クリアランス
[定義]
クリアランスとは、特定の物質が1分間に尿中に排泄された量と同量の特定の物質を含む血漿流量(mL/min)で表される。
(例題)
物質xの尿中濃度を0.5mg/mL、尿量を3mL/min、血漿中濃度を0.05mg/mLにしたときの物質xのクリアランスを考えてみる。
物質xのクリアランスとは1分間で尿中に排泄される物質xと同量の物質xを含む1分間の血漿流量であるので、
答え:30mL/min
「血漿流量・物質というのは実際にはフラスコに入っているわけではなく腎臓を流れている」ことがクリアランスを理解しにくくしている。物質が「どこを流れてきて尿中に排泄されたのか」ということによって、その物質が持つクリアランスの意味が変わってくるからである。
イヌリンのように糸球体濾過のみで尿中排泄される物質であれば、その1分間に尿中に排泄されたイヌリンの量と同量のイヌリンを含む血漿流量(イヌリンクリアランス)が意味するものは糸球体濾過量となる。
また、パラアミノ馬尿酸のように糸球体濾過＋尿細管分泌によって全て尿中排泄される物質であれば、その1分間に尿中に排泄されたパラアミノ馬尿酸(PAH)の量と同量のパラアミノ馬尿酸(PAH)を含む血漿流量(PAHクリアランス)は有効腎血漿流量となる。
様々な物質のクリアランス
クリアランスを考えるときには物質の尿中排泄様式(糸球体濾過・尿細管分泌)と再吸収の程度に注目して考える必要がある。
物質の尿中排泄様式(糸球体濾過・尿細管分泌)と再吸収の程度の違いによってそれぞれの物資クリアランスは異なる特徴的な意味を持つからである。
また、腎臓に達する血漿の約20%が糸球体で濾過されることも前提として押さえておく。
イヌリン
イヌリンは糸球体濾過のみで尿中排泄される。加えて再吸収されることはない。
このためイヌリンクリアランスは糸球体濾過量(GFR)と等しい。
イヌリンはGFRの「gold standard」だとされている。「gold standard」とは最も正確にGFRを計測できるという意味である。
しかし、イヌリンは生体外物質なので人体に静注投与する必要があり手間がかかるので、日常臨床ではほとんど活用されていない。
パラアミノ馬尿酸(PAH)
パラアミノ馬尿酸は糸球体濾過と尿細管分泌で全て尿中排泄される。加えて再吸収されることはない。
このため、PAHクリアランスは有効腎血漿流量と等しい。
パラアミノ馬尿酸(PAH)は腎の排泄領域では1回の循環でほぼ100%除去されるが、腎の非排泄領域を流れる血流が10%あるので、実際の全腎での除去率は約90%となる。その意味でPAHクリアランスを正確には有効腎血漿流量と呼ぶことがある。
クレアチニン
クレアチニンは糸球体濾過とわずかな尿細管分泌で尿中排泄される。
実測CCr(クレアチニンクリアランス)は正確には24時間蓄尿によって測定しなければならないので手間がかかる。このため実測CCrはあまり臨床的には用いられない。
その代わりに、臨床的には血清クレアチニン値・年齢・性別を推算式に当てはめて算出したeGFR(推算糸球体濾過量)を腎機能評価に用いる。血清クレアチニン値を測るだけでeGFRは算出できるので簡単である。
グルコース
グルコースは糸球体濾過されるが、正常血糖値ではほぼ100%尿細管再吸収される。
しかし、正常血糖値より上昇すると再吸収に限界がきて尿中に排泄されるようになる。
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