Renal Function Tests

M.PRASAD NAIDU
Msc Medical Biochemistry,
Ph.D Research scholar.


Kidney Functions:
1. Urine formation
2. Regulation of fluid and electrolyte balance
3. Regulation of acid-base balance
4. Excretion of waste products of nitrogen metabolism
5. Hormonal function
6. Protein conservation

Urine formation:
Normal glomerular filtration rate (GFR) is
approximately 125ml/min.

About 190 liters of glomerular filtrate is formed
daily(24Hours).
Most of it is reabsorbed(99%) except 1 to 1.5 liters
excreted as urine.




In PCT

60 to 80% of glomerular filtrate is reabsorbed.
Na
+
, Cl
-
, K
+
, HCO
3
-
, glucose, amino acids are
reabsorbed.

90% of H
+
is secreted.
Renal threshold for glucose 180mg/dl.
TMG - 350 mg/minute
Renal threshold for bicarbonate 30mequ/L.





Passive reabsorption of water, urea, chloride also
occurs.

Tubular secretion Potassium, H
+
ions , ammonia ,
uric acid, drugs.



Loop of Henle: Concentration of Urine

DCT
Aldosterone increases sodium reabsorption and excretion
of potassium.

Ammonia is secreted in the DCT & buffers H
+
ions &
secreted as ammonium ions.

ADH acts on DCT & increases reabsorption of water.








Excretion of Waste Products

The End products of protein and nucleic acid
metabolism like urea, creatinine , sulphate , uric acid,
phosphate are excreted by the kidney.

Retention of useful compounds

Glucose, aminoacids, sodium etc are reabsorbed


Protein Conservation:

Normal urine contains < 200mg of protein / 24 hour
urine.

Most of the filtered proteins are reabsorbed by PCT.

Note: Albumin excretion < 20mg/24hours urine.






Hormonal Functions:

Erythropoietin A peptide hormone
stimulates hemoglobin synthesis and formation of
erythrocytes.

Calcitriol - (1,25 DHCC)
Active form of vitamin D


Renin
A Proteolytic enzyme secreted by kidney
Which converts angiotensinogen to angiotensin II.

Which in turn increases the secretion of aldosterone


Tests for Glomerular Function:
Clearance Tests
Clearance may be defined as volume of plasma in ml
which contains the amount of substance which is
excreted in urine in 1minute.

UV U= Substance in urine mg/100ml
P P= Substance in plasma mg/100ml
V= Volume of urine ml/mt

% normal Caluculation

eg : Urea UV X 100 X 1.73
P 75 BS

Inulin clearance 125 ml/mt (110 135)

Urea clearance 75 ml/mt (60 90)

Creatinine clearance 120 ml/mt (110 130)



Inulin clearance : 125ml/mt

Inulin is a plant polysaccharide contain fructose.

Inulin has to be given I.V to perform the test.

Inulin clearance test is called gold standard.
Theoretically most ideal test because it is not secreted
into the renal tubule and it is not reabsorbed by the
renal tubules.

Inulin is excreted as such through urine.




But the test is cumbersome, needs I.V administration
of inulin.

Imp: This test is not used routinely.



Urea clearance : 75ml/mt
Urea is the end product of protein metabolism.
after being filtered by the glomeruli, it is partially
reabsorbed by the renal tubules.
Its clearance is < GFR.
It is also influenced by dietary protein content.
Blood urea levels tend to increase only when urea
clearance value falls below 50% normal
Not an Ideal test.




Creatinine Clearance Test: 120ml/mt
Most commonly done test
Creatinine is a waste product derived from creatine
( present in muscle).
Creatinine formation and excretion mainly depends
upon muscle mass.

Not influenced by dietary factors.
The value of creatinine clearance is very close to
GFR.




Procedure:

In the traditional test 24 hour urine is collected and
creatinine concentration estimated both in urine and
serum and clearance is calculated.

Modified Procedure:

Urine is collected for 1 hour after giving water.
Volume of urine is noted.
Serum creatinine and urine creatinine are estimated
and clearance is calculated.



The creatinine clearance is lower in women(less
muscle mass).

Normal serum creatinine levels 0.7 to 1.4mg/dl.
Serum creatinine levels increase beyond the normal
range only when more than 50% of Glomerular
Function is lost.


RENAL TUBULAR FUNCTION
TESTS
Normal urine specific gravity -1.015 to 1.025.
SPECIFIC GRAVITY is tested by URINOMETER.
Specific gravity increased in
diabetesmellitus,
excessive persipration.
Specific gravity decreased in
diabetes insipidus ,excessive water intake ,
chronic nephritis.

The simplest test for tubular function is the
measurement of the specific gravity of urine.
Specific gravity depends on concentration of
solutes .
Osmolality depends on number of osmotically
active molecules.




Osmolality:
The concentration of a solution expressed as the total
number of solute particle per kilogram.

Osmolarity:
the concentration of a solution expressed as the total
number of solute particles per liter.
In moderate forms of kidney damage , blood level of
urea and creatinine may be within normal limits.
The inability to excrete the waste products may be
counterbalanced by large urine output.
Thus ,the earliest manifestation of renal disease may
be DIFFICULTY IN CONCENTRATING THE URINE.
Concentration tests:
Principle : based on the ability of the kidneys to
concentrate urine, and based on measuring specific
gravity of urine.
Simple bedside procedure .
Easy to perform
Tests are conducted either under conditions of
restricted fluid intake
or
By inhibiting diuresis by injection of ADH.

Procedure for concentration tests:
Patient is not allowed to take food or water after a
meal at 6pm.
Next day at 7am bladder is emptied and specimen is
discarded.
A second specimen is collected at 8 am and specific
gravity is measured.
Adequate renal function: specific gravity 1.022 and
osmolality exceeds850 mosm/kg.
In renal tubular disease urine shows a fixed
specific gravity around 1.010 (300mosm/kg) as the
tubules loose their concentrating capacity.
ADH test ( concentration test):
Effectiveness of ADH decreases with IMPAIRED
tubular function.
Procedure:
5 units of ADH injected.
Hourly samples of urine collected for next 24
hrs and tested for specific gravity.
At least one sample should have a specific
gravity MORE THAN 1.020 and osmolality
800mosm/kg.
Measurement of osmolality:
Normally urine osmolality varies from 80 mosm/kg
to 1200 mosm/kg .
Normal plasma osmolality is 285 300 mosm/kg.
Simultaneous measurements of plasma and urine
osmolality and calculation of ratio of urine /plasma is
more useful.
Normally the ratio varies from 3 4.5 .
Osmolality is measured with an osmometer.
Urine Dilution tests:
Principle: the ability of the kidneys to eliminate
water is tested by measuring the urinary output
after ingestion of a large volume of water.
Procedure:
Patient is not allowed to take water after midnight.
Bladder is emptied at 7 am.
Water load is given -1200ml over next 30 minutes.
Urine samples are collected hourly over next four
hrs.

Volume , specific gravity and osmolality of each
sample measured .
A noraml person will EXCRETE ALMOST ALL THE
WATER LOAD WITHIN FOURS HOURS and
specific gravity of at least ONE SAMPLE SHOULD
FALL to 1.003 and osmolality to 50 mosm/kg .
The test is MORE SENSITIVE .
Urine volume,appearance ,odour , colour
Urine specific gravity
Urine pH
Urine osmolality
Blood urea
Serum creatinine
Clearance tests creatinine clearancesss
Abnormal constituents : proteins, blood , reducing
sugars , ketone bodies , bilesalts and
bile pigments.

Test for Tubular Function: PSP test (Phenol sulfo
phthalein)

Give 600ml of water.
Inject 6mg of dye I.V.
Urine 15 mt 35% excreted
In 2 hours 70% of dye eliminated through urine.
This test indicates secretary function of tubules.
Less than 50% of dye elimination in 2 hours.
Indicated tubular defect.


Tubular function test:

PAH clearance 700ml/mt

Glomerular filtration rate(GFR)
The rate in milliliters per minute at which plasma
substances are filtered through the glomeruli into thel
proximal tubule.

Renal threshold
The plasma concentration of a substance above which
it will be present in urine.

Specify gravity
The ratio of the weight in grams per milliliter of a body
fluid compared with water.



Titratable acid:
The combination of hydrogen ion with phosphate present in
final urine.

Urine:
The aqueous liquid and dissolved substances excreted by the
kidney.