Rethinking CKD Evaluation: Should We Be Quantifying Basal or Stimulated GFR to Maximize Precision and Sensitivity?

• Published in: American journal of kidney diseases Vol. 69; no. 5; pp. 675 - 683
• Main Author: Molitoris, Bruce A., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2017
• Subjects: 2-compartment GFR model; Animals; Biomarkers - metabolism; chronic kidney disease (CKD); Creatinine - metabolism; Diabetic Nephropathies - metabolism; Diabetic Nephropathies - physiopathology; diabetic nephropathy; Dietary Proteins - metabolism; Disease Progression; early detection; Early Medical Intervention; estimated GFR; FDA registration; filtration marker; Fluorescein-5-isothiocyanate - analogs & derivatives; Fluoresceins; fluorescent GFR determinations; Glomerular Filtration Rate; glomerular filtration rate (GFR); Humans; hyperfiltration; Inulin - analogs & derivatives; Kidney - diagnostic imaging; kidney disease progression; measured GFR; Nephrology; Oligosaccharides; one-compartment GFR model; Optical Imaging; Plasma Volume; Radiopharmaceuticals; renal function; Renal Insufficiency, Chronic - diagnostic imaging; Renal Insufficiency, Chronic - metabolism; Renal Insufficiency, Chronic - physiopathology; Renal reserve; review; serum creatinine; Severity of Illness Index; surrogate marker; Technetium Tc 99m Pentetate; therapeutic success; therapeutic success; kidney disease progression; plasma volume; FDA registration; chronic kidney disease (CKD); Renal reserve; serum creatinine; hyperfiltration; fluorescent GFR determinations; measured GFR; filtration marker; 2-compartment GFR model; surrogate marker; review; one-compartment GFR model; renal function; glomerular filtration rate (GFR); early detection; estimated GFR; diabetic nephropathy
• ISSN: 0272-6386; 1523-6838
• DOI: 10.1053/j.ajkd.2016.11.028

Chronic kidney disease (CKD) is an increasing clinical problem. Although clinical risk factors and biomarkers for the development and progression of CKD have been identified, there is no commercial surveillance technology to definitively diagnose and quantify the severity and progressive loss of glomerular filtration rate (GFR) in CKD. This has limited the study of potential therapies to late stages of CKD when FDA-registerable events are more likely. Because patient outcomes, including the rate of CKD progression, correlate with disease severity and effective therapy may require early intervention, being able to diagnose and stratify patients by their level of decreased kidney function early on is key for translational progress. In addition, renal reserve, defined as the increase in GFR following stimulation, may improve the quantification of GFR based solely on basal levels. Various groups are developing and characterizing optical measurement techniques using new minimally invasive or noninvasive approaches for quantifying basal and stimulated kidney function. This development has the potential to allow widespread individualization of therapy at an earlier disease stage. Therefore, the purposes of this review are to suggest why quantifying stimulated GFR, by activating renal reserve, may be advantageous in patients and to review fluorescent technologies to deliver patient-specific GFR.