Renal Function Tests

BY

Dr. Amr A. Amin Dr. Abeer Ahmed

Functions of the kidney

Regulatory function Excretion of waste products: Endocrinal function Metabolic Function

NEPHRON FUNCTIONS

GLOMERULAR FILTRATION: glucose, amino acids, creatinine, urea, phosphates, uric acid TUBULAR REABSORPTION: bicarbonate, phosphates, sulfates, 65% of Na and water, glucose, K, amino acids, H ions TUBULAR SECRETION: hydrogen and potassium, remove acids (hydrogen) to maintain appropriate acid base balance, potassium,

Glomerular filtration

Of one-fifth of the cardiac output flows through the two kidneys (i.e. a flow rate of 10001200 ml/min), the glomerulus filters 125130 ml/min (GFR) of an essentially protein-free, cell-free fluid, called glomerular filtrate. The rate of filtration across this membrane is governed by multiple factors including renal blood flow and the integrity of the glomerulus membrane. Glomerulus has multiple small pores through which chemicals are filtered from the blood but excluding any substance with a molecular radius more than 4 nm (e.g. cellular blood component). Moreover, substances that are neutral or have positive charge are more likely to pass through the pores of the glomerulus than substances that are negatively charged (e.g. albumin).

Tubular reabsorption and secretion

The filtrate flows through the renal tubules, where water and solutes may be reabsorbed, secreted, synthesized, or metabolized. Sodium is exchanged in the presence of the hormone aldosterone and water is exchanged in the presence of antidiuretic hormone (ADH). Exchange of solutes may occur as active transport, which occurs against the concentration gradient of the chemical and uses energy, or as passive transport, which occurs with the concentration gradient of the chemical.

Renal Function Tests:

Serum BUN and creatinine ( convenient & insensitive ) Clearance rate (Creatinine ) eGFR Full urine examination Osmolarity measurement in plasma and urine Water depriviation test Acid load test Urine analysis:specific proteinuria, glycosuria,aminoaciduria

Urinalysis (UA)
Fresh sample = Valid sample

Physical

Chemical Microscopic examination

Chemical Examination

To perform the chemical examination, most clinical laboratories use commercially prepared test strips upon which a chemical reaction occurs between urine absorbed and the chemicals of the pad to develop the color of the pad within seconds to minutes. The degree of color change for each pad can be read and interpreted manually or by automated instruments The degree of color change on a test pad can also give an approximation (semiquantitative analysis) of the amount of substance present and reported as (from 1+ to 4+) .

The most frequently performed tests using reagent test strips are: specific gravity , pH , protein , glucose , ketones , blood , leukocyte esterase , nitrite , bilirubin ,and urobilinogen .

Some reagent test strips also have a test pad for ascorbic acid [vitamin C.

Urine Composition
1- Urine Volume Normal: more than 500 ml/day Polyuria: high Pr. Diet/high urea/diuresis/ Tea-Cola, and coffee/diuresis/ high salt intake/ high fluid intake/ DM/high osmosis/high H2O secretion/ Diab. Inspidus/ Ch.R.F/ Hypertension/ high GFR/high filtration). Oliguria: dehydration/ low fluid intake/sweating/vomiting/diarrhea) Hemorrhage and shock/low B.pressure/low GFR/ Acute R.F and Urinary obstruction/ Fever).

2- Color Normal: Amber yellow ,colorless (Urochrome+Urobilin) Red color: Haemoglobinuria or Haematuria Black color after exposure to light: homogentisic acid) Milky: Pyuria (Pus cells).

or

faint

yellow. (Oxid of

Alkaptinuria

Urine Composition
3- Specific Gravity (SG) Specific gravity, is actually a physical characteristic of the urine indicates how much concentrated the urine is, it can be measured using a chemical test.The normal urine may range from 1.010 1.030 There are no "abnormal" specific gravity values.

SG may be as low as 1.002 in case of :

Drinking

of excessive quantities of water in a short period of time/gets an IV-fluids )infusion of large volumes of fluid).

The upper limit of the test pad, SG of 1.035, indicates a concentrated urine, one with many solutes in a limited amount of water. Knowing the urine concentration helps health care providers decide if the urine specimen they are evaluating is the best one to detect a particular substance. For example, if they are looking for very small amounts of protein, a concentrated morning urine specimen would be the best sample.

4- pH
The glomerular filtrate of blood plasma is usually acidified by renal
tubules and collecting ducts from a pH of 7.4 to about 6 in the final urine. Depending on the acid-base status, urinary pH may range from as low as 4.5 to as high as 8. Some substances may be precipitated forming crystals in alkaline urine. Another substances may be precipitated forming crystals in acidic urine.

5- Appearance:

Normal: clear/ Abnormal: Turbid may be due to ppt of P/Mg/Ca (Alkaline pH) OR due to UTI/Haematuria/Pyuria/Chyluria(Fat absorbed/ crystals of oxalates or ureates)

6- Odor: Normal: aromatic due to volatile org. acids. / Abnormal:

acetone in case of DM/ bad odor in case of pyuria

Glucose (
Under normal circum. All glucose is reabsorbed by active mechanism.

Hence, Glucose is normally not detectable in urine. Glucosuria results from either -: An excessively high glucose concentration in the blood, such as
may be seen with people who have uncontrolled diabetes mellitus. A reduction in the renal threshold. Sometimes the threshold concentration is reduced and glucose enters the urine sooner, at a lower blood glucose concentration ( Eldery) Pregnancy (3 8%) . (Gestational Diabetes) Some other conditions that can cause glucosuria include hormonal disorders ,medication

Protein The glomeruli normally filter 7-10 g of protein/day, but almost all is reabsorbed by endocytosis and subsequent catabolized in proximal tubules. The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities. When urine protein is elevated (proteinuria) ;this can be an early sign of kidney disease .Albumin is smaller than most other proteins (68 kDa)and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Other proteins are not detected by the test pad but may be measured with a separate urine protein test .

Ketones

Ketones are not normally found in the urine. Ketones can be extra-synthesized in cases of starvation / Diabetic keto-acidosis (DKA. Ketones in urine can give an early indication of insufficient insulin in a person who has diabetes (Ketosis). Other conditions that may cause ketonuria: Severe exercise, loss of carbohydrates, such as with frequent vomiting, can also increase fat metabolism, resulting in ketonuria.

Bilirubin

Bilirubin is not present in the urine of normal healthy individuals. Bilirubin is a waste product that is produced by the liver from the hemoglobin of RBCs that are removed from circulation. It becomes a component of bile, a fluid that is secreted into the intestines to aid in food digestion. In certain liver diseases ,such as biliary obstruction or hepatitis , bilirubin leaks back into the blood stream and is excreted in urine. The presence of bilirubin in urine is an early indicator of liver disease and can occur before clinical symptoms such as jaundice develop.

Urobilinogen

Urobilinogen is normally present in urine in low concentrations. It is formed in the intestine from bilirubin, and a portion of it is absorbed back into the bloodstream. Positive test results help detect liver diseases such as hepatitis and cirrhosis and conditions associated with increased RBC destruction (hemolytic anemia) When urine urobilinogen is low or absent in a patient with urine bilirubin and/or signs of liver dysfunction, it can indicate the presence of hepatic or biliary obstruction

Leukocyte Esterase

Leukocyte esterase is an enzyme present in most white blood cells (WBCs). Normally, a few white blood cells are present in urine and this test is negative. When the number of WBCs in urine increases significantly, this screening test will become positive. When the WBC count in urine is high, it means that there is inflammation in the urinary tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI ,)such as a bladder or kidney infection.

Nitrite

This test detects nitrite and is based upon the fact that many bacteria can convert nitrate to nitrite in urine. Normally the urinary tract and urine are free of bacteria. When bacteria find their way into the urinary tract, they can cause a urinary tract infection (UTI). A positive nitrite test result can indicate a UTI. However, since not all bacteria are capable of converting nitrate to nitrite, you can still have a UTI despite a negative nitrite test.

URINE collection

Urine for a urinalysis can be collected at any time but the first morning sample is considered the most valuable because it is more concentrated and more likely to yield abnormalities if present. It is important to clean the genitalia before collecting urine . Bacteria and cells from the surrounding skin can contaminate the sample and interfere with the interpretation of test results. Menstrual blood and vaginal secretions can also be a source of contamination. As start to urinate, let some urine fall into the toilet, then collect one to two ounces of urine in the container provided, then void the rest into the toilet. This type of collection is called a midstream collection or a clean catch . Another samples, random, night, P.P, 24-hours may be used. The urine sample should be refrigerated if the analysis delays or a preservative may be added (azide, HCl, Pr-inh.).

BUN ( urea )

BUN results from catabolism of amino acids. After filtration, about 50% is reabsorbed by the tubules. Blood level is related to: renal function, Protein intake, and liver function Urea production is increased by a high protein intake , GIT bleeding , Catabolic state and it is decreased in patients with a low protein intake or in patients with liver disease. Less useful than Creatinine better to be used with Cr Sensitive but non-specific test Reference Range of Serum or plasma BUN is: 820 mg/dL. Reference Range of Blood urea = ( BUN X 2.14 ) is: 1545 mg/dL.

Creatinine

Creatinine (Mol. Wt. 113) is formed from breaking of 1-2% daily of muscle creatine (relative to muscle mass). Freely filtered by the glomeruli. Not reabsorbed. Conc inversely related to eGFR. Low serum and urine creatinnie is found in children, females, and elderly. Small changes in creatinine within and around the reference limits = large changes in GFR. Increased conc occurred very late ( after GFR decrease about 50% of its normal value). Normal values: (Female 0.6-1.1 mg/dl) (Male 0.9-1.3 mg/dl) BUN/Creatinine ratio 10:1

Glomerular Filtration Rate (GFR)

Estimation of GFR is the Best single measure of assessment of renal function since its value is proportional to the number of intact nephrons. The GFR is the volume of fluid filtered from the glomeruli into Bowman's space per unit time. eGFR is more accurate than serum creatinine alone. Serum creatinine is affected by muscle mass, and related factors of age, sex, and race. Many methods are used to estimate the eGFR.

Determination of Clearance Rate

Clearance = (U x V) / P
U is the urinary concentration of creatinine (mg/dl) V is the 24-hours collected urine (L). P is the plasma concentration of creatinine (mg/dl)

Units = volume/unit time (mL/min)

Normal: Male: 97 to 137 ml/min. Female: 88 to 128 ml/min.