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Learning Objectives

 Define GFR
 Define creatinine clearance test
 Discuss intrinsic and extrinsic markers for assessing GFR
 Describe the indications, preparation and procedure,
precaution and interpretation of creatinine clearance test
 Describe the procedure of 24 Hour urine sample collection
 Write down the formula for assessing creatinine clearance
GFR
• The rate of blood flow filtered by the kidney's glomerulus into
Bowman's capsule per unit of time is the glomerular filtration rate, or
GFR.

• GFR is generally considered to be the best index of overall kidney


function

• In young adults it is approximately 120 ml/min/1.73 m2 and some


declines is normal with age.

• Declining GFR is the hallmark of progressive kidney disease

• The GFR can't be measured directly - so we use serum creatinine &


creatinine clearance.
SERUM CREATINE

 Creatinine is derivative of creatine,

 It results from breakdown of creatine phosphate in skeletal


muscle, due to normal wear & tear.

 Produced at a fairly constant rate by the body depending


on muscle mass relating to age, sex and weight

 Filtered through the kidneys as produced and excreted in


urine but not reabsorbed.
 Reliable test for glomerular function
 Normal range in blood:
o Male 0.8 - 1.3 mg/dl
o Female 0.6 - 1 mg/dl
 Raised Serum Creatinine:
 Impaired renal function
 Very high protein diet
 Vary large muscle mass: body builders, giants, acromegaly
 Rhabdomyolysis/crush injury, strenuous exercise
 G.I.Bleeding
 Dehydration, Shock, ketoacidosis
 Urinary stasis
 Surgery
 Diabetic nephropathy
 Anabolic steroid users
 Drugs: Probenecid, Cimetidine, Triamterene, Trimethoprim,
Amiloride

 Lower in women, elderly and persons with


malnutrition, muscle paralysis and short stature
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Limitation of Serum Creatinine

• Creatinine shows some false rise due to increased


dietary intake of meat

• It depends on the muscle mass of the patient.

• Certain medications inhibit secretion e.g : gentamycin,


cephalosporins, cimetidine etc. gives false serum levels

• In muscle wasting disease – not a reliable indicator.


Markers of GFR

1. Exogenous Markers 2. Endogenous


Non-radioactive
Markers
• Inulin
• Iohexol • Creatinine
• Iodoacetate • Urea
•Diethylenetriaminepentaacetic acid
(DTPA)
• Beta2-Microglobulin
Radioactive • Retinol-binding protein
• Tc-diethylenetriamine Penta acetic • Alpha1-Microglobulin
acid (Tc – DTPA)
• Cr-ethylenediamine tetra acetic acid • Cystatin C
• I-hippuran • Neutrophil gelatinase-
• I-iodothalamate associated lipocalin (N-
GAL)
INDICATIONS
 Assessment of potential kidney donor
 Investigation of patient with abnormal renal
function
 Patient on toxic drugs, which are excreted
by the kidneys
 Assessment of renal GFR for both
diagnostic and management purposes in
chronic renal disease
SAMPLING PROTOCOL
 List any prescription and over-the-counter
medications in use since some drugs like
trimethoprim, cimetidine etc affects GFR

 The test should begin at a specific time and end


at the same time on the following day.

 Your test must begin in the morning. On the first


day, do not collect your first urine. Collect all
your urine for the next 24 hours, keeping the
storage container refrigerated.
.
 Collect your first morning urine on the second
day at the same time you began the test
yesterday

 Keep the container refrigerated until it is time to return


it promptly to the lab or doctor’s office as instructed.

 Be sure to notify your healthcare provider if you were


unable to follow all instructions. Report missed urine,
spilled urine, urine collected after the 24-hour time
period ended, or if you were unable to store the
collection bottle in a cool place
Collection of blood sample

 A serum or plasma sample is to be drawn at some


time during the course of the 24-hour collection. It
does not make any difference if it is drawn at the
beginning or the end of the collection unless the
collection is to be done over the weekend and there
will be a delay in returning the urine to the lab. In that
case, the specimen should be drawn when the urine
collection container is given to the patient
FORMULA
 Calculation: Urine Creatininex 24 h urine volume in ml = ml / min
Serum Creatinine Time in minutes
(24x60)

 Ref range: Female: 60 -120 ml/min


Male: 80-140ml/min
INTERPRETATIONS
 There are natural variations in creatinine output due to age and
body mass—the more muscular you are, the higher your range
will be.
 Creatinine values that fall outside the normal range may be an
indication of:
 kidney disease
 kidney infection
 kidney failure
 urinary tract obstruction, such as kidney stones
 late-stage muscular dystrophy
 myasthenia gravis
 Abnormal values can also occur during pregnancy, in
patients who have diabetes mellitus, and in people who have
a diet high in meat.
Calculation

• Calculation by 24hr urine method:


Urine Creatinine x 24 h urine vol in ml = ml/min
Serum Creatinine Time in minutes (24x60)

Ref range: Female: 60 -120 ml/min


Male: 80-140 ml/min

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Serum creatinine conc. inversely related
to GFR

16 Serum Creatinine
Relationship between
Concentration and Creatinine Clearance

800
Serum Creatinine (µmol/L)

700
600
500
400
300
200
100
0
0 25 50 75 100 125
Creatinine Clearance (ml/min)

•Reference limits can be misleading


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