NP7 Nephrology

Assessment of Renal Function/Electrolyte Disorders

Essential Med Notes 2015

3. CRYSTALS
uric acid: consider acid urine, hyperuricosuria
calcium phosphate: alkaline urine
calcium oxalate: consider hyperoxaluria, ethylene glycol poisoning
sulfur: sulfa-containing antibiotics

Urine Biochemistry
commonly measure: Na+, K+, Cl, osmolality, and pH
no normal values; electrolyte excretion depends on intake and current physiological state
results must be interpreted in the context of a patients current state
1. ECF volume depletion: expect low urine [Na+] (kidneys should be retaining Na+)
urine [Na+](>40 mEq/L) suggests a renal problem or the action of a diuretic
urine [Na+] (<20 mEq/L) suggests a prerenal problem
2. daily urinary potassium excretion rate should be decreased (<20 mEq/d) in hypokalemia
if higher than 20 mEq/d, suggests renal contribution to hypokalemia
osmolality is useful to estimate the kidneys concentrating ability
FENa refers to the fractional excretion of Na+
FENa = urine [Na+] x plasma [Cr] / (plasma [Na+] x urine [Cr])
FENa <1% suggests the pathology is prerenal

Fractional Excretion of Sodium

FENa = [Na+]urine x [Cr]plasma x 100
[Na+]plasma x [Cr]urine
Many formulas used in nephrology
are derived from the division of two
fractions, each of which compare a urine
and plasma concentration (e.g.
U1/P1 U2/P2); in the case of FENa, it is
UNa/PNa UCr/PCr, which then gives the
above equation

Examples of Common Urine Electrolyte Abnormalities

high urine [Na+] (>40 mEq/L) in the setting of AKI: suggests renal disease
high urine [Na+] (>40 mEq/L) in the setting of hyponatremia: generally from causes such as
diuretics, tubular disease (e.g. Bartters syndrome), SIADH
additionally, urine pH is useful to grossly assess renal acidification
low pH (<5.5) in the presence of low serum pH is an appropriate renal response
a high pH in this setting might indicate a renal acidification defect (e.g. RTA)

Electrolyte Disorders
Sodium Homeostasis
hyponatremia and hypernatremia are disorders of water balance
hyponatremia usually suggests too much water in the ECF relative to Na+
hypernatremia usually suggests too little water in the ECF relative to Na+
solutes (such as Na+, K+, glucose) that cannot freely traverse the plasma membrane contribute to
effective osmolality and induce transcellular shifts of water
water moves out of cells in response to increased ECF osmolality
water moves into cells in response to decreased ECF osmolality
ECF volume is determined by Na+ content rather than concentration
Na+ deficiency leads to ECF volume contraction
Na+ excess leads to ECF volume expansion
clinical signs and symptoms of hyponatremia and hypernatremia are secondary to cells
(especially in the brain) shrinking (hypernatremia) or swelling (hyponatremia)
Table 4. Clinical Assessment of ECF Volume (Total Body Na+)
Fluid Compartment

Hypovolemic

Hypervolemic

Intravascular
JVP
Blood pressure
Auscultation of heart
Auscultation of lungs

Decreased
Orthostatic drop
Tachycardia
Normal

Increased
Normal to increased
S3
Inspiratory crackles

Interstitial
Skin turgor
Edema (dependent)

Decreased
Absent

Normal/increased
Present

Other
Urine output
Body weight
Hematocrit, serum protein

Decreased*
Decreased
Increased

Variable
Increased
Decreased

*If there is a renal abnormality (e.g. osmotic diuresis), the urine output may be increased despite the presence of hypovolemia

Common Electrolytes
Sodium (Na+) 135-145 mEq/L
Potassium (K+) 3.5-5 mEq/L
Chloride (Cl-) 95-105 mEq/L
Bicarbonate (HCO3-) 18-23 mEq/L