The Test Sample

What is being tested?

Glomerular filtration rate (GFR) is a measure of the function of the kidneys. Glomeruli are tiny
filters in the kidneys that allow waste products to be removed from the blood, while preventing the loss of important constituents, including proteins and blood cells. Every day, healthy kidneys filter about 200 quarts of blood and produce about 2 quarts of urine. The glomerular filtration rate refers to the amount of blood that is filtered by the glomeruli per minute. When a person's kidney function declines due to damage or disease, then the filtration rate decreases and waste products begin to accumulate in the blood. Chronic kidney disease (CKD) is associated with a decrease in kidney function that is often progressive. CKD can be seen with a variety of conditions, including diabetes and high blood pressure. Early detection of kidney dysfunction can help to minimize the damage. This is important as symptoms of kidney disease may not be noticeable until as much as 30 to 40% of kidney function is lost. A measured GFR is considered the most accurate way to detect changes in kidney status, but measuring the GFR directly is complicated, requires experienced personnel, and is typically performed in a research setting. Because of this, an estimate the eGFR is usually used. The eGFR is a calculation based on a serum creatinine test. Creatinine is a muscle waste product that is filtered from the blood by the kidneys and excreted into the urine at a relatively steady rate. When kidney function decreases, less creatinine is excreted and concentrations increase in the blood. With the creatinine test, a reasonable estimate of the actual GFR can be determined.

How is it used?
The eGFR test is used to screen for and detect early kidney damage and to monitor kidney status. It is performed by ordering a creatinine test and calculating the eGFR. The creatinine test is ordered frequently as part of a routineComprehensive Metabolic Panel (CMP) or Basic Metabolic Panel (BMP), or along with a Blood Urea Nitrogen (BUN) testwhenever a doctor wants to evaluate the status of the kidneys. It is ordered to monitor those with known kidney disease and those with conditions such as diabetes and hypertension that may lead to kidney damage. ^ Back to top

When is it ordered?
The eGFR can be determined, with no extra testing, at the same time that a blood sample is sent for a creatininemeasurement. The National Kidney Foundation (NKF) has recommended that it be calculated automatically every time a creatinine test is done. A creatinine test and eGFR may be ordered any time that a doctor wants to evaluate a person'skidney function as part of a health checkup or if kidney disease is suspected. Warning signs of kidney disease may include:

Swelling or puffiness, particularly around the eyes or in the face, wrists, abdomen, thighs, or ankles Urine that is foamy, bloody, or coffee-colored

 A decrease in the amount of urine Problems urinating, such as a burning feeling or abnormal discharge during urination, or a change
in the frequency of urination, especially at night

Mid-back pain (flank), below the ribs, near where the kidneys are located High blood pressure (hypertension)
As kidney disease worsens, symptoms may include:

Urinating more or less often Feeling itchy Tiredness, loss of concentration Loss of appetite, nausea and/or vomiting Swelling and/or numbness in hands and feet Darkened skin Muscle cramps
An eGFR may be ordered periodically when a person has a chronic kidney disease or a condition such as diabetes or hypertension that is associated with kidney damage. ^ Back to top

What does the test result mean?

The eGFR test detects kidney disease in its early stages more reliably than thecreatinine test alone. Because the calculation works best for estimating reduced renal function, the NKF suggests only reporting actual results once values are < 60 ml/min (normal values are 90-120 ml/min, according to the NKF). An eGFR below 60 ml/min suggests that some kidney damage has occurred. The NKF recommends that a person's eGFR result be interpreted in relation to his clinical history and presenting conditions. The NKF has suggested that all persons "know their GFR number." They recommend interpreting eGFR results based on the following table:
KIDNEY DAMAGE STAGE

DESCRIPTION

GFR

OTHER FINDINGS

Normal or minimal kidney damage with 90+ normal GFR

Protein or albumin in urine are high, cells or casts seen in urine

Mild decrease in GFR

60-89

KIDNEY DAMAGE STAGE

DESCRIPTION

GFR

OTHER FINDINGS

3 4 5

Moderate decrease in GFR Severe decrease in GFR Kidney failure

30-59 15-29 <15 ^ Back to top

Is there anything else I should know?

Another method of evaluating renal function involves the measurement of the serum level of a molecule called cystatin C. There is increasing interest in the use of this test for this purpose. The creatinine clearance test also provides an estimate of renal function and of the actual GFR. However, in addition to theserum creatinine, this test requires a timed urine collection (24 hours) for urine creatinine measurement in order to compare blood and urine creatinine concentrations and to calculate the clearance. The actual amount of creatinine that a person produces and excretes is affected by their muscle mass and by the amount of protein in their diet. Men tend to have higher creatinine levels than women or children. A person's GFR decreases with age and some illnesses and can increase during pregnancy. The calculation for eGFR is intended to be used when kidney function, and creatinine production, is stable. If a creatinine level is measured when the kidney function is changing rapidly, such as with acute renal failure, then it will not give a useful estimate of the filtration rate. A slightly different equation should be used to calculate the eGFR for those under the age of 18. An eGFR test may not be as useful for those who differ from normal creatinine concentrations. This may include people who have significantly more muscle (such as a body builder) or less muscle (such as a muscle-wasting disease) than the norm, those who are extremely obese, malnourished, follow a strict vegetarian diet, ingest little protein, or who take creatine dietary supplements. Likewise, the eGFR equations are not valid for those who are 75 year of age or older because muscle mass normally decreases with age. The eGFR test may also be affected by a variety of drugs, such as gentamicin, cisplatin, and cefoxitin that increase creatinine levels, and by any condition that decreases blood flow to the kidneys. The most commonly used equation for calculating the eGFR, and the one recommended by the National Kidney Foundation for general use, is called the MDRD (Modification of Diet in Renal Disease study) equation. It requires a person's serum creatinine, age, and assigned values based upon gender and race.

1. How can my GFR be determined?

The best method for directly determining the GFR is a procedure called an "inulin clearance." It involves introducing a fluid containing the marker molecule inulin (NOT insulin) into your veins (IV intravenous infusion) and then collecting timed urines over a period of hours. The urine volumes are noted and the inulin in each sample is measured to allow determination of the GFR. This test and other methods of determining

GFR, such as those that use radioactive markers, are not routinely ordered and are primarily performed in a research setting. ^ Back to top

2. Could I calculate my own eGFR?

If you have had a recent creatinine measurement, you can calculate the eGFR by using the calculator on the National Kidney Foundation web site. If you have questions about the interpretation of your results, it is best to consult with your physician. ^ Back to top

3. Is an eGFR always calculated when a creatinine test is ordered?

This practice is recommended and is done by many laboratories but has not been universally adopted. The eGFR can always be calculated at your doctor's request. ^ Back to top

4. Why might my doctor repeat my eGFR test?

Besides periodic monitoring, your doctor might repeat your eGFR test if she feels that a temporary condition may be affecting your results. ^ Back to top

5. What other findings might suggest kidney dysfunction?

Diabetics and others at risk for developing kidney disease may be monitored for small amounts of protein in their urine by performing a microalbumin test. Protein, albumin, and blood in the urine can be signs of potential kidney damage.