Creatinine Clearance


Article Author:
Hassan Shahbaz


Article Editor:
Mohit Gupta


Editors In Chief:
Ishwarlal Jialal


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/5/2019 11:31:29 PM

Introduction

The measurement of accurate renal function is vital for the routine care of patients.[1] Determining the renal function status can predict kidney disease progression and prevent toxic drug levels in the body.[2] The glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidneys. The gold standard measurement of GFR involves the injection of inulin and its clearance by the kidneys.[2] However, the use of inulin is invasive, time-consuming, and an expensive procedure. Alternatively, the biochemical marker creatinine found in serum and urine is commonly used in the estimation of GFR.[3] Creatinine clearance (CrCl) is the volume of blood plasma cleared of creatinine per unit time. It is a rapid and cost-effective method for the measurement of renal function. Both CrCl and GFR can be measured using the comparative values of creatinine in blood and urine.

Glomerular Filtration Rate

The GFR in the measurement of volume filtered through the glomerular capillaries and into the Bowman’s capsule per unit of time.[4] The filtration in the kidney is dependent on the difference in high and low blood pressure created by the afferent (input) and efferent (output) arterioles, respectively.[5] The clearance rate for a given substance equals the GFR when it is neither secreted nor reabsorbed by the kidneys.[2] For such given substance, the urine concentration multiplied by the urine flow equals the mass of substance excreted during the time of urine collection. This mass divided by the plasma concentration is equivalent to the volume of plasma from which the mass was originally filtered. Below is the equation used to determine GFR, typically recorded in volume per time (e.g., mL/min):

GFR = [UrineX (mL/mg)] * urine flow (mL/min)/ [PlasmaX (mL/mg)], where X is a substance that is completely excreted.

GFR approximation using Creatinine Clearance

Creatinine is a breakdown product of dietary meat and creatine phosphate found in skeletal muscle. Its production in the body is dependent on muscle mass.[6] The CrCl rate approximates the calculation of GFR since the glomerulus freely filters creatinine. However, it is also secreted by the peritubular capillaries, causing CrCl to overestimate the GFR by approximately 10% to 20%.[4] Despite the marginal error, it is an accepted method for measuring GFR due to the ease of measurement of CrCl.

Cockcroft-Gault formula: Estimated creatinine clearance rate (eCCR)

Creatinine clearance can be estimated using serum creatinine levels. The Cockcroft-Gault (C-G) formula uses a patient’s weight (kg) and gender to predict CrCl (mg/dL).[7] The resulting CrCl is multiplied by 0.85 if the patient is female to correct for the lower CrCl in females.[7] The C-G formula is dependent on age as its main predictor for CrCl. Below is the formula:

eCCr = (140 – Age) x Mass (kg) x [0.85 if female] / 72 x [Serum Creatinine (mg/dL)]

Formulas used in the prediction of GFR

Formulas derived using variables that influence GFR can provide varying degrees of accuracy in estimating GFR. The widely used Modification of Diet in Renal Disease Study Group (MDRD) employs four variables, including serum creatinine, age, ethnicity, and albumin levels.[8] A further complex version of MDRD includes blood urea nitrogen and serum albumin in its formula. However, since MDRD formula does not adjust for body size, results of eGFR are given in units of ml^-1 min^-1 1.73m^-2, 1.73m^2 due to body surface area in an adult with a mass of 63kg and height of 1.7m.[9]

Other formulas used for GFR calculations and their employed variables to estimate GFR include Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas.[10] The CKD-EPI formulas are in categories based on patients that are a black female, black male, non-black female, and non-black male. The Mayo Quadratic formula was developed to better estimate GFR in patients that have preserved renal function.[11] Estimation of GFR in children uses the Schwartz formula, which employs serum creatinine (mg/dL) and child’s height (cm).[1]

In current clinical practice, the use of creatinine derived the KDIGO clinical practice guidelines recommend CKD-EPI formula for the estimation of GFR.[12]

Etiology and Epidemiology

Serum and urine samples are required. The serum collection must be within 24 hours of urine collection.

Blood specimen

A blood sample of 1 mL (minimum 0.5 mL) in a labeled tube, preferably stored in refrigerated or frozen temperature.

Urine specimen

A 24-hour urine sample is collected from the patient to measure creatinine clearance.  A plastic collection container is used to collect urine. The collection starts with an empty bladder. At the start, the patient urinates into the toilet and flushes. The date and time get recorded at the start of the collection. For the next 24 hours, the patient will collect urine and store into a container at room temperature. Total urine collected for 24 hours gets sent to the laboratory for analysis. The patient is required to drink at least 8 cups of liquid on the day of urine collection.

Specimen Requirements and Procedure

A physician may require a creatinine clearance test from patients when routine blood creatinine levels or the estimated GFR are not within normal ranges. Patients with signs and symptoms of deteriorating kidney function are candidates for CrCl test.[13] Patients presenting with an obstruction within the kidney or dysfunction from another disease such as congestive heart failure may be required to perform a CrCl test.

Diagnostic Tests

Elevated serum creatinine levels and a decreased CrCl rate are usually indications for abnormal renal function. For these patients, it is recommended to perform a thorough history, physical exam, renal ultrasound, and urinalysis.[14] Relevant patient history includes medications, history of edema, gross hematuria, diabetes, and polyuria.[13] Physical examination for signs of vasculitis, lupus erythematous, endocarditis, and hypertension can help narrow the diagnosis — renal ultrasound assesses the kidney size, echogenicity, and possible hydronephrosis. Enlarged kidneys usually indicate diabetic nephropathy, focal segmental glomerulosclerosis, or multiple myeloma. A urinalysis positive for proteinuria or urinary sediment indicates the presence of glomerular disease.[13]

Testing Procedures

The normal range of CrCl is 110 to 150mL/min in males and 100 to 130mL/min in females.[15] Serum creatinine level for men with normal kidney function is approximately 0.6 to 1.2mg/dL and between 0.5 to 1.1 mg/dL for women.[15] Creatine levels above the normal range correlate with a reduction of GFR and indicate renal dysfunction.

  • Creatinine 1 mg/dL is the baseline for a given patient with normal GFR
  • Creatinine 2 mg/dL is 50% reduction in GFR
  • Creatinine 4 mg/dL is 70 to 85% reduction in GFR
  • Creatine 8 mg/dL is 90 to 95% reduction in GFR

Alteration of serum creatinine values can occur as its generation is subject to influence by muscle function, activity, diet, and health status of the patient.[16] Increased tubular secretion of creatinine in certain patients with dysfunctional kidneys could provide a false negative value.[17] Elevated serum creatinine levels also present in patients with muscular dystrophy paralysis, anemia, leukemia, and hyperthyroidism. Meanwhile, decreased values present in patients with glomerulonephritis, shock, congestive heart failure, polycystic kidney disease, acute tubular necrosis, and dehydration.[16]

Interfering Factors

Results obtained from a 24-hour urine collection depend on accurate timing and completion. Improper urine sample collection leads to an underestimation of creatinine excretion; therefore, incorrect GFR. A significant limitation of CrCl measurement is an age-related increase in the tubular secretion of creatinine that results in an overestimation of GFR[18]

Creatinine clearance is affected by sex and race. Women have less muscle mass and a lower rate of creatinine production in comparison to men. Latinos produce lower clearance values while blacks produce higher values, indicating greater muscle mass in blacks.[19] Patients with a unique dietary intake (e.g., vegetarian, creatine supplements) or have muscle wasting (e.g., malnutrition, amputation) can produce levels of creatinine that deviate from the general population. Drugs such as trimethoprim-sulfamethoxazole can increase serum creatinine level by approximately 0.4 to 0.5 mg/dL[20]

Results, Reporting, Critical Findings

It is essential to determine CrCl and serum creatine levels when there is suspicion of renal dysfunction. A common complication that results in increased serum creatine levels is acute kidney injury (AKI)[21] A sudden decrease in GFR and oliguria are signs of AKI. This type of injury is common in 20% of hospitalized patients and leads to volume overload, electrolyte imbalances and drug toxicity[21] Management for patients with AKI is to perverse kidney function and prevent further complications.

Persistently elevated levels of serum creatinine and severely reduced GFR are indicative of chronic kidney disease. CKD occurs through multiple pathologic mechanisms of injury and affects several compartments of the kidney.[22] The loss of microvasculature and increased fibrosis leads to hypoxia within the kidney, making patients more substile to acute kidney injuries with poor healing.  The continued loss of tubular cells becomes replaced with collagen scars and macrophage infiltration.[23] These chronic changes are associated with further loss of renal function and progression towards end-stage renal failure[23]

Clinical Significance

Routine blood tests for serum creatinine levels among other substances can prevent future complications of renal disease. Patients with a chronic diagnosis of uncontrolled diabetes and hypertension are especially vulnerable to kidney disease.

Quality control and Lab Safety

The results of CrCl and its estimation of GFR allow for the assessment of the excretory function of the renal system. The CrCl test is used to monitor the progression of renal disease.[3] Staging of chronic kidney disease and nephropathies can be quantified using GFR. Drug dose adjustment may be necessary according to the patient's GFR and kidney functional status. The non-invasive technique to measure GFR via CrCl offers greater patient compliance.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Creatinine Clearance - Questions

Take a quiz of the questions on this article.

Take Quiz
Measurement of creatinine clearance requires consideration of multiple variables. Which of the following factors is a type of variable involved in the calculation creatinine clearance?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following factors does NOT affect creatinine clearance?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is a normal level of creatinine clearance?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What correction, if any, should be made in calculating creatinine clearance value in females?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How does the female creatinine clearance compare to the male creatinine clearance?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
How does the female creatinine clearance compare to the male creatinine clearance?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 65-year-old male weighs 55 kg and has a height of 178 cm. He has a history of uncontrolled chronic hypertension and has been feeling fatigued for the past one week. He reports a decrease in urine volume and frequency for three days. On examination, he has swollen legs and ankles. The patient undergoes appropriate lab work and is found to have a creatinine clearance rate of 30 mL/min (normal range: 110 to 150 mL/min). Which of the following approximates his serum creatinine level?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old female comes to the emergency department complaining of shortness of breath that started two days ago. One week ago, she returned home to Chicago on a direct flight from Australia. She has a past medical history of hypertension and chronic kidney disease. Today, her creatinine level is 3 mg/dL. Which of the following diagnostic test is contraindicated in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old female is recovering from multiple bone fractures after falling down a set of stairs. She has been bedridden for several weeks. Her kidney function is adequate for her age, but her serum creatinine levels have become increasingly elevated during the past few days. This morning, her serum creatinine level was 2.5 mg/dL. Which of the following is the most likely cause of her increased creatinine serum level?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Creatinine Clearance - References

References

Kampmann JP,Hansen JM, Glomerular filtration rate and creatinine clearance. British journal of clinical pharmacology. 1981 Jul;     [PubMed]
Gowda S,Desai PB,Kulkarni SS,Hull VV,Math AA,Vernekar SN, Markers of renal function tests. North American journal of medical sciences. 2010 Apr;     [PubMed]
Stevens LA,Coresh J,Greene T,Levey AS, Assessing kidney function--measured and estimated glomerular filtration rate. The New England journal of medicine. 2006 Jun 8;     [PubMed]
Levey AS,Bosch JP,Lewis JB,Greene T,Rogers N,Roth D, A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Annals of internal medicine. 1999 Mar 16;     [PubMed]
Cockcroft DW,Gault MH, Prediction of creatinine clearance from serum creatinine. Nephron. 1976;     [PubMed]
Zuo Y,Wang C,Zhou J,Sachdeva A,Ruelos VC, Simultaneous determination of creatinine and uric acid in human urine by high-performance liquid chromatography. Analytical sciences : the international journal of the Japan Society for Analytical Chemistry. 2008 Dec;     [PubMed]
Michels WM,Grootendorst DC,Verduijn M,Elliott EG,Dekker FW,Krediet RT, Performance of the Cockcroft-Gault, MDRD, and new CKD-EPI formulas in relation to GFR, age, and body size. Clinical journal of the American Society of Nephrology : CJASN. 2010 Jun;     [PubMed]
Kumar BV,Mohan T, Retrospective Comparison of Estimated GFR using 2006 MDRD, 2009 CKD-EPI and Cockcroft-Gault with 24 Hour Urine Creatinine Clearance. Journal of clinical and diagnostic research : JCDR. 2017 May;     [PubMed]
Jalalonmuhali M,Lim SK,Md Shah MN,Ng KP, MDRD vs. CKD-EPI in comparison to {sup}51{/sup}Chromium EDTA: a cross sectional study of Malaysian CKD cohort. BMC nephrology. 2017 Dec 13;     [PubMed]
Rule AD,Larson TS,Bergstralh EJ,Slezak JM,Jacobsen SJ,Cosio FG, Using serum creatinine to estimate glomerular filtration rate: accuracy in good health and in chronic kidney disease. Annals of internal medicine. 2004 Dec 21;     [PubMed]
Schwartz GJ,Haycock GB,Edelmann CM Jr,Spitzer A, A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics. 1976 Aug;     [PubMed]
Raman M,Middleton RJ,Kalra PA,Green D, Estimating renal function in old people: an in-depth review. International urology and nephrology. 2017 Nov;     [PubMed]
Makris K,Spanou L, Acute Kidney Injury: Definition, Pathophysiology and Clinical Phenotypes. The Clinical biochemist. Reviews. 2016 May;     [PubMed]
Mitch WE,Collier VU,Walser M, Creatinine metabolism in chronic renal failure. Clinical science (London, England : 1979). 1980 Apr;     [PubMed]
Hosten AO, BUN and Creatinine 1990;     [PubMed]
Banfi G,Del Fabbro M, Serum creatinine values in elite athletes competing in 8 different sports: comparison with sedentary people. Clinical chemistry. 2006 Feb;     [PubMed]
Branten AJ,Vervoort G,Wetzels JF, Serum creatinine is a poor marker of GFR in nephrotic syndrome. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2005 Apr;     [PubMed]
Rowe JW,Andres R,Tobin JD,Norris AH,Shock NW, The effect of age on creatinine clearance in men: a cross-sectional and longitudinal study. Journal of gerontology. 1976 Mar;     [PubMed]
Coresh J,Toto RD,Kirk KA,Whelton PK,Massry S,Jones C,Agodoa L,Van Lente F, Creatinine clearance as a measure of GFR in screenees for the African-American Study of Kidney Disease and Hypertension pilot study. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1998 Jul;     [PubMed]
Dunn SR,Gabuzda GM,Superdock KR,Kolecki RS,Schaedler RW,Simenhoff ML, Induction of creatininase activity in chronic renal failure: timing of creatinine degradation and effect of antibiotics. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1997 Jan;     [PubMed]
Levey AS,James MT, Acute Kidney Injury. Annals of internal medicine. 2017 Nov 7;     [PubMed]
Ferenbach DA,Bonventre JV, Acute kidney injury and chronic kidney disease: From the laboratory to the clinic. Nephrologie     [PubMed]
Zafrani L,Ince C, Microcirculation in Acute and Chronic Kidney Diseases. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2015 Dec;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pathology-Chemistry. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pathology-Chemistry, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pathology-Chemistry, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pathology-Chemistry. When it is time for the Pathology-Chemistry board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pathology-Chemistry.