2011 - Critically discuss the methods available for measuring serum creatinine (60%).

What are the advantages and disadvantages of routine reporting of estimated

glomerular filtration rate (eGFR)? (40%).
2009 - Critically evaluate the methods available for the measurement of serum
creatinine.
2007 - Critically evaluate methods for the measurement of serum creatinine
2006 - Critically discuss the methods available for estimating glomerular filtration rate
using serum creatinine as the only biochemical measurement. What are the
advantages and disadvantages of routine reporting of estimated glomerular filtration
rate?

Creatinine
Reference Range: 45 - 120 µmol/L (serum)
Creatinine is an amino acid derivative (113 Da). It is a waste product of creatine and
phosphocreatine and is found almost exclusively (90%) in skeletal muscle tissues. About 2%
of the body's creatine is converted to creatinine every day, resulting in a fairly constant rate
of creatinine production.
Serum creatinine varies with muscle mass and renal clearance.
A diet high in stewed meat will lead to an increase in creatinine, as will supplements (body
builders).
Creatinine is freely filtered through the glomerulus and is also secreted by the proximal
tubules (5% to 10% of the excreted creatinine).
As much as 50 percent of renal function may be lost before a significant rise in plasma
creatinine is seen.
Serum creatinine concentrations are affected by factors that influence the generation,
glomerular filtration, and tubular secretion of serum creatinine.

Creatinine methods
Chemical
Creatinine reacts with alkaline picrate to form an orange red complex (Jaffe reaction-first
described in 1886). The rate of absorbance change is measured at 505nm and compared to
a known calibrant.
Not specific for creatinine. Positive interference can occur with Jaffe-like chromogens eg.
Protein, ketones, pyruvate, glucose, ascorbic acid.
Haemolysed neonatal samples have shown a negative interference, leading to a negative
result.
The addition of ferricyanide (O’ Leary method) oxidises bilirubin to biliverdin, therefore
reducing interference. A blank reaction rate is performed using sodium hydroxide to minimise
the negative interference from bilirubin. Enzymatic can be used if high bilirubin.
To improve specificity – absorption of creatinine into llyods reagent, ion exchange resin or
solvent extraction or oxidation of interferents with cerium sulphate.
Greatest success with kinetic measurement, which measures the absorbance between 20-
80 seconds to avoid interference outside of these times.
Overestimates plasma creatinine by 20%.

Enzymatic – expensive reagents

1.Creatininase catalyses creatinine to creatine which is detected with a series of enzyme
reactions (creatine kinase, pyruvate kinase and lactate dehydrogenase) and the decrease in
absorbance is monitored.
30min incubation to reach equilibrium as poor reaction kinetics
2. creatininase and creatinase. Yields H2O2 which is detected with a variety of methods.
Interference from bilirubin.
3.creatinine deaminase catalyses creatinine to ammonia which can be detected using
glutamate dehydrogenase or bethelot reaction.
More specific than jaffe.
Dry chemistry methods: use enzymatic methods - low amount of reagent needed.
Although enzymatic expensive, used in dry chemistry systems (as lower reagent), including
some POC testing devices.

Isotope dilution-mass spectrometry (IDMS)-definitive method.

Candidate reference method - uses ion-exchange HPLC with UV detection.
Matrix problems when lyophilised preps used.

Imprecision at low creatinine concentrations and therefore greater error in GFR estimations.
Good correlation between Jaffe and enzymatic – differences due to calibration and
interference.
Calibration not standardised, therefore variation between labs which accounts for 85% of
differences.

Glomerular Filtration Rate

GFR can be measured directly by clearance studies of exogenous markers (inulin (gold
standard), iohexol, iothalamate and Cr51-EDTA). But these are costly and time consuming.
GFR can also be measured by clearance studies of endogenous markers such as urea and
creatinine. But these require a paired serum and an accurately timed urine collection. The
patient should be kept well hydrated and still.
Major use of MDRD eGFR is screening for CKD – more sensitive for the detection of CKD
than serum creatinine and more accurate than creatinine clearance. It is mainly used for the
systematic staging of kidney disease (CKD = eGFR < 60mL/min/1.73m2 for at least 3
months).
Several formulae derived from MDRD study.
In adults, eGFR should be calculated using the 4 variable IDMS traceable version of the
MDRD equation:
eGFR (ml/min/1.73m2) = 175 x (sCr x 0.011312 -1.154) x age-0.203 x 0.742 (if female) x
1.212 (if black)
sCr (µmol/L), age (years)
Formula was derived from studies on patients with chronic renal failure. Therefore values
greater than 60 should be reported as >60 (regarded normal if no clinical/lab evidence of
renal disease).
Equations tend to underestimate normal GFR function and slightly low values should not be
over-interpreted.
The patients creatinine level must also be stable
Not applicable in acute renal failure, pregnancy, severe muscle wasting, oedematous
conditions, amputees, malnourished people and in children - Schwartz or Cockcroft-Gault
equations are used for children.
The more a method overestimates true creatinine, the greater the underestimation of GFR.
The precision and accuracy of eGFR decreases as GFR increases.
Declines with age.
If ethnic origin unknown, assume Caucasian ethnicity.
CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation – performs better
than the MDRD equation, especially at higher GFRs with less bias, improved precision and
better accuracy. Could possibly replace the MDRD equation for routine clinical use.