Blog | Monday, February 27, 2017

Things that bug me include a lack of understanding of the eGFR


Once upon a time, we had to estimate GFR from the creatinine using an app or even a calculator. Now almost all labs provide estimated GFR, but this is both a positive and a negative.

I rarely find a resident (or attending physician) who understands the principles behind eGFR, and thus too often they interpret the number incorrectly and use it wrong. Here is my quick guide for understanding eGFR.

Back in the day, before the turn of the century, we measured 24 hour urines. We would measure the volume over 1440 minutes and measure the urine creatinine level. Given these numbers and the serum creatinine level, we would plug the numbers into the classic formula UV/P.

This method had the major problem of actually collecting an accurate 24 hour urine.

Cockroft and Gault published this article in 1976: Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41. [PMID: 1244564]

The formula of “creatinine clearance=(140-age)*wt kg/Scr*72 for men and 85% of that number for women” was the commonly used for many years.

Two other formulas based on the same reasoning are likely familiar to many readers, the MDRD formula (used by most labs) and the CKD-EPI equation.

What are these formulas all doing? They are estimating daily creatinine production! The numerator of the creatinine clearance formula, while the creatinine is stable, represent daily creatinine production. In steady state situations, virtually all the creatinine produced each day from muscle breakdown gets excreted in the urine.

We can predict muscle mass in several ways. Muscle mass estimation allows us to estimate daily creatinine production and hence the numerator of our formula.

MDRD and CKD-EPI both estimate muscle mass from age, gender and race. They assume a reasonable estimation from those demographics.

So we have 2 constraints on the use of eGFR. Serum creatinine has not changed and is not changing, and the patient has a “normal” muscle mass.

So here are the cautions. If the serum creatinine is either increasing or decreasing then eGFR is meaningless and should not be reported or considered. Here is the thought experiment. Mr. Jones has a serum creatinine of 1. We remove both his kidneys. Tomorrow his creatinine is 2. We know that he has no GFR, yet the formula would suggest a GFR 1/2 of the previous days. So just report that the serum creatinine is increasing or decreasing, but do not report eGFR.

We have 2 situations in which patients clear do not have “normal” muscle mass. The first occurs in athletes with increased muscle mass: body builders, many football players, etc. Our formulas underestimate the numerator. The denominator has increased because they do make more creatinine each day. Thus, we will underestimate their creatinine clearance with the eGFR formula. Sometimes this would label these individuals as having CKD. In this situation you will need to measure a 24-hour urine creatinine collection.

The second occurs in patients with decreased muscle mass. Some such situations include spinal cord injury patients, major amputations, muscle diseases, and severe cachexia. We recently had a patient with a spinal cord injury and a serum creatinine of 0.4. The formula suggested that his eGFR was approximately 200. The formula was wrong. His numerator was actually much lower than the formula would predict.

Before you use the serum creatinine and the eGFR to make clinical decisions, you should understand these issues. As clinician educators we must remain vigilant and make certain that our learners understand the reasoning behind eGFR. It really bugs me that all our students and residents do not know this. This speaks to inadequate education.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.