2016-11-03

Renal function tests

Dr Yolandie Hayden
Chemical Pathologist
Department Chemical Pathology, UFS
Aug2014

How will we test if a patients kidney is

working properly?

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Test different functions of

the kidney:
Waste excretion products
of protein and nucleic acid
metabolism e.g. Urea,
creatinine and uric acid
Maintaining extra cellular
fluid composition
Maintaining acid-base
status
Hormone synthesis (anti
diuretic hormone,
aldosterone, parathyroid
hormone, renin,
erythropoietin

Structurally
Glomerulus
Tubuli

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Glomerulus

Glomerulus
Glomerular filtrate (GF) is an ultra filtrate of
plasma; that is, it has a similar composition to
plasma except it is almost free of proteins.
Proteins with mol mass <65 kDa (smaller than
albumin) will be filtered, except if strongly
negatively charged.
The normal glomerular filtration rate (GFR) is
approximately 120 mL/min, equivalent to a
volume of about 170 L/24 h.
However urine production is only 1 2 L/24 h,
depending on fluid intake.

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Disease affecting kidneys can damage

glomerular or tubular function
Tests of glomerular function universally
required in investigation and management of
patient with renal disease
Test most widely used for overall renal
function is plasma creatinine concentration

Tubuli

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Proximal convoluted tubule

much of the GF is reabsorbed isotonically by an energy
dependent process with the active reabsorption of:
glucose
amino acids
potassium
bicarbonate
~ 75% of sodium
Most of the filtered proteins are reabsorbed and
catabolised by the tubular cells with the consequence
that the normal urinary protein excretion is < 150
mg/24h.

Tubuli

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Loop of Henle
Descending limb passive reabsorption of
water.
Ascending limb chloride ions accompanied
by sodium, are pumped out of the loop of
Henle into surrounding interstitial fluid
The ascending limb is impermeable to water.
Thus the tubular fluid becomes increasingly
dilute as it passes up the loop of Henle.

Tubuli

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Distal convoluted tubule

The fluid entering the distal convoluted tubule
is hypotonic (approximately 150 mmol/L) with
respect to GF.
Further sodium reabsorption takes place
controlled by aldosterone with the excretion
of potassium and hydrogen ions.

Tubuli

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Collecting ducts (CD)

The cells lining the collecting ducts are normally impermeable to
water.
Antidiuretic hormone (ADH) renders them (CDs) permeable and
allows water to be reabsorbed passively.

in the absence of ADH dilute urine is produced; in its presence, the

urine is concentrated.
Some reabsorption of sodium occurs under stimulus of aldosterone.
Urea diffuses out of the collecting ducts into the interstitium and
thus contributes to the medullar hypertonicity.
Children with protein malnutrition cannot effectively concentrate
urine.

Hormones produced by the kidneys

Renin
Erythropoietin
Vit D (1,25 dihydroxycholecalciferol)
Secretion of these may be altered in renal
disease.
Secretion and inactivation of other hormones
may also be affected in renal disease.

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Disease processes affecting the kidney

therefore have a considerable potential for
affecting water, salt and hydrogen ion
homeostasis and the excretion of waste
products

Evaluation of kidney function

Test of glomerular function
Creatinine clearance
Serun creatinine and urea
Proteinuria
Samples required and sample collection
Tests of tubular renal function
Osmolality
pH
Proteinuria
Fanconi syndrome

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Urea
Dietary and Endogenous amino acids are important sources of energy via
the gluconeogenic pathway

This process involves the release of amino groups as Ammonia

This is detoxified in the liver via the Urea Cycle with the production of
Urea

An average diet of 1000mmol of amino acids, produce 400-600mmol of

urea

Urea is a small molecule which freely diffuses through most body tissues

The kidney excretes 90% of the urea produced whilst the remainder is lost
through the skin and GIT

Urea is freely filtered by the glomerulus and passively moves out of the
nephron in response to the concentration gradients produced by water
reabsorption

The rate of excretion depends on

1. Glomerular Filtration Rate
2. Urine Flow Rate

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Causes of Increased Serum Urea

Decreased Renal Excretion:
Pre-renal Dehydration, Shock/Blood Loss, CCF
Renal Renal Failure (acute/chronic)
Postrenal Bilateral Ureteric Obstruction, Bladder Neck Obstruction, Urethral
Obstruction

Increased Production of Urea:

Increased Protein Catabolism High Protein meal, haemorrhage into the gut

Causes of Decreased Serum Urea

Decreased Synthesis: Severe Liver Disease

Decreased Precursors:
Decreased Protein Intake dietary, vomiting, IV feeding
Increased Protein Synthesis Infancy, Pregnancy

Haemodilution: Overhydration, Pregnancy

Increased Excretion: Nephrotic Syndrome, Pregnancy

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Creatinine
Cyclic Anhydride of Creatine, that is produced as the final product of
decomposition of Phosphocreatine
Phosphocreatine is dependant on the mass of working muscle
The amount of Creatinine produced each day is fairly constant for a given
individual
Small amounts of Creatine are present in the diet mostly originating from
meat (High Temperature cooking of meat can increase the creatinine
content)

Nearly all the produced creatinine is excreted by the kidney

Some exits via the GIT where bacterial degradation occurs

Creatinine is freely filtered by the glomerulus and this is added to by some

proximal tubular secretion
The amount added by proximal tubular secretion is variable
Normally +/- 10% of filtered load, but in Chronic Renal Failure it may
increase up to 30%
Drugs such as Cimetidine, Probenecid and Bactrim have been shown to
decrease this rate of secretion

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Caused of Increased Serum Creatinine

Increased Creatinine Production
Increased Dietary Intake roasted meats
Large Muscle Mass

Decreased Renal Excretion

Causes of Decreased Serum Creatinine

Low serum Creatinine values are usually not clinically important other
than indicating the possibility of overhydration

Serum Creatinine is a function of the subjects muscle mass, thus low

values will usually be found in infants, children, women and the elderly

It also follows that these subjects can have a fairly severe degree of renal
insufficiency but still have a plasma creatinine value within the normal
range

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Assessment of Kidney Function

The GFR is widely accepted as the best overall measure of kidney function
A decrease in GFR precedes kidney failure in all forms of progressive
disease
Measuring GFR in established kidney dx is useful in targeting treatment,
monitoring progression, and predicting the point at which renal
replacement therapy will be required

A number of methods are used to measure the GFR Most involve the
kidneys ability to clear an exogenous or endogenous marker

The Concept of Clearance

Most of the clinical laboratory information used to assess kidney function
is derived from or related to measurement of the clearance of some
substance by the kidneys

Renal Clearance of a substance is defined as the volume of plasma from

which a substance is completely cleared by the kidneys per unit time

Creatinine Clearance = UC X V (ml)

PC time (min)
Provided a substance S is stable in plasma, physiologically inert, freely
filtered at the glomerulus, Neither secreted, reabsorbed, synthesized or
metabolized by the kidney
The Clearance of the Substance is an accurate estimate of the GFR

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Creatinine Clearance
= UCreat X urine Vol (ml)
PCreat [60 X 24 ]time (min)
1. Serum sample
2. Timed/24h urine sample

A variety of Exogenous(Radioisotopic and Nonradioisotopic) and

Endogenous Markers have been used to estimate clearance

Measurement of Clearance requires accurate measures of both plasma

and urinary concentrations of the marker used plus a reliable urine
collection

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Calculated Clearance - eGFR

The mathematical relationship between serum creatinine and GFR are
used to derive an eGFR
>25 formulaes have been derived to estimate GFR and use serum
Creatinine as well age, gender, body size, ethnicity
It is recommended that such methods are used in preference to serum
Creatinine
Cockcroft and Gault or MDRD formula should be used for adults
The Schwartz and Counahan-Barratt formulas are recommended for
children

When serum creatinine is measured in mol/L:

Cockcroft Gault

Estimated Creatinine Clearance = [140- Age(yr)] X [Mass(kg)

sCreat(umol/l) X 0.81

If Pt is Female X 0.85

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Why NOT Urea Clearance

Wide serum fluctuations over 24 hrs and therefore have to use a shorter
collection period (poor accuracy)
40-60% of filtered urea is reabsorbed in the collecting ducts and therefore
it gives a poor estimation of GFR
Variations in diet can cause significant changes in Urea

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Renal Failure
Renal Failure is said to occur when the kidneys are unable to maintain a
normal internal environment

Acute Renal Failure or Acute kidney injury

RF developing over a short period of time(hrs,days) and is usually
associated with oliguria (urine output < 400ml/day)
The aetiology may be Pre-renal, Renal, Post-renal

Chronic Renal Failure

Renal Failure develops over a long period of time
Associated with both glomerular and tubular dysfunction

Laboratory Investigation
In most cases the cause of high plasma levels of creatinine and urea is
obvious from the clinical picture
In cases where the cause is obscure, evaluation of these may be helpful

Plasma Electrolytes, Urea and Creatinine, Osmolality

Urine Electrolytes, Urea and Creatinine, Osmolality
Derived Indices Urea:Creatinine - Serum and Urine
Urine Osmolality:Plasma Osmolality
Fractional Excretion of Sodium

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Potassium
There are several points worth bearing in mind when evaluating the plasma K
levels in pts with abnormal urea and creatinine

In uncomplicated Chronic Renal Failure, Hyperkalaemia usually does not occur

until the GFR falls to < 20ml/min

Hyperkalaemia in the presence of mild renal failure(Creat <350nmol/l) may be

due to:
1. Distal Tubular Disorders
2. Mineralocorticoid Deficiency
3. Drugs eg. Amiloride, Spironolactone
4. Severe Metabolic Acidosis
5. Excessive K intake
6. Increased K release

Bicarbonate
In Chronic Renal Failure, Metabolic Acidosis usually does not occur unless
the disease is advanced
It is usually a High Anion Gap Metabolic Acidosis

Earlier in the dx process, there may be a Hyperchloraemic (Normal Anion

Gap) Metabolic Acidosis this indicates that tubular dysfunction is
proportionally greater than glomerular dysfunction and is often seen in
Analgesic Nephropathy, Pyelonephritis, Interstitial Nephritis and
Obstructive Uropathy

In uncomplicated Chronic Renal Failure the plasma Bicarbonate does not

usually fall < 12-14 mmol/l due to contribution from the bone buffers

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Urea
Serum urea levels vary widely with the diet, protein metabolism, liver
function and the GFR
Mildly raised levels upto 10mmol/l can occur in the absence of intrinsic
renal disease

The serum Urea usually does not rise until the GFR falls to < 50%
The rate of renal urea excretion varies with the urine flow rate, whereas
the rate of Creatinine excretion is only a function of the GFR
The plasma urea represents a balance between production and excretion

Creatinine
It is generally accepted that the serum creatinine is a better indicator of
the GFR than Urea because the latter is affected by the protein intake

The Creatinine level may be misleading because

* Slight increases in plasma level may occur in the normal subject after a
meal of roast meat
* Creatinine production is a function of the muscle mass, therefore
subjects with a small muscle mass such as infants, elderly, females may
have significant renal disease without significant rise in the plasma
creatinine level
* Compounds such as acetoacetate and cephalosporins can interfere with
the Jaffe reaction used in the estimation of creatinine producing false high
values

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Serum Urea:Creatinine Ratio

In normal subjects the Urea:Creatinine ratio is 40 60

In Pre-renal Uraemia (low GFR but normal renal function) the ratio
increases because the tubular absorption of urea increases with low rates
of urine flow more than that of Creatinine
In Intrinsic Renal Disease the excretion of both analytes decreases
proportionally and the ratio will remain normal
Therefore, the ratio can be used to distinguish pre-renal from Renal

The test can be misleading as:

1. The values found in the 2 disorders can overlap
2. A low Urea can occur in renal uraemia if the protein intake is low

Urinary Urea and Creatinine

In isolation, these estimations are of little value but indices derived from
them can be useful in certain circumstances eg)

Urine:Serum ratio of either provides a rough index of the ability of the

kidney to concentrate urine and can be used to differentiate Pre-renal
from ATN
PRU Ratio > 14 (usually >20)
ATN Ratio < 14

The concentrating ability of the kidney is best estimated by the osmolality

measurements

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Plasma and Urine Osmolality

Urine:Plasma Osmolality ratio can be useful in differentiating the causes of
oliguria - PRU, ATN

PRU Ratio > 1.3 (Usually 2.4)

ATN - Ratio < 1.3

In Chronic Renal Failure the ratio approximated to 1.0 because of the

inability of the diseased kidney to either concentrate or dilute urine

Urine Sodium, Fractional Excretion of

Sodium
Sodium concentrations of spot urine are helpful in distinguishing PRU
from ATN
PRU Urine[Na] < 10 mmol/l
ATN Urine [Na] > 20 mmol/l
A better diagnostic discrimination may be obtained using the renal
Fractional Excretion of Na (FENa)
Una X PCr X 100
Pna X UCr
PRU Fena < 1%
ATN Fena > 1% (usually 3%)
FENa is also > 1% in Obstructive Uropathy, Diuretic Therapy, Osmotic
Diuresis, Chronic Renal Failure, Vomitting

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Cystatin C
Cystatin C is a Low Molecular Weight protein synthesized by all nucleated
cells
Its physiological role is a cysteine protease inhibitor
The promoter region has been identified as of the housekeeping type with
no known regulatory elements
The production rate of Cystatin C is considered to be constant
Plasma concentrations appear to be unaffected by muscle mass, diet or
gender
There are no known extrarenal routes of elimination
There are a number of reports documenting the correlation between
Cystatin C and Creatinine and GFR
Correlation of Cystatin C is consistently superior to that with creatinine

Polyuria
Urinary Volume > 3L/day
The causes can be divided, for diagnostic purposes, into:
1. Water Diuresis
2. Solute Diuresis

Water Diuresis
Decreased ADH Secretion
Physiological: Compulsive H2O secretion
Pathological: Neurogenic Diabetes Insipidus
Defective ADH Action on the Kidney
Congenital Nephrogenic Diabetes Insipidus
Acquired Nephrogenic Diabetes Insipidus
1. Renal Disease eg) Pyelonephritis, Analgesic Nephropathy
2. Hypokalaemia, Hypercalcaemia
3. Drugs eg) Lithium

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Solute Diuresis
Sodium Increased intake, diuretic therapy, renal salt losing disorders
Urea Hypercatabolic states, CRF, Postobstructive Nephropathy, Post ATN
Glucose Diabetes Mellitus

Laboratory Investigations
Urine Osmolality: Pts with a water diuresis will have a urine osmolality
<200 mmol/kg, whereas in solute diuresis, the urine osmolality will be
similar to the plasma osmolality

Urine Electrolytes, urea, glucose

Fluid Deprivation Test:

If the urine osmolality indicates a water diuresis the ADH renal axis should
be tested

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Renal Tubular Acidosis

Diverse group of both inherited and acquired d/o affecting either the
proximal or distal tubule

Characterised by a Hyperchloremic Normal anion gap, and Urinary

Bicarbonate or Hydrogen ion excretion inappropriate for the plasma pH, in
the absence of significant glomerular dysfunction

The classification is based on the biochemical expression and region of

defect rather than an understanding of the exact molecular defect

Type 1 Distal RTA

Due to inability of the distal nephron to secrete hydrogen ions
Characteristics: Hyperchloraemic Metabolic Acidosis
Hypokalaemia renal K wasting
Inability to lower the urinary pH to below 5.5 during systemic
acidaemia
Decreased excretion of H and Ammonia during Systemic Acidaemia

Causes:
Primary
Secondary
a) Autoimune Dx
b) Nephrocalcinosis
c) Drugs (Amphotericin B, Analgesics, Toluene)
d) Renal Transplant
e) Pyelonephritis
f) Obstructive Uropathy

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Type 2 (Proximal RTA)

Inability of the proximal tubule to reabsorb filtered bicarbonate
Characteristics:
Hyperchloraemic Metabolic Acidosis
Hypokalaemia (not consistent)
Ability to lower the urinary pH to below 5.5 during acidaemia (distal nephron is
unaffected)
Normal secretion of H ions and Ammonia during acidaemia
Usually associated with other proximal tubular d/o eg) Fanconis Syndrome
Glycosuria, Amino aciduria

Causes:
Primary
Secondary
a) Drugs eg)acetazolamide
b) Multiple Myeloma, Sjogrens Syndrome, Amyloidosis, Heavy Metal Poisoning
c) Renal Transplant Rejection
d) Inborn errors of metabolism eg)cystinosis, Wilsons Dx, Lowes Syndrome

Type 4
Due to aldosterone deficiency or an inability of the distal nephron to
respond to aldosterone
Failure of distal Hydrogen and Potassium ion secretion

Characteristics:
Hyperchloraemic Metabolic Acidosis
Hyperkalaemia
Ability to lower the urinary pH to below 5.5

Causes:
Mineralocorticoid Deficiency Syndromes

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Laboratory Investigation
The minimal laboratory investigations required for the investigation of
suspected RTA are:
1. Plasma Electrolytes and Creatinine
2. Blood Gases
3. Urinary pH during Systemic Acidosis

Proteinuria
Higher Molecular Weight proteins are retained within the circulation by
the Glomerular Filter.

Lower Molecular weight proteins are freely filtered and reabsorbed and
catabolized within the Tubular Cells.

Clinically, the appearance of significant amounts of protein in the urine

suggests renal disease.

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Proteinuria is classified as either Tubular or Glomerular depending on the

pattern of Proteinuria observed

A 3rd category, Overflow Proteinuria, is also recognized in which filtration

of excessive amounts of low molecular weight protein exceeds the tubular
capacity for reabsorption eg)Bence Jones Proteins, Myoglobinuria

Inflammatory Processes of the Urinary Tract results in Secretory

Proteinuria

Types of Proteinuria Causes Examples of Proteins

Seen

Glomerular Increased Glomerular Inc Excretion of High MW

Permeability proteins as permeability
increases eg Albumin, IgG

Tubular Proximal Tubular Damage: dec a1 Microglobulin

tubular reabsorptive capacity
and.or release of intracellular
components
Decreased Nephron No
Distal Tubular Damage
b2 Microglobulin
Retinol Binding Protein
Enzymuria(ALPase)
As Above
Tamm-Horsfall GlycoP

Overflow Increased Plasma Bence-Jones Protein

Concentration of relatively Myoglobin
freely filtered protein Lysozyme

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Nephrotic Syndrome
Gross changes in glomerular permeability characterize the nephrotic
syndrome

The diagnostic criteria for establishing Nephrotic Syndrome are the

presence of Proteinuria (TP > 3g/day or Albumin > 1.5 g/day)
Hypoalbuminaemia, Hypercholesterolaemia, Oedema

Nephrotic Syndrome can result from a variety of causes, including Minimal

Change Nephropathy(most common in children), Focal Segmental
Glomerular Sclerosis(FSGS), Membranous Nephropathy which may be
idiopathic or associated with Carcinoma, Drugs or Infection, SLE, and
Diabetic Nephropathy

Nephrolithiasis
Renal Calculi occur in 2-3% of the population
The majority of the stones contain Calcium

The formation of stones ultimately depends on the formation of

Crystalluria, which may result from:
1. Metabolic Diseases eg) Hypercalciuria, Hyperuricaemia
2. Low Urine Volume eg) Hot Climates
3. Variation in urine pH eg) Calcium precipitates in an alkaline urine, uric
acid precipitates in an acid urine
4. Urinary Tract Infections
5. Urinary Stasis eg)Obstruction, Malformation of urinary tract
6. Lack of Inhibitors: recent evidence suggests the normal urine contains a
no of inhibitors which preclude stone formation

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Laboratory Investigations
Depends to a certain extent on the composition of the stone
Other Information
Plasma: Electrolytes, Calcium, Urate
Urine: pH, Calcium, Phosphate, Urate, Oxalate, Cystine, Xanthine

Laboratory Evaluation should be delayed for 4-6 wks after the passage of
stones as this process may induce renal tubular abnormalities which may
be misinterpreted

Non-biochemical Investigations Bacteriological examination of the urine,

radiology of the urinary tract and a comprehensive drug and dietary
history are essential

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Case 1
A 46 yr old man (70kg) with Septicaemia, Dehydration and Oliguria
Plasma
Na 138 mmol/l 135-148
K 3.7 mmol/l 3.5-5.0
Cl 104 mmol/l 98-108
T-CO2 21 mmol/l 22-28
Urea 26 mmol/l 3.0-6.8
Creat 210mmol/l 60-120
Osmol 305 mosm/kg 285-300

Urine
Na 9 mmol/l
Creatinine 7.7 mmol/l
Vol/24hrs 630 ml
Osmolality 529 mosm/kg

FeNa < 0.18%

U/P Osmol = 1.7

U/P Creat > 14

If renal function is intact then dehydration is associated with maximal

conservation of Na and H2O by the kidney

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Case 2
The ffg pt had dehydration and a low urine output due to vomitting and diarrhea
Plasma
Na 1 37 mmol/l 135-148
K 4.1 mmol/l 3.5-5.0
Cl 98 mmol/l 98-108
t-CO2 23 mmol/l 22-28
Urea 16 mmol/l 3.0-6.8
Creat 215 umol/l 60-120
Osmol 297 mosm/kg 285 300

Urine
Na 51 mmol/l
Creat 10.7 mmol/l
Vol/24hr 790 ml
Osmolality 560 mosm/kg

FeNa 0.72%

U/P Osmol 1.88

U/P Creat 51

In this case the Urine [Na] suggests ATN but the other parameters indicate
PRU
The high Urine[Na] is a reflection of the concentrating ability of the kidney
and not Tubular Dysfunction
Thus the FeNa is a better indicator of tubular function than the
Urinary[Na]

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Case 3
A pt with severe crush injuries and oliguria
Plasma
Na 136 mmol/l 135-148
K 6.5 mmol/l 3.5-5.0
Cl 96 mmol/l 98-108
t-CO2 15 mmol/l 22-28
Urea 35 mmol/l 3.0-6.8
Creat 710 umol/l 60-120
Osmol 335 mosm/kg 285-300

Urine
Na 55 mmol/l
Creat 5.3 mmol/l
Osmol 360 mosm/kg

FeNa 6%
U/P Osmol 1.07
U/P Creat 6.7

Acute Renal Failure usually occurs over a short period (hrs/days) and is
usually, but not always associated with oliguria (Urine Output < 400 ml/d)
The 2 main features of ATN are Decreased GFR and Tubular Dysfunction

Urea and Creat increased dec GFR

K tubular dysfxn and K release from cells
Low Bicarb dec H secretion
Na

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Case 4
45 yr old Women with a hx of Analgesic Abuse
Plasma
Na 133 mmol/l 135-148
K 5.4 mmol/l 3.5-5.0
Cl 101 mmol/l 98-108
t-CO2 16 mmol/l22-28
Urea 34.5 mmol/l 3.0-6.8
Creat 988 umol/l 60-120
Osmol 315 mosm/kg 385-300
CorrCa 1.69 mmol/l 2.15-2.55
PO4 2.81 mmol/l 0.60-1.25

Urine
Na 26 mmol/l
Creat 5.8 mmol/l
Vol/24hr 1450 ml
Osmol 467 mosm/kg

Chronic Renal Failure describes dysfunction which develops over an extended

period of time
The Biochemical Abn can be explained in terms of the destruction of renal
parenchyma and the resultant decrease in functional nephron mass

Sodium
K
Bicarb
Urea and Creat
Ca and PO4
Osmo

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