Renal Function Test

Dr C. L. Teng tengcl@gmail.com Family Medicine IMU Clinical School

23rd Nov 2010, IMU Bukit Jalil

Learning outcomes
Describe common tests on urine and compare between urine dipstix and microscopy for diagnosis of renal diseases. Compare blood urea and creatinine levels in the assessment of renal impairment. Identify different ways of imaging renal tracts and their common abnormalities. Describe how renal biopsy is done.

Urine test
Urinalysis
Quantity Colour Specific gravity* pH* Protein* Others (ketone, glucose, bilirubin)*

Microscopy
RBC** WBC** Cast Crystal Bacteria**

* Can be measured by dipstix (e.g. Combur-10) ** Can be tested using dipstix (indirectly)

Urine volume and colour

Urine volume: 700 2500 ml/day (Glomerular filtrate = 180 L/day)
Oliguria: <400 ml/day Anuria: <100 ml/day

Smoky urine - small amount of blood (e.g. AGN)

Patient 1: A 50 year-old man with severe left loin pain and haematuria

Patient 2: A 10 year-old girl with facial puffiness, hypertension and cloudy urine

Patient 3: A 45 year-old man who ate jering

A healthy 45-year-old Sarawakian man presented with colicky left loin pain, dysuria, frank haematuria and foul smelling urine a day after ingesting jering. He developed oliguria and was anuric by the 3rd day. Serum creatinine 176 mol/L, urea 18 mmol/L, potassium 4.4 mmol/L and bicarbonate 21.1 mmol/L.

Abnormal urine colour may not be due to renal disease

Urine dipstix
Reagent strips allowing 1 or more tests. Semi-quantitative. Quick screening test. Less accurate when compared with microscopy.

blood

Renal concentrating ability

Normal SG: 1.002 1.025 Proportional to urinary concentration of urea and sodium Renal concentrating ability is normal if SG > 1.018 In CRF, SG fixed at 1.010 (= glomerular filtrate)

Renal acidifying ability

Normal pH < 7.0 Renal acidifying ability is normal if urine pH < 5.5 Acidosis occurs only in advanced CRF. In renal tubular acidosis, urine pH exceed 5.4 after given ammonium chloride (i.e. failure to acidify the urine following an oral acid loading challenge).

Two children with facial puffiness

Nephrotic syndrome Nephritic syndrome

Acute post-streptococcal glomerulonephritis

4 year-old BP 80/40 mmHg (normal) Urinalysis Protein: 3+ Blood: negative WBC: negative RBC: negative 10 year-old BP 150/100 mmHg (high) Urinalysis Protein: 2+ Blood: positive WBC: 1+ RBC: 2+

Proteinuria
Normal
24 H urine protein <300 mg/day

Proteinuria
>300 mg/day

Massive proteinuria
>3.5 g/day (nephrotic)

Urine protein dipstix: negative to trace

1+

3+

Normal Microalbuminuria Albuminuria

24 H urine albumin <30 30-300 >300 mg/day

Urine protein dipstix: negative negative/trave 1+ ACR (mg/mmol) M: <2.5 F: <3.5 M: 2.5-30 F: 3.5-30

ACR=Albumin:Creatinine ratio

Urine microscopy

Urine microscopy - blood

Overtaken by automated test with dipstix Centrifuged urine has
< 1 rbc/hpf < 5 wbc/hpf
A 56-y.o. woman with oedema, decreased urine volume, fever, general malaise and abdominal pain

Dipstix cant differentiate between haematuria and haemoglobinuria

www.udel.edu/medtech/mclane/csmain.html

Colour: Amber Protein: 1+ Blood: 2+ WBC: 1+ RBC: 2+

WBC: 5-10/hpf RBC: 10-20/hpf Celluar casts: 0-2/lpf

Dysmorphic RBC = glomerular bleeding (GN)

High power light microscopy

A Normal rbc B-F Dysmorphic rbc (Scanning electron microscopy)

Acanthocytes
specific for glomerular bleeding

Phase contrast microscopy x1450 x3250

http://content.nejm.org/cgi/ijlink?linkType=FULL&journalCode=nejm&resid=334/22/1440

Urine microscopy WBC, bacteria

Pyuria infection or injury of renal tract. Bacteria can be detected by gram stain. Most UTIs are caused by gram ve bacteria (E. coli) Dipstix detects WBC by leucocyte esterase reaction. Positive nitrite in dipstix suggests significant bacteriuria (>105 organisms/mL) Gram ve bacteria reduced nitrate to nitrite.

Microscopy casts

Hyaline cast

Granular cast

Waxy cast

Red cell cast

White cell cast

Broad cast

Microscopy casts
Hyaline cast normal Red cell cast GN White cell cast GN, pyelonephritis Epithelial cast acute tubular necrosis Broad cast chronic renal failure Granular cast, waxy cast renal disease

Microscopy crystals
normal crystals

Ammonium magnesium Phosphate crystals

Calcium oxalate crystals

abnormal crystals

Cystine crystals

Urate crystals

Can I trust the test result?

Urine collection: early morning midstream clean catch urine. False positive: blood in urine may be due to contamination (menstruation in female). False negative: nitrite negative may be due to dilute urine.

Positive test = Disease present?

Disease present Test positive TRUE POSITIVE FALSE NEGATIVE Disease absent FALSE POSITIVE TRUE NEGATIVE

Test negative

Estimation of GFR
Normal GFR is 70-170 ml/min (varies with sex, weight and surface area). Blood urea and creatinine levels are good substitutes in clinical practice

Blood urea
Normal range is 2.5 6.6 mmol/L. Its level varies with protein intake. Raised by dehydration, fever and GI haemorrhage. 50% of filtered urea is reabsorbed. Very high level correlates well with uraemia.

Serum creatinine
Normal range is 62 124 Qmol/L (0.7-1.4 mg/dL) Level less affected by extrarenal factors. Serum creatinine correlates better with GFR than blood urea. Creatinine clearance declines by 1 ml/min/y over the age of 40 (aging process).

Reciprocal relationship between creatinine clearance and plasma creatinine concentration

GFR calculator
http://www.kidney.org/professionals/KDOQI/gfr_calculator.cfm

Classification of CKD
Stage GFR Description Normal Renal Function (but urinalysis, structural abnormalities or genetic factors indicate renal disease) Mildly reduced renal function (Stage 2 CKD should not be diagnosed on GFR alone - but urinalysis, structural abnormalities or genetic factors indicate renal disease) Moderate decrease in renal function, with or without other evidence of kidney damage Moderate decrease in renal function, with or without other evidence of kidney damage Severely reduced renal function Very severe (end stage) renal failure Management Observation and control of blood pressure Observation, control of blood pressure and cardiovascular risk factors Observation, control of blood pressure and cardiovascular risk factors Observation, control of blood pressure and cardiovascular risk factors Planning for end stage renal failure Transplant or Dialysis I 90+

II

60-89

IIIa

45-59

IIIb

30-44

IV V

15-29 <15

Renal profile in a 62 year-old man with type 2 diabetes 2009 2010 Sodium 145 146 (135-145) Potassium 3.8 4.3 (3.5-5.1) Chloride 107 102 (95-110) Urea 5.6 9.0 (3.0-9.0) Creatinine 91 146 (60-130) eGFR 78 42 mL/min/1.73m2

A small rise in creatinine

Leads to a big drop in GFR

Test your knowledge

An 80 y.o. nursing home resident is admitted with respiratory tract infection. Her blood test results are:
Sodium 157 (135147 mmol/L) Urea 30 (2.5 6.6 mmol/L) Creatinine 150 (62 124 Qmol/L)

Diagnosis: Dehydration

Imaging
KUB (Kidney Urinary Bladder) IVP (Intravenous pyelography) Ultrasound CT scan (Computed tomography)

Plain X-ray (KUB)

Kidneys overly the 12th ribs (renal angle) Difficult to visualise because of bowel gas. Can detect radioopaque stone

IVP

Multiple X-rays with contrast injection. Delineate structure and obstruction clearly. Note calyceal system and path of ureters.

(1) Right kidney (2) Left kidney (3) Minor calyx (4) Major calyx (5) Renal pelvis (6) Ureter

What is wrong with this KUB

Normal KUB

What is wrong with the right IVP

Answer
KUB Bilateral staghorn calculus (deer horns). Conform to the shapes of calyceal system. IVP
Rt hydronephrosis Rt ureter partially obstructed at level of L5 Dilated balloon of Foley catheter in bladder Missing left kidney nephrectomy, nonfunctioning

Ultrasound
No radiation. Delineate structure clearly. Detect mass lesions, cysts and hydronephrosis. Measurement of kidney size.

CT scan
Cross-sectional view of various slices of body. Delineate structure well. Require good knowledge of crosssectional anatomy

A. external oblique B. right costal carightilage C. rectus abdominus D. transverse colon E. transverse colon F. ascending colon G. pancreas - head H. duodenum - 2nd part I. renal vein J. diaphragm K. psoas major L. renal pyramid
http://iris3.med.tufts.edu/medgross/abl1.htm

Figure 1

Transpyloric plane cuts through the pylorus, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra.

The transpyloric plane is clinically notable because it passes through several important abdominal structures. These include: the fundus of the gallbladder the neck of the pancreas the origins of the superior mesenteric artery and portal vein the hila of the kidneys the root of the transverse mesocolon the duodenojejunal junction the 2nd part of the duodenum the termination of the spinal cord the spleen

Polycystic kidneys
Ultrasound

CT scan

Renal biopsy
Percutaneous needle biopsy from the lower pole. Establish diagnosis adult nephrotic Determine prognosis renal involvement in SLE Interpretation of renal pathology

http://www.niddk.nih.gov/health/kidney/pubs/kidney-biopsy/biopsy.htm

Renal biopsy specimen (a) Renal cortex, note the glomeruli, recognized as round red areas (wet preparation x10). (b) Renal medulla, reddish vasculature is present but no glomeruli seen (wet preparation x10)