Renal functions include maintaining an acid–base balance; regulating fluid balance; regulating sodium, potassium, and other electrolytes; clearing toxins; absorption of glucose, amino acids, and other small molecules; regulation of blood pressure; production of various hormones, such as erythropoietin; and activation of vitamin D. The kidney has many functions, which a well-functioning kidney realizes by filtering blood in a process known as glomerular filtration. A major measure of kidney function is the glomerular filtration rate (GFR). The glomerular filtration rate is the flow rate of filtered fluid through the kidney. The creatinine clearance rate (CCr or CrCl) is the volume of blood plasma that is cleared of creatinine per unit time and is a useful measure for approximating the GFR. Creatinine clearance exceeds GFR due to creatinine secretion, which can be blocked by cimetidine. Both GFR and CCr may be accurately calculated by comparative measurements of substances in the blood and urine, or estimated by formulas using just a blood test result (eGFR and eCCr). The results of these tests are used to assess the excretory function of the kidneys. Staging of chronic kidney disease is based on categories of GFR as well as albuminuria and cause of kidney disease. Estimated GFR (eGFR) is recommended by clinical practice guidelines and regulatory agencies for routine evaluation of GFR whereas measured GFR (mGFR) is recommended as a confirmatory test when more accurate assessment is required.
Definition Glomerular filtration rate (GFR) is the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. GFR is equal to the renal clearance rate when any solute is freely filtered and is neither reabsorbed nor secreted by the kidneys. The rate therefore measured is the quantity of the substance in the urine that originated from a calculable volume of blood. Relating this principle to the below equation – for the substance used, the product of urine concentration and urine flow equals the mass of substance excreted during the time that urine has been collected. This mass equals the mass filtered at the glomerulus as nothing is added or removed in the nephron. Dividing this mass by the plasma concentration gives the volume of plasma which the mass must have originally come from, and thus the volume of plasma fluid that has entered Bowman's capsule within the aforementioned period of time. The GFR is typically recorded in units of volume per time, e.g., milliliters per minute (mL/min). Compare to filtration fraction.
G F R = Urine concentration × urine flow Plasma concentration {\displaystyle GFR={\frac {{\mbox{Urine concentration}}\times {\mbox{urine flow}}}{\mbox{Plasma concentration}}}}
There are several different techniques used to calculate or estimate the glomerular filtration rate (GFR or eGFR). The above formula only applies for GFR calculation when it is equal to the clearance rate.
Regulation Central to the physiologic maintenance of GFR is the differential vasoconstriction of the afferent (input) and efferent (output) arterioles. Vasodilation of the afferent or vasoconstriction of the efferent arteriole increases GFR. Conversely, vasoconstriction of the afferent or vasodilation of the efferent will decrease GFR. There are multiple mechanisms that the body has to regulate the constriction or dilation of these arterioles: local feedback within the kidney, hormonal regulation, and sympathetic nervous control. These systems are closely intertwined. The kidney can maintain a relatively constant GFR even as mean arterial pressure changes. Local feedback within the kidney (renal autoregulation) includes the myogenic response and tuberoglomerular feedback. In the myogenic response, increased stretch of the afferent arteriole due to higher blood pressure results in afferent vasoconstriction, thereby preventing an increase in GFR. With tuberoglomerular feedback, the macula densa cells at the downstream nephron tubule senses changes in ion levels. If sodium chloride sodium levels in the urinary filtrate are too high, the macula densa signals to constrict the afferent arteriole; if too low, the signal is to vasodilate the afferent arteriole and to release renin (activating the RAAS system). The RAAS system is the major hormonal control of GFR. Low blood pressure activates the RAAS system, increasing the amount of the hormone Angiotensin II. Angiotensin II binds to receptors on the efferent arteriole; the resulting efferent vasoconstriction increases GFR. There is sympathetic innervation of both afferent and efferent arterioles at the glomerulus. Sympathetic activation, for instance during a state of stress, causes vasoconstriction of both the afferent and efferent arterioles. This decreases renal blood flow and GFR. Sympathetic activation also causes the release of renin.
Measurement
Creatinine In clinical practice, however, creatinine clearance or estimates of creatinine clearance based on the serum creatinine level are used to measure GFR. Creatinine is produced naturally by the body (creatinine is a breakdown product of creatine phosphate, which is found in muscle). It is freely filtered by the glomerulus, but also actively secreted by the peritubular capillaries in very small amounts such that creatinine clearance overestimates actual GFR by 10–20%. This margin of error is acceptable, considering the ease with which creatinine clearance is measured. Unlike precise GFR measurements involving constant infusions of inulin, creatinine is already at a steady-state concentration in the blood, and so measuring creatinine clearance is much less cumbersome. However, creatinine estimates of GFR have their limitations. All of the estimating equations depend on a prediction of the 24-hour creatinine excretion rate, which is a function of muscle mass which is quite variable. One of the equations, the Cockcroft and Gault equation (see below) does not correct for race. With a higher muscle mass, serum creatinine will be higher for any given rate of clearance.
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