Addis Ababa University

College of Health Science

Department of Medical Laboratory science

MSc Track: Master of Clinical Chemistry

Course: Advanced analytical clinical chemistry and enzymology

Individual assignment 1: case presentation 1

Title: Case presentation on estimated glomerulus filtration rate

(eGFR) test at Black Lion specialized hospital
Name: Abush Getaneh

ID NO: GSR/6773/14

Submitted to: Drs. Mistire Wolde (PhD, Associate Professor)

Submitted date: June, 04/22

Addis Ababa, Ethiopia

Acknowledgments
I would like to give my deepest gratitude for Dr Mistire Wolde (PhD, Associate Professor) for
giving such types of assignment to explore more information on the case and next to this I would
like to thanks black lion specialized hospital medical laboratory staffs for their support.

i
Table of Contents
Objective ........................................................................................................................................ v
Patient demographic character and abnormal test result with its reference range ............... 1
BUN/Creatinine Ratio .................................................................................................................. 2
Introduction ................................................................................................................................... 4
Kidney anatomy, physiological function and kidney function test........................................... 5
Nephron anatomy and physiological function ............................................................................ 5
Biochemistry of the analyte: chemical structure, synthesis, metabolism, excretion. .............. 7
Chemical structure of creatinine ............................................................................................. 7
Synthesis, metabolism, excretion of creatinine....................................................................... 7
Synthesis of creatine ................................................................................................................. 7
Catabolism of creatine and formation of creatinine .................................................................. 8
Excretion of creatinine ............................................................................................................. 9
The physiological function of the creatine .................................................................................. 9
Normal values of the creatinine and eGFR .............................................................................. 10
Pathological features associated with the eGFR ...................................................................... 11
Expected sign and symptoms due to abnormal metabolism of the creatinine, too low value
of eGFR ........................................................................................................................................ 12
Laboratory diagnosis of approaches (options) of the creatinine, eGFR ................................ 12
1. serum creatinine method of measurement .................................................................... 13
A. Chemical method: Jaffe reaction ................................................................................ 13
B. Enzymatic method ...................................................................................................... 13
What is difference between eGFR and GFR? .......................................................................... 14
Black Lion Specialized Hospital clinical chemistry laboratory, serum creatinine diagnostic
method.......................................................................................................................................... 14
Background of Black Lion Specialized Hospital (TASH) ....................................................... 14
Clinical significance of the test............................................................................................... 14
Principle of the test ................................................................................................................. 15
Creatinine reagent .................................................................................................................. 16
Calibration ................................................................................................................................... 17
Quality control ............................................................................................................................ 17
REFERENCE RANGES .................................................................................................................... 19
The supportive test results look like? ........................................................................................ 20

ii
Interpretation, and conclusion on the abnormal finding of the eGFR .................................. 24
Interpretation, and conclusion About patients’ health status ................................................ 26
Reference ..................................................................................................................................... 27

iii
List of Figure(s)

Fig 1: Reference range of eGFR (ml/min)

Fig 2: basic component of kidney
Fig 3: anatomy and structure of nephron

Fig 4: synthesis of creatine

Fig 5: the breakdown path and formation of creatinine from creatine
Fig 6: reference range of ACR (Albumin to Creatinine Ratio)

iv
Objective

The main objective of this case presentation is to present the patient’s general health status by
performing different and interrelated test that have some factor for decrement of patient’s
estimated Glomerulus test result (eGFR), In order to generalize the patient’s health status

v
 Case presentation on estimated glomerulus filtration rate (eGFR) test.

Patient demographic and abnormal test result with its reference range.
✓ Patient ID: TASH0000427116
✓ Sex: Female
✓ Age: 68 years old
✓ Sample collection time: 05/19/2022 03:00
✓ Result released time: 05/19/2022 04:30:29
✓ Serum creatinine: 8.1 mg/dl reference range: 0.6-1.3 mg/dl
✓
Estimated GFR: 5 ml/min/1.73cm2 reference range: 90-120 ml/min
eGFR = 186 *Serum Cr−1.154 age−0.203 * 1.212 (if patient is black) * 0.742 (if female)
= 186 * (8.1) −1.154 * (68) −0.203 * 0.742
= 186 * 0.09 * 0.425 * 0.742
= 5.28 approximately 5 mL/min/1.73m2

Fig 1: Reference range of eGFR (ml/min)

Source: https://www.kidney.org/atoz/content/gfr

1
BUN/Creatinine Ratio
Indication For Blood Urea Nitrogen/Creatinine Ratio [1]

❖ It will differentiate prerenal and postrenal azotemia from renal azotemia

Calculated: serum BUN (mg/dl)

serum creatinine (mg/dl)
Normal BUN/Creatinine ratio = 10-20 :1
1. Increased ratio (BUN/Creatinine) with increased BUN while creatinine is normal

Prerenal failure, where BUN rises without the increase in creatinine, is due to decreased GFR
and is seen in: - Heart failure (poor renal perfusion) , Dehydration or GI tract hemorrhage.

2. Increased BUN/Creatinine ratio with increased BUN and slightly increase creatinine
level raised is seen in Postrenal failure.

Tend to be caused by post-renal conditions that obstruct urine flow: Stone, Tumor, Sever
infection, prostatic hypertrophy, prostate cancer, cervical cancer or Intratubular causes
include crystals (e.g., urate)

3. Increased ratio with increased BUN, increased creatinine

Tend to be caused by - renal conditions that decrease kidney function:

✓ Acute renal failure

✓ Chronic renal failure
✓ Glomerulonephritis
✓ Tubular necrosis
4. Decreased BUN/Creatinine ratio <10:1 with decreased BUN value is seen in:

Tend to be caused by conditions of decreased urea production:

✓ Starvation.
✓ Low-protein diet.
✓ Severe liver disease.
✓ Any etiology leading to decreased synthesis of urea.

2
How to differentiate Acute Renal failure from Chronic Renal Failure

Acute kidney failure is the sudden loss of kidney function whereas, Chronic kidney failure is a
condition where the kidneys' ability to filter waste from the bloodstream becomes worse over
time, generally over a period of years

BUN/Creatinine ratio rise in CKD and less than 10:1 in AKD

An eGFR below 60 for three months or more means chronic kidney disease

Urea = 226 mg/dl

BUN (mg/dl) = Urea (mg/dl) / 2.1428
= 226 mg/dl
2.1428
105.47 mg/dl
BUN/ creatinine ration = BUN/ Creatinine
105.47 mg/dl = 13: 1
8.1 mg/dl

Interpretation: it indicates Postrenal failure because Urea (226 mg/dl) is approximately 13

times high and serum creatinine (8.1mg/dl) was increased by 7 times from reference range, so
this increase ratio was disproportional and indicated post renal impairment. Beside this serum
uric acid level were too high above reference range so it indicates it might due to renal stone.

3
Introduction

What is the eGFR?

The estimated glomerular filtration rate (eGFR) is a test that measures the level of kidney
function and used to determines stage of kidney disease. It can be calculated from the results of
blood creatinine test, age, body size, and gender.

If some one’s eGFR results is low, it indicates kidneys may not be working as well. People with a
lower eGFR are at increased risk of having chronic kidney disease (CKD) progress to kidney
failure [2]

Normally, eGFR normally declines with age. A low eGFR in an older person does not always
mean CKD, even if the eGFR is less than 60. For a patient age greater than 70 years those eGFR
test is not recommended.

So many related factors may decrease eGFR below normally like cardiovascular disease,
hypertension and kidney disease, eGFR increase in diabetic patient, So, we should carry out other
related test before giving conclusion about the patients’ health status [2-3]

Modification of Diet in Renal Disease (MDRD): equation was based on 6 variables: age, sex,
ethnicity, serum creatinine, urea, and albumin (MDRD 6). Subsequently, the MDR was
simplified to a 4-variable version (MDRD-4) that included age, sex, ethnicity, and serum creatinine
[4]

eGFR = 186 Serum Cr−1.154 age−0.203 * 1.212 (if patient is black) * 0.742 (if female)

4
Kidney anatomy, physiological function and kidney function test

Before going to the biochemistry analysis of creatinine, it is better to understand the kidney
physiology and its anatomy.
The kidneys are a pair of bean-shaped organs on either side of your spine, below your ribs and
behind your belly. Each kidney is about 4 or 5 inches long, roughly the size of a large fist. The
kidneys' job is to filter your blood [5]

Major component of kidney:

✓ Nephron
✓ Arterioles: Afferent and Efferent
✓ Glomerulus
✓ Bowman’s capsule
✓ Tubules

Fig 2: basic component of kidney

Kidney Functions
✓ Glomerular Filtration:
✓ Tubular Reabsorption
✓ Tubular Secretion

Nephron anatomy and physiological function

Nephron, functional unit of the kidney, the structure that actually produces urine in the process of
removing waste and excess substances from the blood. There are about 1,000,000 nephrons in each
human kidney [5]

5
Fig 3: Anatomy and structure of nephron

Source: https://www.niddk.nih.gov/health-information/kidney-disease/kidneys-how-they-work

What are different types of kidney function tests?

✓ Blood urea nitrogen (BUN)

✓ Estimated GFR (eGFR)
✓ Serum creatinine
✓ Creatinine clearance rate (Crcl)
✓ Microalbuminuria and macroalbuminuria looks for a specific protein called albumin.
✓ Urinalysis evaluates urine for blood, proteins and function.

Urea and BUN

Urea: used to assess Formation and excretion function.

Protein → amino acids → ammonia →[LIVER] → urea

BUN x 2.14 = urea

6
 Biochemistry of the analyte: chemical structure, synthesis, metabolism,
excretion.

Chemical structure of creatinine

Creatinine is a breakdown product of creatine phosphate from muscle and protein metabolism. It
is released at a constant rate by the body [5]
✓ Molecular formula C4H7N3O
✓ IUPAC ID 2-Amino-1-methyl-5H-imidazol-4-one
✓ Molecular mass 113.12 g/mol
✓ Boiling point 201.1 °C
✓ Density 1.09 g/cm³

Source: https://www.dreamstime.com/stock-illustration-creatinine-chemical-formula-molecule-
structure-medical-vector-illustration-image45499258

Synthesis, metabolism, excretion of creatinine

Synthesis of creatine

Creatine is mainly synthesized start in the kidney and finished in liver. Initially use three amino
acids: glycine, arginine and methionine, glycine transaminidase enzyme transfers an amidine
group from arginine to glycine, to give guanidinoacetic acid (GAA) in the kidney.
This acid is then methylated by the enzyme guanidinoacetate methyltransferase (GAMT) to
form creatine in the liver.

7
Creatine is synthesized in the liver, pancreas, and kidneys from the transamination of the amino
acids’ arginine, glycine, and methionine.
Creatine phosphate and phosphocreatine which is then stored in the skeletal muscles and used for
energy [6]

Fig 4: synthesis of creatine

Source: https://www.researchgate.net/figure/Biosynthesis-of-creatine-and-disorders-of-creatine-
metabolism-Creatine-is-synthesized-in_fig1_8671976

Catabolism of creatine and formation of creatinine

As muscles use energy the tissue that makes up muscles breaks down. This natural breakdown of
muscle tissue causes creatinine to be released into bloodstream. This is when creatine becomes
creatinine. Normally, creatinine is filtered out of your blood by the kidneys.
Creatinine, also a NPN waste product, is produced from the breakdown of creatine and
phosphocreatine and can also serve as an indicator of renal function [6-7]

8
Source: https://www.sciencedirect.com/topics/nursing-and-health-professions/creatine-phosphate

Excretion of creatinine

Creatinine is released into the circulation and is almost exclusively excreted in the urine. In steady
state conditions, urinary excretion will equal creatinine production, irrespective of the serum
creatinine concentration [5]

The physiological function of the creatine

Creatine is a naturally occurring non-protein compound of which the primary metabolic role is
to combine creatine with a phosphoryl group to generate phosphocreatine, which is used to
regenerate ATP or adenosine triphosphate [8]

9
Source: https://www.precisionnutrition.com/all-about-creatine

The chemical waste is a by-product of normal muscle function. The more muscle a person has, the
more creatinine they produce. Levels of creatinine in the blood reflect both the amount of muscle
a person has and their amount of kidney function.
The amount of Creatinine filtration by our kidney indicates the function of kidney, it tells whether
our kidney works properly or not [5]

Normal values of the creatinine and eGFR

The creatinine blood test measures the level of creatinine in the blood. This test is done to see how
well someone’s kidneys are working.

A normal result is

✓ 0.7 to 1.3 mg/dL (61.9 to 114.9 µmol/L) for men and

✓ 0.6 to 1.1 mg/dL (53 to 97.2 µmol/L) for women.

Women often have a lower creatinine level than men. This is because women often have less
muscle mass than men. Creatinine level varies based on a person's size and muscle mass [9]

eGFR = 186 Serum Cr−1.154 age−0.203 * 1.212 (if patient is black) * 0.742 (if female)

10
Normal reference range of eGFR [9]

❖ eGFR of 90 or higher is in the normal range

❖ eGFR of 60 -89 may mean early kidney disease
❖ eGFR of 15 -59 may mean kidney disease
❖ eGFR below 15 may mean kidney failure

Generally, in adults, the normal eGFR number is more than 90 ml/min. eGFR declines with age,
even in people without kidney disease.

Pathological features associated with the eGFR

Abnormal eGFR results provide information about the function of kidney and also, indicate the of
stage of kidney damage [10]

There are five stages:

Stage 1 (eGFR of 90 ml/min or higher) indicates mild kidney damage, but the kidneys are working
well.

Stage 2 (eGFR between 60mg/min and 89 ml/min) indicates an increase in kidney damage from
stage 1, but the kidneys continue to function well.

Stage 3 (eGFR between 30 ml/min and 59 ml/min means decreased kidney function and may
experience symptoms.

Stage 4 (eGFR between 15 ml/min and 29 ml/min) is poor kidney function, with moderate to
severe kidney damage.

Stage 5 (eGFR below 15ml/min) is a sign of kidney failure. It means less than 15% kidney
function. This stage is the most serious and can be life-threatening and requires dialysis (a machine
to filter blood) or a kidney transplant.

11
 Expected sign and symptoms due to abnormal metabolism of the creatinine,
too low value of eGFR

If GFR is too low, metabolic wastes will not get filtered from the blood into the renal tubules. If
GFR is too high, the absorptive capacity of salt and water by the renal tubules becomes
overwhelmed [11]
Depending on how severe it is, loss of kidney function can cause:.

• Vomiting.
• Loss of appetite.
• Fatigue and weakness.
• Urinating more or less.
• Muscle cramps.
• more tired, have less energy or are having trouble concentrating
• dry and itchy skin
• see blood in the urine
• urine is become foamy
• persistent of puffiness around eye
• kidney diseases

Laboratory diagnosis of approaches (options) of the creatinine, eGFR

why we use serum creatinine for calculation of eGFR, because it is [12]

✓ Endogenous substance
✓ Amount produced is constant day to day: levels vary <10% per day
✓ Amount produced is proportional to muscle mass
✓ Filtered by glomerulus; not handled by tubules
✓ Not affected by diet

12
 1. serum creatinine method of measurement

A. Chemical method: Jaffe reaction

Creatinine + alkaline picrate → Jankowski complex

(yellow) (red-orange color)

• Read Absorbance of the colored formed at 520/800nm

• Lacks specificity

B. Enzymatic method

Creatinine + H2O creatininase Creatine

Creatine + H2O creatinase sarcosine + urea

Sarcosine + O2 + H2O sarcosine oxidase glycine + HCHO + H2O2

H2O2 + 4-aminophenazone peroxidase quinonimine chromogen + H2O

The color intensity of the quinone imine chromogen formed is directly proportional to the
creatinine concentration

Laboratory diagnosis of eGFR test

To get an estimated GFR, A GFR calculator is a type of mathematical formula that estimates the
rate of filtration. It does this by comparing the results of a blood test that measures creatinine, a
waste product filtered by the kidneys, with other information about patient like Age, serum
creatinine result, gender and race.

eGFR = 186 *Serum Cr−1.154 age−0.203 * 1.212 (if patient is black) * 0.742 (if female)

13
What is difference between eGFR and GFR?

GFR is Glomerular Filtration Rate and it is a key indicator of renal function. eGFR is estimated
GFR and is a mathematically derived entity based on a patient's serum creatinine level, age, sex
and race.

Black Lion Specialized Hospital clinical chemistry laboratory, serum

creatinine diagnostic method
Background of Black Lion Specialized Hospital (TASH)

TASH (Tikur Anbessa Specialized Hospital) located on the main campus for preclinical training.
Tikur Anbessa Specialized Hospital is now the main teaching hospital for both clinical and
preclinical training of most disciplines

TASH have many laboratories department separately, like hematology room, clinical chemistry
section, urine and parasitology room, molecular biology room, sample collection room and others.

Clinical chemistry room equipped with many clinical chemistry analyzers like Beckman coulter
DX 700 AU for electrolyte and organ function test and DX 800 for hormonal analysis.

Source: http://www.aau.edu.et/chs/tikur-anbessa-specialized-hospital/

Instrument information: Beckman Coulter au-700 Analyzer

Source: Beckman coulter Au- 700 analyzer serum creatinine assay SOP

Clinical significance of the test

Measurements of creatinine are used in the diagnosis and treatment of renal disease. Serum
creatinine measurements prove useful in evaluation of kidney glomerular function and in
monitoring renal dialysis. Both serum creatinine and BUN are used to differentiate prerenal and
postrenal (obstructive) azotemia.

14
Principle of the test

This Creatinine procedure is a kinetic modification of the Jaffe procedure, in which creatinine
reacts with picric acid at alkaline pH to form a yellow orange complex. However, this reaction is
not completely specific for creatinine since other reducing substances such as glucose, pyruvate,
ascorbic acid, and acetoacetates will react with picrate to form a similar color.

Fabiny and Ertingshausen found that alkaline creatinine picrate reaches maximum color
development at a different rate than pseudo-creatinine material. Cook utilized different reaction
rates of alkaline picrate positive substances to obtain greater specificity with the Jaffe reaction.

The rate of change in absorbance at 520/800nm is proportional to the creatinine concentration in

the sample.

Creatinine + Alkaline Picrate Yellow-Orange Complex

A read increased absorbance A1 after 30 sec and A2 at 90 sec
A2-A1 =change A of standard or sample
A sample * Concentration of standard = concentration of serum creatinine in md/dl
A standard

Type of specimen used

Serum or heparinized samples free from hemolysis are the recommended specimens and should
be separated from the red cells as soon as possible.

Artifacts such as hemolysis, lipemia, and icteremia can also affect accuracy. Hemolysis releases
Jaffe-reacting chromogens and therefore will falsely increase results.

Handling and storage conditions

Serum Creatinine is stable for 7 days at 2 – 8°C and indefinitely when frozen (≤ -20°C).

15
Equipment and Materials used
Equipment: Beckman Coulter AU 700 chemistry analyzer

Materials
1. Beckman Coulter AU System creatinine Reagent
2. Beckman coulter System calibrator
3. Quality control
4. Test tubes 12 -16 mm in diameter or sample cups

Creatinine reagent
R1 contained 40mmol/L of picric acid and 40 micro mol/L of potassium ferricyanide, R2 contained
alkaline buffer: 300 mmol/L with PH 12.7 were use and for preparing working reagent: mixed 1
volume of R1 and 1 volume of R2.

Working reagent = 1 volume of R1 and 1 volume of R2

Sample volume used = 200-500μl

Measurement assay: kinetic fixed time

Absorbance read at: 520/800nm

STORAGE AND STABILITY

1. The unopened reagents are stable until the expiration date printed on the label when stored
at 2 – 8°C.
2. Opened reagents are stable for 7 days when stored in the refrigerated compartment of the
analyzer.
3. R1 is light sensitive. Store in the dark before placing on the instrument.

Indications of Deterioration

✓ Visible signs of microbial growth, turbidity, precipitate, or any change in color in the
Creatinine reagent may indicate degradation and warrant discontinuance of use.

16
Calibration
✓ Calibrator name: System calibrator (Chemistry Calibrator (Cat # DR0070)

calibration procedure:

✓ Calibrate the reagent on a daily basis

✓ Recalibration of this test is required when any of these conditions exist:
1. A reagent lot number has changed or there is an observed shift in control values.
2. A fresh bottle of reagent is used for testing.
3. Major preventative maintenance was performed on the analyzer or critical part was replaced.

Storage Requirements

• Un-reconstituted calibrator is stable until the expiration date stated on the label when stored
at 2 - 8°C.

• Once reconstituted the calibrator is stable for 30 hours when stored at 2-80c and one month at
-200c for creatinine reagent.

Quality control
During operation of the Beckman Coulter AU analyzer at least two levels of an appropriate quality
control material should be tested a minimum of once a day. In addition, controls should be performed
after calibration, with each new lot of reagents, and after specific maintenance or troubleshooting
done.

17
Beckman Coulter Qc and calibrator preparation for au-700

1. Remove the vials of calibrator/controls and let stand at room temperature for 5 minutes
2. Open and add exactly 5ml of Distilled water on the lyophilized control/calibrator.
3. Invert the vial 3 times and then leave to stand for 10 minutes. Dissolve the contents
completely by gently mixing on a roller for 30 minutes
4. Ensure contents are completely dissolved by swirling gently. And avoid formation of foam.
5. Record the date the vial was reconstituted on the bottle.

Procedure how to run calibrator, control and patient sample on AU 700

To run calibration

1. Dispense approximately the prepared calibrators on the sample cup at yellow rack and
the blank [Distilled water] at blue rack.
2. Program the test which is calibrates& load the racks and run the machine.
3. Review the calibrations for any failed calibration.

To run patient sample

1. Program tests on the instrument from the work list

2. On the white rack, put the sample cup.
3. Label the patient ID number from the print out
4. Request the sample from the sample management section.
5. Dispense 200-500μl of serum to the labeled sample cup.
6. Load the white rack on AU-700, and then run machine.
7. Review the printout result for any discordant.
8. Enter the result to LIS/iCare.
9. Make a review for proper transcription of the result and print the result.

18
To run Quality Control

1. Just put the control at room temperature for 20minute.

2. Dispense approximately 500micrliters of the prepared control to the sample cup.
3. Program/select which test is run QC& Load the green rack and run the machine.
4. Review the QC result for the breaches.
5. Document the result.

Calculations: Automatically printed out for each sample in mg/dL at 37°C.

REFERENCE RANGES
Serum creatinine (mg/dl)

❖ Male-------------------------- 0.7 - 1.3 mg/dL

❖ Female----------------------- 0.6 - 1.2 mg/dl
❖ Neonates -------------------- 0.31-0.98mg/dl
❖ Infants ---------------------- 0.16-0.39mg/dl
❖ Child ---------------------- 0.26-0.77mg/dl

eGFR: 90-120ml/min

Linearity

0.06 to 25.0 mg/dL

Samples exceeding the upper limit 25 mg/dl of linearity should be diluted at 1:4 with saline and
repeated. Then multiply the result by factor 4

Interfering Substances

Other reducing substance may affect the result.

✓ Bilirubin: No significant interference up to 20 mg/dL Bilirubin

✓ Hemolysis: No significant interference up to 500 mg/dL Hemolysate
✓ Lipemia: No significant interference up to 700 mg/dL Intralipid*
✓ Protein: Interference less than 20% between 3 and 12g/dL Protein

19
N: B: Fabiny and Ertingshausen found that alkaline creatinine picrate reaches maximum color
development at a different rate than pseudo-creatinine material. Cook utilized different reaction
rates of alkaline picrate positive substances to obtain greater specificity with the Jaffe reaction.

The supportive test results look like?

When eGFR results become too low, it may be due to many factors and another supportive test
should be carried out like:
✓ Blood pressure/Hypertension
✓ Family history of kidney disease
✓ Diabetes
✓ Cardiac problem
✓ And others

1. Blood pressure test

High blood pressure can constrict and narrow the blood vessels, which eventually damages and
weakens them throughout the body, including in the kidneys.
Uncontrolled high blood pressure can cause arteries around the kidneys to narrow, weaken or
harden. These damaged arteries are not able to deliver enough blood to the kidney tissue. Damaged
kidney arteries don't filter blood well [13]
2. Kidney disease
As chronic kidney disease progresses, eGFR number decreases. eGFR number tells how much
the patient kidney. As chronic kidney disease progresses, eGFR number decreases.
Some kidney function test [14]
✓ ACR (Albumin to Creatinine Ratio) and
✓ GFR (glomerular filtration rate).
❖ In adults, the normal eGFR number is more than 90 ml/min or (90-120ml/min)
✓ Micro-albuminuria
Microalbuminuria is defined as small quantities of albumin in the urine, ranging from
30 to 300 mg/d.

20
 ✓ Macro- albuminuria
Macroalbuminuria is defined as a urinary albumin-to-creatinine (ACR) level of
more than 300 mg/g Cr

Fig 6: reference range of ACR (Albumin to Creatinine Ratio)

Source:https://www.researchgate.net/figure/Cutoff-Values-Indicating-Normoalbuminuria-
Microalbuminuria-and-Macroalbuminuria_tbl1_23241895

3. Diabetes test
Diabetes also can cause progressive scarring of glomeruli. This is called glomerulosclerosis.
Diabetes mellitus causes micro and macro-vascular changes in the body and this includes diabetic
nephropathy [14-15]

It does this through hyperglycemia which leads to hyperfiltration and hence increased glomerular
filtration rate.
Having high blood glucose levels can interfere with the function of the glomerulus. The filtering
function of the kidneys doesn't work properly and proteins start to leak from the blood into the
urine [16]
Diabetes test: Random blood glucose test (RBS) , HbA1c and Fasting blood glucose test FBS)
Reference range: RBS Between 4.0 to 5.4 mmol/L (72 to 99 mg/dL) when fasting.
Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating.

The normal range for the hemoglobin A1c level is between 4% and 5.6%. Hemoglobin A1c
levels between 5.7% and 6.4% mean you have prediabetes and a higher chance of getting diabetes.
Levels of 6.5% or higher mean you have diabetes [17]

21
 4. Cardiac problem
Heart failure may reduce GFR directly through hemodynamic impairment (eg, reduced cardiac
output or increased central venous pressure) or through kidney injury [18]
Test done to check cardiac health status of a patient’s like:
✓ Creatine kinase 2 (CK -MB)
Normal range 46-171 IU/L (Male)
34-145 IU/L (Female)
✓ Troponin I
reference range < 0.04 ng/ml (normal)
> 0.40 ng/ml (myocardial infraction)

5. Hypoalbuminemia
damaged kidneys that cause albumin to be lost in the urine. This is called albuminuria or
hypoalbuminemia.

6. Electrolyte (P, K+, Na+, Ca)

Renal Failure is often complicated by elevated potassium, phosphate and magnesium
and decreased sodium and calcium
High phosphorus, also called hyperphosphatemia, High phosphorus is often a sign of kidney
damage [19-24]

22
Source: https://en.wikipedia.org/wiki/Renal_physiology
Where, ADH (anti-diuretic hormone) is a peptide hormone secreted by the pituitary gland and
Aldosterone is a steroid hormone produced in the outer section (cortex) of the adrenal glands,
which located above the kidneys. Both used to regulate water and salt balance [20-21]

23
Interpretation, and conclusion on the abnormal finding of the eGFR
After I got such types of abnormal result, I did the following available tests. Date; 19/5/2022
Test Result N/Ab Ref range
RFT UREA 226 mg/dl Abnormal 7.0-38.0 mg/dl
creatinine 8.1 mg/dl Abnormal 0.6 -1.3 mg/dl
UA 9.9 mg/dl Abnormal 2.6 -7.2 mg/dl
eGFR 5ml/min/1.73cm2 Too low 90-120 ml/min
LFT Albumin 4.1 g/dl Normal 3.5- 5 g/dl
ALT 33 IU/L Normal 10-40 IU/L
AST 17 IU/L Normal 10-42 IU/L
ALP 62 IU/L Normal 32 – 92 IU/L
Cardiac marker Ck MB No calibrator - 0.6 – 6.3 ng/ml
Troponin I 0.01 ng/ml Normal 0.0 -0.05 ng/ml
AST 17 IU/L Normal 10-42 IU/L
Diabetes mellitus HbA1c 4% Normal 4.6 -6.2%
test
Electrolyte Phosphorus (P) 4.7 mg/dl Slightly H 2.5 – 4.6 mg/dl
Calcium (Ca) 8 mg/dl Slightly L 8.4 – 10.2 mg/dl
Sodium (Na+) 134.9mmol/l Slightly L 136 – 145 mmol/l
Potassium (K+) 5.15mmol/l Slightly H 3.6 – 5 mmol/l

Previous patient history

Date: 19/10/2021, at 08: 38 am
Test done UA (uric acid) =10 mg/dl ref range [2.6 -7.2 mg/dl] Abnormal
Date: 21/10/2021, at 02: 44 pm
Test done: albumin: 3.8 g/dl ref range [3.5- 5 g/dl] it is Normal

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Date: 11/01/2022, at 09: 53 am
Test done: ALB = 3.6 g/dl ref range [3.5- 5 g/dl] Normal
HgA1c: < 4% ref range [Less than 5.7] Normal
LFT, AST 15 IU/L ref range [10-42 IU/L] Normal
ALT 12 IU/L ref range [10-40 IU/L] Normal
ALP 77 IU/L ref range [32-92IU/L] Normal
Urea: 113mg/dl ref range [7-38mg/dl] Abnormal high
Creatinine: 6.3 mg/dl ref range [0.6-1.3 mg/dl] Abnormal high
eGFR: 7 ml/min/1.73cm2 ref range [90-120 ml/min] Abnormal too low

Date: 24/02/2022, at 03: 08 pm

Test done: ALB: 4.2 g/dl ref range [3.5- 5 g/dl] Normal
Uric acid: 10.2mg/dl ref range [2.6 -7.2 mg/dl] Abnormal
Urea: 183mg/dl ref range [7-38mg/dl] Abnormal high
Creatinine: 7.2 mg/dl ref range [0.6-1.3 mg/dl] Abnormal high
eGFR: 6 ml/min/1.73cm2 ref range [90-120 ml/min] Abnormal too low

Date: 20/04/2022, at 09: 25 am

Test done: Urea: 233mg/dl ref range [7-38mg/dl] Abnormal high
Creatinine: 7.4 mg/dl ref range [0.6-1.3 mg/dl] Abnormal high
eGFR: 5 ml/min/1.73cm2 ref range [90-120 ml/min] Abnormal too low

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Limitation of this case presentation
By the time I couldn’t carried out creatinine clearance test to assess the function of the kidney.
Because I tried but couldn’t get the patient urine sample.

Creatinine clearance (ml/min) = urine creatinine (mg/dl) *volume of 24 hours urine (ml)

Serum creatinine (mg/dl) *1440min

Crcl = reference range Male: 97 to 137 mL/min (1.65 to 2.33 mL/s).

Female: 88 to 128 mL/min (14.96 to 2.18 mL/s).

Interpretation, and conclusion About patients’ health status

The patient had abnormal results on RFT (urea, serum creatinine, eGFR and uric acid) this
indicates that the patient had been post renal failure status because of her eGFR is 5
ml/min/1.73cm2 and BUN to Creatine ratio were increased disproportionally.
The other related laboratory test was done and I got normal results with in reference range, like
LFT (Albumin, AST, ALT, ALP), cardiac marker (troponin, AST) and HbA1c test result was
normal, this indicated she was normal for DM, Liver impairment and cardiac problem.

Conclusion: her eGFR result was become too low because of severe renal failure, her kidney
damage is classified under stage 5 kidney damage class, she experiences post renal failure, it might
due to renal stone or crystal formed because of her serum uric acid level is too high it suggested
for the presence of renal stone it might due to uric acid precipitation within the renal tubules.
Her Serum Uric acid was too high and founded in alarming level, is called uricemia. High levels
of uric acid could harm kidneys and lead to kidney disease or kidney failure. She might to develop
Acute uric acid nephropathy (UAN) is due to uric acid precipitation within the distal tubules and
collecting ducts.

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