Assessment of kidney function: clinical indications for measured GFR

Natalie Ebert, Sebastjan Bevc, Arend Bökenkamp, Francois Gaillard, Mads Hornum, Kitty J. Jager, Christophe Mariat, Bjørn Odvar Eriksen, Runolfur Palsson, Andrew D. Rule, Marco van Londen, Christine White, Elke Schaeffner*

*Corresponding author for this work

Research output: Contribution to journalReview articlepeer-review

20 Citations (Scopus)


In the vast majority of cases, glomerular filtration rate (GFR) is estimated using serum creatinine, which is highly influenced by age, sex, muscle mass, body composition, severe chronic illness and many other factors. This often leads to misclassification of patients or potentially puts patients at risk for inappropriate clinical decisions. Possible solutions are the use of cystatin C as an alternative endogenous marker or performing direct measurement of GFR using an exogenous marker such as iohexol. The purpose of this review is to highlight clinical scenarios and conditions such as extreme body composition, Black race, disagreement between creatinine- and cystatin C-based estimated GFR (eGFR), drug dosing, liver cirrhosis, advanced chronic kidney disease and the transition to kidney replacement therapy, non-kidney solid organ transplant recipients and living kidney donors where creatinine-based GFR estimation may be invalid. In contrast to the majority of literature on measured GFR (mGFR), this review does not include aspects of mGFR for research or public health settings but aims to reach practicing clinicians and raise their understanding of the substantial limitations of creatinine. While including cystatin C as a renal biomarker in GFR estimating equations has been shown to increase the accuracy of the GFR estimate, there are also limitations to eGFR based on cystatin C alone or the combination of creatinine and cystatin C in the clinical scenarios described above that can be overcome by measuring GFR with an exogenous marker. We acknowledge that mGFR is not readily available in many centres but hope that this review will highlight and promote the expansion of kidney function diagnostics using standardized mGFR procedures as an important milestone towards more accurate and personalized medicine.

Original languageEnglish
Pages (from-to)1861-1870
Number of pages10
JournalClinical Kidney Journal
Issue number8
Publication statusPublished - 1 Aug 2021

Bibliographical note

We acknowledge support from the German Research Foundation (DFG) and the Open Access Publication Fund of Charite´– Universitätsmedizin Berlin.

Publisher Copyright:
© The Author(s) 2021.

Other keywords

  • biomarker
  • chronic kidney disease
  • clinical indications
  • creatinine
  • cystatin C
  • kidney function
  • measured glomerular filtration rate


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