Assessment of kidney function

Clinical assessment

Clinical assessment can be used to assess the function of the kidneys. This is because a person with abnormally functioning kidneys may have symptoms that develop. For example, a person with chronic kidney disease may develop oedema due to failure of the kidneys to regulate water balance. They may develop evidence of chronic kidney disease, that can be used to assess its severity, for example high blood pressure, osteoporosis or anaemia. If the kidneys are unable to excrete urea, a person may develop a widespread itch or confusion.

Urine tests

Part of the assessment of kidney function includes the measurement of urine and its contents. Abnormal kidney function may cause too much or too little urine to be produced. The ability of the kidneys to filter protein is often measured, as urine albumin or urine protein levels, measured either at a single instance or, because of variation throughout the day, as 24-hour urine tests.

Blood tests

Blood tests are also used to assess kidney function. These include tests that are intended to directly measure the function of the kidneys, as well as tests that assess the function of the kidneys by looking for evidence of problems associated with abnormal function. One of the measures of kidney function is the glomerular filtration rate (GFR). Other tests that can assess the function of the kidneys include assessment of urea and electrolyte levels such as potassium and phosphate, assessment of acid-base status by the measurement of bicarbonate levels from a vein, and assessment of the full blood count for anaemia.

Glomerular filtration rate

The glomerular filtration rate (GFR) describes the volume of fluid filtered from the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. Creatinine clearance (C_Cr) 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 C_Cr 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 eC_Cr) 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.

Central to the physiologic maintenance of GFR is the differential basal tone of the afferent and efferent arterioles (see diagram). In other words, the filtration rate is dependent on the difference between the higher blood pressure created by vasoconstriction of the input or afferent arteriole versus the lower blood pressure created by lesser vasoconstriction of the output or efferent arteriole.

GFR is equal to the renal clearance ratio 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.

${\displaystyle GFR=\frac{\text{Urine Concentration}\times \text{Urine Flow}}{\text{Plasma Concentration}}}$

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.

The normal range of GFR, adjusted for body surface area, is 100–130 average 125 (mL/min)/(1.73 m²) in men and 90–120 (mL/min)/(1.73 m²) in women younger than the age of 40. In children, GFR measured by inulin clearance is 110 (mL/min)/(1.73 m²) until 2 years of age in both sexes, and then it progressively decreases. After age 40, GFR decreases progressively with age, by 0.4–1.2 mL/min per year.

Estimated GFR (eGFR) is now 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.

Medical imaging

The kidney function can also be assessed with medical imaging. Some forms of imaging, such as kidney ultrasound or CT scans, may assess kidney function by indicating chronic disease that can impact function, by showing a small or shrivelled kidney.. Other tests, such as nuclear medicine tests, directly assess the function of the kidney by measuring the perfusion and excretion of radioactive substances through the kidneys.

Kidney function in disease

A decreased renal function can be caused by many types of kidney disease. Upon presentation of decreased renal function, it is recommended to perform a history and physical examination, as well as performing a renal ultrasound and a urinalysis. The most relevant items in the history are medications, edema, nocturia, gross hematuria, family history of kidney disease, diabetes and polyuria. The most important items in a physical examination are signs of vasculitis, lupus erythematosus, diabetes, endocarditis and hypertension.

A urinalysis is helpful even when not showing any pathology, as this finding suggests an extrarenal etiology. Proteinuria and/or urinary sediment usually indicates the presence of glomerular disease. Hematuria may be caused by glomerular disease or by a disease along the urinary tract.

The most relevant assessments in a renal ultrasound are renal sizes, echogenicity and any signs of hydronephrosis. Renal enlargement usually indicates diabetic nephropathy, focal segmental glomerular sclerosis or myeloma. Renal atrophy suggests longstanding chronic renal disease.

Chronic kidney disease stages

Risk factors for kidney disease include diabetes, high blood pressure, family history, older age, ethnic group and smoking. For most patients, a GFR over 60 (mL/min)/(1.73 m²) is adequate. But significant decline of the GFR from a previous test result can be an early indicator of kidney disease requiring medical intervention. The sooner kidney dysfunction is diagnosed and treated the greater chance of preserving remaining nephrons, and preventing the need for dialysis.

The severity of chronic kidney disease (CKD) is described by six stages; the most severe three are defined by the MDRD-eGFR value, and first three also depend on whether there is other evidence of kidney disease (e.g., proteinuria):

0) Normal kidney function – GFR above 90 (mL/min)/(1.73 m²) and no proteinuria

1) CKD1 – GFR above 90 (mL/min)/(1.73 m²) with evidence of kidney damage

2) CKD2 (mild) – GFR of 60 to 89 (mL/min)/(1.73 m²) with evidence of kidney damage

3) CKD3 (moderate) – GFR of 30 to 59 (mL/min)/(1.73 m²)

4) CKD4 (severe) – GFR of 15 to 29 (mL/min)/(1.73 m²)

5) CKD5 kidney failure – GFR less than 15 (mL/min)/(1.73 m²) Some people add CKD5D for those stage 5 patients requiring dialysis; many patients in CKD5 are not yet on dialysis.

Note: others add a "T" to patients who have had a transplant regardless of stage.

Not all clinicians agree with the above classification, suggesting that it may mislabel patients with mildly reduced kidney function, especially the elderly, as having a disease. A conference was held in 2009 regarding these controversies by Kidney Disease: Improving Global Outcomes (KDIGO) on CKD: Definition, Classification and Prognosis, gathering data on CKD prognosis to refine the definition and staging of CKD.