METHODS AND INTERPRETATION

This is a series of tests to see if the kidneys

are working properly or not.
It is a collective term for a variety of
individual tests& procedures that can be to
evaluate how well the kidneys are
functioning.
KFT help to determine if the kidneys are
performing their tasks adequately.
Urine and/or blood are taken as samples.

Three types of kidney function tests can be
distinguished:

COMPLETE URINE EXAMINATION
GLOMERULAR FUNCTION TESTS
TUBULAR FUNCTION TESTS
Urinalysis
Appearance
Specific gravity and osmolality
pH
Glucose
Protein
Urinary sediments
Urinalysis is important in screening for disease is routine test for every
patient, and not just for the investigation of renal diseases
Urinalysis comprises a range of analyses that are usually performed at the
point of care rather than in a central laboratory.
Urinalysis is one of the commonest biochemical tests performed outside
the laboratory.
Examination of a
patient's urine should
not be restricted to
biochemical tests.
Urinalysis
Biochemical testing of urine involves the use of commercially available
disposable strips When the strip is manually immersed in the urine specimen,
the reagents react with a specific component of urine in such a way that to form
color
Colour change produced is proportional to the concentration of the component
being tested for.
To test a urine sample:
fresh urine is collected into a clean dry container
the sample is not centrifuged
the disposable strip is briefly immersed in the urine specimen;
The colour of the test areas are compared with those provided on a colour
chart
Urinalysis using disposable strips
Fresh sample = Valid sample.
fresh urine is collected into a clean dry container
the sample is not centrifuged
Appearance: -
Blood
Colour (haemoglobin, myoglobin,)
Turbidity (infection, nephrotic syndrome)
Urinalysis
Blue Green Pink-Orange-
Red
Red-brown-black
Methylene Blue Haemoglobin Haemoglobin
Pseudomonas Myoglobin Myoglobin
Riboflavin Phenolpthalein Red blood cells
Porphyrins Homogentisic Acid
Rifampicin L -DOPA
Melanin
Methyldopa
This is a semi-quantitative measure of concentration.
NORMAL SPECIFIC GRAVITY :1.015-1.025
A higher specific gravity indicates a more concentrated urine.
Assessment of urinary specific gravity usually just confirms the impression
gained by visually inspecting the colour of the urine. When urine
concentration needs to be quantitated,
Urinalysis: Specific gravity
Osmolality serves as general marker of tubular function. Because the ability
to concentrate the urine is highly affected by renal diseases.
This is conveniently done by determining the osmolality, and then
comparing this to the plasma.
If the urine osmolality is 600mosm/kg or more, tubular function is usually
regarded as intact
When the urine osmolality does not differ greatly from plasma (urine:
plasma osmolality ratio=1), the renal tubules are not reabsorbing water

pH
- Urine is usually acidic
- Measurement of urine pH is useful in suspected drug toxicity, abuse.., or
where there is an unexplained metabolic acidosis (low serum bicarbonate or
other causes).
Urine sediments
- Microscopic examination of sediment from freshly passed urine involves
looking for cells, casts, fat droplets
- Blood: haematuria is consistent with various possibilities ranging from
malignancy through urinary tract infection to contamination from menstruation.
- Red Cell casts could indicate glomerular disease
- Crystals
- Leucocytes in the urine suggests acute inflammation and the presence of a
urinary tract infection.
Urinalysis
-are cylindrical structures produced by the kidney and
present in the urine in certain disease states.
- They form in the distal convoluted tubule and collecting
ducts of nephrons, then dislodge and pass into the urine,
where they can be detected by microscope.
- They form via precipitation of Tamm-Horsefall mucoprotein
which is secreted by renal tubule cells, and sometimes also
by albumin.
Urinary casts
Red blood cell cast in
urine
White blood cell cast in
urine
Urinary casts. (A) Hyaline cast
(200 X); (B) erythrocyte cast
(100 X); (C) leukocyte cast
(100 X); (D) granular cast (100
X)
Urinary crystals. (A) Calcium oxalate crystals; (B) uric acid
crystals (C) triple phosphate crystals with amorphous
phosphates ; (D) cystine crystals.
Crystals
- Water homeostasis is determined by several interrelated processes:
1. Water intake and water formed through oxidation of food stuffs.
2. Extra-renal water loss: insensible water loss the via faeces, and
sweating.
3. A solute load to be excreted that is derived from ingested minerals and
nitrogenous substances.
4. The ability of the kidneys to produce concentrated or dilute urine.
5. Other factors such as vomiting and diarrhoea become important in
various disease states;
loss of ability to produce concentrated urine is a feature of virtually
all types of chronic renal diseases.

Urine volume
To maintain water homeostasis, the kidneys must produce urine in a
volume precisely balances water intake and production to equal water
loss through extra renal routes.
Minimum urine volume is determined by the solute load to be excreted
whereas maximum urine volume is determined by the amount of excess water
that must be excreted
Urine volume
Measurement of GFR
Clearance tests
Plasma creatinine
Urea, uric acid and 2-microglobulin
GFR can be estimated by measuring the urinary excretion of a substance that is
completely filtered from the blood by the glomeruli and it is not secreted,
reabsorbed or metabolized by the renal tubules.
Clearance is defined as the (hypothetical) quantity of blood or plasma
completely cleared of a substance per unit of time.

Clearance of substances that are filtered exclusively or predominantly by
the glomeruli but neither reabsorbed nor secreted by other regions of the
nephron can be used to measure GFR.

GFR =
(U V)
P

inulin
inulin
V is not urine volume, it is urine
flow rate
Measurement of glomerular filtration rate
Inulin clearance
it is a small ,inert polysachharide molecule that
readily passes through the glomeruli into the urine
The Volume of blood from which inulin is cleared or
completely removed in one minute is known as the
inulin clearance and is equal to the GFR.
Measurement of inulin clearance requires the
infusion of inulin into the blood and is not suitable for
routine clinical use
1 to 2% of muscle creatine spontaneously converts to creatinine
daily and released into body fluids at a constant rate.
Endogenous creatinine produced is proportional to muscle mass, it
is a function of total muscle mass the production varies with age
and sex
Dietary fluctuations of creatinine intake cause only minor variation
in daily creatinine excretion of the same person.
Creatinine released into body fluids at a constant rate and its
plasma levels maintained within narrow limits Creatinine
clearance may be measured as an indicator of GFR.

Creatinine
The most frequently used clearance test is based on the
measurement of creatinine.
Small quantity of creatinine is reabsorbed by the
tubules and other quantities are actively secreted by the
renal tubules So creatinine clearance is
approximately 7% greater than inulin clearance.
The difference is not significant when GFR is normal but
when the GFR is low (less 10 ml/min), tubular secretion
makes the major contribution to creatinine excretion and
the creatinine clearance significantly overestimates the
GFR.
Creatinine clearance and clinical utility
An estimate of the GFR can be calculated from the creatinine content of a
24-hour urine collection, and the plasma concentration within this period.
The volume of urine is measured, urine flow rate is calculated (ml/min)
and the assay for creatinine is performed on plasma and urine to obtain the
concentration in mg per dl or per ml.
Creatinine clearance in adults is normally about of 120 ml/min,
The accurate measurement of creatinine clearance is difficult, especially in
outpatients, since it is necessary to obtain a complete and accurately timed
sample of urine
Creatinine clearance clinical utility
The 'clearance' of creatinine from plasma is directly
related to the GFR if:
The urine volume is collected accurately
There are no ketones or heavy proteinuria present
to interfere with the creatinine determination.
It should be noted that the GFR decline with age (to a
greater extent in males than in females) and this must be
taken into account when interpreting results.
Creatinine clearance and clinical utility
Use of Formulae to Predict
Clearance
Formulae have been derived to predict
Creatinine Clearance (CC) from Plasma
creatinine.
Plasma creatinine derived from muscle mass
which is related to body mass, age, sex.
Cockcroft & Gault Formula
CC = k[(140-Age) x weight(Kg))] / serum Creatinine
(mol/L)
k = 1.224 for males & 1.04 for females
Modifications required for children & obese subjects
Can be modified to use Surface area
Catabolism of proteins and nucleic acids results in
formation of so called nonprotein nitrogenous
compounds.
Protein
Proteolysis, principally enzymatic
Amino acids
Transamination and oxidative deamination
Ammonia
Enzymatic synthesis in the urea cycle
Urea
Measurement of nonprotein nitrogen-
containing compounds
Urea is the major nitrogen-containing metabolic product of protein
catabolism in humans,
Its elimination in the urine represents the major route for
nitrogen excretion.
More than 90% of urea is excreted through the kidneys, with
losses through the GIT and skin
Urea is filtered freely by the glomeruli
Plasma urea concentration is often used as an index of renal
glomerular function
Urea production is increased by a high protein intake and it is
decreased in patients with a low protein intake or in patients
with liver disease.
Plasma Urea
Many renal diseases with various glomerular, tubular, interstitial or vascular
damage can cause an increase in plasma urea concentration.
The reference interval for serum urea of healthy adults is 5-39 mg/dl. Plasma
concentrations also tend to be slightly higher in males than females. High protein
diet causes significant increases in plasma urea concentrations and urinary excretion.
Measurement of plasma creatinine provides a more accurate assessment than
urea because there are many factors that affect urea level.
Nonrenal factors can affect the urea level (normal adults is level 5-39 mg/dl)
like:
Mild dehydration,
high protein diet,
increased protein catabolism, muscle wasting as in starvation,
reabsorption of blood proteins after a GIT haemorrhage,
treatment with cortisol or its synthetic analogous

Plasma Urea
States associated with elevated levels of urea in blood
are referred to as uremia or azotemia.
Causes of urea plasma elevations:
Prerenal: renal hypoperfusion
Renal: acute tubular necrosis
Postrenal: obstruction of urinary flow
In human, uric acid is the major product of the catabolism of the
purine nucleosides, adenosine and guanosine.
Purines are derived from catabolism of dietary nucleic acid
(nucleated cells, like meat) and from degradation of endogenous
nucleic acids.
Overproduction of uric acid may result from increased synthesis of
purine precursors.
In humans, approximately 75% of uric acid excreted is lost in the
urine; most of the reminder is secreted into the GIT
Uric acid

Renal handling of uric acid is complex and involves four sequential steps:
Glomerular filtration of virtually all the uric acid in capillary plasma
entering the glomerulus.
Reabsorption in the proximal convoluted tubule of about 98 to 100%
of filtered uric acid.
Subsequent secretion of uric acid into the lumen of the distal portion
of the proximal tubule.
Further reabsorption in the distal tubule.
Hyperuricemia is defined by serum or plasma uric acid concentrations higher
than 7.0 mg/dl (0.42mmol/L) in men or greater than 6.0 mg/dl (0.36mmol/L)
in women

Uric acid
2-microglobulin is a small peptide (molecular weight 11.8 kDa),
It is present on the surface of most cells and in low concentrations
in the plasma.
It is completely filtered by the glomeruli and is reabsorbed and
catabolized by proximal tubular cells.
The plasma concentration of 2-microglobulin is a good index of
GFR in normal people, being unaffected by diet or muscle mass.
It is increased in certain malignancies and inflammatory diseases.
Since it is normally reabsorbed and catabolized in the tubules,
measurement of 2-microglobulin excretion provides a sensitive
method of assessing tubular integrity.
Plasma 2-microglobulin
1. urine concentration test:
Done to check the ability of kidneys to
concentrate urine.
minor inconvieneance to patient
requires water deprivation for 14 hrs, intead
of intial 24 hrs.
test should not be performed on dehydrated
individual.

Patient takes early supper, no food or water allowed after
6pm on preceeding night of test,with any urination during
the night discarded.
On test day, first specimen is voided at 7am, bladder
emptied completely,and the specimen discarded
2nd specimen is collected at 8am,14hrs after the
commencement of test and its osmolality or specific gravity
is measured.
Normal values:
Osmolality:850mOs/kg, can reach to 1350mOs/kg
Specific gravity:1.022-1.032
If values of osmolaity and sp. Gravity are less than
850mOs/kg and 1.022 resp.,sample is again collected at 9am
and essayed.
In case, kidney fails to concentrate urine, the values of
osmolality and sp.gravity may be as low as300mOs/kg and
1.010 resp.
Patient is administerd vassopressin analog
desmopressin.patient has nothing to drink after
6pm,at 8pm 5units of vassopressin tennate is
injected to him sub-cutaneously.all urine
samples are collected separatelyuntill 9am, next
morning.
Interpretation:satisfactory conc.is shown by
atleast 1 sample having a sp.gravity above 1.020
or an osmolaity above 800mOs/kg.
The test may be combined with measurement of
plasma osmolaity. The urine:plasma osmolality
ratio should reach 3,and values less than 2are
normal

After an overnight fast,the patient who is not allowed to
smoke empties his bladdercompletely and is given 1000ml
of water to drink.
Urine specimen are collected for the next four hours,the
patient emptying his bladder on each ocassion.
INTERPRETATION:unless there is renal function
impairment, the patient will excrete 700ml of urine in 4hrs
and atleast one sample will have a sp.gravity less than
1.004.
Severly damaged kidneys cant excrete the urine of lower
sp.gravity than 1.010 or volume above 400ml in this
time.there is delayed diuresis.
Abnormal results may also be obtained in case of delayed
water absorption or adrenal cortical hypofunction.
Test should not be done if there is edema or renal failure
as water intoxication may happen.
Done to test the ability of renal tubules to form
an acidic urine and to excrete ammonia.
Usefull to differentiate whether acidosis is due
to pre-renal cause or due to kidney damage ,as
in tubular acidosis.
PROCEDURE: patient fasts from midnight,untill
the conclusion of test.
The patient empties his bladder completely,
urine is collected. Then the patient is
administered 0.1g(1.9mmol) of NH4cl/kg of body
weight and drinks a liter of water. A standard
dose of 5g is sometimes used.
urine samples are collected at 2hrs,4hrs and 8hrs
interval.
INTERPRETATION:
Normally the urine will be acidified to pH 5.3 or
less and will contain more than 1.5mmol of NH3/
hour, in at least one of the specimens.

If there is a markable damage to renal acidifying
power, the pH of the latter specimen of urine will
be unaltered from the rest specimen, and less than
0.5mmol of NH3/hour will be excreted.

The pH results are more significant than the NH3
results,as three days are needed for full
development of extra ammonium ion excretion.