NP5 Nephrology

Assessment of Renal Function

Essential Med Notes 2015

3. Estimate GFR using MDRD formula

most common way in which GFR is estimated (MDRD 7 equation)
complex formula incorporating age, gender, serum Cr, and African descent, but does not
include weight
GFR is reported as mL/min/1.73 m2 body surface area
4. Estimate GFR using CKD-EPI equation
the best current equation
calculated using serum Cr, age, sex, and race
Limitations of Using Serum Cr Measurements
1. must be in steady state
constant GFR and rate of production of Cr from muscles
sudden injury may reduce GFR substantially, but it takes time for Cr to accumulate and then
re-establish steady state
clinical correlation: in AKI, the rise in Cr is often delayed
2. GFR must fall substantially before plasma [Cr] rises above normal laboratory range
with progressive renal failure, remaining nephrons compensate with hyperfiltration
GFR is relatively preserved despite significant structural damage
3. plasma [Cr] is influenced by the rate of Cr production
lower production with smaller muscle mass (e.g. female, elderly, low weight)
for example, consider plasma [Cr] of 100 mol/L (1.13 mg/dL) in both of these patients
20 yr old man who weighs 100 kg, GFR = 144 mL/min
80 yr old woman who weighs 50 kg, GFR = 30.6 mL/min
clinical correlation: GFR decreases with age but would not be reflected as a rise in serum Cr
due to the age-associated decline in muscle mass
4. tubular secretion of Cr increases as GFR decreases
serum Cr and CrCl overestimate low GFR
certain drugs (cimetidine, trimethoprim) interfere with Cr secretion
5. errors in Cr measurement
very high bilirubin level causes [Cr] to be falsely low
acetoacetate (a ketone body) and certain drugs (cefoxitin) create falsely high [Cr]
Measurement of Urea Concentration
urea is the major end-product of protein metabolism
plasma urea concentration reflects renal function but should not be used alone as it is modified
by a variety of other factors
urea production reflects dietary intake of protein and catabolic rate; increased protein intake or
catabolism (sepsis, trauma, GI bleed) causes urea level to rise
ECF volume depletion causes a rise in urea independent of GFR or plasma [Cr]
in addition to filtration, a significant amount of urea is reabsorbed along the tubule
reabsorption is increased in hypernatremic states such as ECF volume depletion
typical ratio of urea to [Cr] in serum is 1:12 in SI units (using mEq/L for urea and mol/L for Cr)

Cystatin C
Cystatin C is a protease which is
completely filtered by the glomerulus
and is not affected by muscle mass; it
is not currently used in clinical practice,
but may be a more accurate way to
measure renal function in the future,
particularly in DM

Clinical Settings in which Urea Level

is Affected Independent of Renal
Function
Disproportionate Increase in Urea
Volume depletion (prerenal azotemia)
GI hemorrhage
High protein diet
Sepsis
Catabolic state with tissue breakdown
Corticosteroid or cytotoxic agents
Disproportionate Decrease in Urea
Low protein diet
Liver disease

Urinalysis
use dipstick in freshly voided urine specimen to assess the following:
1. Specific Gravity
ratio of the mass of equal volumes of urine/H2O
range is 1.001 to 1.030
values <1.010 reflect dilute urine, values >1.020 reflect concentrated urine
value usually 1.010 in ESRD (isosthenuria)
2. pH
urine pH is normally between 4.5-7.0; if persistently alkaline, consider:
RTA
UTI with urease-producing bacteria (e.g. Proteus)
3. Glucose
freely filtered at glomerulus and reabsorbed in proximal tubule
causes of glucosuria include
1. hyperglycemia >160-200 mg/dL (>9-11 mEq/L) leads to filtration that exceeds tubular
resorption capacity
2. increased GFR (e.g. pregnancy)
3. proximal tubule dysfunction (e.g. Fanconis syndrome)
4. Protein
dipstick only detects albumin; other proteins (e.g. Bence-Jones, Ig, Tamm-Horsfall) may be missed
microalbuminuria (defined as 2.0 mg/mEq Cr in males and 2.8 mg/mEq Cr in females) is not
detected by standard dipstick (see Diabetes, NP28)
sulfosalicylic acid detects all protein in urine by precipitation
gold standard: 24 h timed urine collection for total protein

24 h Urine Collection
Discard first morning specimen
Collect all subsequent urine for the
next 24 h
Refrigerate between voids
Collect second morning specimen
Clarity: Cloudiness may indicate
infection
Color: usually pale yellow or amber, but
may be colorless (diabetes insipidus,
excess water intake), bright yellow
(due to riboflavin ingestion or vitamin
tablets), or dark yellow (concentrated
urine in intravascular volume depletion)

Estimating Urine Osmolality

Last 2 digits of the specific gravity x 30
= urine osmolality approximately
(e.g. specific gravity of 1.020
= 600 mOsm)