eGFR 60–90: When to Watch, When to Worry

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this podcast, consultant nephrologists Jeremy Levy and Andrew Frankel are joined by Dr. Mohammad Haidar, a GP and clinical lead for cardiovascular and renal medicine in North West London. They discuss how to interpret eGFR (estimated glomerular filtration rate) results, particularly when values fall between 60 and 90, a range often misunderstood in primary care. The conversation highlights that while this range can indicate early chronic kidney disease (CKD) when combined with other abnormalities (e.g., proteinuria or abnormal ultrasound findings), an isolated eGFR of 60–90—especially in older adults, may simply reflect normal age-related decline in kidney function rather than a pathological condition.

The discussion emphasises the importance of context when interpreting eGFR results and advising repeating tests to account for natural fluctuations, assessing urinary abnormalities, blood pressure, and family history, and avoiding unnecessary labelling of patients with CKD when no other risk factors are present. They also address the practical challenges for primary care teams, such as patient anxiety over flagged “abnormal” lab results, and the need for clear communication and appropriate follow-up.

Three main takeaways:

1.      An eGFR of 60–90 does not necessarily indicate CKD—context, age, and additional markers like proteinuria are crucial in determining risk.

2.      Repeat testing and urine analysis are key steps in distinguishing between true kidney issues and normal variations or age-related decline.

3.      Patient reassurance and appropriate monitoring (e.g., annual or biannual reviews) are essential, while avoiding unnecessary investigations or alarming terminology when kidney function is stable and otherwise healthy.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub

Chapters

• 0:00 Introduction to Kidney Function Assessment
• 1:46 Understanding eGFR and Its Implications
• 4:53 Challenges in Primary Care Management
• 6:12 Practical Advice for Managing eGFR Results
• 8:22 The Role of Urine Analysis in Kidney Health
• 9:38 Addressing Patient Concerns and Follow-Up
• 14:06 Summary and Key Takeaways

Transcript

Jeremy Levy
Hello again, I'm Jeremy Levy. I'm a consultant nephrologist at Imperial College Healthcare NHS Trust.

Andrew Frankel
Hello there, and I'm Andrew Frankel, a colleague of Jeremy, also working at Imperial College NHS Trust. In our previous podcast, we've talked about how we actually measure kidney function, particularly about interpretation of estimated glomerular filtration rate, or EGFR. What we want to do today is to explore in more detail the approach to take when a blood result comes back indicating the kidney function is reduced, although still remaining in the range of 60 to 90.

Although in the presence of other kidney abnormalities, we refer to this as CKD stage 2, in the absence of any other kidney abnormality, either ultrasound or albuminuria, this patient would not be coded in primary care as CKD. I tend to refer to this as optimal GFR.

Our primary care colleagues tell us they can sometimes be uncertain as to how to respond to this. So joining us today is Dr. Haider Mohammed, who is a practicing GP from Brent and is also the North West London Integrated Care Board lead for cardiovascular and kidney long-term conditions. Welcome Haidar, and could you let us know from your perspective what are the key issues for you in primary care in relation to this level of kidney function?

Dr Mohammad Haidar
Hello, I am Dr. Mohammed Haidar, a GP in North West London and the clinical lead for cardiovascular disease and renal medicine at North West London ICB. We've been stepping up our efforts to check kidney health in people at risk. In addition, many patients are having kidney function tests carried out either by their primary care team or through a private provider for a range of medical conditions or as part of NHS health checks. As a result, we've been seeing more eGFR results in the 60 to 90 range.

There are situations where some of our allied health professionals and wider team do not quite understand how to respond and whether to seek advice from secondary care colleagues or initiate a kidney protective therapeutic intervention within primary care. This uncertainty highlights the need for clearer guidance and support in managing early signs of kidney function decline.

Jeremy Levy
I'm sure that's exactly the point, Haidar, I think you're right. And this is an area where it's very difficult—this range of GFRs of 60 to 90. And I think the first thing we ought to emphasise is that sometimes you need to repeat the test. We know these tests are very variable. And certainly sometimes it’s not about telling the patient they’ve got a problem, but to actually repeat the test and see what the two results are.

After that, we should just think a bit about the numbers and remind people of what's really normal. And as Andrew says, what might be abnormal or suboptimal. So for a normal young person, a GFR should be undoubtedly more than 90 and that's definitely normal. But you lose kidney function as you age, and so from the age of 50 or so, your GFR can actually decline quite a lot—and you can lose one, sometimes even two mLs a minute per year. It shouldn't be quite as much as two, but it depends on your blood pressure and some other factors.

So by the time you get to your 70s or your 80s, your GFR will often be in that range of 60 to 90. It was completely normal when you were 30, but it’s just age. You've lost a bit of kidney function. And we talked about some of this in our edition on frailty and older people. So therefore, normal is actually quite hard to define. And also we talked about the fact that your creatinine might be slightly higher for various other reasons, which might also cause a slight drop in GFR.

So there's this change, particularly with aging and over time.

Andrew Frankel
Jeremy, it's also worth highlighting that some laboratories report EGFR as normal above 60. And this is because of the difficulties in interpreting the figure between 60 to 90.

If someone has an EGFR in that range, the results repeated over time can be quite noisy—going up, going down with each measurement. And this, I think, also amplifies the confusion that primary care have about managing people with results in this range.

Jeremy Levy
That's exactly right, Andrew. That noise can be quite considerable in that range, 60 to 90. By noise we mean the numbers going up and down. One day you'll get a result of 65, but actually two weeks later it might be 80, with no change in your true kidney function—because lots of other factors affect the blood creatinine and hence the EGFR. For example, if you happen to be a bit dehydrated on one occasion, or even if you've eaten a meal of cooked meat on another occasion, which releases creatinine, with absolutely no change in your kidney function. I'm sure you see this, Haidar, as well.

Dr Mohammad Haidar
Yes, Jeremy, we often come across people with significant muscle mass who show a lower EGFR, which we know can be misleading. But we also sometimes see relatively young patients who aren't overweight and don't have muscular build presenting with a similar result, and this is in the absence of any long-term condition typically linked to kidney disease progression. For example, a 40- to 50-year-old attending a routine blood test with eGFR of 80 and no identified risk factors. What should we be doing in that situation?

Andrew Frankel
Okay, so let's try and give some practical advice. And this is the way I approach it when I'm asked this by primary care. So in that example of a 45-year-old with a GFR of 80, the important point is to assess other parameters of kidney health, most particularly urinary abnormalities and blood pressure. It's also important, if possible, to get some form of time perspective that tells you whether the kidney function is declining or just fluctuating within that range of 60 to 90.

There are some elements of the history that are important. I always recommend that you inquire about family history, as a history of a close relative requiring dialysis or transplantation should raise your level of alert about the possibility that this individual could be at risk of progressive kidney disease.

I would always ask about supplements—and we have covered this also in one of our previous podcasts—most particularly Chinese herbs, that can be associated with slowly progressive decline in kidney function. Where you have found no explanation for that GFR between 60 to 90, or as I call it sub-optimal, one little trick I also recommend is to ask about birth history—as being born very early or very small can be associated with failure of the kidneys to develop, resulting in lifelong sub-optimal GFR but not progressive kidney disease.

And in the long term, the outlook for people who have stable GFRs in the range of 60 to 90, in the absence of proteinuria, absence of evidence of systemic disease, absence of family history, or evidence of progressive decline, is that they are actually at very low risk of long-term progression but still require intermittent—perhaps every year or every other year—monitoring of kidney health.

Jeremy Levy
And I'm going to butt in there because we should also remind everybody that those patients therefore don’t have chronic kidney disease. They've just had a measure of a slightly low or sub-optimal GFR, but no proteinuria, no other evidence of a kidney disease—so they shouldn’t be given a label, which is often quite frightening, in that context of chronic kidney disease.

But the other way around, I think we must remind people, is important—though I don't want to confuse anybody. The opposite situation is where you've got a so-called suboptimal GFR—let's say you're 45 years old with a GFR of 80—but you do have urine abnormalities, either blood or protein in the urine. And in that circumstance, you need to take that GFR seriously because they have got something that might be going on in their kidney and might need further investigation.

So in that GFR range that we've been talking on, 60 to 90, there's a range of people—those who do have early signs and significant kidney disease, and those who have no actual underlying kidney problem at all and they've just got, as Andrew says, there's a phrase I like as well, suboptimal GFR. And so, as always, this urine dipstick is really, really helpful in trying to separate those two episodes. And we're to do another episode about low-level albuminuria to come later as well. But I think that’s a really important distinction to try and separate that confusing area.

And as Haider alluded to earlier, it's not just of course GPs. We've got lots of practice nurses and pharmacists who are also picking up the GFR numbers.

Dr Mohammad Haidar
Thank you, Andrew and Jeremy. Really helpful. Based on what we have described, this kind of patient might warrant a recall on annual or biannual basis. However, if the EGFR falls between 60 and 90 with no urinary abnormality, they wouldn't meet the criteria to be coded as having CKD. That makes it more challenging for us in primary care to justify or systematise regular follow-up.

Another issue we face is that patients often receive their results directly, and both the EGFR and creatinine are flagged as abnormal. This puts us in a rather difficult position, as it may appear that we are not acting on abnormal results, even when clinical guidance doesn't necessarily recommend intervention.

Andrew Frankel
So I agree, these are two very difficult issues on the borderline of managing CKD, and sometimes there isn’t a perfect answer. But I would suggest an approach based on explaining the implications of the results for that patient.

People with suboptimal GFR with other abnormal features, as Jeremy has highlighted, do need intervention and do need to be alerted to the health implication of their situation. On the other hand, those with no abnormality and with stable sub-optimal GFR need to be reminded that their outlook is very good in relation to kidney health—but intermittent surveillance is in their interest.

Jeremy Levy
That’s exactly right and I agree with you—and it's a real problem for our primary care colleagues, both that issue about what to do and how patients respond. So that phrase “sub-optimal GFR” I sometimes find useful, but sometimes I really just say to people, “Well, their kidneys are normal—they're just at the lower end of a normal range.”

And everything in biology has a range—we’re not measuring the length of one metre with an accurate ruler. There are taller and shorter people. And I say to people, “Well, being five foot as opposed to being six foot is not sub-optimal—unless you're a basketball player. It's just at the lower end of the normal range for heights.” And I say the same thing for GFR. If you're 45 and you've got a GFR of 80, you've just got a GFR that's at the lower end of a normal range. And actually, patients should forget about it in that context of no proteinuria and no other diseases.

Dr Mohammad Haidar
One thing that hasn’t been mentioned and that I’d like to get some clarity on is whether we should be routinely ordering kidney ultrasounds for these patients. Given that this could be quite a large group of patients, there are real resource implications and it can also cause unnecessary anxiety for individuals who may otherwise be well.

Jeremy Levy
You’re right, Haider. And again, both those aspects are important. So I think, first of all, if there is a urine abnormality or the other things Andrew alluded to—such as family history—but particularly a urine abnormality, those people definitely do need an ultrasound scan. Have they got two kidneys? Have they got one kidney, which they were born with? Have they got evidence of a congenital problem, for example?

But in other people who’ve got absolutely no urine abnormalities, they've got this sub-optimal GFR or GFR just at the lower end of normal—I generally do want to have an ultrasound to make sure that they've got two normal-looking kidneys with nothing else. It rarely changes things, but it may point out that this is in fact somebody who did have a distant history of some kidney problem.

So I think there isn't an absolute answer here. I think that you do need to look at the urine, which is a really important key to determining future risk and therefore what you need to do about it. And otherwise, you can just tell people, as I have said, “You've got a GFR that's just at the lower end of a normal range.” And certainly in anybody older—anyone over the age of 70 and with a GFR in the range we're talking about with no urine abnormalities—those people do not need an ultrasound. They've definitely got sort of aging kidneys and don’t need it.

So younger people—possibly yes. Older people in this range—almost certainly no.

Dr Mohammad Haidar
Thanks, Jeremy. Andrew, would you mind summarising the key points for us—particularly what you think primary care teams should take away from this discussion in terms of practical next steps, please? Thank you.

Andrew Frankel
So firstly, when you get a result of an EGFR between 60 and 90, it is important to consider that result in the context of that individual. Look at their age, look at their body habitus. Secondly, these individuals should have an assessment of kidney health—and by that, of course, we've discussed this many times in our podcast. That includes urine analysis and blood pressure assessment.

In the absence of any urinary abnormality, abnormality of blood pressure, or evidence of underlying systemic disease, people with suboptimal GFR have a generally good prognosis but still require periodic review of kidney health. But they can at least be reassured and do not need coding or labelling as having chronic kidney disease. So I hope you found that helpful, Haider. It’s been great talking with you today and hearing about these issues from the primary care perspective.

Jeremy Levy
It's been great. Thank you for that summary, Andrew. And thank you, Haider. Andrew and I do appreciate that this can be really interesting, problematic, and challenging in primary care. We don't underestimate some of the difficulties that you've alluded to. So it's been really great having your insights.

Dr Mohammad Haidar
Thank you, Andrew and Jeremy. It has been brilliant, extremely helpful. I'm sure this podcast will be immensely helpful for our wider primary care team—that includes clinical pharmacists, advanced nurse practitioners, paramedics, physician associates, and the wider team in managing and acting on blood test results in day-to-day practice. Thank you both very much.