Pre-Analytical Errors in Renal Diagnostics: Implications for Kidney Disease Evaluation, Patient Safety, and Clinical Decision-Making

Abstract

Renal diagnostics are central to modern nephrology, guiding the evaluation, staging, and management of chronic kidney disease (CKD) and acute kidney injury (AKI). However, most laboratory errors occur in the pre-analytical phase, including patient preparation, specimen collection, labeling, handling, transport, and storage. Such upstream failures can significantly compromise the accuracy of kidney biomarkers such as serum creatinine, estimated glomerular filtration rate (eGFR), albuminuria, and electrolytes. This review examines the classification, burden, and clinical impact of pre-analytical errors in renal diagnostic testing, emphasizing their implications for kidney disease evaluation, patient safety, and evidence-based clinical decision-making. A narrative synthesis of recent nephrology and laboratory medicine literature was conducted, focusing on major categories of pre-analytical failure, including identification errors, specimen collection problems, sample interferences, transport instability, and medication- or physiology-related confounders. Specialized nephrology populations and emerging quality improvement strategies were also reviewed. Pre-analytical errors may lead to CKD misclassification, inaccurate eGFR estimation, unreliable urine albumin-to-creatinine ratio testing, and delayed AKI recognition. High-risk groups such as pediatric patients, lupus nephritis populations, oncology-associated kidney injury cases, and perioperative surgical patients are particularly vulnerable. Clinical consequences include inappropriate drug dosing, avoidable dialysis initiation, unnecessary hospital admissions, and increased healthcare resource utilization. Standardization initiatives, quality indicators, harmonization frameworks, and innovations such as artificial intelligence, delta checks, and smart sample tracking offer promising approaches to reduce preventable diagnostic variability. Strengthening pre-analytical integrity is essential for accurate renal biomarker interpretation, guideline-concordant CKD management, and improved patient outcomes.