Faculty of Laboratory diagnosis

Jing Hu
 Common tests used for urinary system disease
 Urine routine test
noninvasive
 Renal function test

 Renal biopsy/kidney biopsy

Invasive

pathological examination
 Renal function
 Excrete metabolic product: H2O, NH3
 Secrete: renin, erythropoietin
 Characteristics of renal function:
 powerful reserve ability(>2 millions
nephrons)
 individual variation
original urine

final urine
 To learn damage degree of kidney
 To decide the therapeutic regimen
 To estimate prognosis
 Serum creatinine (Scr)
 Endogenous creatinine clearance (Ccr)
 Serum urea (SU)
 Serum uric acid (Sua)
 Serum cystatin C (CysC)
 Glomerular filtration rate (GFR)---
 the volume of fluid filtered from
the renal (kidney) glomerular capillaries into
the Bowman's capsule per unit time.
 Describes the amount of plasma filtered across
the glomerular capillaries per unit time.
 Clearance rate:
 The clearance rate of a substance is the volume
of plasma in which that substance is cleared
completely out by kidneys per unit time.
 GFR is equal to the Clearance Rate
 when any solute is freely filtered
 and is neither reabsorbed
 nor secreted by the kidneys
 The rate therefore measured is the quantity of
the substance in the urine that originated from a
calculable volume of blood.
 It can pass glomerular filtration.
 It passes without renal tubular’s reabsorption
or secretion.
 Its detection method is simple, and has good
reproducibility.
 Its concentration in blood is constancy.
 Take a blank paper
 Write your name and number
 Answer question:
What is Glomerular filtration rate (GFR)？
 Except sample of Ccr has special requirments.
 Anticoagulated blood with heparin.
 Serum or plasma can be used.
 Adult males: 44~133 μmol/L
 Adult females: 70~106 μmol/L
 Scr is not increased until GFR decrease more
than 60% of normal.
 Scr is not the early indicator for kidney injury.
 Differentiate prerenal and renal oliguria
 prerenal oliguria(heart failure, dehydration, etc.) : Scr
↑<200μmol/L
 renal oliguria: Scr ↑>200μmol/L
 IncreasedScr occurs also in large muscle mass
(bodybuilders, etc.) and crush injury.
 Acute renal failure: Cr progressive elevation
(with oliguria)
 Chronic renal insufficiency:
 Compensatory renal failure：Scr < 178 μmol /L
 Decompensatory renal failure：Scr > 178 μmol /L
 Renal failure：Scr >445 μmol /L
 [Definition]
The volume of plasma in which the endogenous
creatinine is cleared completely out by kidneys
per minute is called endogenous creatinine
clearance (Ccr).
 Creatinine-free diet for 3 days before test.
 No meat
 Low protein
 Avoid heavy exercise.
 Avoid diuretic agent.
 The urine at 8:00am should be abandoned，
then all subsequent urine collected for 24 hrs.
 Plasma of empty stomach is needed.
 Detect the creatinine concentration in plasma
and urine.
 V: urine volume per min
 U: Cr conc. in urine
 P: Cr conc. in plasma
 Ccr (correct) = Ccr × 1.73 m2 (standard body
surface area) / the body surface area of the
patient
 Ccr 80~120 ml/min/1.73m2
 Ccr is more sensitive than SU and Scr in
evaluating the damage of renal glomerulus
function.
 Ccr is decreased in the early stage of renal
damage.
 Ccr can be used to judge renal transplantation
succeed or not
 Ccr↓ indicates kidney works
 Ccr↑ indicates rejection
 Ccr
can be used to evaluate the extent of
impaired glomerulus including renal failure：
 compensatory period of renal failure ：51-80ml/min
 Decompensation period of renal failure ：50-20ml/min
 Renal failure： 19-10 ml/min
 end-stage renal failure/uremia ： <10ml/min
 Ccr
can be used in clinical treatment and
medication guidance:
 Ccr < 30 ~ 40ml/min： limits protein intake
 Ccr < 30ml/min： diuretics were not effective
 Ccr < 10ml/min： need renal replacement therapy
(blood dialysis, transplantation)
 Serum urea in adult 2.9~8.2 mmol/L
 Serum urea(SU) is used to evaluate renal
function with Scr, when effective nephron
remains below 50% .
 Not an early indicator
 Obviously increased Sur occurs in azotemia.
 Prerenal: low renal blood flow, such as dehydration,
shock, acute blood loss…
 Post-renal: urinary tract obstruction, bladder cancer…
 Hyper proteolysis: high fever, burns, malignant tumors…
 Differential diagnosis of oliguria (combined
with Scr) :
 Renal oliguria:
 SU ↑ accompany with Scr
 SU/Scr (mg/dl) ≤20:1
 Prerenal oliguria:
 SU ↑↑ , Scr ↑ is not obvious
 SU/ Scr (mg/dl) > : 20:1
 Adult males UA 208~428 μmol/L
 Adult females UA 155~357 μmol/L
 UA↑
 Kidney disease
 Gout痛风
 Others: leukemia, diabetes, eclampsia, long-
term fasting, etc
 UA↓
 Proximal renal tubular injury：reabsorption↓, UA
loss from urine
 Severe liver damage
 The reasons of elevated serum
uric acid
Kidney disease
Gout Diabetes，
long-term
GFR↓ fasting

Leukemia Nucleic acid UA↑

tumor decomposition↑

Eclampsia Diuretics

32
secrete
Freely
filtered
 Serum Cys-C 0.59~1.03 mg/L
 Sensitive and reliable indicator reflecting
glomerular filtration function.
 Specificity and sensitivity are superior to Scr.
 Increase earlier than Scr when GFR deceased.
 The preferred indicator for glomerular
filtration function.
 CysCis most critical for early detection of
rejection after renal transplantation
 Success: the rate and amplitude of CysC
decreased were higher than Scr
 Rejection: CysC increased faster than Scr
 Distal tubule function
 Mosenthal test/ concentration and dilution test
 Urine osmolality
 Proximal tubule function
 α1-microglobulin
 N-acetyl-beta-D-glucosaminidase(NAG)
 [Specimen collection]
 Collect specimen every 2hrs in totally 24hrs
 Fluid intake is restricted to 500ml with each
meal.
 And then measure the volume and SG of each
specimen.

Detect volume and SG

 Urine Volume/24h is 1000~2000ml.
 Ratio of daytime to evening is 3~4:1.
 Volume of nocturia<750ml.
 Highest SG >1.020.
 Highest SG －lowest SG>0.009
 Increased urine volume indicates distal
tubules damage.
 Decreased SG and /or fixed at 1.010 means
distal tubules has no ability of concentration.
 [Definition]
 Osmolality is a measure of the number of
particles dissolved in a solution.
 Uosm is based on concentration ability of kidneys
and serum levels of solute.
 The difference is due to the number of particles after solution.
 it has no association with kind, size or electric charge of the solute.
 Protein, glucose (non-ionizing) have little effect on it.
 [Specimen collection]
 First morning urine specimen
 The patient is instructed to avoid taking fluid
after 8 o’clock last night.
 [Detection method]
 Freezing point depression method
 urine freezing point is tested
 Osm/kgH2O= Freezing point of urine(℃)/1.86

freezing-point osmometer
 Uosm: 600-1000 mOsm/kgH2O
 Posm: 275-305 mOsm/kgH2O
 Uosm / Posm = 3～4.5 : 1
 Obviously decreased Uosm indicates
decrease of distal nephron’s concentration
function
 e.g. Chronic nephritis, chronic pyelonephritis,
interstitial nephritis…
 Uosm /Posm≈1, called isosmotic urine; Uosm
<300mOsm called hypotonic urine.
 Differentiate prerenal and renal oliguria
 prerenal : ＞ 450 mOsm/kgH2O
 renal oliguria: <350mOsm/kgH2O
free
G
Uptake and
decomposition
α1-MG
Combined with IgG
or albumin
 Serum α1-MG: 10-30 μg/ml
 Urine α1-MG: <15μg/ml

Serum and urine α1-MG all can be detected.

 Urine α1-MG↑
 Early sensitive indicator of proximal renal tubular
dysfunction
 Blood α1-MG↑
 Reduced glomerular filtration function
 more sensitive than Scr
 Blood and urine α1-MG↑
 Function of the glomerular and tubules all are
impaired
 Blood α1-MG↓
 Severe liver injury
 UrineNAG <2.37U/mmol/L cr
 Serum NAG <24.6U/L

Serum and urine NAG all can be detected.

 Blood or urine NAG↑
 Renal tubular impaired due to various causes
 Early diagnosis of rejection after renal
transplantation (1 ~ 3d)
 Diabetic nephropathy, chronic interstitial
nephritis, etc
Clinical situation Items selection

physical examination Urine routine test

hypertension or diabetes α1-MG、 β2-MG

Glomerulonephritis Scr, Ccr, SU, UA, cysC, α1-MG

Pyelonephritis, Interstitial nephritis Mosenthal test, osmolality,

Urine α1-MG, NAG

Identification of acute oliguria Uosm、SU/ Scr

 Tests of Glomerular Function are ( )
A. Scr
B. UA
C. Ccr
D. cysC
E. SU
 The preferred indicator for glomerular
filtration function is ( )
A. Scr
B. UA
C. Ccr
D. cysC
E. SU
 Which test reflects distal tubule function ?
A. SU
B. NAG
C. Mosenthal test
D. osmolality
E. SG