RENAL

Laboratory tests of renal function

Andy McWilliam Ross Macnab

Learning objectives
After reading this article, you should:  be able to list six laboratory tests that assess renal function  know how to calculate glomerular ltration rate  be able to state normal blood and urine biochemistry  values.

Abstract
The human kidney provides essential regulatory and excretory functions. Body water content, plasma electrolyte composition and plasma pH are all under the regulatory control of the kidney. In addition, the kidney provides a path of excretion for blood-borne, water-soluble, low-molecular-weight compounds. These include the end-products of protein metabolism, such as urea and creatinine, as well as foreign compounds with similar physico chemical characteristics and their metabolites. Endocrine activity of the human kidney includes the secretion of the hormones erythropoietin and renin and the activation of vitamin D by hydroxylation to its 1,25-dihydroxycholecalciferol form. The renal blood ow is immense, constituting 25% of resting cardiac output. The glomeruli form 170200 litres of ultraltrate per day and the selective reabsorption of water and solutes results in the nal formation of approximately 1.5 litres of urine for excretion. Here, commonly used laboratory tests of renal function are discussed, including glomerular ltration rate (GFR), creatinine clearance, serum creatinine concentration estimation of GFR, cystatin C assay, serum urea concentration, urinalysis, free water clearance and endocrine changes in renal disease. It must be noted, however, that these tests require a clinical assessment of the patient to allow meaningful interpretation.

substances should have a constant plasma concentration. Any substance freely ltered by the glomerulus and not subsequently secreted, reabsorbed or metabolized by the distal parts of the renal system has a clearance equivalent to the glomerular ltration rate (GFR).13 Renal clearance is calculated using a formula that equates the total mass of substance cleared from plasma to that found in urine: Cs Ps = Us V where Cs is the volume of plasma containing the substance, Ps is the plasma concentration, Us is the urinary concentration of the substance and V is the urinary volume containing the ltered substance. Rearranging the equation and expressing the volumes as millilitres per minute gives us the equation for clearance: Cs = (Us V)/Ps The clearances of many substances have been measured and used as an index for GFR. Exogenous markers include the carbohydrate compound inulin, 124I-iothalamate and 51Cr-EDTA.

Keywords creatinine; creatinine clearance; glomerular ltration rate; renal function; urea; urinalysis Assessment of renal function
The assessment of renal compromise requires a number of laboratory investigations in conjunction with a thorough clinical evaluation (Box 1). Deviation from normal levels of many blood and urinary constituents can reect renal insult or systemic disorder (Table 1). Glomerular ltration rate This is the rate at which substances are ltered from the blood of the glomeruli into the Bowmans capsules of the nephrons. It is calculated by the clearance of specic substances. Endogenous

Equations for assessment of renal function

1 The CockroftGault equation (UK) eCcr = (140 age) weight (kg) (constant)/serum creatinine (mol/l) where eCcr is the estimated creatine clearance; the constant is 1.23 for men and 1.04 for women. This formula provides a simple way to estimate glomerular ltration rate (GFR). 2 The Modication of Diet in Renal Disease Study Group equation eGFR (ml/min/1.73 m2) = 186 serum creatinine (mol/l) 1.154 age 0.203 1.21 (if black) 0.742 (if female) 3 The Schwartz equation eCcr (ml/min/1.73 m2) = (length in cm k)/serum creatinine(mg/dl) where k is 0.33 for premature infants, 0.45 for infants term to 1 year, 0.55 for children 113 years and 0.70 in adolescent males (constant for females remains at 0.55). 4 Free water clearance (FWC) FWC = V(1 Uosm/Posm) where V is the urine volume, Uosm is the urine osmolality and Posm is the plasma osmolality. Box 1

Andy McWilliam FRCA is a Specialist Registrar in Anaesthesia in the North Western Deanery, UK. He qualied from Aberdeen in 1997. Conicts of interest: none declared. Ross Macnab FRCA is a Consultant in Anaesthesia at the Manchester Royal Inrmary, UK. He qualied from St Andrews University and Manchester Medical School in 1993 and trained in the North Western Deanery. He has an interest in anaesthesia for renal transplantation. Conicts of interest: none declared.

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Normal valuesa
Blood biochemistry Sodium 132144mmol/l Potassium 3.55.5mmol/l Urea 3.57.4mmol/l Creatinine 4480mol/l Chloride 95110mmol/l Venous bicarbonate 2430mmol/l Urate (male) 0.170.48mmol/l Urate (female) 0.140.39mmol/l Plasma osmolality 275295 mosmol/kg Anion gap (Na++K+) (HCO3+Cl) 1216mmol/l Urine biochemistry Sodium 100200mmol/24h Potassium 3090mmol/24h Urate 312mmol/24h Protein<0.15g/24h Creatinine 917mmol/24h Creatinine clearance 120ml/min

eCcr = ((140 age) weight (kg) (0.85 if female))/72 serum creatinine (mg/dl) Because serum creatinine in the UK is measured in micromole per litre, the formula is modied and a constant is used for both men and women to complete the estimation: eCcr = ((140 age) weight (kg) (constant))/serum creatinine (mol/l) The constant is 1.23 for men and 1.04 for women. This formula provides a simple way to estimate GFR. The MDRD Study Group developed an alternative to this formula that was indexed to body surface area. In its original form, it used six measurements to estimate GFR (eGFR), including blood urea nitrogen and albumin levels. A basic four-variable form of the calculation containing serum creatinine, age, race and gender is: eGFR (ml/min/1.73 m2) = 186 (serum creatinine (mol/l)/ 88.4)1.154 age0.203 1.21 (if black) 0.742 (if female) These equations are not validated in children, in whom an alternative, the Schwartz equation, should be used. (Box 1) Height in centimetres is multiplied by an age-dependent constant; this total is then divided by the serum creatinine concentration to give an estimation of GFR indexed to body surface area. Creatinine-based equations have many limitations, reecting the variability of creatinine production with many factors. The diuretics spironolactone and triamterene, as well as other drugs such as trimethoprim, cimetidine and probenecid, interfere with tubular secretion of creatinine, and thus can increase serum creatinine concentrations while not reecting alterations in GFR. Extremes of muscle mass or breakdown, pregnancy, very low body mass index or rapidly changing renal function impair accuracy and extrapolation of GFR. It must be noted also that a rise in plasma creatinine concentration is regarded as a late sign of renal dysfunction, with estimates of a reduction in GFR of more than 50% occurring before there is any alteration in serum creatinine. Serum urea As a breakdown product of hepatic protein metabolism urea has important physiological functions in the maintenance of the renal concentrating function and provides the route of excretion of nitrogenous waste. Elevated urea levels may indicate renal impairment, but this is a non-specic nding and can be related to other things such as the absorption of blood following gastrointestinal haemorrhage. Urea-based models are to be regarded as less sensitive and specic than creatinine-based models. Serum cystatin C This alkaline non-glycosylated protein is produced at a constant rate by almost all nucleated cells. It is freely ltered at the glomerulus and is almost completely reabsorbed and catabolized in the proximal tubule. Estimation of the GFR using cystatin C (e.g. the Filler equation)1 has been found to compare favourably with creatinine-based methods. Although initially it was thought that serum levels of cystatin C were independent of age, sex,
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Reference ranges quoted from the Biochemistry Laboratories at the Manchester Royal Inrmary, 2009. a Always consult local laboratory for values.

Table 1

Practical difculties in the administration and measurement of these substances preclude their usefulness in clinical settings, so they remain predominantly research tools. Therefore, the common practice is to use endogenous compounds as markers for GFR. Creatinine clearance Creatinine is the most commonly used endogenous marker for renal function. It is a product of muscle metabolism that is freely ltered at the glomerulus and secreted in small amounts in the proximal tubule. This results in a small overestimation of GFR, the impact of which is attenuated by the plasma creatinine assay, which generally also leads to an overestimation of the actual concentration of creatinine by also measuring non-creatinine chromogens(such as acetone and ascorbic acid). The measurement of the clearance of creatinine normally involves a 24-hour collection of urine and a measurement of serum creatinine concentration, assumed to represent the steady-state concentration for the measurement period. A clearance value is then given and expressed in terms of millilitres per minute, thus giving an interpretable value for estimation of the GFR. Shorter time periods for collection, for example 2 hours, have been used in catheterized patients on an intensive care unit.4 The limitations of this method include collection errors and inconvenience for the patient. The predictions of GFR made from serum creatinine levels are more convenient and are a mainstay of modern GFR assessment. Creatinine-based equations for glomerular ltration rate Creatinine concentration alone can be used to estimate GFR by a number of mathematical models. The most commonly used are the CockroftGault (CG) and modication of diet in renal disease (MDRD) formulae. The CG model estimates creatinine clearance (eCcr), and hence GFR, based on serum creatinine, age, sex and body mass. The original formula used weight in kilograms and creatinine in milligrams per decilitre, as is standard in the USA:

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body morphology and composition, we now know they vary with lean body mass.1 Free water clearance Although rarely calculated, this allows quantication of urinary excretion of water and electrolytes by theoretically separating urine into two components: one consisting of isosmotic urine containing all solutes and the other containing only free water. Clearance of this free water is responsible for altering plasma osmolality and, in particular, the plasma sodium concentration. Clearance of free water can indicate the ability of the kidneys to conserve water by the production of concentrated urine (free water clearance of less than zero): the production of isosmotic urine is indicated by a clearance of 1 and the production of hypotonic urine and thus free water loss is indicated by free water clearance of greater than 1. In the diagnosis of acute renal failure, this measurement yields no advantage over creatinine clearance, and it is subject to limitations by factors that affect urine osmolality. It may, however, still offer practical benets in the assessment of hypernatraemia in resolving acute renal failure. Other serum biochemistry in glomerular ltration rate reduction Serum electrolyte levels are non-specic markers of renal dysfunction and offer little in the way of quantitative analysis. Acute reduction in GFR is often accompanied by an elevation of serum potassium, urate and phosphate (as well as urea and creatinine) and a reduction in serum bicarbonate and calcium levels. Additionally, metabolic acidosis with an elevated anion gap is characteristic.

than 50% after administration of desmopressin, suggests cranial diabetes insipidus rather than a nephrogenic cause of impaired tubule function.

Urinalysis
The physicochemical properties of urine as well as the presence and concentration of substances can be used as non-specic markers of renal disease but are also assessors of renal function. Urine dipstick testing allows bedside cost-effective analysis and screening for many common conditions. Indices examined on dipstick testing include pH, specic gravity, protein, glucose, ketones, nitrite, blood, bilirubin, urobilinogen and leucocytes. The urine specic gravity reects the concentration of the urine, providing an indication of tubular function. This is subject to many limitations, with an altered specic gravity found in many other circumstances including glycosuria, proteinuria, drugs and extremes of age. Microscopic analysis of urine can identify the presence of red blood cells (RBCs), white blood cells (WBCs), epithelial cells, hyaline casts, RBC casts, WBC casts and bacteria. Although non-specic, many of these ndings can indicate signicant renal pathology. The presence of dysmorphic RBCs and, in particular, RBC casts suggests glomerulonephritis or signicant tubule damage with RBC leakage. WBC casts may indicate intrarenal disease such as pyelo- or glomerulonephritis because these casts are formed in the kidney not in the distal urinary tract. Hyaline casts are non-specic and can be found in healthy patients. Bacteria are commonly seen in urine under micro scopy, often reecting contamination. The diagnosis of infection requires culture; however, a colony count of >100,000/ml from a true clean catch, catheter or suprapubic sample carries greater signicance. Microalbuminuria, as dened by an albumin excretion of >20 g/min or 30300 mg/day, suggests hypertensive disease in patients with diabetes. The presence of macroalbuminuria (>200 g/min or >300 mg/day) suggests diabetic nephropathy, which can be conrmed by the co-existence of a declining GFR and elevated blood pressure.

Tests for tubular dysfunction

Proximal tubular failure causes acidosis accompanied by a fall in serum potassium, phosphate, urate and bicarbonate levels, reecting a failure of reabsorption. Usually, urea and creatinine levels are normal. Acidication of the urine by oral ammonium chloride is occasionally carried out to indicate the presence of renal tubular acidosis. This measures the ability of the kidney to produce acidic urine (pH < 5.3) in response to the ammonium chloride. This compound is metabolized hepatically to urea with the consumption of bicarbonate. Exclusions to this test include alkaline urine in the presence of metabolic acidosis (diagnostic of renal tubular acidosis) and hepatic impairment, and difculties in interpretation occur when urinary infection, low potassium or elevated calcium are present. The ability of the distal tubules to reabsorb water may be assessed by the water deprivation test. This test is conducted when diabetes insipidus is suspected and involves repeated measurements of urine osmolality and body weight while allowing only dry food for 8 hours. The measurement of urine osmolality provides information on the ability of the kidneys to concentrate urine in response to water balance. The urine osmolality and volume and body weight are measured at hourly intervals until steady state or a urine osmolality of 750 mosmol/l is reached. If the urine osmolality fails to rise by 30 mosmol/l, a desmopressin test can be conducted. Recovery of concentrating ability, which is indicated by an increase in the urine osmolality of greater
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Urine tests for differentiation between pre-renal and intrarenal failure

The use of urinary components to distinguish between pre-renal compromise and acute tubular necrosis relies on the normal response of the kidney to conserve sodium and water in the presence of reduced renal perfusion. Clinical assessment is vital in making the diagnosis, with emphasis on assessment of uid status, medication or toxin ingestion, heart or liver disease or a history suggestive of excessive muscle breakdown. However, information from urinary and blood tests can provide supporting evidence. Pre-renal failure is characterized by concentrated urine with low sodium excretion (<20 mEq/l) and a fractional excretion of sodium (FENa) of less than 1%. Intrarenal failure typically has a FENa of greater than 2% and a urinary sodium concentration >20 mEq/l. A raised ratio of urine to serum urea and creatinine and a urinary osmolality >500 mosmol/l suggest that renal concentrating function is intact, which supports a diagnosis of pre-renal failure. In practice, no single test can differentiate

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between pre-renal and intrarenal impairment. Inadequate management of pre-renal failure can result in the development of intrarenal damage.

Endocrine tests in renal disease

Many hormone levels may be altered from their normal values by the presence of renal disease. Alterations in breakdown (e.g. reduced metabolism of insulin, calcitonin or parathyroid hormone (PTH)), alterations in secretion (e.g. increased secretion of insulin) or alterations in production (e.g. erythropoietin and 1,25-vitamin D3) can all occur. The presence of anaemia with co-existing chronic kidney disease suggests impaired erythro poietin production. Assays of this hormone are rarely conducted because the diagnosis relies on the clinical picture, exclusion of other causes and the response to therapy. Assays of hormones such as PTH can be conducted as part of the overall assessment of a patient with chronic renal failure, but again these are non-specic tests. Elevated parathyroid hormone levels can indicate secondary or tertiary hyperparathyroidism.

References 1  Craig R, Hunter J. Recent developments in the perioperative management of patients with chronic kidney disease. Br J Anaesth 2008; 101: 296310. 2  Stevens L, Coresh J, Greene T, Levey A. Assessing kidney function: measured and estimated glomerular ltration rate. N Engl J Med 2006; 354: 247383. 3  Power I, Kam P. Principles of physiology for the anaesthetist. London: Arnold, 2001. 4  Sladen R, Endo E, Harrison T. Two-hour versus 22-hour creatinine clearance in critically ill patients. Anaesthesiology 1987; 67: 101316.

FurtHer reaDIng Barrett J, Harris K, Topham P. Oxford desk reference nephrology. Oxford: Oxford University Press, 2009. eGFR Calculator. Also available at: http://www.renal.org/eGFRcalc/GFR.pl (accessed 4 Jan 2009).

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