RENAL LABORATORY TESTS

PETER S. AZNAR, MD, FPSP, MHPE

Basic Functional Unit of the Kidney:

Nephron
 Proximal Tubules- majority of solutes are reabsorbed.

Descending Loop of Henle- permeable to water, so

water goes out.

Ascending Loop of Henle- Impermeable to water, so

water stays.

Distal Tubule Aldosterone retains sodium (Na).

Collecting Tubule water is conserved by ADH.

Polyuria

Diabetes Insipidus

Diabetes Mellitus
 Diabetes Insipidus

associated with deficiency of antidiuretic hormone (ADH)

will result to severe polyuria

associated with increase serum osmolality and decrease

urine osmolality

urine will have low specific gravity

H2O

ADH

URINE
H2O

ADH

URINE
 Diabetes Mellitus
associated with defect in carbohydrate
metabolism

will also result to polyuria

associated with increase urine osmolality and

decrease serum osmolality

urine will have a high specific gravity

H2O

RTG
180

URINE
 H2O

SERUM GLUCOSE
RTG

300 180

120
 KIDNEY FUNCTION TESTS
A1. Tests measuring Glomerular Filtration
Rate (GFR)

A2. Tests measuring Renal Blood Flow

A3. Tests measuring Tubular Function

 A1. Tests measuring Glomerular
Filtration Rate (GFR)
I. Creatinine Clearance Tests

II. Inulin Clearance Tests

III. Urea Clearance Tests

A2. Tests measuring Renal Blood Flow

I. Creatinine
II. Urea
III. Blood Uric Acid (BUA)
IV. Ammonia
V. Amino Acids
VI. Creatine
 A3. Tests measuring Tubular Function
I. Excretory Tests
Ia. Para-Amino Hippurate Test (PAH)
Ib. Phenolsulfonphthalein (PSP) Dye
Excretion Test
II. Concentration Tests
IIa. Specific gravity
IIb. Osmolality
IIc. Fishberg Concentration Test
A1.TESTS MEASURING GLOMERULAR
FILTRATION RATE

Tests which measure the rate of glomerular

filtration are generally called clearances.
 General Formula for Clearance
C (ml/min) = U x Volume (ml/min) x 1.73
P A
Where:
C- clearance of the substance expressed in ml/min.
U- concentration of substance in urine
P- concentration of substance in plasma (blood)
Volume (ml/min)- total volume of urine excreted in 24 hours
converted to ml/min.
1.73- generally accepted body surface area of an individual in squa
meters
A- body surface area of patient whose value is obtained from a
nomogram (height and weight are needed)
Given:
Urine creatinine = 120 mg/dL
Serum creatinine = 1.5 mg/dL
Total urine volume in 24 hours = 1800 mL

C (ml/min) = U x Volume (ml/min) x 1.73

P A
C (ml/min) = 120 x 1800 (ml/min) x 1.73
1.5 A
C (ml/min) = 120 x 1.25 (ml/min) x 1.73
1.5 A
C (ml/min) = 80 x 1.25 (ml/min) x 1.73
A
C (ml/min) = 100 (ml/min) x 1.73
A
 I. Creatinine Clearance Tests

In product of muscle metabolism

derived from creatine
Most commonly used substance for
clinical assessment of GFR
Normal values: 107-139 ml/min (men)
87-107 ml/min (women)
 II. Inulin Clearance Tests

Normally not present in the plasma,

therefore it is neither secreted or
reabsorbed by the renal tubules.
Most accurate measure of GFR
Not particularly pleasant to the patient,
thus it is not regularly used.
 III. Urea Clearance Tests

Not commonly employed because of

variable results
1.33 constant for maximum urea clearance
1.85 constant for standard urea clearance
 A2. TESTS MEASURING RENAL BLOOD
FLOW

NON-Protein Nitrogens (NPN)

GENERAL INFORMATION

All NPNs (urea, creatinine, uric acid and

ammonia) are increased in the plasma in renal
impairment; referred to as azotemia

In cases of suspected renal impairment, the best

laboratory evaluation is for glomerular filtration
rate (GFR).
 I. CREATININE

Can also be measured to evaluate renal

function; NOT as sensitive as GFR

Reference ranges
a) Men = 0.9-1.5 mg/dL
b) Women = 0.7-1.3 mg/dL
 I. CREATININE

Creatinine phosphate + ADP + H+

Creatine + ATP nonezymatic creatinine

 II. BLOOD UREA NITROGEN (BUN)

End product of protein metabolism

Increased in impaired renal function

Rises more rapidly than serum creatinine

BUN/Creatinine ratio is normally about 10:1-20:1

 III. URIC ACID

End product of purine metabolism

Increased in gout, renal failure and

leukemia
 IV. AMMONIA

Derived from the action of bacteria on the

contents of the colon

Metabolized by the liver normally

Increased plasma ammonia is toxic to the

CNS
 IV. AMMONIA
Hyperammonia (increased ammonia)
a) Advanced liver disease (most
common cause)
aa. Reyes syndrome
ab. Cirrhosis
ac. Viral hepatitis
b) Impaired renal function
Blood urea is increased (increased
excretion into intestine, where it is
converted to ammonia)
A3. TEST MEASURING TUBULAR FUNCTION

I. Excretory Tests

Ia. Para-Amino Hippurate Test (PAH)

Ib. Phenolsulfonphthalein (PSP) Dye

Excretion Test
A3. TEST MEASURING TUBULAR FUNCTION

II. Concentration Tests

IIa. Specific gravity

IIb. Osmolality

IIc. Fishberg Concentration Test

 DIABETES WORK UP

PETER S. AZNAR, MD, FPSP, MHPE

Cardinal signs of Diabetes Mellitus:

Polyuria

Polydipsia

Polyphagia

Pruritus
 Types of Diabetes Mellitus

Type I (Insulin dependent diabetes mellitus)

Type II (Non-insulin dependent diabetes mellitus)

Diabetes Mellitus Type I
Also known as Insulin Dependent Diabetes
Mellitus (IDDM) or juvenile onset
diabetes mellitus

Main defect is decrease or absence of insulin

Associated with ketoacidosis

Treatment: insulin
 Diabetes Mellitus Type II

Also known as Non-Insulin Dependent

Diabetes Mellitus (NIDDM) or adult
onset diabetes mellitus

Main defect is absence or decrease receptors

Ketoacidosis not present

Treatment: Sulfonylureas
 Diagnostic Criteria for DM:

Random plasma glucose > 200 mg/dL

Fasting plasma glucose > 126 mg/dL

2-hours plasma glucose > 200 mg/dL

 Impaired Glucose Tolerance*

FBS more than 100mg/dL but less than

126mg/dL

OGTT 2 hour value more than 140mg/dL but less

than 200mg/dL

*Latent or chemical diabetes

Glucose Metabolism Tests

2- hour Postprandial Test

Oral Glucose Tolerance Test (OGTT)

 2 hour Postprandial Test:

Patient is made to fast for 8 hours and sample is

collected

Patient is given 75 grams of oral glucose

Patients blood glucose is taken after 2 hours

 Results

Normal patients- glucose level is less than 140 mg/dL

Diabetic patients- glucose level is more than 200 mg/dL

 Oral Glucose Tolerance Test

75 grams of glucose is given

blood samples and urine specimens are taken at

30, 60, 120 and 180 minutes
 Normal Neg Neg Neg Neg

Abnormal Pos Pos Pos/ Pos/

Neg Neg

Min 30 60 120 180

200 Abnormal

180
160
140
Normal
120
100

Min 30 60 120 180

Monitoring of Glucose Levels:

Daily: FBS, RBS

Weekly: Fructosamine (every 2 weeks)

Monthly: Hemoglobin A1C (every 3 months)

Proinsulin Insulin

C-peptide
 Increased in:
Insulinoma
Type II diabetes mellitus

Decreased in:
Exogenous insulin administration (eg., factitious
hypoglycermia)
Type I diabetes mellitus
 Insulin/ C-Peptide Ratio

Use
To differentiate insulinoma from fractitious
hypoglycermia due to insulin

Interpretation
<1.0 in molarity units ( or>47.17 g/ng in con. units)
Increased endogenous insulin secretion (e.g., insulinoma,
sulfonylurea administration)
Renal failure
>1.0 in molarity units (or<47.17 ug/ ng in con. units)
Exogenous insulin administration
Cirrhosis
 Diabetes Mellitus, Gestational

Hyperglycemia that develops for the first time during pregnancy:

after ~4% of pregnant women; most have return to normal
glucose tolerance after delivery. 60% become diabetic in next
16 yrs.

Infants of Diabetic Mothers

Blood glucose less than 30mg/dL in 50% of diabetic
mothers.
Associated with hypocalcemia, occurring 24-36 hrs. after
birth.
Asymptomatic at birth but should be monitored every 6hrs.
 Diabetes Mellitus, Neonatal

Blood glucose is often between 245 and 2300

mg/dL

Metabolic acidosis of some degree is usually

present

Ketonuria is variable

Laboratory findings due to dehydration

 Diabetes Mellitus, Neonatal

Laboratory findings due to infection or CNS lesions,

which are present in one third of patients

Has been detected as early as fourth day. Usually is

transient

Increased association with postmaturity, low birth

weight, neonatal hypoglycemia, steroid therapy early
in neonatal period.
 Tumors of Pancreas
(Hormone-Secreting), Primary

Cell Type Hormone Secreted Tumor

B cell Insulin Insulinoma
D cell Gastrin Gastrinoma
A cell Glucagon Glucagonoma
H cell VIP Vipoma
D cell Somatostatin Somatostatinoma
HPP cell Human Pancreatic HPP- Secreting Tumor
Poly- Peptide (very rare tumor)
Thank You!