Correct evaluation of renal glomerular filtration rate requires clearance assays

Iohexol clearance is an accepted, but time-consuming assay for the measurement of glomerular filtration rate (GFR). We investigated if simpler methods could predict GFR. Sixty-nine children with hematological-oncological disorders participated. A linear relationship was established by regression analysis between iohexol clearance ( n=734) and 1/s-creatinine ( r=0.45, n=727), s-cystatin C ( r=0.41, n=518), and the Schwartz ( r=0.45, n=723), Counahan-Barratt ( r=0.48, n=723), and modified Counahan-Barratt formulae ( r=0.48, n=723). These correlations improved when one GFR measurement per individual was compared with each of the five parameters. We further investigated if iohexol clearance could accurately be replaced. The degree of variation in predicting GFR was estimated by the standard deviation of the residuals (S(res)). For 1/s-creatinine and s-cystatin C, S(res) was 39 and 38 ml/min per 1.73 m(2). For the formulae of Schwartz, Counahan-Barratt, and modified Counahan-Barratt, the S(res) was 43, 40, and 40 ml/min per 1.73 m(2), respectively. The wide variations of the S(res) were not reduced when one GFR measurement per child was compared with the five parameters. Due to the large deviation in predicting GFR, we conclude that the five alternative methods studied cannot replace iohexol clearance for measurement of GFR.     

The impairment of true glomerular filtration rate in long-term cyclosporine-treated pediatric allograft recipients

We performed indium-111-DTPA plasma clearance studies in 61 pediatric kidney and liver recipients treated with cyclosporine to compare true glomerular filtration rate with calculated GFR (cGFR). The mean true GFR of 61.9 +/- 36.6 ml/min/1.73 m2 indicated renal impairment. The mean cGFR of 85.2 +/- 22.4 ml/min/1.73 m2 was significantly higher (P less than 0.001), and overestimated GFR by 38%. cGFR alone did not accurately reflect the degree of renal dysfunction. A group of 48 pediatric orthotopic liver transplant recipients was studied in more detail: 73% of these patients had a true GFR less than 70 ml/min/1.73 m2, while 85% had a true GFR below 90 ml/min/1.73 m2, the lower limit for normal GFR in children. The mean true GFR for patients treated more than 24 months with CsA was lower (P = 0.02) than patients treated with CsA for 12 to 24 months. OLT patients with normal true GFR (greater than 90 ml/min/1.73 m2) had significantly lower plasma CsA levels, and 50% of patients with a true GFR less than or equal to 50 ml/min/1.73 m2 had hypertension. There was no effect on true GFR of age, liver function, azathioprine use, or peritransplant treatment with other nephrotoxic drugs. We conclude that true GFR is significantly impaired in long-term CsA-treated allograft pediatric recipients. Calculations of GFR underestimate the degree of renal dysfunction. As patients treated greater than 24 months had the lowest true GFRs, the fall in GFR may be progressive.     

Normal glomerular filtration rate in long-term follow-up of children after orthotopic liver transplantation

BACKGROUND: Cyclosporine A (CyA) and tacrolimus are the principal immunosuppressive agents used for OLT in children. However, progressive deterioration of renal function from calcineurin inhibitor toxicity after OLT has been widely reported. The aim of this study was to assess long-term renal function in children after OLT. METHODS: We reviewed all OLT patients surviving >1 year at Sainte Justine Hospital from 1987 to 2003. The GFR (ml/min/1.73 m) was measured yearly by the Tc-99m DTPA single injection technique RESULTS: In all, 101 OLT patients (27 tyrosinemia, 33 biliary atresia, 5 fulminant hepatic failure, 36 miscellaneous) were studied. Median age at OLT was 35 months (range 6-178 months) in tyrosinemia group and 58 months (range 1-226 months) in the "Others" (P = NS), median pediatric end-stage liver disease score was respectively 3 (range -9 to 21) and 15 (-9 to 35), (P=0.001), and median follow-up was 6 (range 1-14) and 6 (range 1-17) (P = NS) years, respectively. Median annual GFR values in tyrosinemia fluctuated between 61 and 104 ml/min/1.73 m, with an improving tendency, and 94-121 ml/min/1.73 m in the Others. GFR did not differ on CyA vs. tacrolimus treatment. The median duration of therapy with calcium-channel blocker in the tyrosinemia group was 5 (1-13) vs. 2 (1-13) years in the Others. CONCLUSIONS: Median GFR remained normal in most nontyrosinemia patients (Others). Tyrosinemia patients remained stable at a lower GFR. CyA administration in three daily doses and prolonged calcium-channel blocker therapy may have contributed to this stability. Impairment of kidney function was associated with congenital kidney disease, toxic kidney injury, and portal hypertension.     

Expressing glomerular filtration rate in children

We have reviewed the studies that provide the current standards of reference for glomerular filtration rate (GFR) in normal children from 14 days to 12 years of postnatal age. These standards currently are presented as ml/min per 1.73 m², i.e., adjusted to average adult body surface area. Children from birth to 1 year of age have adjusted values below the adult range, making comparisons of observed to reference values difficult. Currently, there is no accepted way of obtaining reference values that vary smoothly with age. An analysis of the absolute GFR values in normal children taken from published studies led to an equation that estimates average GFR in relation to weight and term-adjusted age from-2 months (7 months gestational age) to 12 years in children at least 14 days post delivery. When these data are transformed to percentage of normal (% nl) for age and weight (i.e., percentage of the estimated average), it is possible to describe approximate apparent lower limits of normal GFR as is now done for adults and older children. For children with loss of renal mass, GFR expressed as % nl for age and weight provides a convenient standardization which has several useful applications. First, results expressed as % nl for children of different ages, particularly under 1 year of age, can be combined with those of older children for summary purposes. Second, the course of GFR measured serially in children is more appropriately described using this method for expressing GFR. Reporting GFR in absolute values is also useful, particularly in patients whose body mass is significantly distorted or whose absolute GFR is low.     

Slope‐only glomerular filtration rate and single‐sample glomerular filtration rate as measurements of the ratio of glomerular filtration rate to extracellular fluid volume

Aims: The Jacobsson single‐sample equation for measuring glomerular filtration rate (GFR) after bolus injection is based on two factors of questionable theoretical validity for correcting the single‐compartment assumption. The aims were to redevelop a more transparent equation, show its fundamental similarity with ‘slope‐only’ GFR and compare it with the original equation and with slope‐only GFR. Methodology: The modified Jacobsson equation is k = (1/t).ln[V(t)/V(0)], where k is the rate constant of the terminal exponential and V(0) and V(t) are distribution volumes at times 0 and t. V(0) exceeds extracellular fluid volume (ECV): that is k′ = (1/t).ln[V(t)/ECV], where k′ > k. Moreover, [GFR/ECV] >k (= k + [15.4.k²]). The ratio k/k′ was determined in 476 patients to calculate single‐sample k (3 or 4 h post‐injection). Slope‐only and single‐sample GFR/ECV were measured using Cr‐51‐EDTA in 105 further studies, multiplied by ECV (estimated from weight), scaled to 1.73 m² and compared with GFR/1.73 m² from the original Jacobsson equation against reference multi‐sample GFR/1.73 m² simultaneously and independently measured with iohexol. Results: The relation between k and k′ was linear. k/k′ was 0.827 at 3 h and 0.864 at 4 h. There was no difference in bias or precision between the original Jacobsson and modified equations. In both, precision was better than slope‐only GFR/BSA. When GFR remained scaled to ECV, slope‐only GFR showed marginally better precision against reference GFR/ECV. Conclusions: Single‐sample and slope‐only techniques give GFR as k. Although the theory of the modified Jacobsson equation is more transparent than the original equation, it gives the same result. It is, however, easier to use.     

Effect of hyperfiltration on long-term follow-up of glomerular filtration rate in male Wistar rats

It has been suggested that a prolonged course of hyperfiltration could lead to progressive deterioration of renal function. In order to test this hypothesis, the following protocol was applied to 60 male Wistar rats. At 12 weeks of life, the rats were submitted to a surgical procedure: sham operation (25 rats), unilateral nephrectomy (25 rats) or 3/4 nephrectomy (10 rats). The three groups were again divided into two subgroups: one with high-protein intake (36%) and one with a low-protein intake (12%). In order to avoid any additional traumatic procedure which could shorten the animal's life, the glomerular filtration rate (GFR) was measured without blood sampling, using a previously validated technique based on an image recorded by a gamma camera between the 9th and the 10th min after intravenous injection of^99m technetium diethylenetriaminepentaacetate (DTPA). The sum of both kidneys and bladder activity was expressed as a percentage of the injected dose. The test was performed before surgery and every month thereafter. Six weeks after surgery, the highest filtration rate was found in the rats with two kidneys/high-protein diet, followed by the two kidneys/low-protein diet, the one kidney/high-protein diet, the one kidney/low-protein diet and the 1/2 kidney. The overall GFR in the one kidney/high-protein diet rat and in the 1/2 kidney rat was respectively 80% and 55% of the pre-operative values. Until 109 weeks of age, the survival rate was comparable in the five groups of rats. At 109 weeks of age, non-significant changes in renal function were observed, the follow-up slopes of the different subgroups being more or less parallel. At that age, the lesions of glomerular sclerosis were focal and discrete, without significant differences in the five groups.     

Longitudinal analysis of serum cystatin C for estimating the glomerular filtration rate in preterm infants

Background

Cystatin C (Cys-C) is a more sensitive marker of renal function than creatinine (Cre) in pediatric and adult populations. However, the reference values of serum Cys-C for estimating glomerular filtration rates (eGFRs) in premature infants during the first year of life have not been sufficiently studied.

Methods

In this prospective study, 481 blood samples were collected from 261 preterm infants with uncomplicated clinical courses during their first year of life. Infants were divided into three groups according to gestational age at birth: 27–30 weeks, 31–33 weeks, and 34–36 weeks. Serum Cys-C and Cre levels were measured at 6–30 days, 3–5 months, 7–9 months, and 12–14 months after birth and the eGFR was calculated using two previously published equations.

Results

The median serum Cys-C levels were 1.776, 1.248, 1.037, and 0.960 mg/L at the first, second, third, and fourth measurement time-point, respectively, with the value significantly decreasing with age up to 12–14 months. Cys-C levels were independent of gestational age and gender. In contrast to Cys-C, serum Cre values declined rapidly up to 3–5 months, then remained constant up to 12–14 months. Using the Cys-C-based equation, the eGFR significantly increased with increasing age until approximately 1 year after birth; however, no such trend was noted using the equation based on Cys-C + Cre.

Conclusions

Reference ranges for Cys-C in premature infants decline gradually over the first year after birth. Cys-C appears to be a more reliable marker than Cre for estimating GFR in preterm infants.

     

Creatinine for estimation of glomerular filtration rate

The aim of this study was to evaluate the plasma creatinine concentration (P_Cr) and creatinine clearance (C _Cr) for estimation of glomerular filtration rate (GFR). Inulin clearance (C _in) was used as the reference standard for GFR. Thirty-nine concurrentC _in andC _Cr studies provided data for comparingC _in with the measuredC _Cr and with the calculatedC _Cr (calc-C _Cr). (Calc-C _Cr=k·L/P_Cr, where L=height in centimeters and k is the proportionality constant.) Thirty-one children 5.3–20.8 years of age, withC _in ranging from 2.8 to 138.8 ml/min per 1.73 m², participated in these studies at The Children's Mercy Hosptial. The measuredC _Cr was 16.7±10.3 ml/min per 1.73 m² (P<0.001) greater than theC _in, and the calc-C _Cr overestimatedC _in by a mean of 31.6±20.8 ml/min per 1.73 m² (P<0.001). Although there is good correlation betweenC _in andC _Cr (r=0.96), andC _in and calc-C _Cr (r=0.90), the 95% confidence intervals are quite broad. Hence, theC _Cr and the calc-C _Cr, derived using Schwartz values for k, consistently overestimate GFR. However, if the k value in the equation GFR=k·L/P_Cr is derived from k=C _in/L, rather than from k=C _Cr·P_Cr/L, a more accurate estimate of GFR may be obtained.     

Glucocorticoids and control of glomerular filtration rate

Glucocorticoids given acutely or chronically at physiological/pharmacological doses increase GFR in both experimental animals and humans. Glomerular micropuncture studies have shown that in the normal rat kidney, glucocorticoids vasodilate both the preglomerular and efferent resistances and result in an increase in glomerular plasma flow, which is the sole factor responsible for the increase in GFR. However, the mechanism(s) initiating these alterations in the glomerular microcirculation remain obscure. The glucocorticoid-induced increase in GFR does not appear to be due to volume expansion or alteration in tubulo-glomerular feedback activity. Chronic glucocorticoid administration has been shown to increase renal prostaglandin synthesis in some but not all species; however, a link between increased prostaglandin production and glucocorticoid-induced increase in GFR has not been established. A number of studies have examined glucocorticoid-induced alterations in renal vascular reactivity to vasoconstrictor agonists and the data have been conflicting. The suggestion that glucocorticoid-stimulated ANP production evokes the increase in GFR is unlikely to be correct based on substantial differences in the glomerular hemodynamic changes seen with ANP or glucocorticoids. An interesting proposal that appears well worth exploring is that glucocorticoids may increase GFR through their effects on catabolism of proteins to increase production of amino acids. Amino acid infusion markedly elevates GFR and has a similar glomerular hemodynamic profile as that of glucocorticoids. By virtue of their action to increase GFR, glucocorticoids increase the rate of electrolyte and water delivery into the nephron. Therefore, glucocorticoid-induced alterations in electrolyte and water excretion may be secondary to an elevation in GFR, in addition to direct actions of glucocorticoids on the tubule. Also, by determining the hemodynamic state of the kidney, and hence, rate of fluid delivery through the nephron, glucocorticoids may influence the sensitivity of the nephron to regulatory influences. Glucocorticoids have their most profound effect (especially clinically) by modifying the immunological or cellular mechanisms responsible for glomerular injury. Less important is their ability to increase GFR. In view of some evidence that suggests increasing glomerular pressure accelerates the progression of established renal disease, some might speculate that glucocorticoids actually increase glomerular damage under certain conditions.     

Estimation of glomerular filtration rate in children

The aim of this study was to develop a method to predict the glomerular filtration rate (GFR) in children by using the population pharmacokinetic approach. This powerful approach is widely used for drug development in order to study relationships between patients' characteristics (demographic, morphological, biological covariates) and pharmacokinetic parameters. For the first time, (51)Cr-EDTA plasma concentrations from 64 children (development data set) were analyzed using the Non-linear Mixed Effects Model (NONMEM) program to determine the most appropriate equation to relate (51)Cr-EDTA clearance (as a measurement of GFR) and patient characteristics. The most predictive equation was based on body weight, square height, and plasma creatinine (PCr, determined by the Jaffé method). This equation was then validated using the data from a further 33 patients. This equation produced estimates of GFR that were less biased and more precise than those obtained using the widely used Schwartz formula. The coefficient of correlation between estimated and actual GFR was 0.83, and the 10th to 90th percentiles for percentage errors were -20% to +30%. Finally, analysis of the whole data set (97 patients) led to an equation (i.e., GFR (ml/min)=[56.7 x Body weight (kg)+0.142 x Length(2)(cm)]/PCr ( microM)) very similar to that obtained from the development data set. This equation would be useful for estimating GFR in children when isotopic determination of the (51)Cr-EDTA clearance cannot be performed.     

Estimating absolute glomerular filtration rate in children

Normal values of glomerular filtration rate (GFR) in children are often expressed in a value adjusted to adult ideal body surface area. These values work well for many clinical situations, but in infants and children, especially those with atypical body mass, they may not accurately reflect renal function. Most body composition values in children are expressed in developmentally appropriate ranges. Absolute GFR (ml/min) also changes during childhood increasing rapidly in infancy and then gradually with age and body size. Previously, we developed a bedside equation for estimating GFR (ml/min) in children that accounted for changes with age and body size, and which correlated well with steady-state cold iothalamate GFR (ml/min) measurements: GFR (ml/min) = k_*sqrt[(age(months) + 6)*wt (kg)/serum Cr (mg/dl)], where k=0.95 for females and 1.05 for males. In the present study GFR (ml/min) measured by iothalamate infusion was compared by correlation analysis with estimates calculated from the above equation in 566 children. This equation provides clinicians with a simple bedside method to estimate absolute GFR (ml/min).     

Estimated glomerular filtration rate and renal function

Glomerular filtration rate (GFR) is an important clinical indicator of kidney function. It can be used as an independent predictor of long-term survival after cardiac surgery. Definition, methods of measurement, and corrected value by body surface area are briefly introduced in this paper. Details of the calculation of estimated GFR (eGFR) by Levey's formula with serum creatinine, age, gender, and race are offered. The relationship between estimated GFR and the four factors is shown graphically and discussed. An eGFR/creatinine conversion table for individual patients derived from the eGFR equation with clinically significant cutpoints is given, which can be used by physicians as a pragmatic reference.