Physiological basis of evaluation of renal function

introduction
Urine is formed by the help of nephrons
About 1 million nephrons are present in one kidney
Nephron contains bowmens capsule, proximal convoluted tubule, loop of Henle , distal
convoluted tubule and collecting tubule
blood supply high-1200ml/min
120-125ml/min is filtered which is known as glomerular filtration rate (GFR)
Formation of urine
Process of urine formation basically involves two steps
Glomerular filtration: formation of ultrafiltrate waste materials of plasma are filtered
Tubular reabsorption: formation of pure urine PCT & DCT retain water and most of the soluble
constituents of the glomerular filtrate by reabsorption
Renal Functions
1) Production of urine
2) Elimination of metabolic end products (Urea/Creatinine)
3) Elimination of foreign materials (Drugs)
4) Control of volume & composition of ECF
Water and electrolyte balance
Acid/Base status
5) Endocrine Functions -Vit D, Renin
Renal threshold
Renal threshold of a substance is the concentration in blood beyond which it is excreted in urine
Renal threshold for glucose is 180mg/dL
Tubular maximum (Tm): maximum capacity of the kidneys to absorb a particular substance
Tm for glucose is 350 mg/min
Why Test Renal Function?
1) To identify renal dysfunction.
2) To diagnose renal disease.
3) To monitor disease progress.
4) To monitor response to treatment.
5) To assess changes in function that may impact on therapy (e.g. Digoxin, chemotherapy).
Renal function tests
1) Analysis of urine
2) Analysis of blood
3) Renal clearance test
4) Radiology and renal imaging
5) Renal biopsy

Analysis of urine
1)Volume 2)Colour 3)Osmolality and Specific gravity 4)PH 5)Chemical analysis of abnormal
urinary constituents6)Microscopic examination 7) Bacteriological examination
1) Volume normal urinary output 800 2500 ml /day
Polyuria more than 3 L / day
Oliguria less than 500 ml / day
Anuria no urine (less than 50 ml /day)
2) Colour normal urinary colour light yellow
Brownish yellow conj. Bilirubin
Cloudy appearance alkaline urine (ca phosphate ppt.)
Frothy appearance proteinuria
Red-dark brown tinge - porphyria
3) Osmolality & sp. Gravity Normal osmolality - 50 mOsm / kg 1200 mOsm / kg
Normal sp. Gravity - 1.003 1.030
MethodCollect early morning urine sample and normal value should be > 600 mOsm/kg , > 1.018
4) PH
Normal urinary ph 4.5 8.0 (slightly acidic)
But Infection with urea spitting bacteria, Impairment of tubular acidification can change ph
5) Abnormal urinary constituents
1) Protein
When there is more secretion of protein in urine called Proteinuria ( > 150 mg/day)
Mild transient proteinuria found in congestive heart failure
Glomerular proteinuria (increase in glomerular permeability) nephrotic syndrome, acute GN
Tubular proteinuria(tubular reabsorption of low mol. Wt. protein affected) tubulointerstitial
disorder and fanconis syndrome
2) Glycosuria
Urinary glucose found in condition like
DM, renal glycosuria, alimentary glycosuria
Inborn error in metabolism other sugar also present in urine
3) Ketonuria

Ketone bodies in sever DM or prolong starvation ( acetoacetic acid , beta hydroxyl butyric acid ,
acetone )

4) Bilrubinuria
Presence of conj. Bilirubin in urine indicate hepatic or post hepatic jaundice
Excessive urobilinogen ( normal 1 -3.5 mg /daily ) haemolytic anemia

5) Haemoglobunuria
Occur in Intravascular hemolysis ( black water fever )
6) Porphobilinogen in urine
Found In condition like Acute intermittent porphyria
Red brown colour (burgundy wine) IN STANDING URINE
7) Haematuria
Acute GN, renal stone, malignancy
8) Aminoaciduria
In Congenital tubular disorder
6) Microscopic examination (centrifuged sediment)
1) Cast
Renal tubule epithelium produce Tamm Horsfall protein which coagulated and washed out by
tubular flow
Normally protein are in the form of Non cellular cast Hyaline and granular
But in abnormal condition it form Cellular cast
Red cell cast acute GN
Leucocyte casts acute bacterial pyelonephritis
Epithelial cast acute tubular necrosis
Fatty cast nephrotic syndrome

2) Crystal
When uric acid crystal and cysteine crystal present in excess have clinical significance
3) Cells
Already covered in cellular cast with protein
In bacteriological Bacteriological examination following abnormality can find

Mid - stream sample of urine for pus + bacteria

Urinary tract INF.
2) Analysis of blood
Normally this this sub. Excreted by kidney that means any abnormality in their plasma level
directly indicate problem in filtration via kidney
1) Blood urea
Normaly 20-40mg%, blood urea level
Increase in level when 50% glomerular damage occur
2) Plasma creatinine conc.0.6 1.5 mg % is normal plasma creatinine level
When decrease in 50% GFR function, then significant change in level of creatinine
3) Serum protein level
Normal, Total protein 6.7- 8 gm%(A/G 1.7:1)
In NEPHROTIC SYNDROME REVERSAL OF A/G ratio occur
4) Serum cholesterol
150 200% ,is normal cholesterol level, in nephrotic syndrome its increeases
5) Serum electrolyte
Value varies with renal disease
Chr. Renal failure high k+, PO4 but low Na+, Ca++
3) Renal clearance test
Definition it is the Volume of plasma that is cleared of sub. In one minute by excretion of
substance in urine.
C = Renal clearance
U = urine conc. Of substance
V = rate of flow of urine
P = plasma conc. of substance

C=UV/P

PRINCIPLE GOVERNING RENAL CLEARANCE

1) Freely filtrated, not reabsorbed and secreted (inulin)
C in = GFR
2) Freely filtrated, partially reabsorbed

C x < GFR
3) Freely filtrated, completely reabsorbed (Na+, glucose, A.A., Cl-)
C x (lowest)
4) Freely filtrated, secreted by tubules not reabsorbed (PAH, diotrast)
Clearance depends on range of blood flow
Renal clearance of different substance and their application
1) C inulin
Glomerular filtration calculate by clearance of inulin(C inulin)
Inulin
1) Not exist in body naturally
2) Freely filtered by glomeruli, no absorption or secretion
3) Biologically inert, non-toxic
4) Not metabolise or store by kidney
5) Easily lab reading
Method IV single bolus, followed by continuous constant i.v INF.
Application
1) To calculate GFR
2) Indicator of plasma clearance mechanism
3) For comparing clearance of given sub.
2) C creatinine (as index of GFR, preferred over inulin)
Creatinine
Endogenous sub.
Normally 0.6 1.5 mg/dl constant plasma value
Marginally secreted by tubules
Method 24 hr urine collected
Plasma conc. Measure at midpoint of urine collection
C creatinine 80 -110 ml / min (normal)
As Age advances muscle mass get decrease also decrease creatinine value also decrease in
GFR
3) C urea
Urea
End product of protein metabolism
Clearance depend on diet

Partially reabsorb by tubule

Method
Completely void urine and time recorded
After 1hr asked to void again measure conc. in urine
Blood sample collected at midpoint of test
For C urea there are two calculation 1) Maximum urea clearance(C urea (m)) - When urine volume more than 2ml / min
Normal value is 75 ml / min

2) Standard urea clearance(C urea(s)) - When urine volume less than 2 ml/min

Normal value is 54 ml / min

C urea below 75 % consider serious indicator of renal damage

Normally 40% urea reabsorb constantly so, {C urea 1.2} in % = GFR
4) C PAH
Secretion to tubular fluid via carrier in PCT by Tm
when Tm reaches C PAH become more function of glomerular filtration
RENAL PLASMA FLOW
FICK PRINCIPE
Amount of substance excreted by kidney per unit time (UV) is equal to renal plasma flow (RPF)
multiply by arteriovenous difference in plasma conc.
UV = RPF (Pa Pv)
RPF = (Pa Pv) / UV

PAH used for RPF

1) Completely extracted from kidney during each passage via kidney
2) Not metabolise, store or produce by kidney
3) Not affect renal blood flow
4) Conc. Can measure easily
5) Not affect renal flow

6) Actively secret by tubules in lumen

Method of estimation of RPF
PAH continuously infuse in low dose
So, RPF = Pa(PAH) - Pv(PAH) / U PAH . V
But at low dose Pv (PAH) = 0 ( all excreted in urine )
PAH excreted only by kidney so peripheral arterial blood conc. As value of Pa(PAH)
RPF = P PAH / U PAH . V ----------------------------------------- (1)
C (PAH) = P PAH / U PAH . V ------------------------------------- (2)
By eq.1 and eq.2
RPF = C (PAH)
About 10% of total RPF perfuse to non-excretory portion of kidney I.e.
Renal capsule, renal pelvis
so, effective RPF = C PAH
i.e. True RPF = C PAH / 0.9
From haematocrit value (Hct) we can also determine the value of Renal Blood Flow (RBF)
RBF = RPF (1/1-Hct)
NORMAL
ERPF = 650 ml/min/1.73 m2 BODY SURFACE AREA (BAS) (M)
ERPF = 600 ml/min/1.73 m2 BODY SURFACE AREA (BAS) (F)

5) C osm and C H2O

1) Osmotic clearance (C osm )
Amount of plasma (ml) completely cleared of osmotically active solutes that appear in urine
each minute

NORMAL VALUE 3 ml / min

C osm increase In osmotic diuresis
C osm decrease in fasting or diet deficient in protein
2) Free water clearance (C H2O)
Volume of pure water that must be removed from or added to, the flow of urine ( ml/min) to
make it iso osmotic with plasma
Free water generate at (thick ascending limb and early distal tubule )
NaCl reabsorb and free water left in tubules
ADH ABSENT solute free water excreted , C H20 is positive
ADH PRESENT water reabsorbed in late DT & CT , C H20 is negative
C H20 = V - Cosm
Relationship between C H20,V & C osm
1) Iso osmotic urine
V = C osm
AS C H20 = V C osm = 0
Example - Loop diuretics inhibit TAL(THICK ASC. LOOP) it inhibit dilution(TAL inhibition) and
conc.(abolish corticopapilary gradient) Capacity of urine---isosmotic urine

2) Hypo osmotic urine

Two virtual volume will form
Cosm contain solute iso osmatic to plasma
C H20 free solute water positive
V = Cosm + C H20
Example - Excess water intake , central DI , nephrogenic DI
3) Hyperosmotic urine
-C H20(T CH2O/free water reabsorption) volume of free water needed to make urine iso
osmotic with plasma negative
Cosm = V + T C H2O
Example -Water deprivation, SIADH
6) TEST FOR TUBULAR FUCTION

1) Urine conc. Test

Measure ability of tubules to conc. Urine
Measure sp.gravity of urine after either 12 hr of water deprivation or 12 hr of vasopressin inj.
Sp. Gravity above 1.020 is normal tubular function
2)Urine acidification test
NH4Cl orally 0.1 gm/kg----urine sample tested for PH after 6 hr.---PH should below 5.3(because
of liver NH4Cl NH3 + HCl)
If more PH inability to excrete H+
3) Urine dilution test
Pt. ask to drink 1 lit water-----sample collected for every hr. for 4hr
Total 750 ml urine should be excreted
At least one sample should be osmolality less than 100 mOsm/Kg or specific gravity less than
1.004
4) Tubular secretory capacity
Phenolsulphonepthalein Px (PSP) excretion test
PSP inj. i.v. and checked first appearance in urine and quantity eliminate in defined period
measure functional capacity of kidney
25% dye excreted in 15 min,75% in 2hr (normal)
Slight impairment 59 - 40%
Moderate impairment 39 25%
Marked impairment 24 - 11%
5 ) Other method to study tubular function
Micro puncture technique analyse tubular fluid at different levels
Microcryoscopic study renal tissue slice at different dept
Microelectrode study measure membrane potential of tubular cells
4) RADIOLOGY AND RENAL IMAGING
1) Plain radiograph of abdomen
Useful to detect radiopaque stone(Ca++ containing )
2) Intravenous pyelography (IVP)
Inj. i.v. Radiopaque dye ( urographin ) ----- take radiograph of abd. At short interval ( 1,5,10 ,30
min.) -----visualisation of glomeruli, renal tubule ultimately renal parenchyma----visualisation of
pelvicalyceal system
3) Ultrasonography

Quick , non expensive , non invasive method

4)Computed tomography
Detect abnormality in and around of kidney
5)Radionuclide studies
Inj. Of radioactive compound which conc. and excreted by kidney(using gamma camera)
5) Renal biopsy
For renal biopsy Vim Silverman needle use
Use1) To diagnose proteinuria of unknown origin
2) Unexplained renal failuar
3) Systemic disease asso. With kidney
Light , electron , immunofluorescence microscopic study