Renal function test

Anatomy of Kidney
Nephron-functional unit of Kidney
• Urine is

• (1) excreted by the kidneys,

• (2) passed through the ureters,

• (3) stored in the bladder, and

• (4) discharged through the urethra.

• In health, it
• (1) is sterile and clear.
• (2) is of amber or straw color,
• (3) has a slightly acid pH (5.0 to 6.0); and
• (4) has a characteristic odor, and specific
gravity of about 1.024 g/ml.
In addition to dissolved compounds, it
contains a number of cellular fragments,
complete cells, proteinaceous casts, and
crystals (formed elements). Changes in
these formed elements are studied using
urine microscopy.
 Tests to asses renal function

• As kidney performs important and

sensitive functions, it is essential that the
abnormalities must be detected at the
earliest. Several tests are employed in the
laboratory to asses kidney function.
• It must be remembered that about two-
thirds of the renal tissue must be
damaged to show any abnormalities by
these tests.
• Renal function tests may be divided into
these groups-
1. Routine examination of urine:
 Physical examination of urine:
 Volume: 1.5L/day Oliguria
(<500ml/day) found in renal failure,
dehydration, heart failure.
Polyuria(>3L/day) found in diabetes mellitus
And diabetes incipidus.

 Specific gravity and osmolartiy: Normal:

600-900mosm/L.
Increase in diabetes mellitus, heart failure,
dehydration.
Decrease in diabetes incipidus, acute
renal failure.
Appearance: Turbid in urinary tract
infection and cloudy if contain RBC, WBC,
epithelial cells.
 Colour: Yellow in jaundice, pink to red in
haematuria and smoky if RBC is present.

 Chemical examination of urine:

 pH: Acidic in normal condition and

acidosis Alkaline in alkalosis.
 Test for blood(Benzidine test): Positive in
haematuria(stone, carcinoma in bladder)

 Test for protein(Heat coagulation test):

Positive in nephrotic syndrome, AGN.
 Test for glucose (Benedict’s test): Positive
in diabetes mellitus, renal glycosuria.

 Test for ketone bodies(Rothera’s test):

Positive in ketosis and ketoacidosis.
 Test for bile pigment (Fouchet’test):
Positive in hyperbillirubinemia.
 Test for bile salts ( Hay’s sulfar test):
Positive in obstructive jaundice.
 Test for urobillinogen (Ehrlich test):
Incraeses in hemolytic jaundice and
decraeses in obstructive jaundice.
Microscopic examination of urine for cells
(RBC, pus cells) casts. Their presence in
urine indicates glomerular diseases,
pyelonephritis, tubular diseases.
2. Glomerular function test:
 Measurement of GFR by radio isotope
clearance study (e.g. Technetium labelled
diethylene triamine penta acetic acid
clearance test).
 Measurement of GFR by formula based
estimated GFR.
 Estimation of non protein nitrogenous
substance in blood: Estimation of serum
creatinine, estimation of blood urea.

 Clearance tests: Creatinine clearance test,

urea clearance test.
3.Tubular function test:

 Test for proximal convoluted tubule:

Examination of urine for glucose and
amino acid.
 Test for distal convoluted tubule: Urine
concentration or dilution test, urine
acidification test.
4. Others:
 Evaluation of renal blood flow by doppler
study
 Evaluation of quantitative functional status
of kidney by isotope scanning.
 Important renal function tests
1) Routine examination of urine
2) Estimation of serum creatinine
concentration
3) Estimation of blood urea concentration
4) Measurement of creatinine clearance and
urea clearance
5) Measurement of GFR
 Creatinine clearance test

• Creatinine is the excretory product derived

from creatine phosphate(largely present in
muscle). The excretion is rather constant
and is not influenced by body metabolism
and dietary factors.
• The value of creatinine clearance is close
to GFR. Creatinine clearance may be
defined as the virtual volume of plasma
that would be completely cleared of
creatinine per minute.
• Procedure: In traditional method,
creatinine content of a 24hrs urine
collection and plasma concentration in
this period are estimated. The creatinine
clearance(C) can be calculated as follows-
• C= UV/P

• Normal range: 70-140ml/min

• A decrease in creatinine clearance

indicates renal damage.
 Water Deprivation Test
Principle:
The maximum concentration of urine is produced
in response to fluid deprivation, which stimulates
ADH.
Indication
The investigation of polyuria (Urine volume
consistently >2.5L/24hr)
Procedure:
The patient is weighed before the test and after 4,
The test should be stopped if the body weight
falls by more than 3% of baseline weight, or if
the patient feels unwell or looks dehydrated.
Measurements
At 08:30 h the bladder should be emptied and
urine discarded. Urine is then passed hourly
and the volume recorded. The following urine
samples should be saved.
• Urine 1: First hour: 08:30 – 09:30; Urine 2: third
to fourth hour: 11:30 – 12:30; Urine 3: sixth to
seventh hour: 14:30 – 15:30; Urine 4: seventh
to eighth hour: 15:30 – 16:30 ;
• At the mid point of each saved urine sample,
5mL blood (gold top with gel vial) should be
taken as follows for osmolality and sent to the
laboratory.
• Serum 1: 09:00hr Serum 2: 12:00hr Serum 3: 15:
00hr Serum 4: 16:00hr
• Interpretation
• If the result of Serum 1 (taken at 09:00) is low
(280mosmol/kgH2O), water depletion is
unlikely and polyuria is probably an appropriate
response to excessive water intake.
• A normal subject will produce urine with an
osmolality of 600 mosmol/kgH2O or more and
the plasma osmolality will not rise above
300mosmol/kgH2O.
• In diabetes insipidus the plasma becomes
abnormally concentrated with an osmolality
that may exceed 300mosmol/kgH2O while
the urine osmolality remains less than that of
the plasma.
 Limitations of renal function tests

1. Blood urea concentration is a poor guide

to renal function because it is non
specific. Apart from renal failure, blood
urea also increases in high protein diet,
GIT haemorrhage, trauma, severe
infection.
2. Serum creatinine concentration is more
reliable because it is produced from
muscle at a constant rate. So with
constant muscle mass, changes in
serum creatinine reflects the changes in
renal function.
But it is insensitive marker because serum
creatinine concentration does not
increase until more than 50% renal
function has been lost.
3. Creatinine clearance overestimates GFR
since creatinine after filtration not
reabsorbed, but partly secreted by the
tubules and secreted creatinine
constitutes a large portion of urinary
creatinine excretion.
 Proteinuria

• It is the urinary excretion of protein more

than normal.
• Normal urinary protein excretion rate(PER):
<30mg/day or <20µg/day.
• Types of proteinuria(albuminuria):

1. Microproteinuria: Here, Urinary excretion

of protein/albumin is increased, but
insufficient to be positive on urinary
dipstick test.
• Causes:

 Early diabetic nephropathy

 Hypertension

 Generalized vascular disease

2. Macroproteinuria(Macroalbuminuria):
Increased urinary protein excretion
sufficient to be positive on urinary dipstick
test.
• Causes:

 Nephrotic syndrome

 Glomerulonephritis

 Preeclampsia

 Septicemia
 Pyelonephritis

 Multiple myeloma(Bence-Jones protein)

 High fever, stress, severe exercise

 Urinary tract infection

• Clinical types of proteinuria(based on
AER/PER):
1. Asymptomatic proteinuria: AER<1g/day

2. Moderate proteinuria: AER is 1-3g/day

3. Massive proteinuria: AER>3g/day

• Microalbuminuria(MAU): It is defined as the
excretion of 30-300 mg of albumin in urine
per day. Microalbuminuria represents an
intermediary stage between normal albumin
excretion and macroalbuminuria. It predicts
impairment of renal function in diabetic
patient (diabetic nephropathy).
Indications of renal function test
Diagnosis of renal diseases and assesment
of their severity and prognosis.
Differential diagnosis of edema and
proteinuria
Electrolyte imbalance and acid base
disorders