UNDERSTANDING URINE

CONCENTRATION
AND ITS HOW IS URINE
RELATIONSHIP TO
KIDNEY FUNCTION
FORMED?
•Localization of azotemia
1. Glomerular Filtration
•Diagnosis of renal failure
2. Tubular Reabsorption
•Interpret the urinalysis 3. Tubular Secretion
•Identify causes for polyuria

Important terms

DILUTION CONCENTRATION
HOW DOES THE Remove solute in
excess of water
Remove water in
excess of solute
KIDNEY CONSERVE
WATER?

What is required to Antidiuretic Hormone

excrete concentrated (vasopressin)

urine?

Hyperosmotic renal medulla

 CLINICAL APPLICATION

What isIsyour
urineinterpretation?
dilute?
HOW MUCH KIDNEY DAMAGE
MUST OCCUR BEFORE
Specific gravity = 1.017 URINE CONCENTRATION IS IMPARIED?

CLINICAL AXIOM

Renal Function
(33%) Inability to concentrate
Significant impairment in
urine to urine concentration
>1.025-10.30 in dogs
Renal Maintaining >1.035 to 1.040 in cats is not detected until
Homeostasis
Insult Metabolic waste removal
Electrolyte balance
2/3 of functioning renal
Acid-base balance parenchyma is
Endocrine balance
destroyed.

Renal Function
(25%)
Impaired urine
HOW MUCH KIDNEY DAMAGE concentration
MUST OCCUR BEFORE Renal Maintaining
Homeostasis Azotemia
AZOTEMIA DEVELOPS? Insult Electrolyte balance
Acid-base balance
Endocrine balance
 CLINICAL APPLICATION
KEY POINT:

• Urine concentrating ability is

What is your interpretation?
lost prior to development of
renal azotemia. Specific gravity = 1.030

“FIXED” URINE SPECIFIC GRAVITY

WHAT IS A Complete loss of ability to

concentrate or dilute urine
“FIXED” URINE according to the body’s
SPECIFIC GRAVITY? fluid needs.

Specific Gravity =
1.008 to 1.012
Specific gravity of glomerular filtrate = 1.008 to 1.0012

CLINICAL APPLICATION

HOW CAN URINE

What is your interpretation?
SPECIFIC GRAVITY
AID LOCALIZATION
Specific gravity = 1.012 OF AZOTEMIA?
 AZOTEMIA AZOTEMIA
Abnormally high Abnormally high
blood creatinine blood creatinine
Primary Prerenal Azotemia Primary Renal Azotemia
Renal 1. ⇑ BUN or creatinine 1. ⇑ BUN or creatinine Prerenal
Azotemia2. Adequate U Sp G 2. Inappropriate urine Sp G Azotemia
>1.030 in dogs 1.007 to 1.029 in dogs
>1.035 in cats 1.007 to 1.034 in cats
3. Underlying causes
4. Rapid correction of
azotemia with Rx

Postrenal Postrenal
Azotemia Azotemia

AZOTEMIA
Abnormally high
blood creatinine KEY POINT:
Primary
Renal Prerenal
• Why is it important to localize
Azotemia Azotemia azotemia?
• Prognoses related to severity
Postrenal Azotemia of renal failure should be
1. ⇑ BUN or creatinine
2. Variable urine Sp G withheld pending correction
3. Dysuria, anuria of pre and post renal causes.
4. Detection of
urinary obstruction
or rupture

HOW WOULD YOU INTERPRET

THESE FINDINGS?

Urinalysis
Coty Collection Cysto
12yr, Mixed breed
Color Yellow/clr
Hx: Dog was boarded Specific gravity 1.027
over past 2 weeks
vomiting, anorexia pH 6.0
weak, lethargic Oc blood Neg
PE: Depression
Cannot stand Glucose Trace
5% dehydration Bilirubin 2+
Protein 1+
Casts 0 to 2 hyaline
 NORMAL
COULD COTY HAVE LIVER
FAILURE? Urea

Urinalysis
Urea
Collection Cysto
Color Yellow/clr Urea
-
ClCl -
Urea
Specific gravity 1.027 Cl- - Cl- Na +
Cl- Cl Cl- Na+ Cl- -
pH 6.0 Na+ +Cl- - Cl- Cl- -
Na Cl Cl Cl- + Cl -
Urea
- Na+ ClUrea
-Urea - Na +Cl+
+ - Na Urea
- + +Cl - Cl-
Oc blood Neg Na + Cl- Na +Cl Cl - + Cl
Urea NaCl
Na Na + ClNa Urea
+Na Urea
+-
Urea Na + NaNa + + Cl
+ - Na + Na + + Na
Na Na + Cl - -
Na+NaCl - +Cl
Na
Na +Cl Na
+- + Cl Urea
- -Cl-
Cl 2500
Na Na
Na
Na Na+ + +
+ + - Na Cl+
Na + Na+
+ +
+ + ClNa ClNa ++ Na Na
Na Na +Na + Na+
Na2500 2300 - Cl
Glucose Trace Na
Cl
Na - + Na+Na+ Cl+-+ Na + -
Na + - Na+Cl Na
Cl
-
NaCl
+Cl- - Cl
Na
-+
Na +
+ -Na
+ + - + -Cl Cl - - Na
Na Cl - Cl Na
- - Cl
Bilirubin 2+ NaCl NaCl
NaClCl- Cl-
Cl- ClNa - +Cl -
Cl+- Cl- Cl Na
- Urea
+
Cl- Na Na- + Cl C
Cl
Cl- Cl- Cl- Urea UreaNa Urea+ Cl++- Urea Cl Urea-
Na+NaCl+-Urea Na + Na Urea+ Urea+ Urea
Na Cl-
Protein 1+ Cl
Urea
- Na
Urea+
Urea
Na
-
+Cl Urea 2700 Na+ ++ Urea
Na NaNa
Urea + Na
Urea
Urea + Na+ + Na
Na Na + Urea
Na +
Casts 0 to 2 hyaline Na
Na+NaUrea Urea
+ Na
Urea Na + Urea
NaNa++ NaNa++Urea
Na + Na + Urea
+
Urea Urea Na

LIVER FAILURE HYPOADRENOCORTICISM

Urea

-
ClCl -
Urea
Cl- - Cl- Na +
Cl-- Cl Cl- Na+ Cl- - Urea
Na+ +Cl- - Cl- Cl - Cl- Cl- Na+ Cl
Na Cl Cl - -
Urea Urea Urea Urea Urea
Na + - - + Cl Cl+ +Na+ Cl- + Cl- Urea Na+ +Cl-
NaCl+ ClNa + +
NaNa Cl+- Urea Na
Na + Urea Na
+
Na Cl Na- + Cl Cl Na Na
- -
Na + Urea + Na + Urea
Urea +
UreaUrea NaUrea Urea UreaNa+
Urea
Na + Urea
+
Na2500 - Na - Na Urea
2300
Urea UreaNa+
- -
+ Cl Cl - + Na+ ClNa+ UreaClUrea Na+ Na+ Urea
Urea Na+
Urea Cl- Urea
Urea
Urea Cl-
NaNa+ Cl-Cl Na
Cl - Na+ - - - - + C Urea Urea
Cl- Urea Urea Urea Cl-
Urea Cl ClCl-Urea Cl Cl Na +- +
Na
Cl Na+ Na Urea Urea Urea
Urea Urea Urea
Urea+ +
Cl-Cl - Urea Urea
Urea Urea Urea Urea
+ Cl
NaNa + -Cl-
Na Cl+ - Cl
+
-Cl-
- Na Na Urea Cl - Urea Urea Urea+ Urea
NaUreaCl 2700Na+ Urea
+ + Na Urea Urea
Na+Urea Urea Urea Urea Na
Urea
+Urea
NaNa + NaNa Urea Urea Urea
NaNa+ +
+ Na
Na +Na
+ + Na+ Urea + + Urea
Na Na + NaNaNa+

KIDNEY FAILURE
COULD COTY HAVE
PRIMARY GASTRITIS?

Urinalysis
Urea
Collection Cysto
Color Yellow/clr
Urea
Specific gravity 1.027
pH 6.0
Urea Urea
Na+ +Cl- + Urea
- Na+ +Cl- Oc blood Neg
Na+ +ClUrea
- Na +
Na
Na+Cl + Na
Na+
Na Na Na
Na+- Na+ - + Na+ - Cl- Glucose Trace
Cl Cl Na - Cl - Cl
Na+ - Cl- Cl- Cl- Cl- Cl- Cl Cl- Na
Cl +
Cl- Na+ Urea Bilirubin 2+
Urea Urea -
Urea+ Cl Cl-
+
Na Na -
Cl+Urea Cl-
Cl- Urea+Cl-
Na Urea + Na Protein 1+
Urea+ + Na +
Na Na+ Urea
Na Na+ + Na
Urea Urea Casts 0 to 2 hyaline
Na
Urea Na++Na+
Na Na+Na+
Vomiting, Anorexia, Dehydration Coty: 12yr, f/s
HCT 43 Amylase 2671 (n=850)
Primary GI dz Secondary GI dz
HGB 15 BUN 107 (n<28)
D Pancreatic Disease WBC 10,300 Creatinine 2.1 (n<1.5)
A Renal Disease Neutrophil 8,500 Glucose 54
M Liver Disease Band 0
Lipase 619 (n<500)
N Adrenal Disease Lymph 1,700
Phosphor 7.6 (n<7)
I Thyroid Disease Platelets 354,000
Albumin 2.4 T bilirubin 1
T
ALP 197 Sodium 141
ALT 158 Potassium 5.7 (n<5.3)

A KEY POINT:
COMMON • If clinical signs warrant
evaluation of renal function,
CAUSE FOR urine specific gravity should
be evaluated at the same time
MISDIAGNOSIS before instituting therapy.

IS

CLINICAL APPLICATION
Is urine dilute? CLINICAL
Is urine APPLICATION
concentration ‘fixed”?

What is your interpretation? What is your interpretation?

Specific gravity = 1.003 Specific gravity = 1.003

 IsCLINICAL
urine adequately dilute to
APPLICATION Does this dog have renal failure?
prevent the polysystemic
signs of primary renal DAY 1 Normal
failure?
WT (kg) 13
Creat (mg/dl) 2.1 (168 µmol/L) 0.6-1.5
What is your interpretation?
BUN (mg/dl) 44 (31 mmol/L) 14-33
P (mg/dl) 5 (1.6 mmo/L) 4-8
Specific gravity = 1.003 K(mmol/L) 4.5 4-6
Hct 52%
U Sp Grav 1.003

For which patient is a UP/UC ratio needed to

diagnose Protein-losing glomerulonephropathy?
A B C D
Color Yellow Lt Yellow Yellow Lt Yellow
DETERMINING THE
Turbidity Clear Clear Clear Clear
CAUSE OF POLYURIA
Sp Gravity 1.025 1.008 1.060 1.015
pH 8.0 6.5 6.5 7.5
Glucose Neg Neg Neg Neg
Occult Bld 3+ 1+ Trace Neg
Urine Output >50ml/kg/day
Protein 3+ 4+ 1+ 2+
RBC/hpf >50 0 3 0
WBC/hpf 80 0 3 0
Bacteria Many 0 0 0

Water Consumption Water Consumption

Plasma osmolality Intravascular

(Serum [Na]) Volume/Pressure

Hypothalamus
Pituitary

(-) ADH

KIDNEY

Urine Production Urine Production

 Water Consumption Water Consumption

Plasma osmolality Intravascular Plasma osmolality Intravascular

(Serum [Na]) Volume/Pressure (Serum [Na]) Volume/Pressure

Hypothalamus Hypothalamus
Pituitary Pituitary

(-) ADH ADH

KIDNEY 1o Diseases KIDNEY 2o Diseases

(structural) (functional)

Urine Production POLYURIA

Pathophysiologic Mechanisms Pathophysiologic Mechanisms

POLYURIA –driven (Primary polyuria) POLYURIA –driven (Primary polyuria)

1. Lack of ADH
2. Renal Insensitivity to ADH
a. Primary nephrogenic diabetes Insipidus
b. Secondary nephrogenic diabetes insipidus
¾ Tubular insensitivity to ADH
¾ Inability to generate a concentrated medulla
3. Osmotic Diuresis
1. Lack of ADH
2. Renal Insensitivity to ADH
a. Primary nephrogenic diabetes Insipidus
b. Secondary nephrogenic diabetes insipidus
¾ Tubular insensitivity to ADH
¾ Inability to generate a concentrated medulla
3. Osmotic Diuresis

POLYDIPSIA –driven (Primary polydipsia) POLYDIPSIA –driven (Primary polydipsia)

Pathophysiologic Mechanisms Pathophysiologic

CongenitalMechanisms
Inherited

POLYURIA-driven POLYURIA -driven

1. Lack of ADH Central Diabetes Insipidus
2. Renal Insensitivity to ADH Idiopathic
a. Primary nephrogenic diabetes
TraumaInsipidus
b. Secondary nephrogenicNeoplasia
diabetes insipidus
¾ Tubular insensitivity to ADH
¾ Inability to generate a concentrated medulla
3. Osmotic Diuresis
1. Lack of ADH
2. Renal Insensitivity to ADH
a. Primary nephrogenic diabetes Insipidus
b. Secondary nephrogenic diabetes insipidus
¾ Tubular insensitivity to ADH
¾ Inability to generate a concentrated medulla
3. Osmotic Diuresis

POLYDIPSIA -driven POLYDIPSIA -driven

 Pathophysiologic Mechanisms Pathophysiologic Mechanisms
Renal Failure
Decreased urea production
Loop diuretic
POLYURIA -driven POLYURIA -driven Hypertension
1. Lack of ADH 1. Lack of ADHHyperthyroidism
2. Renal Insensitivity to ADH Hypoadrenocorticism
2. Renal Insensitivity to ADH
a. Primary nephrogenic diabetes Insipidus a. Primary nephrogenic diabetes Insipidus
b. Secondary nephrogenic diabetes insipidus b. Secondary nephrogenic diabetes insipidus
¾ Tubular insensitivity to ADH ¾ Tubular insensitivity to ADH
¾ Inability to generate a concentrated medulla ¾ Inability to generate a concentrated medulla
3. Osmotic Diuresis 3. Osmotic Diuresis
Hypercalcemia
Hypokalemia
POLYDIPSIA -driven POLYDIPSIA -driven
Endotoxins
Hyperadrenocorticism
Post-obstructive diuresis

Pathophysiologic Mechanisms Pathophysiologic Mechanisms

Diabetes Mellitus
Fanconi Syndrome Psychogenic
POLYURIA -driven POLYURIA -driven Encephalopathy
Post-obstructive Diuresis
1. Lack of ADH 1. Lack of ADH Neurologic
Mannitol
2. Renal Insensitivity to ADH 2. Renal Insensitivity to ADH Fever
Renal failure
a. Primary nephrogenic diabetes Insipidus a. Primary nephrogenic diabetes
Pain Insipidus
b. Secondary nephrogenic diabetes insipidus b. Secondary nephrogenic diabetes insipidus
¾ Tubular insensitivity to ADH ¾ Tubular insensitivity to ADH
¾ Inability to generate a concentrated medulla ¾ Inability to generate a concentrated medulla
3. Osmotic Diuresis 3. Osmotic Diuresis

POLYDIPSIA -driven POLYDIPSIA -driven

DETERMINING THE DETERMINING THE

CAUSE OF POLYURIA CAUSE OF POLYURIA

1. Verify (Urine Specific Gravity)

>1.025 <1.020
Urine Output >50ml/kg/day Dysuria Polyuria
Confirmed
 DETERMINING THE DETERMINING THE
CAUSE OF POLYURIA CAUSE OF POLYURIA

1. Verify (U SG < 1.020) 1. Verify (U SG < 1.020)

2. Verify Persistence 2. Verify Persistence
3. Localize

DETERMINING THE LOCALIZING POLYURIA

CAUSE OF POLYURIA
1. Verify (U SG < 1.020)
2. Verify Persistence
3. Localize (SCP, CBC, UA, UC)
WATER DIURESIS
• Central Diabetes Insipidus
• Primary Nephrogenic DI
• Psychogenic polyuria
• Others
SOLUTE DIURESIS
• Primary renal failure
• Pyelonephritis
• Diabetes Mellitus
• Renal glucosuria
• Hepatic Failure
• Hyperadrenocorticism
• Hypoadrenocorticism
• Hypercalcemia
• Hypokalemia
• Hyperthyroidism

U SG < 1.007 U SG =1.007 to 1.020

Why is this dog polyuric?

DETERMINING THE
CAUSE OF POLYURIA Normal Range
Creatinine 0.6 mg/dl 0.6 to 1.6
BUN 22 mg/dl 9 to 31
1. Verfiy (U SG < 1.020) Ca 10.4 mg/dl 9.3 to 11.5
2. Verify Persistence Na 142 mmol/L 145 to 153
3. Localize (SCP, CBC, UA, UC) Cl 107 mmol/L 109 to 118
4. Determining the underlying K(mmol/L) 4.7 mmol/L 3.6 to 5.3
cause T. Protein 5.4 gm/dl 5 to 6.9
Albumin 2.7 g/dl 2.7 to 3.7
U Specific Gravity 1.014
 Pathophysiologic Mechanisms
Is a Water Deprivation Test Indicated?
Normal Range
POLYURIA –driven (Primary polyuria)
1. Lack of ADH Creatinine 0.6 mg/dl 0.6 to 1.6
2. Renal Insensitivity to ADH BUN 22 mg/dl 9 to 31
a. Primary nephrogenic diabetes Insipidus Ca 10.4 mg/dl 9.3 to 11.5
b. Secondary nephrogenic diabetes insipidus
¾ Tubular insensitivity to ADH
Na 142 mmol/L 145 to 153
¾ Inability to generate a concentrated medulla Cl 107 mmol/L 109 to 118
3. Osmotic Diuresis K(mmol/L) 4.7 mmol/L 3.6 to 5.3
T. Protein 5.4 gm/dl 5 to 6.9
POLYDIPSIA –driven (Primary polydipsia)
Albumin 2.7 g/dl 2.7 to 3.7
U Specific Gravity 1.014