Renal Function Tests

Lecturer: Dr. Atibagos

Transcriber: Huey M. Javier, RN

OUTLINE  The volume of blood filtered per minute is the glomerular

 Functional units filtration rate (GFR) and its determination in evaluating renal
function
 Kidney functions
 Routine renal function tests (RFTs) PROXIMAL CONVULATED TUBULE
o Serum creatinine
 Returns the bulk of each valuable substance back to the
o Creatinine clearance
blood circulation
o Cockroft-Gault formula for GFR estimation
o 75% of the water, sodium, and chloride
o Other formulas for GFR formulation
o 100% of the glucose (up to the renal threshold)
o Serum urea
once it reaches the threshold do not expect for the
glucose to be reabsorbed
FUNCTIONAL UNITS
o Almost all of the amino acids, vitamins, and
 The nephron is the functional unit of the kidney proteins
 Each kidney contains about 1,000,000 to 1,300,00 o Varying amounts of urea, uric acid, and ions, such
nephrons as magnesium, calcium and potassium
 The nephron is composed of glomerulus and renal tubules  Secretes products of renal tubular cell metabolism, such as
 The nephron performs its homeostatic function by ultra hydrogen ions, and drugs, such as penicillin
filtration at glomerulus and secretion and reabsorption at
renal tubules LOOP OF HENLE
 Facilitate the reabsorption of water, sodium, and chloride
 The osmolality in the medulla in this portion of the nephron
increases steadily from the corticomedullary junction inward

DISTAL CONVOLUTED TUBULE

 The filtrate entering this section of the nephron is close to its
final composition
 Effects small adjustments to achieve electrolyte and acid-
base homeostasis (under the hormonal control of both
antidiuretic hormone (ADH) and aldosterone)
 The distal convoluted tubule is much shorter than the
proximal tubule with two or three coils that connect to a
collecting duct
 20 glasses of water a day – expect the urine to be diluted
(color pale yellow)
 If it is concentrated – expect the urine to be concentrated
(yellow na yellow)

COLLECTING DUCT
 The collecting ducts are the final site for either concentrating
or diluting the urine
Representation of a nephron and its blood supply
 The hormones ADH and aldosterone act on this segment of
the nephron to control reabsorption of water and sodium
NEPHRON
 Chloride and urea are also reabsorbed here
 Each nephron is a complex apparatus comprised of five
basic parts
KIDNEY FUNCTION
 Regulation of
GLOMERULUS
o Water and electrolyte balance
 Functions to filter incoming blood
o Acid base balance
 Factors that facilitate filtration o Arterial blood pressure
o High pressure in the glomerular capillaries, which
 Excretion of metabolic waste products and foreign
is a result of their position between two arterioles
chemicals
o The semipermeable glomerular basement
 Hormonal function: secretion of erythropoietin and
membrane which has a molecular size cutoff value
activation of angiotensin by renin
of approximately 66,000 Da
 Metabolic function: site for gluconeogenesis

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WHY TEST RENAL FUCTION?
 Many diseases affect renal function
 For example diabetes, hypertension
 In some, several functions are affected
 In other, there is selective impairment of glomerular function
or one or more tubular functions
 Most types of renal diseases cause destruction of complete
nephron
 Leading to chronic kidney disease and renal failure
leading to dialysis and renal transplant
 Routine RFT’s include the measurement of
o Serum creatinine (Cr)
o Creatinine clearance
o Estimated GFR
 Reflection of creatinine clearance
o Serum urea
 Both serum Creatinine and creatinine clearance are used as
kidney function tests to
o Confirm diagnosis of renal disease
o Estimate the severity of the disease
o Follow up treatment
SERUM CREATININE
 Normal values: 55 – 120 umol/L in adult
 Creatinine is the end product of creatinine catabolism
 98% of the body creatinine is present in the muscles in the
form of creatinine phosphate
 1-2% of total muscle creatinine or creatine phosphate pool is
converted daily to creatinine though the spontaneous, on-
enzymatic loss of water or phosphate
 Creatinine in the plasma is filtered freely at the glomerulus
and secreted by renal tubules (10% of urinary creatinine)
 Creatinine is not reabsorbed by the renal tubules
 Plasma creatinine is an endogenous substance not affected
by diet
 Plasma creatinine remains fairly constant throughout adult
life
 A raised serum creatinine is
o A good indicator of impaired renal function
 But normal serum creatinine
o Does not necessarily indicate normal renal
function as serum creatinine may not be elevated
until GFR has fallen by as much as 50%
CREATININE CLEARANCE
 The GFR provides a useful index of the number of
functioning glomeruli
 It gives an estimation of the degree of renal impairment by
disease
 Accurate measurement of GFR by clearance tests require
determination of the concentration in plasma and urine of a
substance that is
o Freely filtered at glomeruli
o Neither reabsorbed nor secreted by tubules
o Its concentration in plasma needs to remains
constant throughout the period of urine collection
o Endogenous substance
o Easily measured
 Creatinine clearance is usually about 110 ml/min in the
20-40 year old adults
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 It falls slowly but progressively to about 70ml/min in
individuals over 80 years of age
 In children, the GFR should be related to surface area, when
this is done, results are similar to those found in young
adults
 Clearance is the volume of plasma cleared from the
substance excreted in urine per minute
 U = concentration of creatinine in urine umol/L
 V= Volume of urine per min
 P = concentration of creatinine in serum umol/L
ESTIMATION OF GFR
 The creatinine clearance is measured by using a 24 hour
urine collection, but this does introduce the potential for
errors in terms of completion of the collection
 An alternative and convenient method is to employ various
formulate devised to calculate creatinine clearance using
parameters such as serum creatinine level, sex, age, and
weight of the subject
 COCKCROFT-GAULT FORMULA
 Where K is a constant that varies with sex:
o 1:23 for male and 1.04 for females
 The constant K is used as females have a relatively lower
muscle mass
 He might ask for the formula during the exam
COCKCROFT-GAULT FORMULA FOR ESTIMATION OF GFR
 Limitations
o It should not be used if
 Serum creatinine is changing rapidly
 The diet is unusual, e.g., strict vegetarian
 Low muscle mass, e.g., muscle wasting
 Obesity
 Cockroft for Asians for obesity are lower
OTHER FORMULA FOR ESTIMATION OF CPD
 Different equations may be used to calculate eGFR
 The following two are most common and require a person’s
blood creatinine result, age, and assigned values based
upon sex and race
 Chronic kidney disease epidemiology collaboration (CKD-
EPI) creatinine equation (2009)
 Modification of Diet in Renal Disease Study (MDRD)
equation
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The black population has a higher GFR

CKD STAGE BASED ON GFR

CKD STAGE GFR, mL/min/1.73m2
I >90
II 60-89
III 30-59
IV 15-29
V <15

 Serum creatinine is a better RFT than creatinine clearance

because
o Serum creatinine is more accurate
o Serum creatinine level is constant throughout adult
life
 Creatinine clearance is only recommended in the following
conditions
o Patients with early (minor) renal disease
o Assessment of possible kidney donors
o Detection of renal toxicity

NORMAL ADULT REFERENCE VALUES

 Urinary excretion of creatinine is 0.5 – 20 g per 24 hours in a
normal adult, varying according to muscular weight
o Serum creatinine – 55 – 120 umol/L
o Creatinine clearance
 90 – 140 ml./min (males)
 80 – 125 ml/min (females)

SERUM UREA
 Normal values: 2.5 – 6.6 mmol/L in adult
 Urea is formed in the liver from ammonia released from
deamination of amino acids
 As a renal function test, serum urea is inferior to serum
creatinine because:
o High protein diet increases urea formation
o Any condition of increased protein catabolism
(Cushing syndrome, diabetes mellitus, starvation,
thyrotoxicosis) increases urea formation  PPT (2019)
o 50% or more of urea filtered at the glomerulus is  Recordings
passively reabsorbed by the renal tubules

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