ISRCTN42955626 Confidential once completed Please answer all the questions

eGFR-C Laboratory Data Collection Form

Not to be used for BVS study samples (Study Number starting Bxxxxx)

Assessment visit (please tick)
Assessment due at baseline and months
iiLiiBaseline / iiLii6 months / iiLii12 months / iiLii18 months
iiLii24 months / iiLii30 months / iiLii36 months

Part A: Identifying Details

Study No.: iiI iiI iiI ii iiI ii / Date of completion:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
CRF completed by: (Please PRINT):
……………………………………..……………… / Patient’s DOB:iMi MiiMi/ YiiiYiiiYiiiYii

Part B: Analysis Results

Code /
Colour / Test / Result / Date
LSCr / Yellow / Serum Creatinine(mass spectrometry)
(μmol/L): / iiI iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KSCy / Yellow / Serum Creatinine(enzymatic)
(μmol/L): / iiI iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KSCy / Yellow / Cystatin C (mg/L): / iI i.. iiI ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KUACR /Neutral / Albumin Creatinine Ratio (ACR, mg/mmol): / iiI iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii

eGFR

The Chief Investigator will be notified if any of the GFR estimates are <15 mL/min/1.73 m2. / eGFR (mL/min/1.73 m2):
MDRDcreatinine / I iiI iiI i. ii
CKD-EPIcreatinine / I iiI iiI i. ii
CKD-EPIcystatin / I iiI iiI i. ii
CKD-EPIcystatin-creatinine / I iiI iiI i. ii

mGFR (reference GFR measurement by iohexol)

At the following timepoints only:
iiLiiBaseline GFR / iiLii12 month GFR (sub-study only)
iiLii24 month GFR (sub-study only) / iiLii36 month (final) GFR
20 patient study of intra-individual biological variability (Canterbury only)
iiLiiBaseline / iiLiiWeek 2 / iiLiiWeek 3 / iiLiiWeek 4
Code / Sample time point (mins) / Iohexol (mmol/L)
KIH5 / Green / 5 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KIH120 / Green / 120 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KIH180 / Green / 180 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KIH240 / Green / 240 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LIH5 / Green / 5 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LIH120 / Green / 120 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LIH180 / Green / 180 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LIH240 / Green / 240 / I iiI iiI i. ii / Date Sample taken:iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KENT USE ONLY: GFR (mL/min/1.73 m2):
The Chief Investigator will be notified if the value is <15 mL/min/1.73 m2.
I iiI iiI i. ii
LONDON USE ONLY: GFR (mL/min/1.73 m2):
The Chief Investigator will be notified if the value is <15 mL/min/1.73 m2.
I iiI iiI i. ii

Part C: Biomarkers

Sample Code / Sample / Date
KUBM / Neutral(x2 at iohexol visits) / Urine: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KUBM / Neutral(second sample only at iohexol visits) / Urine: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LUBM / Neutral / Urine: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KPBM / Purple / Plasma: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LPBM / Purple (only at iohexol visits) / Plasma: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
KSBM / Yellow / Serum: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
LSBM / Yellow / Serum: / Date Sample taken: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date Received: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii
Date of Analysis: iDiiDi/ MiiMiiMi/ YiiiYiiiYiiiYii

Thank you for completing the eGFR-CLaboratory Data Collection Form. Please enter data online:

eGFR-C Online Data Entry: (24hrs) or return to:

eGFR-C Study Office, Birmingham Clinical Trials Unit, College of Medical & Dental Sciences, Robert Aitken Institute, University of Birmingham, Edgbaston, Birmingham, B15 2TT

Tel: 0121 415 9130 Fax: 0121 415 9135

eGFR-CStudy Website:

eGFR-CStudy Mailbox:

Please enter data online at or return form to: eGFR-C Office, Birmingham Clinical Trials Unit, College of Medical & Dental Sciences, Robert Aitken Institute, University of Birmingham, Edgbaston, BirminghamB15 2TT, UK.

eGFR-C – Lab Data Collection FormPage 1 of 4 Version 1.0 14th Feb 2014