RENAL FUNCTION TESTS

RENAL
ARTERY

RENAL
VEIN
Functional unit of Kidney: NEPHRON
 Major functions of the kidneys
Excretion of metabolic wastes
Regulation of electrolytes including acid
base balance
Responding to physiologic needs and
variation by generating either a
concentrated or dilute urine
Regulation of extracellular volume and
osmolality
 Production of hormones
like:
Erythropoietin (by interstitial cells)
Renin (by JG cells)
Calcitriol (activation of vitamin D at PCT)
Target organ for the hormones
like:
Parathyroid hormone
Aldosterone
ADH
 RENAL THRESHOLD:
Compounds whose excretion in urine are dependent
on blood level are known as threshold substances.

TUBULAR MAXIMUM (Tm)

The maximum re-absorptive capacity for a particular
substance is known as the tubular maximum or Tm

E.g. For Glucose:

Renal threshold=180mg/dL
Tm= 375mg/min
 Indications of Renal Function Test
1. History and clinical examination suggestive of
renal pathology
2. Assessment of renal damage and its extent.
3. Monitoring the progression of renal disease
4. For the assessment of the need for renal
replacement therapy.
5. Monitoring and adjusting the dose of potentially
renal toxic drugs excreted by the kidney.

Routine urine examination is 1st test to be undertaken

to assess renal function
 In nearly all types of diffuse renal diseases;
Impaired function of the kidneys is
attributed to the:

Diminished number of functioning nephrons

 Renal Function Tests
To screen for
kidney disease 2) To assess tubular function
a) Reabsorption studies
Complete urine analysis b) Secretion tests
c) Concentration and dilution tests
To assess renal d) Renal acidification tests

function
1) To assess glomerular Tests for structural
function
a) Blood urea, serum
integrity
creatinine levels a) Renal biopsy
b) Glomerular filtration rate b) Renal imaging studies
(Clearance studies)
c) Glomerular permeability
(Proteinuria)
 Blood Urea/Creatinine ratio
Levels of blood urea depends upon many
factors like:
Diet, GI haemorrhage,
dehydration/hypovolemic shock
In these pre-renal cases of high blood urea;
serum creatinine is normal
In post-renal obstructive etiologies:
Both blood Urea and Creatinine rise
So the ratio becomes crude discriminator of the
pre-renal and renal/post-renal etiologies
 Normal U/Cr Ratio: 10-20:1

High U/Cr Ratio: >20

Pre- renal azotemia
Decreased renal blood flow, dehydration,
hypovolemic shock, GI haemorrage, high protein
intake

Pre-renal azotemia superimposed on the kidney

diseases.
 Low U/Cr ratio: <10

Low Blood Urea low protein intake, severe

liver diseases, starvation
In renal pathologies, sometimes the
increment in the serum creatinine is more as
compared to the blood urea.
 Renal Function Tests
To screen for
kidney disease 2) To assess tubular function
a) Reabsorption studies
Complete urine analysis b) Secretion tests
c) Concentration and dilution tests
To assess renal d) Renal acidification tests

function
1) To assess glomerular Tests for structural
function
a) Blood urea, serum
integrity
creatinine a) Renal biopsy
b) Glomerular filtration rate b) Renal imaging studies
(Clearance studies)
c) Glomerular permeability
(Proteinuria)
 Renal blood flow is 1200 mL per minute

Glomerular filtration rate is 120-125 mL per

minute
 GFR is widely accepted as one of best overall
measure of kidney function
A statement of the complex function of the kidney
in a single numerical expression

A decrease in GFR precedes kidney failure in

most forms of progressive renal parenchymal
diseases.
GFR is useful:
In targeting treatment
Monitoring progression
Predicting the point at which renal
replacement therapy will be required
Used as a guide to dosage of renally excreted
drugs to prevent potential drug toxicity
GFR cannot be measured directly.
To measure GFR, most methods involve the
kidneys ability to clear (CLEARANCE) either an
exogenous or endogenous marker.
 Concept of Clearance
The volume of plasma from which the substance is
completely cleared by the kidneys per unit time.

Provided that the substance S:

Is in stable conc. In the plasma
Physiologically inert
Freely filtered at the glomerulus
Neither secreted nor reabsorbed, synthesized or
metabolized by the kidney tubules.

Then the amount of that substance S filtered at the

glomerulus is equal to the amount excreted in urine.
 Thus,
The amount of S filtered at glomerulus= GFR x Ps
(Plasma conc. Of S)
The amount of S excreted= Urinary flow rate (V,
the volume of urine excreted per unit time) x Us
(Urinary conc. Of S)
Since,
Filtered S = Excreted S
GFR x Ps = Us x V
GFR= Us x V
Ps
 GFR= Us x V
Ps
Units of measurement:
Glomerular filtration rate (GFR) : is Clearance in units of ml
of plasma cleared of the substance S per minute (ml/min)

Conc. Of the substance S in Urine (Us) as well as in Plasma

(Ps) expressed in mg/dL

Volume (V) is flow rate of urine in ml/min

 Relationship of GFR with Clearance
Renal handling of the Clearance values vs
Example
substance (S) GFR
Substance only
filtered;
Clearance = GFR Inulin
Neither reabsorbed
nor secreted
Substance filtered ;
partially Clearance ~GFR Creatinine
reabsorbed/secreted
Substance filtered;
Significant Clearance< GFR Urea
reabsorption
Substance filtered;
Significantly secreted Clearance > GFR PAH
but not reabsorbed
 MARKERS USED
EXOGENOUS MARKERS ENDOGENOUS MARKERS
Inulin Creatinine
125I- iothalamate Cystatin C
Iohexol
Urea
99Tc DTPA
51Cr -EDTA
Inulin:
Exogenous marker

A naturally occurring fructose polymer

Satisfies all the criteria of an ideal marker

GFR determined by the inulin clearance is

an accurate reflection of GFR

But requires iv infusion

Urea
Endogenous marker

40% is reabsorbed by the tubules after

filtration

Under-estimates the GFR

Clearance (Curea) also is highly dependent on

urine flow rate

Not very useful for estimation of GFR

Creatinine

Endogenous marker
Derived from muscle
Production is usually constant
Plasma concentration is stable for a given
individual
 Advantages and Disadvantages of using
Creatinine Clearance tests as a GFR marker
Advantages
1. Extra-renal factors will rarely interfere
2. Conversion of creatinine phosphate to
creatinine is spontaneous, non enzymatic.
3. As production is continuous; blood levels
will not fluctuate
4. It is not affected by diet
 Can detect functional impairment in kidneys
early.

Changes in serum creatinine levels are not

even apparent but theres gross drop in its
clearance
Disadvantages:
1. Creatinine is filtered by the glomeruli
But is also actively secreted by the tubules
Of the total excretion; 10% is tubular component.
Thus, Creatinine Clearance tends to over-estimate
the GFR by about 10- 20 mL/min especially when
the impairment is much significant.

2. Creatinine clearance is also affected by body

weight, muscle mass, gender, and age.
Estimated (eGFR)
Makes use of only serum creatinine conc.
and takes care of limiting factors
Corrected Creatinine Clearance using
Cockcroft-Gault formula
 Cystatin C
Endogenous marker
Is a protein expressed in virtually all organs of
the body
It is most abundant extracellular cysteine
protease inhibitor.
Produced at a constant rate and is freely filtered
No tubular secretion
Blood levels are not dependent on age, sex,
muscle mass or inflammatory process.
A sensitive and Early marker
 Normal values

Creatinine clearance
90-130ml/min
Urea clearance
60-100ml/min
 Markers of Glomerular Permeability

Passage of macromolecules is selective

Is based on their charge , size and shape

Molecules smaller than 5 kD (urea, glucose,

creatinine ) freely filtered.

Glomerular membrane retains Albumin (mol wt.

69 kD).
 Low MW proteins are freely filtered, reabsorbed
or catabolized by renal tubular cells.

Normal urinary protein excretion is less

than 150 mg/24 hours.

Appearance of albumin increased

glomerular permeability
 Measurement of urinary proteins
They provide diagnostic and prognostic information
when proteinuria is a feature in renal disease

Dipstick test
A colorimetric pH indicator
(tetrabromophenol blue) is contained in
an acidic buffer at pH 3.0.
Because the urinary proteins have a
negative charge binds with the
indicator dye inducing a change of color
reflects abnormal proteinuria

Dipstick is a useful screening test

 24hr urine protein
Is a most commonly used quantitative
method for the assessment of proteinuria

Protein is measured colorimetrically

 Proteinuria
I. Glomerular increase in filtered load due to
glomerular damage and vascular permeability
II. Microalbuminuria
III. Overflow proteinuria increased circulating
concentration of low mol weight proteins
IV. Tubular proteinuria decrease in
re-absorptive capacity due to tubular damage
 1.Glomerular Proteinuria
First voided urine sample

Detection limit with dipstick 200-300 mg/L

300- 1000 mg / day Pathological

proteinuria

>1000 mg / day glomerular proteinuria

 Microalbuminuria (MCA)
When small quantity of albumin is
seen (30 -300 mg/ day) in urine sample

Not indicated in patients with overt

proteinuria ( +ve Dipstick)

Early indication of nephropathy in

patients of DM & HTN
 Random albumin/creatinine ratio has
an advantage over 24 hr protein
estimation
Easy to perform
Negates the uncertainties associated with use
of dilute or concentrated urine.

Normal values:
Males < 23 mg/gm of creatinine
Females < 32 mg / gm of creatinine
 Protein selectivity index
Increased IgG/albumin ratio

Advanced form of glomerulonephritis

Glomerular injury with resulting loss of

larger molecular globulins in the urine
 3. Overflow Proteinuria
When small mol weight proteins are
increased in blood overflow in urine

Haemoglobinuria

Myoglobinuria muscle crush injury

Bence jones proteins multiple myeloma

 4. Tubular Proteinuria
Functional nephrons are reduced

GFR is decreased

Remaining nephrons are over working

Tubular reabsorbtion mechanism is impaired

low molecular weight proteins appear in urine

Eg retinol binding protein ; alpha 1 microglobulin

TUBULAR FUNCTION TESTS
 TUBULAR FUNCTION TESTS

PROXIMAL TUBULAR
FUNCTION:
PSP excretion test
Fraction of HCO3- REGULATORY FUNCTIONS:
excretion Water homeostasis
PAH secretion Acidification tests
 Per day :
Glomerular filtrate = 170-
180 L
Out of which 1.5 L urine is
formed.
 Phenolsulphonephthalein (PSP) excretion test

This is a test of tubular function

PSP, injected intravenously, is not filtered by the glomeruli but

is secreted by the tubules

PSP excretion in urine indicates the efficiency of tubular

function

The subject is asked to drink two glasses of water to ensure

an adequate output of urine
 One ml of 0.6% solution of PSP (a total dose of 6 mg of PSP) is
injected intravenously

Urine is collected 15 minutes and 70 minutes after the

injection

The total amount of PSP present in each urine sample is

measured

Normal subjects excrete 20-25% of the injected dose within

15 minutes and 55-70% within 70 minutes

Decreased excretion indicates impairment of tubular function

 Renal blood flow and tubular function

Clearance of PAH (Paraaminohippurate)

>90% of the PAH is removed from the kidney by tubular

secretion (80%) and glomerular filtration (20%)

PAH is infused to constant plasma concentration and its

clearance is calculated

131I iodohippurate is also used

PAH clearance
650 160ml/min (men)
590 100ml/min (women)
 The loading dose is 3 ml of 20% PAH solution diluted with 250
ml of isotonic saline infused at the rate of 20 ml/minute

This is followed by an infusion of 14 ml of 20% PAH diluted with

500 ml of isotonic saline at the rate of 4 ml/minute

Urine and blood samples are collected before and after one
and half hour of second infusion
Urine output and PAH concentrations in urine and serum are
measured

PAH clearance is calculated by the formula UV/S

This equals the Renal plasma flow
 2-microglobulin: Early diagnosis of tubulointerstitial disease

Completely filtered by the glomeruli and is reabsorbed and

catabolized by proximal tubular cells

2-microglobulin excretion provides a sensitive method of

assessing tubular integrity
 Water Homeostasis
Plasma osmolality is maintained within an extremely close
tolerance (2833 mOsm/ kg)

The kidneys can vary the rate of excretion of water and solute
independently with urine osmolality ranging from as low as
50mOsm/kg to as high as 1200 mOsm/kg or greater
Decrease body water leading to hyperosmolality stimulates
ADH secretion and water reabsorption

Loss of ability to produce concentrated urine is a hallmark of

virtually all types of chronic renal diseases
Testing concentrating ability
Water deprivation test

With-hold fluid overnight

Collect first voided specimen in the morning and measure osmolality

Maximum urine concentration requires fluid deprivation for 36-48 hrs

 Urine osmolality that exceeds 850mOsm/kg after fluid
deprivation for 12-18 hrs, is considered normal renal
concentrating mechanism (or a specific gravity of 1.025 or
more)

Loss of concentrating ability:

diabetes insipidus (central or nephrogenic)
Other defects like medullary damages eg. Polycystic kidneys, reflux
nephropathy, tubular necrosis
Testing diluting ability:

Water challenge test

Patient is not allowed to drink water after midnight.

In the morning Bladder emptied
The subject is asked to drink 1,200 ml of water within 30
minutes

Urine specimens are collected every hour for four hours, and
their specific gravity /osmolality is measured

In normal subjects, at least one of the specimens should have

a specific gravity of 1.003 or less or <50mosmol/kg.
 Renal function and acid base disorders
A decreased GFR may result in retention of metabolic acids
with resultant acidosis

The decreased filtration of phosphate reduces the ability of

the body to remove H+ by formation of dihydrogen phosphate
ion (H2PO-4) in the distal tubule

Decreased formation of ammonium ion (NH4+) and the

associated decrease in the removal of H+

An impairment of the Na+-H+ exchange, especially in renal

tubular acidosis (RTA)
 Renal Tubular Acidosis (RTA)
Is a medical condition that involves an
accumulation of acid in the body due to a
failure of kidneys to appropriately acidify the
urine

Type 1: Insufficient H+ secretion in DCT

Type 2: Failure to reabsorb HCO3- ions in PCT

Type 4: Aldosterone resistance

 NH4Cl Loading Test

Oral administration of NH4Cl

Artificial Metabolic Acidosis

Urine Sample Collected hourly from2-8 hrs after

ingestion

pH determination

Urine with a pH < 5.3 in atleast one of the sample is

normal.
 NH4Cl Loading Test

Oral administration of NH4Cl for 3 days

Artificial Metabolic Acidosis

Urine Sample Collected

pH determination

Urine with a pH < 5.3 is normal

Renal tubular acidosis: Urine with increased pH

Fractional solute excretion: It measures the percent of
filtered solute that is excreted in the urine

Used to help differentiate pre-renal disease (decreased

renal perfusion) from acute tubular necrosis (ATN) as the
cause of acute kidney injury
 Fractional excretion of sodium

Below 1% = prerenal cause

Above 2% or 3% = acute tubular necrosis or
other renal damages

Fractional Excretion of Urea, uric acid

 Renal Failure Index

Prerenal causes - < 1

Renal and post renal - > 1