 29, 2019. PMID: 31034005 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2731708
  14. Delgado C, Baweja M, Crews DC et al A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. September 23, 2021 PMID: 34563581 Review. https://www.ajkd.org/article/S0272-63862100828-3/fulltext - Journal of the American Society of Nephrology, JASN September 2021, ASN.2021070988 https://jasn.asnjournals.org/content/early/2021/09/22/ASN.2021070988 - Inker LA, Eneanya ND, Coresh J et al New Creatinine- and Cystatin C-Based Equations to Estimate GFR without Race. N Engl J Med. 2021. September 23. PMID: 34554658 https://www.nejm.org/doi/full/10.1056/NEJMoa2102953 - Hsu C,Yang W, Parikh RV et al. Race, genetic ancestry, and estimating kidney function in CKD. N Engl J Med 2021 Sep 23; [e-pub] PMID: 34554660 https://www.nejm.org/doi/10.1056/NEJMoa2103753
  15. Liu P, Quinn RR, Lam NN et al. Accounting for age in the definition of chronic kidney disease. JAMA Intern Med 2021 Aug 30; [e-pub] PMID: 34459844 PMCID: PMC8406213 (available on 2022-08-30) https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2783456
  16. Shafi T et al. Quantifying individual-level inaccuracy in glomerular filtration rate estimation: A cross-sectional study. Ann Intern Med 2022 Jul 5; [e-pub]. PMID: 35785532 https://www.acpjournals.org/doi/10.7326/M22-0610
  17. Carrero JJ et al. Discordances between creatinine- and cystatin C-based estimated GFR and adverse clinical outcomes in routine clinical practice. Am J Kidney Dis 2023 Nov; 82:534. PMID: 37354936 Free article https://www.ajkd.org/article/S0272-6386(23)00691-1/fulltext - Pinsino A et al. The difference between cystatin C-and creatinine-based estimated GFR in heart failure with reduced ejection fraction: Insights from PARADIGM-HF. Am J Kidney Dis 2023 Nov; 82:521. PMID: 37086965 https://www.ajkd.org/article/S0272-6386(23)00609-1/fulltext - Grubb AO et al. Etiologic and diagnostic implications of morbidity and mortality associations when cystatin C-based estimated GFR is lower than creatinine-based estimated GFR. Am J Kidney Dis 2023 Nov; 82:509. PMID: 37737748 https://www.ajkd.org/article/S0272-6386(23)00778-3/fulltext
  18. National Kidney Foundation's renal function calculator http://www.kidney.org/kls/professionals/gfr_calculator.cfm

Component-of

creatinine & glomerular filtration rate panel renal function tests; renal function panel