Determining The Glomerular Filtration Rate: Andani Puspita Rani 1315244

DETERMINING THE
GLOMERULAR FILTRATION RATE

Review Article
Elke Schaeffner, MD, MSc
Journal of Renal Nutrition,
Vol 27 No 6 (November), 2017
Andani Puspita Rani

1315244
Introduction
• Glomerular Filtration Rate (GFR) is still considered the
best indicator of kidney function worldwide
• Exact assessment of GFR is crucial for several reasons:
GFR determines the stage of chronic kidney disease
(CKD), as the staging system is based on GFR
• This staging system has several clinical implications, such
as drug dosing, the application of potentially nephrotoxic
contrast agents, the timing of renal replacement therapy,
the appropriateness of living organ donation, and also
the labeling of the diagnosis ‘‘CKD,’’ which has insurance
(and therefore financial) and psychological implications
cont..
• During the last 5 to 10 years, different groups
have worked to optimize GFR assessment, which
has led to a variety of publications about GFR
estimation or measurement
• In an endeavor to come as close as possible to
the true GFR, several novel GFR estimation
formulae (eGFR) have been developed
• A huge body of literature also exists for GFR
measuring (mGFR) methods which are supposed
to be closer to the true GFR compared with the
estimated and serve as ‘‘gold standards’’
whenever a new estimation formula is developed
Measuring GFR
• Measuring GFR is regarded as the more precise
method for determining kidney function and is
therefore frequently referred to as ‘‘gold
standard.’’
• This gold standard method principally involves a
clearance method.
• The one that is still most often used in Germany
is the creatinine clearance. In this case, urine is
collected over a certain period of time—usually
24 hours (with 12 hours also being possible)—to
record the urinary creatinine concentration.
• Another, more precise option is the application of an
intravenous exogenous filtration marker, with
subsequent measurement of its plasma clearance
(possibly in combination with the urinary clearance.
• A distinction is made in a 2-compartment model
between a ‘‘fast component’’ and a ‘‘slow
component’’ phase, with the former corresponding to
the ‘‘central’’ distribution of the marker in the blood
and organs and the latter to its distribution in the
peripheral areas (i.e., areas with less blood circulation,
such as muscle or fatty tissue) and the renal
elimination of the contrast medium from the blood
Estimated GFR
• An estimation formula that was only
developed in sick people (e.g., Modification of
Diet in Renal Disease [MDRD] study)
underestimates GFR in healthy people.
• Conversely, a formula that was principally
developed in healthy people would
overestimate GFR in sick people.
Newer Estimation Formulae
Non-GFR Determinants
• Non-GFR determinants are factors that can
influence endogenous biomarkers such as
creatinine or cystatin C independently of GFR
• For this reason, it is important to be aware of
non-GFR determinants, so that GFR results
can be better interpreted in certain clinical
situations
• Scenarios could be a normal creatinine but
elevated cystatin C because of different causes:
– That is, an elderly woman with low muscular mass
who has CKD
– patient being treated with chemotherapy for
lymphoma.
• In the first case, creatinine is dependent on
muscle mass and thus not a suitable marker to
detect reduced kidney function in this particular
patient
• In the second scenario, cystatin C is influenced
(elevated) by the chemotherapy falsely
suggesting impaired kidney function
Standardization of Assays
• Standardization of Assays The standardization
of laboratory assays is extremely important
when endogenous biomarkers such a
creatinine and cystatin C are used.
• Creatinin use an enzymatic method or isotope
dilution mass spectrometry (IDMS traceable)
or Colorimetric Jaffe method
• Cystatin C use nephelometric Siemens assay
corresponded to this standardization
Conclusion
• Kidney function can be determined using either
estimation formulae or measuring methods
• After being the primary filtration marker for decades,
creatinine has now been joined by cystatin C in recent
years
• In this context, physicians should become more aware
of the significance of ‘‘non-GFR determinants’’ for
interpreting GFR values
• Also worth mentioning are the new FAS formulae,
which are being applied as the first formulae for all age
categories, although they are still waiting for external
validation before being used area-wide.
• As a rule, laboratories should only use standardized
assays, even if this reality is still in the distant future.
Thank You

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DETERMINING THE

GLOMERULAR FILTRATION RATE

Andani Puspita Rani

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