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MLT476 LECTURE 2

By:
Mohd Fahmi Mastuki
Mohd Nazri Abu
Department of Medical Laboratory Technology
Faculty of Health Sciences, UiTM
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Learning Outcomes
At the end of the session, you should be able to describe:

1. List the origin and principle clinical significance of BUN, Creatinine, Uric
Acid and Ammonia

2. List the reference ranges for the 4 principle ( Non - Protein Nitrogen )
NPNs

3. Discuss why creatinine is the most useful NPN to evaluate renal


function

4. Calculate Creatinine Clearance

5. Discuss the common methodologies used to measure BUN, Creatinine,


Uric Acid and Ammonia 2
The Kidneys

• located in the abdomen


toward the back, normally
one on each side of the
spine.
• have the ability to monitor :
o the amount of body fluid
o the concentrations of
electrolytes like sodium
and potassium, and the
acid-base balance of
the body.

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Functions of the kidneys
3 major functions:
1- Production of urine:
Excretion of waste
Elimination of metabolic end products (urea & creatinine)
Elimination of foreign material (drugs).
2-maintance of extracellular fluid (ECF) volume & composition:
Water and electrolyte balance
Acid/ base status →hydrogen ion homoeostasis
3-Hormone synthesis:
i. 1,25-dihydroxycholecalciferol → calcium homoeostasis
ii. erythropoietin → erythropoiesis
iii. Renin → control blood pressure

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Why Test Renal Function?

• Detect renal damage – early signs &


symptoms – corrective therapy

• Monitor functional damage –


disease progression – efficacy of
therapy

• Help determine etiology

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RENAL FUNCTION
TEST (RFT)
a.k.a. NON - PROTEIN NITROGEN

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Introduction
 NPN ( Non - Protein Nitrogen ) is a term that can be
used for a bunch of different substances that have
the element nitrogen in them, but are not proteins.

 This is a little unusual, because most of the body’s


nitrogen is associated with proteins.

 There are many different unrelated NPNs, but we are


only interested in 4 of them:

 Creatinine , Blood Urea Nitrogen ( BUN ), Uric Acid


and Ammonia

 In general, plasma NPNs are increased in renal


failure and are commonly ordered as blood tests to
check renal function
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Renal profile
 Creatinine  Na
 Urea  K
 Uric acid  Cl
 Calcium  Phosphate

 Optional - Glucose

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BUN (Blood Urea Nitrogen)

 Blood Urea Nitrogen = BUN = Urea


 50% of the NPNs

 Product of protein catabolism which produces ammonia


 Ammonia is very toxic – converted to urea by the liver
 Liver converts ammonia and CO2 Urea

 Filtered by the glomerulus but also reabsorbed by renal tubules (40 %)


 Some is lost through the skin and the GI tract ( < 10 % )

 Plasma BUN is affected by

 Renal function
Specimen : Plasma or serum
 Dietary protein
 Protein catabolism
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BUN (Blood Urea Nitrogen)

 BUN disease correlations

 Azotemia = Elevated plasma BUN

 Prerenal  BUN ( Not related to renal function )

 Low Blood Pressure ( CHF, Shock, hemorrhage,


dehydration )
 Decreased blood flow to kidney = No filtration
 Increased dietary protein or protein catabolism

 Prerenal  BUN ( Not related to renal function )

 Decreased dietary protein


 Increased protein synthesis ( Pregnant women ,
children )
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BUN (Blood Urea Nitrogen)

 Renal causes of  BUN

 Renal disease with decreased glomerular filtration

 Glomerular nephritis
 Renal failure form Diabetes Mellitus

 Post renal causes of  BUN (not related to renal function)

 Obstruction of urine flow

 Kidney stones
 Bladder or prostate tumors
 UTIs

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BUN (Blood Urea Nitrogen)

 BUN / Creatinine Ratio

 Normal BUN / Creatinine ratio is 10 – 20 to 1 Increased BUN


 Creatinine is another NPN Normal Creat

 Pre-renal increased BUN / Creat ratio


 BUN is more susceptible to non-renal factors Increased BUN
Increased Creat

 Post-renal increased ratio BUN / Creat ratio


 Both BUN and Creat are elevated
Decreased BUN
Normal Creat
 Renal decreased BUN / Creat ratio
 Low dietary protein or severe liver disease
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Creatinine

Liver Amino Acids Creatine


Muscles Creatine Phosphocreatine
Muscles Phosphocreatine Creatinine

Creatinine is formed from the oxidation of creatine.

Creatinine formed at a constant rate by the muscles as a function of muscle mass

Creatinine is removed from the plasma by glomerular filtration

Creatinine is not secreted or absorbed by the renal tubules

Therefore : Plasma creatinine is a function of glomerular filtration

Unaffected by other factors

It’s a very good test to evaluate renal function


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Creatinine

 Creatinine disease correlations

 Increased plasma creatinine associated with decreased


glomerular filtration ( renal function )

 Glomerular filtration may be 50 % of normal before


plasma creatinine is elevated

 Plasma creatinine is unaffected by diet

 Plasma creatinine is the most common test used to


evaluate renal function

 Plasma creatinine concentrations are very stable from


day to day - If there is a delta check , its very suspicious
and must be investigated
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Creatinine

 Creatinine analytical techniques

 Jaffee Method ( the Classic technique )

Creatinine + Picrate Acid Colored chromogen

Specimen : Plasma or serum

Elevated bilirubin and hemolysis causes falsely decreased results

Reference range : 0.5 - 1.5 mg / dl

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Uric Acid

 Breakdown product of purines ( nucleic acid / DNA )

 Purines from cellular breakdown are converted to uric acid by


the liver

 Uric acid is filtered by the glomerulus ( but 98 – 100 %


reabsorbed )

 Elevated plasma uric acid can promote formation of solid uric


acid crystals in joints and urine

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Uric Acid

 Uric acid diseases

 Gout
 Increased plasma uric acid
 Painful uric acid crystals in joints
 Usually in older males ( > 30 years-old )
 Associated with alcohol consumption
 Uric acid may also form kidney stones

 Other causes of increased uric acid

 Leukemias and lymphomas (  DNA catabolism )


 Megaloblastic anemias (  DNA catabolism )
 Renal disease ( but not very specific )
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Uric Acid

Uricase
Uric acid + O2 + H2O Allantoin + CO2 + H2O2
Uric acid absorbs light @ 293 nm.
The rate of decreased absorption is proportional to the uric acid concentration.

Specimen : Plasma or serum

Reference range : 3.5 - 7.2 mg/dl (males)


2.6 - 6.0 mg/dl (females)

Let’s remember 3.0 - 7.0 mg/dl

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Ammonia

 Produced from the deamaination of amino acids in the


muscle and from bacteria in the GI tract
 Ammonia is very toxic - The liver converts ammonia into
urea
 Urea is less toxic and can be removed from the plasma by
the kidneys
 In severe hepatic disease, the liver fails to convert ammonia
into urea, resulting in increased plasma ammonia levels
 Increased plasma ammonia concentrations in :
 Liver failure

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Ammonia

Ammonia analytical techniques

NH4+ + 2-OXOGLUTARATE + NADPH L-GLUTAMATE +


NADP+
There is a decreasing absorbance @ 340 nm, proportional to the
ammonia concentration.

Specimen : EDTA or Heparinized Whole Blood on ice


Must be tested ASAP or plasma frozen
Delayed testing caused false increased values

Reference range : 20 – 60 µg / dl

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Creatinine Clearance

 Calculated measurement of the rate at which creatinine is


removed from the plasma by the kidneys

 Measurement of glomerular filtration ( renal function )

 A good test of glomerular filtration because

 Creatinine is an endogenous substance ( not affected by


diet )
 Creatinine is filtered by the glomerulus, but not secreted
or re-absorbed by the renal tubules

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24 Hour Urine collection
Container.

The volume can be measured


directly off the container.

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 Creatinine Clearance specimens

 24 hour urine specimen


 Plasma / serum creatinine collected during
the urine collection

  UV  1.73
24 Hour Creatinine Clearance 
Formula
  
 P  A 

 CREATININE CLEARANCE =

U = Creatinine concentration of the 24 hour urine ( mg / dl )


V = 24 hour urine volume ( ml ) per minute - V / 1440 = ml / minute
P = Plasma creatinine concentration ( mg / dl )
A = Correction factor accounts for differences in body surface area
obtained from a height – weight chart

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Example of a 24 Hour Creatinine Clearance calculation

24 hour urine volume = 1000 mls


24 hour urine creatinine = 20.0 mg / dl
Plasma creatinine = 5.0 mg / dl

Patients height / weight = 6’00 / 190 lbs


UV   1.73   20.0  1000
1440   1.73 
Creat Cl    
 P  A   5.0   2.05 

Creat Cl = 2 ml / min …. Very poor clearance !!!

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 Reference range

 97 - 137 ml / min ( male)


 88 - 128 ml / min (female)

 Let’s remember 90 - 130 ml / min

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Procedure for 24 Hour Urine Collection

 Have the patient empty his / her bladder ( discard


this urine ).

 Note the time . For the next 24 hours, have the


patient collect and save all urine in an appropriate
container.

 At the end of the 24 hour period have the patient


void one last time into the urine container. This
completes the collection.

 If possible, keep the urine specimen refrigerated.


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NPN TOP 10
 Increased Creatinine associated with renal failure
 Increased BUN associated with renal failure and
protein catabolism
 Increased Uric Acid associated with Gout
 Increased Ammonia is associated with liver disease
 Creatinine derived from cellular creatine … very
constant from day to day
 BUN ( Urea ) is derived from protein catabolism
 Protein Ammonia Urea
 Uric Acid is derived from purine( a component of
DNA ) catabolism
 Decreased Creatinine Clearance associated with
decreased Glomerular Filtration

 UV  1.73 
Creatinine Clearance    
Don’t forget to divide V by 1440 !  P  A 
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Reference Ranges

 BUN 10 - 20 mg / dl

 Creatinine 0.5 - 1.5 mg /dl

 Uric Acid 3.0 - 7.0 mg / dl

 Creatinine Clearance 90 - 130 ml / min

 Ammonia 20 - 60 ug / dl

 BUN / Creat Ratio 10 - 20 to 1

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ASSIGNMENT 1

DIFFERENTIATE BETWEEN
ACUTE RENAL FAILURE
AND
CHRONIC RENAL FAILURE
(in a table)

Due date: 25/8/2010


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