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Measured and estimated glomerular filtration rate: current status and future directions

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Abstract

Evaluation of glomerular filtration rate (GFR) is central to the assessment of kidney function in medical practice, research and public health. Measured GFR (mGFR) remains the reference standard, but the past 20 years have seen major advances in estimated GFR (eGFR). Both eGFR and mGFR are associated with error compared with true GFR. eGFR is now recommended by clinical practice guidelines, regulatory agencies and public health agencies for the initial evaluation of GFR, with measured GFR (mGFR) typically considered an important confirmatory test, depending on how accurate the assessment of GFR needs to be for application to the clinical, research or public health setting. Our approach is to use initial and confirmatory tests as needed to develop a final assessment of true GFR. We suggest that GFR evaluation might be improved by more complete implementation of current recommendations and by further research to improve the accuracy of mGFR and eGFR.

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Fig. 1: Assessment of true GFR.
Fig. 2: An approach to the evaluation of GFR.
Fig. 3: Estimated performance of eGFR using a panel of filtration markers.

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Acknowledgements

The authors are grateful to J. Chen, at Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, for assistance with statistical analysis, and to J. Chaudhari at Tufts Medical Centre, Boston, MA, USA, for assistance with manuscript preparation.

Author information

All authors contributed to ideas expressed in the manuscript. J.C. and H.T. performed statistical analyses. A.S.L. wrote the first draft. All co-authors contributed to critical revisions.

Correspondence to Andrew S. Levey.

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Competing interests

A.S.L., J.C., T.G. and L.A.I have received grants from the National Kidney Foundation (NKF) and National Institutes of Health for GFR estimation and CKD epidemiology. A.S.L has received a grant from Siemens to Tufts Medical Centre outside of the submitted work. T.G. has received personal fees from DURECT Corporation, Janssen and Pfizer outside of the submitted work. L.A.I. has received grants from Retrophin, Omeros and Reata Pharmaceuticals for research and contracts with Tufts Medical Centre, and consulting agreements with Tricida and Omeros Corp. A.S.L., J.C. and L.A.I. also have a provisional patent (filed 15 August 2014; precise estimation of glomerular filtration rate from multiple biomarkers, patent number PCT/US2015/044567), and Tufts Medical Centre, John Hopkins University and Metabolon have a collaboration agreement to develop a product to estimate GFR from a panel of markers. H.T. declares no competing interests.

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CKD-PC instrument: http://www.ckdpcrisk.org/lowgfrevents/

CKD-PC instrument for kidney donor candidates: http://www.ckdpcrisk.org/esrdrisk/

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