Renal Function Test

Introduction
The kidneys playavital role in the excretion of waste products and toxins such as
urea, creatinine
and uric acid, regulation of extracellular fluid volume, serum
osmolality and electrolyte
concentrations, as well as the production of hormones like erythropoietin and 1,25 dihydroxy
vitamin Dand renin. The functional unit of the kidney is the nephron, which consists of
the
glomerulus, proximal and distal tubules, and collecting duct. Assessment of renal function is
important in the management of patients with kidney disease or pathologies affecting renal
function. Tests of renal function have utility in identifying the presence of renal disease,
monitoring the response of kidneys to treatment, and determining the progression of renal
disease. According to the National Institutes of Health, the overall prevalence of chronic kidney
disease (CKD) is approximately 14%. Worldwide, the most common causes of CKD are
hypertension and diabetes.

Specimen Collection
Specimern collection requirements are dependent on the procedure or test requested. Generally,
for serum creatinine and blood urea nitrogen (BUN) levels, no additional patient preparation is
required, and a random blood sample suffices. However, the effect of recent high protein
ingestion may increase serum creatinine and urea levels to a significant extent. Also, hydration
status can have a considerable impact on BUN measurement.
For timed urine collections such as the 24-hour urine creatinine clearance, it is essential that
urine be collected accurately over the required periodas under or over collection will affect final

results. Hence, a5 to 8-hour timed collection is preferable to a 24-hour collection.

The collection of midstream urine for urine analysis is required as this sample is less likely to be
contaminated by epithelial cells and commensal bacteria.

Procedures
Assessment of Renal Function
There are several clinical laboratory tests that are useful in investigating and evaluating kidney
function. Clinically, the most practical tests to assess renal function is to get an estimate of the
glomerular filtration rate (GFR) and to checkfor proteinuria(albuminuria).

Glomerular Filtration Rate

The best overall indicator of the lomerular function is the glomerular filtration rate (GFR) GR
is the rate in milliliters per minute at which substances in plasma are fitered through the
glomerulus, in other words, the clearance of asubstance from the blood. The normal GFR for an
adult male is 90 to 120 mL per minute. The characteristics of an ideal marker of GFR are as
follows:
It should appearendogenously in the plasma at a constant rate
It should befreely filtered at the glomerulus
It can be neither reabsorbed nor secreted by the renal tubule
It should not undergo extra renal elimination.
Assessment
As no such endogenous marker currently exists, exogenous markers ofGFR are used.
method for the estimation of
of GFR using inulin, a polysaccharide, is considered the reference
levels after a specified
GFR. It involves the infusionof inulin and then the measurement of blood
exogenous markers used are
period to determine the rate of clearance of inulin. Other
acid (51 Cr-EDTA), and
radioisotopes such as chromium-51 ethylene diamine-tetra-acetic
most promising
technetium-99-labeled diethylene-triamine-pentaacetate (99 Tc-DTPA). The
agent, iohexol, especially in children,.
exogenous marker is the non-radioactive contrast
exogenous markers, specifically that the testing
The inconvenience associated with the use of
be performed in specialized centers, and the difficulty to assay these substances, has
has to
markers.
encouraged the use of endogenous

Creatinine function i
used endogenous marker for the assessment of glormerular
The most cornmonly of GER Thie
calculated clearance of creatinine is used to provide an indicator
creatinine, The
timed
collection of urine over a24-hour period or preferably over an accurately
involves the
since 24-hour collections are notoriously unreliable. Creatinine clearance
period off5 to 8hours
equation:
is thencalculated using the
2
 C=(Ux V) /P
C= clearance, U = urinary concentration, V = urinary flow rate (volume/time i.e.
ml/min), and P
= plasma concentration

Creatinine clearance should be corrected for body surface area. Improper or incomplete urine
collection is one of the major issues affecting the accuracy of this test; hence timed collection is
advantageous. Furthermore, due to tubular secretion, creatinine overestimates GFR by around
10% to 20%.

Creatinine is the by-product of creatine phosphate in muscle, and it is produced at a constant

rate by the body. For the most part, creatinine is cleared from the blood entirely bythe kidney.
Decreased clearance by the kidney results in increased blood creatinine. The amount of
creatinine produced per day depends on muscle bulk. Thus, there is a difference in creatinine
ranges between males and females with lower creatinine values in children and those with
decreased muscle bulk. Diet also influences creatinine values. Creatinine can change as much as
30% after the ingestion of red meat. As GFR increases in pregnancy, lower creatinine values are
found in pregnancy. Additionally, serum creatinine is a later indicator of renal impairment-renal
function is decreased by 50% before a rise in serum creatinine is observed.
Serum creatinine is also utilized in GER estimating equations such as the Modified Diet in Renal
Disease (MDRD) and the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation.
These eGFR equations are suprior to serum creatinine alone since they include race, age, and
gender variables. GFR is classified into the following stages based on kidney disease.
Kidney Disease Improving Global Outcomes (KDIGO) stages of chronic kidney disease (CKD):
Stage 1 GFRgreater than 90 ml/min/1.73 m²
Stage 2 GFR-between 60 to 89 ml/min/1.73 m²
Stage 3a GFR45 to 59 ml/min/1.73 m²
Stage 3b GFR 30 to 44 ml/min/1.73 m²
Stage 4 GFR of 15 to 29 ml/min/1.73 m²
disease)
Stage 5-GFR less than 15 ml/min/1.73 m² (end-stage renal
This provides an easier estimation of GFR without the collection of urine or the use of exogenous
materials. However, as they utilize serum creatinine, they are also affected by the issues around
serum creatinine measurement; hence the correction Tor the race, gender, and age is reguired
Blood Urea Nitrogen (BUN)
Ureaor BUN is anitrogen-containing compound formed in the
liver as the end product of protein
metabolism and the urea cycle. About 85% of urea is eliminated via kidneys, the rest re is excreted
viathe gastrointestinal (GI) tract. Serum urea levels increase in conditions
where renal clearance
decreases (in acute and chronic renal failure/impairment). Urea may also increase in other
conditions not related to renal diseases such as upper Gl bleeding, dehydration, catabolicstates,
and high protein diets. Urea may be decreased in starvation, low protein diet, and severe liver
disease. Serum creatinine is a more accurate assessment of renal function than urea; however,
urea is increased earlier in renal disease.
The ratio of BUN:creatinine can be useful to differentiate pre-renal from renal causes when the
BUN is increased. In pre-renal disease, the ratio is close to 20:1, while in intrinsic renal disease, it
is closer to 10:1. Upper GI bleeding can be associated with avery high BUN to creatinine ratio
(sometimes >30:1).

Cystatin C
protease inhibitor produced by
Cystatin Cis alow-molecular-weight protein that functions as a
constant rate and freely filtered by the kidneys.
all nucleated cells in the body. It is formed at a
In
correlated with the glomerular filtration rate (GFR).
Serum levels of cystatin C are inversely
values indicate low GFRs, while lower values indicate higher GFRS, similar to
other words, high filter
renal handling of cystatin C differs from creatinine. While glomeruli freely
creatinine. The renal
cystatin C is filtered, it is reabsorbed and metabolized by proximal
both, once
under normal conditions, cystatin C does not enter the final
tubules, unlike creatinine. Thus, urine. The
significant degree. Cystatin C is measured in serum and
excreted urine to any bulk. or diet
over creatinine are that it is not affected by age, muscle
advantages of cystatin C
it is a more reliable marker of GFR than creatinine
indicated that
and various reports have into eGFR equations.
Chas also been incorporated
particularly inearly renal impairment. Cystatin
KDIGO CKD-EPl equation.
such as the combined creatinine-cystatin and
affected by the presence of cancer, thyroid disease.
Cystatin Cconcentration may be
smoking.

4
 Albuminuriaand Proteinuria
Albuminuria refers to the abnormal presence of albumin in the urine. Microalbumin, considered
an obsolete term as there is no such biochemical molecule, is now referred to only as
urine
albumin. Albuminuria is used as a marker for the detection of incipient nephropathy in diabetics.
It isan independent marker for the cardiovascular disease since it connotes increased endothelial
permeability, and it is also a marker for chronic renal impairment. Urine albumin may be
measured in 24-hour urine collections or early morning/random specimens as an

albumin/creatinine ratio. The presence of albuminuria on two occasions with the exclusion of a
urinary tract infection indicates glomerular dysfunction. The presence of albuminuria for three
or more months is indicative of chronic kidney disease. Frank proteinuria is defined as greater
than 300 mg per day of protein. Normal urine protein is up to 150 mg per day (30% albumin;30%
globulins;40% Tamm Horsfallprotein). Increased amounts of protein in the urine may be due to:
Glomerular proteinuria: Caused bydefects in permselectivity of the glomerular filtration barrier
to plasmaproteins (for exampl, glomerulonephritis or nephrotic syndrome)
Tubular proteinuria: Caused by incomplete tubular reabsorption of proteins (for example,
interstitial nephritis)
Overflow proteinuria: Caused by increased plasma concentration of proteins (for example,
multiple myeloma-Bence Jones protein, myoglobinuria)
Urinary tract inflammation or tumor
Urine protein may be measured using either a24-hour urine collection or random urine protein:
creatinine ratio (early morning sample is preferred since it is anear representative of the 24-hour

sample).
albuminuria:
The KDIGO classification defines three stages of
A1: Less than 30 mg/g creatinine
A2: 30 to 300 mg/g creatinine
A3: Greater than 300 mg/g creatinine
day and is associated with
In nephrotic syndrome, urine protein excretion exceeds 3.5 g per
hypercholesterolemia.
edema, hypoalbuminemia, and

Tests of Tubular Function

5
The renal tubules playa vitalrole inthe reabsorptionof electrolytes, water, and maintaining aid
base balance. Electrolytes sodium, potassium, chloride, magnesium, phosphate as well as
glucose can be measured in urine. Measurement of urine osmolality allows for assessment o
concentrating ability of urine tubules. Aurinary osmolality higher than 750 mOsmol/Kg H20
implies a normal concentrating abilityof tubules. Awater deprivation test can be used to ezclude
nephrogenic diabetes insipidus. Also, in distal renal tubular acidosis (RTA), an arnmoniun
chloride test can be used to confirm the diagnosis of distal RTA with failure to acidify the urine to

a pH of less than 5.3. In Fanconi's syndrome, there is aminoaciduria, glycosuria, phosphaturia,

and bicarbonate wasting (proximal RTA).

Urine Analysis
to aid in disease diagnosis. It
Urine analysis involves the assessment of urine characteristics
examination. The physical inspection
consists of physical observation,chemical, and microscopic
straw-colored, while in the presence of
involves assessing color andclarity. The normal urine is
hematuria or porphyria or could
dehydration, urine is darker in color. Red urine may indicate
urine may be seen in the presence of
represent the dietary intake of food like beets. Cloudy
gravity is an indicator of the renal concentrating
pyuria due to urinary tract infection. Specific
or chemically by the use of urine dipstick.
ability, which can be measured using refractometry
increased in
is 1.003 to 1.030. Specific gravity is
The physiological range for specific gravity
concentrated urine and decreased in dilute urine.
analysis.
of different analytes in urine using chemical
Urine dipstick provides qualitative analysis
chemistry methods to detect the presernce of protein, glucose, blood, ketones,
Dipstick uses dry point
urobilinogen, nitrite, and leukocyte esterase. The dipstick can be performed as a
bilirubin,
following interaction of the urine with the chemical reagents
of-care test. The color changes interpret the
of the dipstick are compared to the color chart guide to
impregnated on the paper
results.
urine specimens.
dipstick-protein should not be detectable in healthy
Analytes tested on urine patients but may be
in healthy
detected in normal urine. Glucose is not detected
Bilirubin is not mg/dl
renal glycosuria when the renal threshold of 180
pregnancy, and
seen in diabetes mellitus, and some antibiotics may affect
results
(vitamin C)
presence of ascorbic acid causing a falsely
isdecreased. The infection, with ascorbic acid
after renal tract injury or
Blood may be present
6
negative result. Urine dipstick detects the globin portion of hemoglobin, and thus cannot detect
the difference between the presence of myoglobin or hemoglobin in urine.
Additionally, both intact red blood cells (RB) and hemoglobinuria are detected. The presence of
"blood" on urine dipstick test with normal RBC indicates rhabdomyolysis and can help
differentiate it from hematuria, where RBCs are also detected on the urine dipstick. In normal
urine, RBC per high-power field is between 0 to 3 and white blood cells (WBC) between 0 to 5.
Ketones are present in fasting, severe vomiting, and diabetic ketoacidosis. Urine dipstick only
detects acetoacetate and acetone, not the ketone beta-hydroxybutyrate. Bilirubin is detected in
the presence of conjugated hyperbilirubinemia. Urobilinogen may typically be present, but it is
absent in conjugated hyperbilirubinemia and increased in the presence of prehepatic jaundice
Some
and hemolysis. Nitrite and leucocyte esterase are indicators of urinary tract infection.
bacteria, for example, Enterobacteriaceae, convert nitrates to nitrites.
of cells,
The microscopic analysis involves awet-prep analysis of urine to assess the presence
usually denote
casts, and crystals as well as micro-organisms. Red blood casts
glomerulonephritis, while white blood cellcasts are consistent with pyelonephritis. The presence
renal injury; RBC
of white blood cells and WBC casts indicates infection; red blood cells indicate
protein and may
casts indicate tubular damage or glomerulonephritis. Hyaline casts consist of
syndrome. Crystals may also be
occur in glomerular disease. Fatty casts are seen in nephrotic
identified in urine and are indicative of the following conditions:
appearance and can be seen in alkaline urine and
Triple phosphate crystals have the "coffin-lid"
urinary tract infection.

associated with gout.

Uric acidcrystals are needle-shaped and are
present inethylene glycol poisoning or primary and
Oxalate crystals are envelope-shapedand are
secondary hyperoxaluria.

observed in cystinuria.
Cystine crystals are hexagonal and are
is a freshly voided midstream urine. Midstream urine is less
analysis
The best specimen for urine
commensal bacteria and epithelial cells.
likely to be contaminated by
Acute versus Chronic Renal Impairment
Acute renal impairment or acute kidney injury (AKI) refers to the sudden onset of kidney injury
within a period of afew hours or days. Chronic kidney disease (CKD) is caused by long-term
diseases such as hypertension and diabetes. Causes of acute kidney injury can be divided into

The following:
causes), for example,
Causes that result in decreased blood flow to the kidneys (pre-renal
major trauma
hypotensive and cardiogenic shock, dehydration, and blood loss from
direct damage to the kidneys (renal /intrinsic causes) such as
damage to
Causes that result in
cancers such as myeloma,
kidneys by nephrotoxic medications and other toxins, sepsis,
damage to the kidney tubules
autoimmune diseases or conditions that cause inflammation, or
as bladder, prostate, or cervical cancer,
Causes that result in blockage of the urinary tract such
tract
large kidney stones, and blood clots in the urinary
(ATN)
important to note that pre-renal kidney injury may progress to acute tubular necrosis
It is
and cause intrinsic renal injury.
function and is used in guidelines to define AKI.
Urine output is a useful tool forevaluating kidney
400ml per day). The RIFLE classification (risk,
Patients with AKIpresent with oliguria (less than
on serum
and end-stage kidney disease) is based
injury, failure, loss of kidney function,
determinants. The Acute Kidney Injury Network (AKIN)
creatinine, GFRchanges, and urine output
it
creatinine changes and urine output; however,
classification criteria for AKI also uses serum
not relyon GFR changes and does not require a baseline serum creatinine.
does diagnosis of
investigations apart from serum creatinine play a vital role in the
Other laboratory important,
differentiating between different types of acute kidney injury. This is
AKI and assist in pre-renal
appropriate patient management, with patients that have
as it will determine the causes
replacement. In contrast, those with renal and post-renal
causes being treated with fluid
conservatively.
would be given fluids more
renal injury is pre-renal, renal, or post-renal include
if the
Investigations that assist in determining
which is increased (greater than 1.020) in dehydration
specific gravity,
the measurement of urine cells, tubular epithelial cells, casts, or
and red blood
presence of white
and pre-renal causes. The assist in the differential diagnosis.
microscopy can
sediment under light
crystals in the urinary

8
 Fractionalexcretion of sodium (FeNa) is useful in distinguishing acute tubular necrosis from pre
renal uremia. It requires the measurenment of serum creatinine and sodiun and measurernent of
creatinine and sodium in spot urine specimens. Fractional excretion is calculated using the
following formula:

FeNa = 100 x (urinary sodium x serum creatinine) / (serum sodium x urinary creatinine).
intrinsic
Avalue of less than 1% indicates a pre-renal cause, and values greater than 2% indicate
not reliable. Spot urine
causes. However, in patients receiving diuretic therapy, the FeNa is
AKI. Fractional
sodium concentrations of less than 20 mmol/| are an indicator of pre-renal
instead of sodium
excretion of urea calculated similarly to FeNa using serum urea and urine urea
intrinsic AKI, with values less than
can also be used to determine the presence of pre-renal versus
than 500 mOsm/Kg is associated
35% suggesting pre-renal injury. A urine osmolality of greater
(approximately 300 mOsm/kg)
with pre-renal causes, while an osmolality similar to serum
reflects an intrinsiccause.

Novel Biomarkers
determination of AKI and have
Several new biomarkers have been reported to be useful for the
pre-renal and intrinsic AKI. These include
utility in differentiation between AKland stable CKD and
circulation and undergo
low-molecular-weight proteins, which are present in the systemic
and retinol-binding protein)
glomerular filtration (for example, cystatin C, beta2-microglobulin,
injury (NGAL (Neutrophil gelatinase
and proteins that are produced in response to cellular/tissue
fatty acid-binding protein (L-FABP),
associated lipocalin), Kidney injury molecule 1 (KIM-1), L-type
beta-trace protein). Their optimum clinical utility will be
FGF23 (Fibroblast growth factor 23), and
realized with ongoing studies.

Indications
to
assessment of renal function are varied and range from acute emergency
Indications for the
renal function tests are performed to identify the renal disease to
chfonic settings. Primarily,
management and prevent further deterioration of renal function
determine appropriate patient
whom the renal disease has been identified are to stage level
Further indications in patients in
disease to ensure that optimal
disease and to monitor the progression of renal
or type of renal
management occurs timeously and to monitor response to
renal function tests may be required to establish and interventions In other scenarios,
monitor renal function where a known or
possibly nephrotoxic therapeutic agent is initiated for patient
are also indicated in those
management Renal function tests
individuals who are transplant donors to assess the initial donor
suitability, and after that, to detect any significant deterioration of renal function post donation
Tests of renal function can also be utilized to identify which area of the
functional unit of the
kidney (nephron) is affected, for example, glomerular versus tubular disease.

Potential Diagnosis
Tests of renal function can be used to assess overall renal function by direct measurement or
estimation of the glomerular filtration rate. Estimation of the GFR is utilized to determine the
presence of renal impairment. If reduced over a specified period, it can identify the presence of
chronic kidney disease as well as its staging. Additionally, tests of renal function can be utilized
to determine ifthe renaldisease is acute or chronic. In the case of urine albumin, it can be used
to detect incipient nephropathy in at-risk patients, for example, in patients with diabetes.
Disorders of tubular function such as Fanconi syndrome can be detected using tests of renal

function, in particular, the measurement of urine amino acids, glucose, phosphate, and pH.

Normal and Critical Findings

minute. A GFRof less than 15 ml perminute
The normal GFR for an adult male is 90 to 120 ml per
renal replacement therapy, e.g., dialysis. The
isconsidered to be end-stage renal failure requiring
may be
normal GFR does not exclude the presence of renal disease, which
presence of a
albuminuria/proteinuria or imaging.
evidenced bythe presence of
age and gender.
intervals for serum creatinine and urea are dependent on
Reference the collection
of
electrolytes in urine depends onthe hydration status,duration
The presence of intervals are often wide and dependant
pathological factors, and reference
of urine apart from
on the clinical context.

Interfering Factors
Creatinine
management occurs timeously and to monitor response to interventions. In other
scenarios,
renal function tests may be required to establish and monitor renal
function where a known or
possibly nephrotoxic therapeuticagent is initiated for patient management. Renal function tests
are also indicated in those individuals who are transplant donors to
assess the initial donor
suitability, and after that,to detect any significant deterioration of renal function post-donation.
Tests of renal function can also be utilized to identify which area of the functional unit of the

kidney (nephron) is affected, for example, glomerular versus tubular disease.

Potential Diagnosis
Tests of renal function can be used to assess overall renal function by direct measurement or
estimation of the glomerular filtration rate. Estimation of the GFR is utilized to determine the
presence of renalimpairment. If reduced over a specified period, it can identify the presence of
chronic kidney disease as well as its staging. Additionally, tests of renal function can be utilized
be used
to determine if the renal disease is acute or chronic. In the case of urine albumin, it can
diabetes.
to detect incipient nephropathy in at-risk patients, for example, in patients with
using tests of renal
Disorders of tubular function such as Fanconi syndrome can be detected
phosphate, and pH.
function, in particular, the measurement of urine amino acids, glucose,

Normal and Critical Findings

minute
120ml per minute. A GFR of less than 15 ml per
The normal GFR for an adult male is 90to
renal failure requiring renal replacement therapy, e.g., dialysis. The
is considered to be end-stage
be
does not exclude the presence of renal disease, which may
presence of a normal GFR
albuminuria/proteinuria or imaging.
evidenced by the presence of
age and gender.
intervals for serum creatinine and urea are dependent on
Reference of the collection
hydration status, duration
in urine depends on the
The presence of electrolytes wide and dependant
pathological factors, and reference intervals are often
of urine apart from
onthe linical context.

Interfering Factors
Creatinine

10
Preanalytical issues such as high-protein intake and increased muscle bulk may lead to elevated
creatinine levels, but it is not representative of the actual renalfunction in an individual. Likewise,
muscle
serum creatinine as a marker of renal function is often unreliable in those with decreased
Creatinine is
bulk such as the elderly, amputees, and individuals affected by muscular dystrophy.
commonly measured on automated analyzers using either acolorimetric reaction known as the
the formation of an alkaline
Jaffe reaction or an enzymatic assay. The Jaffe reaction involves
interferences (for example,
picrate. It is subject to negative (for example, bilirubin) and positive
have been made to overcome
ketones and proteins). Various modifications to the Jaffe reaction
some of these issues.

BUN
the presence of a high-protein diet or with
Serum urea/BUN concentrations may also be raised in
patients using oral corticosteroids.
Urine A/bumin and Protein
renal
the presence of conditions not related to
Urine albumin or protein may be increased in
Furthermore, in the presence of a urinary tract
disease, for example, posture, fever, and exercise.
intrinsic renal pathology present.
infection, urine protein levels may be raised without any

Complications
to
the majority of tests of renal function are rare apart from those related
Complications of
However,
Measurement of GFR using isotopes may expose to minimal radiation.
venepuncture.
experience
advised to have repeated exposures over short periods. Some patients may
it is not
containing iodine.
allergic reactions to radiocontrast agents

Patient Safety and Education small

isotopes, patients should be advised regarding the
radioactive
For GFR measurement using Pregnancy must be
test.
ionizing radiation they will be exposed to during this
amounts of
carried out.
female of child-bearing age before this test is
excluded in any regarding potential issues of
should be advised
are having blood drawn
In general, patients who
bruising and pain.
11
 Twentytour hour urine collection bottles may contain small amounts of
landdirect contact with skin and mucous preservatives such as
membranes must be avolded. Collection bottles
must be kept out of reach of small children who may
accidentally ingest the preservatives
contained inside.
nstients should also be advised to retain their regular intake of fluids before these tests.

Clinical Significance

Creatinine

Serum creatinine is elevated when there is a significant reduction in the glomerular filtration rate
or when urine elimination is obstructed. About 50% of kidney function must be lost before a rise
in serum creatinine can be detected. Thus serum creatinine is a late marker of acute kidney injury.

BUN
disease.
Serum urea/BUN level increases in acute and chronic renal
renal disease, stage of CKD, and to
eGFR equations are used to determine the presence of
monitor response to treatment.