NON-PROTEIN NITROGENOUS COMPOUNDS

KIDNEY FUNCTION TESTS

§ The NPNs can also reflect the functions of the kidney (why they are also called the kidney function tests)

NPN vs. CHON

NPN CHON (Proteins)
v Low MW v High MW (why they are also called as macromolecules)
v Crystals in nature – doesn’t cause turbidity or haziness in the v Colloidal – opaque and large; when present in spx, they cause
spx turbidity or haziness

The Urinary System

Kidney – filters the blood

- Weighs less than 1% of the total human body, but receives about 25% of
cardiac output
Ureter – attached to the kidney
Urinary bladder – area in which the urine is being stored
Urethra – where urine is excreted

Major Blood Vessels

1. Aorta (large artery) – where blood from the heart will pass through,
where it will be delivered towards the kidney via the renal artery
2. Once the blood reaches the kidney, it will be filtered, so all toxic materials
and unnecessary substances will be excreted through the ureter down to
the bladder, then to the urethra
3. The filtered blood which is needed by the body will be returned to the
bloodstream via the renal vein

The kidneys are full of blood vessels such as the arteries, arterioles, and capillaries, which
surround the entirety of the kidneys

Example:
We can have approximately 1.1 L/min of our blood flowing through our kidneys. For a normal
person who has about 5 L of blood, it would mean that within 5 mins, all of the blood has already
passed through the kidneys and it has already been filtered before returning to the bloodstream

1. The blood coming from the heart will be delivered to the kidneys via the renal artery
a. We can expect that the blood coming from the renal artery is oxygenated because it comes from the heart
2. The renal artery will branch off into smaller vessels (renal arterioles)
a. Once the blood reaches the kidney, it will be filtered and the reabsorption of ions and necessary nutrients will also happen
here
3. All the filtered blood will be collected into the renal vein
a. From the renal vein, it will be delivered to the bloodstream, to the rest of the body
b. The blood coming from the vein has lesser oxygen; it is deoxygenated because the oxygen has already been used up in the
filtration and reabsorption process occurring in the kidneys
4. Renal cortex – outer part
5. Renal medulla – middle part
nephron will be in the renal cortex and will fall down to the
6. Nephron – functional unit of the kidney renal medulla back to the cortex down to the renal
a. Situated between the cortex and the renal medulla medulla

b. Has millions of nephrons per kidney because the kidney contains approximately 1.5 million of nephrons
7. Renal calyx (plural: calyces) – first part of the kidney where the urine is present/the first part which comes in contact with the urine
8. Renal pelvis – all the urine that was gathered from the renal calyx will be collected to the central part of the kidney, which the renal
pelvis
9. Renal hilum (Hila) – If there are tubes or vessels coming out in an organ, which is the kidney
 Arterioles – meets the glomerulus
- Glomerulus – tuft of capillaries
o Filters the blood
- Afferent arteriole – the arteriole that is going towards the
glomerulus going towards the kidney
- Efferent arteriole – arteriole that is coming out or has left the
glomerulus
o Eventually, it will turn into a capillary
- The blood coming from the heart will be delivered to the renal
artery àafferent arterioles à glomerulus à efferent
arterioles à capillary à venule à renal vein (the one that
will return the filtered blood to the bloodstream to the rest of
the body)

You might be wondering why there’s a lot of fluid leaking in this area (red circle) but it doesn’t happen anywhere
else in our body. Just like for example sodium, glucose and amino acids and other smaller molecules can leak out
from the arteriole (red circle) towards the bowman’s space.

How does it happen?

a. Inside the glomerular capillaries (red arrow) you can see smaller molecules such as sodium and glucose and you also have
large protein molecules; Since they are large, normally they cannot pass through the blood vessels.
§ You have to take note that the lining of this capillary is filled with endothelial cells (purple arrow) which are
“fenestrated” or contains fenestrations – that means they contain holes or pores.
b. The holes will allow these smaller molecules to pass through the glomerular capillaries toward the bowman’s space and other
proteins are also allowed to leak through it but larger proteins can’t leak towards the bowman’s space because there’s another
layer that sits in between endothelial cells.
§ It’s like a membrane but it’s not a complete barrier. It is called the “basement membrane” (light blue arrow)
§ Basement membrane is semi-permeable. It makes sure that small things can pass through this glomerular capillaries just
like sodium, amino acids, glucose but the bigger proteins bounce back either because they can’t make it through the
fenestration or the basement membrane prevents them from leaking into the bowman’s space.
c. Another layer would be the tubular cells (green arrow); they are like long cells. This tubular cells make up the interaction point
on the end of the bowman’s capsule.
§ Sometimes their structure looks like they are anchored to the endothelial cells. They have this leg-like projections
called “podocytes” meaning foot (blue arrow).
§ This podocytes in addition to tubular cells will help that the connection between the endothelial cells and the basement
membrane will stay close. That’s how some of the substances passes through this layer of cells while other substances
such as larger proteins cannot make it through the fenestration or cannot make it through the basement membrane and
eventually to the tubular cells; not all substances can pass through the glomerulus towards the bowman’s space.

Parts of the Nephrons.

The nephron which is the functional unit of the kidney lies between the renal cortex and the renal medulla.
Each of our kidney contains 1.5 million of nephrons.
a. Main site of filtration is a tuft of capillaries known as the “glomerulus”.
b. Bowman’s capsule
c. Proximal convoluted tubule
§ Proximal because it is near to the glomerulus
§ Convoluted because the structure of this PCT has a lot of twist and turns
§ Reabsorbs a lot of electrolytes (sodium, glucose and etc.)
Ø And because sodium is reabsorbed in this area, water is also reabsorbed in the PCT.
d. Loop of Henle
§ We have the descending limb and the ascending limb
Ø Both limbs have opposite directions and they also reabsorb different kinds of things.
§ Descending limb – mainly reabsorbs water; permeable to water but impermeable to ions.
§ Ascending limb -- permeable to ions (Na, Cl, K) but impermeable to water

Because of the opposing directions, we have the system called “counter current multiplication”

§ Counter current owing to the fact the limbs of the loop of Henle have opposing directions
§ Multiplication because that means when we reabsorb ions in the ascending limb it will make the medulla salty.
Ø With that by not reabsorbing water and only ions are allowed to be reabsorbed here that drives water to be
reabsorbed passively in this descending limb. Passive means the water is reabsorbed without the expenditure of
energy.
 § In the ascending limb, active transport is used to reabsorb ions. By actively pumping ions into the
medulla and no wateris reabsorbed in the area, the medulla (lower portion) will become very salty so
the amount of water that are passively reabsorbed in the descending limb can then be multiply.
§ All the substances that are reabsorbed in your kidney go to the space which we call as the
“Interstitium” or interstitialspace. (violet random drawings)
e. Distal convoluted tubule
§ Distal because it’s somewhat away from the glomerulus and the convoluted tubule
§ Reabsorbs other ions such as sodium and chloride; picks up more important nutrients that
are needed in ourbloodstream
§ Passes through or comes closely to the glomerulus. When that happens, the DCT comes closer to
the glomerulus, itcreates the structure known as the “juxtaglomerular apparatus”
Ø This structure (juxtaglomerular apparatus) is mainly responsible for controlling our blood pressure.
f. Collecting duct
§ Take note that this collecting duct contains many DCTs
§ Gathers all materials that has not returned to the blood and dispose it as urine.
§ Again, from the nephron, the urine will go out and will touch first the renal calyces down to the renal
pelvis down to the ureter. That is how the kidneys dispose those filtrate and unnecessary substances
out of our body and also you have to take note that water is also reabsorbed in the collecting duct and
aside from water, urea is also reabsorbed from the collecting duct. This urea is one of the main waste
product of the kidney. It is reabsorbed in the collecting duct just to help maintain the osmolarity of the
medulla. When the ions are reabsorbed in the ascending limb and urea is reabsorbedin the collecting
duct, that means it will drive again the passive reabsorption of water in the descending loop of henle.
Take note: the renal medulla is very salty because there are a lot of ions reabsorbed in the area.

To sum it up, the blood coming from the renal artery will pass through this renal
arteriole which will eventually pass through the glomerulus and will be filtered in here
and the toxic substances and the necessary materials will not be caught in this bowman’s
space down to the proximal convoluted tubules down to this descending loop of henle
towards the ascending loop of henle towards the distal convoluted tubule and eventually
to the collecting duct and that filtrate will now be discarded as urine and the filtered
blood, those that contains necessary materials and necessary substances which are
needed by the body will pass through this efferent arteriole and then that efferent
arteriole will branch off into smaller capillaries so this smaller capillaries will now
collect all the remaining materials coming from the interstitium because it surrounds
your nephron this is what we call as the peritubular capillaries and eventually this
peritubular capillaries will branch off as this renal vein. This renal vein will now return
the filtered blood coming from the kidney towards the blood stream to the rest of the
body. That’s how the blood is being filtered and reabsorbed and delivered from the
heart, towards the kidney and out from the kidney, the rest of the body

Again, the functional unit of the kidney is the nephron. The nephron is consist of glomerulus
and the tubules. The glomerulus mainly functions for filtration and the tubules mainly function
for reabsorption and secretion

The glomerulus again is wrapped in what we call as the bowman’s capsule. The glomerulus plus
the bowman’s capsule collectively we call them as the renal corpuscle.

The main difference between reabsorption and secretion is that when we say reabsorption, all
the materials in the tubules and all the materials reabsorbed from the interstitium will be
returned to the blood. That is from the tubule to the blood. Opposite to that is the secretion.
From the blood towards the tubule.

Functions of the kidneys

Excretion
§ Elimination of metabolic waste products through the formation of urine
§ This is the job of your nephrons

3 main functions of the kidney when talking about excretion:

a. Glomerular filtration
b. Tubular filtration
c. Tubular secretion
Synthetic
§ The kidney is capable of producing a lot of substances

Erythropoietin Renin Prostaglandins

Remember that EPO or Erythropoietin is Regulate the water and sodium balance in the Maintains the balance of the fluid and
produced by your kindeys but the action of body especially if you have low blood volume electrolyte in the body
this erythropoietin is towards your bone or low blood sodium. This renin will get
marrow to increase the production of your activated in order to maintain homeostasis in Functions for uterine contractions and also
RBCs this substances in lowering the BP
Metabolic
§ Inactivation of aldosterone, glucagon, insulin
- Take note that the main function of aldosterone is that it reabsorbs sodium and it excretes potassium
- Any defect or imbalance in aldosterone level will lead to imbalances to your sodium and potassium
- Glucagon increases blood sugar and insulin lowers blood sugar

§ Activation of vitamin D to its active form Vitamin D3

How does kidney convert Vitamin D?
- The vitamin D that we get from sunlight or from supplements that we take, this kidney will transform it into its active form because
without the kidney this vitamin D cannot be used up by the body since the vitamin D that we are acquiring from the external environment
is still inactive. That’s why when you have chronic kidney diseases for example you can expect low levels of vitamin D
§ Formation of creatine
- This is very important for muscle contractions

To sum up the function of kidney, we have here the Mnemonic: A WETBED

Acid-Base balance
Water balance
Electrolyte balance
Toxin removal
Blood pressure control
Erythropoietin production
Vit D metabolism

Major NPNs in the blood

Urea
§ the major NPN compound in the plasma

Other constituents: (in decreasing order)

• Amino acids
• Uric Acids
• Creatinine
• Creatine
• Ammonia (very toxic, very very little amount can be found in the blood)

Mnemonic: AUCCA = All Underarms Create Cheesy Aroma Basic structure of amino acid

§ One of the MAJOR PRODUCTS of excretion of protein catabolism

- we have to remember that the body is unable to store proteins or amino acids so that means when excessive
amount of proteins are ingested, the excess amino acids produced from this digesting proteins are
transported from our small intestine towards the liver . That is the reason why this urea is formed in the
liver from this CO2 and ammonia.
§ Formed in the LIVER from CO2 and the ammonia (toxic product) generated from the deamination of
amino acids
§ What will happen now is that when the amino acids are absorbed by the liver cells, a
§ series of chemical reactions begin so the amino acid now is oxidized in the presence of an enzyme catalyst in your liver
§ Process of deamination = there is a removal of the amine group and together also with the hydrogen atom. This reaction will produce a
toxic product = AMMONIA

Take note: Ammonia is highly toxic so therefore it cannot be allowed to accumulate so with the help of specific catalyst in the liver cells, the
CO2 now will react chemically w/ this ammonia that was produced. Once the CO2 reacts to the ammonia, a less toxic nitrogenous compound,
UREA, is produced together with water.

§ That is how urea is produced, coming from the ammonia

§ Over 90% is excreted, partially (around 10%) are reabsorbed along with water
§ Readily filtered from the plasma by the glomerulus (since this is an NPN, so it’s smaller in size compared to proteins)
§ One of the most popular test for assessing renal function (however this is not that specific an sensitve because.. *read below)

a) 70-80% of glomerular destruction must occur first before there is an increase in the level of plasma urea
b) Concentration of urea in the plasma is an indicator of renal function and perfusion (blood flow), also the dietary intake of protein will
also be reflected by the level of urea and the level of CHON metabolism because again this is the major product of protein catabolism
c) Measurement of plasma urea is further enhanced when results are considered together with serum creatinine. (because again, Urea is not
that sensitive, glomerulus has to be destroyed first around 70-80% must occur first before the urea will be increased unlike creatinine
which is more sensitive to urea test.) (urea is greatly affected by the intake of your proteins in your diet while creatinine is not affected
by the protein diet)

Clinical Significance
Azotemia – an elevated concentration of urea in the blood
- pre-renal azotemia
- renal azotemia
- post-renal azotemia
Uremia – a very high plasma urea concentration accompanied by renal failure (uremic syndrome; difference between azotemia)
Pre-renal azotemia
§ Related to the renal circulation
§ The flow of blood to the kidneys
§ Normal renal function of the kidney (kidneys don’t have any problem at all but it is on the flow of the blood towards the kidneys)
§ Conditions: congested heart failure, shock, hemorrhage, dehydration (all of these conditions slow down the flow of the blood towards
your kidneys)

Ex: in normal conditions, urea goes through the kidneys for excretion and reabsorption.
If there is a prerenal problem because of the conditions mentioned, the urea doesn’t make it to the kidney’s to be filtered, so there is an
increase or build-up of urea in the blood and that leads us to pre-renal azotemia

Other related conditions:

• High-protein diet (urea is greatly affected by protein consumption)
• Muscle wasting (starvation)
• Glucocorticoid treatment
• Increased chon breakdown (stress, fever)
Renal azotemia
§ involves the kidney – there is a lack of ability to function correctly
§ Decrease ability to excrete substances and one of that is urea
§ Conditions:
• Acute/chronic renal failure
• Glomerulonephritis
• Tubular necrosis
• Chronic nephritis
• Polycystic kidney
§ Kidneys are affected so it has no capability to filter the urea so the urea now will stay in the blood
leading to renal azotemia
Post-renal azotemia
§ The function of kidney is also normal similar with pre-renal azotemia and no problems in the blood flow towards your kidneys
§ Obstruction of the flow of the urine from the kidneys
§ Increase diffusion of urea from the renal tubule into the circulation
§ Post-renal azotemia usually comes from the issues in the ureters and bladder

For ex: you have kidney stones, UTI or tumors

So what will happen is that urea can’t be excreted out to your urine so it stays in your blood leading to post-renal azotemia
Creatinine
§ The main storage component of high energy phosphate needed for muscle metabolism
§ Anhydride of creatine
ú Creatinine is formed once the creatine loses water and it is not reused in the body’s metabolism that’s why creatinine is only a
waste product
§ Synthesize mainly in liver from three amino acids
ú Arginine
ú Glycine
ú Methionine
§ Filtered & secreted, not reabsorbed
ú That’s why you only have very little amount of creatinine in the blood
§ Less affected by intake and excretion
ú Unlike urea, this is less affected by intake and excretion such as the intake of proteins
§ Most commonly used in the assessment of GFR (Glomerular Filtration Rate)

Ø Clinicopathologic Correlation
§ Increased (elevated) Creatinine in blood
In cases of:
ú Skeletal muscle necrosis or atrophy
- Creatinine is the anhydride of creatine and the body content of creatine in normal men usually is proportional to the muscle
mass so if there’s skeletal muscle necrosis or atrophy, elevated levels of creatinine in the blood is expected
ú Decrease in glomerular filtration rate
Creatinine clearance
§ Test commonly performed in the laboratory
§ Reported in milliliters per minute
§ 2 specimens are needed
ú Serum or plasma from the px
ú Urine specimen from the px for 24 hrs

Calculation:
𝑈𝑟𝑖𝑛𝑒 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 (𝑚𝑔⁄𝑑𝐿) 𝑥 24 ℎ𝑟 𝑢𝑟𝑖𝑛𝑒 𝑣𝑜𝑙𝑢𝑚𝑒
𝐶𝐶(𝑚𝐿⁄𝑚𝑖𝑛) =
𝑆𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 (𝑚𝑔⁄𝑑𝐿)𝑥 1440 (𝑚𝑖𝑛𝑠 𝑖𝑛 24 ℎ𝑟𝑠)
To make it short:
𝑈𝑉
𝐶𝐶 =
𝑃𝑥1440
Example:
A patient with 24-hour urine volume is 2000 mL and a creatinine level of 50 mg/dL. The serum creatinine is 1.0 mg/dL. Determine
the creatinine clearance.
𝑈𝑉
𝐶𝐶 =
𝑃 𝑥 1440
50 𝑚𝑔⁄𝑑𝐿 𝑥 2000 𝑚𝐿
𝐶𝐶 =
1.0 𝑚𝑔⁄𝑑𝐿 𝑥 1440
CC= 69 mL/ min
 Uric acid (urate)
§ The breakdown product of nucleic acid and purine catabolism in humans
ú Purines are normally found in food such as
- Liver
- Dried beans
- Peas
- Beer
§ At pH 7.4, (normal blood pH) more than 95% of uric acid in the body fluids exist as monosodium urate
§ Take note that uric acid formation occurs only in tissues that contain the enzyme Xanthine oxidase
ú Mainly responsible or mainly involved in purine metabolism
ú It will catalyze the oxidation of Xanthine to Uric acid
ú Highest levels of Xanthine oxidase are primarily found in the liver but it can also be found in the heart, pulmonary, and adipose
tissues
- All of these tissues that contain the Xanthine oxidase, uric acid formation could also occur in here
§ 90% of the uric acid are reabsorbed through active transport
§ Uric acid is synthesized in the liver and intestine (intestinal mucosa)

Ø Clinicopathologic Correlation
§ Gout – comprises of heterogeneous group of disorders such as:
ú Hyperuricemia
- Increased uric acid
ú Attacks of acute inflammatory arthritis
- Inflammations in the hands, knees, and feet of the px—usually in the joints of the patient
ú Deposition of monosodium urate crystals throughout the body
- Because of this px is prone to Nephrolithiasis or kidney stones or calculi
ú Nephrolithiasis

Ammonia
§ Toxic to the body, dispose as urea
§ Derived from bacterial action on the contents of the colon
§ Metabolized by the liver normally
ú With the process of deamination and also with the help of the carbon dioxide & water molecule
§ Increased plasma ammonia is toxic to CNS
ú That’s why most ammonia is ultimately disposed as urea

Ø Clinicopathologic Correlation
§ Altered ammonia metabolism occurs in severe liver diseases
ú Because this ammonia can’t be removed by the liver so it stays in the blood so it’s increased in the
blood and it could affect the CNS
§ Elevated in REYE’s syndrome (condition in children)
ú Acute encephalopathy associated with hepatic dysfunction but without hyperbilirubinemia
ú Survival reaches to 100% if plasma ammonia concentration remains below 5 times the normal
ú Normally, cause is unknown but usually associated with aspirin consumption especially in children affected with viral illnesses
ú Both liver and kidneys are affected
Amino acids
§ Readily reabsorbed in the renal tubules by active transport
§ <5% are excreted in the urine
ú That’s why after urea, this is the most abundant NPN

Ø Clinicopathologic Correlation
§ Increased urinary excretion of AA fall under 2 major types
ú OVERFLOW aminoacidurias
- Increased urinary excretion of these AA with increased plasma concentration of AA
- Caused by: Acquired secondary or inborn error of metabolism
ú RENAL aminoacidurias
- Diminished tubular reabsorption
- Caused by: Acquired secondary or inborn specific or nonspecific disorder of the renal tubular reabsorptive mechanism
o The problem here lies in the fact that the renal tubules can’t readily reabsorb the amino acids that’s why there’s
increased urinary excretion of AA