Original Investigation
Pathogenesis and Treatment of Kidney Disease
Measuring GFR: A Systematic Review

https://doi.org/10.1053/j.ajkd.2014.04.010Get rights and content

Background

No comprehensive systematic review of the accuracy of glomerular filtration rate (GFR) measurement methods using renal inulin clearance as reference has been published.

Study Design

Systematic review with meta-analysis of cross-sectional diagnostic studies.

Setting & Population

Published original studies and systematic reviews in any population.

Selection Criteria for Studies

Index and reference measurements conducted within 48 hours; at least 15 participants studied; GFR markers measured in plasma or urine; plasma clearance calculation algorithm verified in another study; tubular secretion of creatinine had not been blocked by medicines.

Index Tests

Endogenous creatinine clearance; renal or plasma clearance of chromium 51−labeled ethylenediaminetetraacetic acid (51Cr-EDTA), diethylenetriaminepentaacetic acid (DTPA), iohexol, and iothalamate; and plasma clearance of inulin.

Reference Test

Renal inulin clearance measured under continuous inulin infusion and urine collection.

Results

Mean bias < 10%, median bias < 5%, the proportion of errors in the index measurements that did not exceed 30% (P30)  80%, and P10  50% were set as requirements for sufficient accuracy. Based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, the quality of evidence across studies was rated for each index method. Renal clearance of iothalamate measured GFR with sufficient accuracy (strong evidence). Renal and plasma clearance of 51Cr-EDTA and plasma clearance of iohexol were sufficiently accurate to measure GFR (moderately strong evidence). Renal clearance of DTPA, renal clearance of iohexol, and plasma clearance of inulin had sufficient accuracy (limited evidence). Endogenous creatinine clearance was an inaccurate method (strong evidence), as was plasma clearance of DTPA (limited evidence). The evidence to determine the accuracy of plasma iothalamate clearance was insufficient. With the exception of plasma clearance of inulin, only renal clearance methods had P30 > 90%.

Limitations

The included studies were few and most were old and small, which may limit generalizability. Requirements for sufficient accuracy may depend on clinical setting.

Conclusions

At least moderately strong evidence suggests that renal clearance of 51Cr-EDTA or iothalamate and plasma clearance of 51Cr-EDTA or iohexol are sufficiently accurate methods to measure GFR.

Section snippets

Search Strategy

The search strategy was adapted from the PICO process (population [adults, children, elderly, and different patient groups], index test [endogenous creatinine clearance; renal and plasma clearance of 51Cr-EDTA, DTPA, iohexol, and iothalamate; and plasma clearance of inulin], control/reference test [renal inulin clearance], and outcome [bias, precision, and accuracy]). Librarians conducted the literature search in PubMed, Cochrane Library, EMBASE, CINAHL (Cumulative Index to Nursing and Allied

Study Overview

The literature search flow is shown in Fig 1. Population characteristics at study level and individual study quality assessments are available online.3 The assessment of the performance of index methods was based on meta-analysis results for bias, P30, and P10 and is presented in Table 1. The assessment of the accuracy of the index method endogenous creatinine clearance was based on mean bias and is presented in Table 2.

DTPA Clearance

Six studies, including 226 measurements for 174 participants, compared DTPA

Discussion

This systematic review has confirmed that several alternatives to renal inulin clearance exist when a measured GFR is required. The empirical evidence is strong for the renal clearance of iothalamate and moderately strong for renal and plasma clearance of 51Cr-EDTA and plasma clearance of iohexol. The scientific evidence to suggest that renal clearance of iohexol and plasma clearance of inulin can substitute for renal inulin clearance is limited. Similarly, limited evidence suggests that plasma

Acknowledgements

Members of the SBU GFR Review Group are as follows: Carl-Gustaf Elinder (chair), Maria Ahlberg, Susanne Vilhelmsdotter Allander, Anders Alvestrand, Charlotte Asker-Hagelberg, Max Bell, Ulla Berg, Jonas Björk, Agneta Brolund, Sten-Erik Bäck, Thomas Davidson, Nasim Farrokhnia, Anders Grubb, Anders Larsson, Lars-Åke Marké, Ingegerd Mejaré, Patrik Midlöv, Magnus Nord, Anders Norlund, Ulf Nyman, Karin Rydin, Per Sjöström, Inga Soveri, Gunnar Sterner, Maria Svensson, and Sara Wickström; Adjunct

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    A list of the members of the Swedish Council on Health Technology Assessment (Swedish abbreviation, SBU) GFR Review Group appears in the Acknowledgements.

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