Al-Dubai_w , Medical Biochemistry Biochemistry of Urogenital system Basic facts: I- The kidneys are paired encapsulated organs, each weighing approximately 150 grams with a smooth outer surface. A longitudinal cut reveals two distinct layers; the dark reddish colored outer cortex which makes up about 70% of the tissue mass and the paler colored inner medulla. 2-Each kidney consists of approximately one million functional units called Nephrons. 3-The nephron is the functional unit of the kidney, it consists of two parts: A-The renal corpuscle, composed of a glomerulus and Bowman’s capsule; the glomerulus is the initial filtering unit. Glomerular blood pressure provides the driving force for water and solutes to be filtered out of the blood and into rate is the space made by Bowman’s capsule; the resulting glomerular fi further processed along the nephron to form urine. B-The renal tubule, composed of the proximal tubule, loop of Henle (descending and ascending limbs) and distal convulated tubule. 4-The kidney’s ability to perform many of its functions depends on the three fundamental functions of filtration, re-absorption and secretion: A> Filtration means, blood flows through glomerular capillaries due to hydrostatic and oncotic pressure, and small molecules filter into Bowman’s capsule and to tubules. Normally, about 20% of the plasma that enters the glomerulus is filtered. B-Re-absorption As the filtrate passes through the tubules, substances of value to the body are returned to the peritubular capillary plasma. C- Secretion is the selective transfer of non-filtered substances from peritubular capillaries to the renal tubular lumen. Tubular secretion is mainly an active transport process. Usually only a few substances are secreted, unless they are present in great excess, or are natural poisons.Al-Dubai w , Medical Biochemistry 5-Renal function is an indication of the physiological state of the kidney: glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidney, while creatinine clearance rate (Cr) is the volume of blood plasma that is cleared of creatinine per unit time, and is a useful measure for approximating the GFR. Most clinical tests use the plasma concentrations of the waste substances of creatinine and urea, as well as electrolytes, to determine renal function. 6-An adult will filter approximately 150-180 liter of blood plasma in 24 hour but eliminate only about 1.5-1.8 liter of urine in the same period. The kidneys filter the all plasma volume about 65 times per day. 7-Individuals with only one kidney can live normally: Glomerulus (capillary bed Atferont stterisle arteriole Distal Bowmane convulated Capsule | tubule a convulated ‘tubule Collecting Duet Renal + Conoxs ? 7 Renal © medulla Descending loop of Henle fasconding Toop of Henle Figure 3.1 Nephron StructureAl-Dubai_w , Medical Biochemistry Kidney funetion 1- Secretion of hormones, including erythropoietin, which regulates red blood cell production in the bone marrow, renin, which is a key part of the renin-angiotensin—aldosterone system. Formation the active forms of vitamin D (calcitriol) and prostaglandins Kidney maintains water, electrolyte and acid base balance of the body through filtration, reabsorption and secretion process. 3-Kidney clears several metabolic waste products like urca, uric acid, creatinine etc., from circulation, 4-Gluconeogenesis Investigations of renal funetion 1-Examination of urine (full urine report) A urine analysis helps to screen for urinary tract infections, renal disease, pregnancy, genetic diseases of metabolism and diseases for other organs that result in abnormal metabolites (break-down products) appearing in the urine. ine and urea estimation 2-Blood creat a-Creatinine Creatinine is the end product of creatine metabolism. Creatine is synthesized in the liver, pancreas, and kidneys from the amino acids arginine, glycine, and methionine. Creatine is transported through the circulatory system to muscle, brain, and other organs, where it is converted to phosphocreatine and acts as an energy reservoir. Creatinine is formed in muscle from creatine phosphate by irreversible, nonenzymatic dehydration and loss of phosphate. Creatinine diffuses into the plasma and is excreted in the urine. It is removed from the circulation by glomerular filtration and excreted in the urine. Production of creatinine is constant because of the constancy of endogenous eatinine). production (About 1-2% of creatine phosphate is converted to ¢Al-Dubai_ w , Medical Biochemistry The normal range of creatinine in blood is from 0.6 to 1.2 mg/dl. Plasma creatinine concentration depends on muscle mass, the rate of creatine turnover, and renal function Increased blood creatinine levels occur in the following conditions: 1- Renal disease, acute and chronic renal failure 2-Obstruction of urinary tract 3-Muscular dystrophy 4-Poliomyelitis 5-Congestive heart failure 6-Dehydration 7- Acromegaly and Gigantism 8- Shock (kidney) ARGOUNE SLY ‘TRENSAIAIDN 7 fe HA=C }N-CH,—COO™ *H.N—CH,—COO™ Ornithine _Glycocyamine on (quanidoacetate) ie a (ver) coo S-Adenosyl LAsginine methionine S.Adenosyl- ‘ homocysteine =F N—c NH~® 7 ? 9 aN=c | HN=C N—GH, / N-CHe-cOo CH, P+H,0 CH Creatinine Creatine phosphate Figure 3.2 Formation of ereatiAl-Dubai_w , Medical Biochemistry b-Urea Urea is the major excretory product of protein metabolism. It is formed in the liver from amino groups (-NH2) and free ammonia generated during protein catabolism. Following synthesis in the liver, urea is carried in the blood to the kidney, where it is readily filtered from the plasma by the glomerulus. Most of the urea in the glomerular filtrate is excreted in the urine, and some urea is reabsorbed by passive diffusion during passage of the filtrate through the renal tubules. The concentration of urea in the plasma is determined by renal function and perfusion, the protein content of the diet, and the rate of protein catabolism. The normal range of blood urea is < 50 mg/dl.An elevated concentration of urea in the blood is called uremia. Increased urea levels occur in the following conditions: A-Prerenal causes 1-Congestive heart failure (due to decreased blood flow to the kidneys, decreased renal excretion, and accumulation in circulating blood) 2-Excessive protein ingestion (due to increased protein metabolism) 3-Gastrointestinal (GI) bleeding (Excessive blood protein in the GI tract and increased protein metabolism) 4-Shock (due to decreased blood flow to the kidneys, decreased renal excreation) 5-Dehydration 6-Increase protein Catabolism (trauma, diabetes, surgery, starvation) B-Renal causes |-Renal failure ( due to decreased renal excretion) 2-Glomerulonephritis C-Postrenal causes 1-Urinary tract obstruction (Stones, benign prostatic hypertrophy)Al-Dubai_w , Medical Biochemistry B-Tests of glomerular function Clearance Tests Clearance Test is used to assess glomerular filtration rate. This fests measures clearance of a substance by kidney from blood which may be of endogenous or exogenous origin. Clearance is defined as volume of plasma which is completely cleared of a substance by kidneys per minute. It is expressed as ml of plasma cleared per minute (ml/min). A substance that meets following criteria is used for clearance test. (a) The substance must be filtered completely through the glomerulus (b) The substance does not undergo reabsorption: (c) The substance is not secreted by renal tubules. given below: UVX_L73 PXA Formula for calculation of clearance Clearance of substance (ml/min U=Concentration of the substance in urine. V = Volume of urine in ml per minute P= Concentration of the substance in plasma A= Body surface area 1-Creatinine Clearance Test Creatinine clearance rate is the volume of blood plasma that is cleared of creatinine per minute and is a useful measure of glomerular function. Creatinine clearance is more accurate in evaluation the renal function because blood urea and creatinine will not be raised above the normal range until 60% of total kidney function is lost. Normal creatinine clearance values are: 70-140 mL/min/1.73 m? Children Adult male 85-125 ml./min/1.73 m* Adult female 75-115 mL/min/1.73 m? For each decade Decrease after 40 yearsr 6-7 mL /min/ 1.73Dubai w , Medical Biochemistry Creatinine clearance is decreased in: I-Renal failure, glomerulonephritis, pyelonephritis, nephrotic syndrome, acute tubular dysfunction 2-Shock 3-Dehydration 4-Hemorrhage S-Congestive heart failure 6-Urinary tract obstruction Example If urine volume is 2.0 liter/day, creatinine in urine after dilution is 80 mg/dl, creatinine in serum is 1.1 mg/dl, calculate creatinine clearance ? Creat e clearance creatinine in urine mg/dl X urine volume (ml) creatinine in serum mg/dl X 1440 Creatinine clearance = 80 x 2000/ 1.1 x 1440 = 101 m/min 2-Urea clearance Test Urea is another endogenous substance used as marker for the measurement of glomerular filtration rate but diet influences urea production and it undergoes reabsorption to some extent so that urea clearance test may not reflect the accurate glomerular function C-Tests for Renal tubular function In renal tubules glomerular filtrate is converted to urine due to reabsorption of glucose, amino acids, bicarbonate, water, sodium, chloride etc., from filtrate and secretion of hydrogen, ammonia, uric acid etc., into filtrate, so, in diseases affecting tubular function ,the specific gravity, osmolality (Osmolality is the number of solute particles per kilogram of water, irrespective of the size or nature of the particles and can be measure by using freezing pointAL-Dubai w , Medical Biochemistry osmometer) and volume of urine are changed. The simplest test of tubular fanction is the measurement of the specific gravity of urine. 1-Concentration Test This test measured the ability of the kidney to concentrate urine by measuring specific gravity of urine.The patient need to fast after 2 meal at 8 PM to the next day at 9 AM, the bladder is emptied and specimen is discarded. A second specimen is collected at 10 AM and the specific gravity is measured. If the specific gravity is more than 1.022, the patient has adequate renal function. 2-Dilution Tests This test measured the ability of the kidney to eliminate water after ingestion a large volume of water.The patient need to fast after midnight and bladder is emptied at 7AM and a water load is given (1200 ml within 30 minutes). Hourly urine samples are collected for the next 4 hours separately. Volume, and specific gravity of each sample are measured. A normal person will excrete more than 80% (L000ml) of water within 4 hours and the specific gravity of at least one sample should be 1.003 or less. Notes: ‘The measurement of the urine volume of urine excreted during the day and index of tubular function. Normally night urine the night is another simpl volume is only half of the day urine volume, but an increased excretion of urine during night (nocturia) is an early indication of tubular dysfunction. 1-Microalbuminuria ( means urinary albumin excretion in urine is about 30-300 mg/day). It represents the early marker of diabetic nephropathy and marker for a progressive decline in renal function. 2-Spot (random) urine Protein : creatinine ratio is better than 24 hours urine protein because the concentration of 24 hrs protein in the urine is Spot urine Protein : creatinine ratio, urine affected by urine volume butA ‘Dubai w , Medical Biochemistry proteins and creatinine are highly soluble in water, and have the same dilution effect in urine and 24 hrs urine collections may be associated with significant collection errors (over-collections and _under-collections, incomplete bladder emptying, using drugs). Normal range < 0.2 mg/mg Nephrotic syndrome (nephrosis) > Example If urine protein is 120 mg/dl and urine creatinine after dilution is 60 mg/dl Spot urine Protein : creatinine ratio = 120/60 = 2 3- Cystatin C Cystatin C is low molecular weight protein ac as a cysteine proteinase inhibitor, synthesized in most organs of the body, and may be used as an alternative to creatinine and creatinine clearance to screen and monitor kidney dysfunction, it is unaffected by age , muscle mass, gender and race.It is produced and destroyed at a constant rate, and is freely filtered by the glomerulus and almost completely reabsorbed and broken down by the renal tubules.It may be especially useful in cases where creatinine measurement is not appropriate, for example , in case of liver cirrhosis and in malnourished persons, or who have reduced muscle mass. Measuring cystatin C may also be useful in the early detection of kidney disease.Al-Dubai_w , Medical Biochemistry Renal Calculi (Stones Stone formation accurs when dissolved elements in the urine form crystals that then aggregate. Conditions favoring the formation of renal calculi are similar to those favoring formation of urinary crystals, including pH, chemical concentration, and urinary stasis. Stone formation may be either homogeneous(of the same type) or heterogeneous(more than one type). Common types of stone Calcium oxalate and phosphate 38% Calcium oxalate 26% Calcium phosphate ™% Magnesium ammonium phosphate 21% Uric acid 5% Cystine 3% ‘Types Of Kidney Stones Stone Composition Cause of Stone Formation Calcium oxalate Hyperparathyroidism High urine calcium Vitamin D toxicity Sarcoidosis Osteoporosis Magnesium ammonium Phosphate infectious processes Excess alkali consumption Calcium phosphate Infection with urease producing organismsem are Al-Dubai_w , Medical Biochemistry Uric acid Gout High levels of uric acid in blood and urine Cystine Inherited cystinuria Risk factors for stone formation Presence of promoters of stone formation (Calcium, oxalate, urate, cysteine slow pH, low urine flow) Absence (or reduced levels) of inhibitors of stone formation (Citrate, high urine flow) Infection Urinary stasis Concentrated urine (poor fluid intake) Diet too high or too low in calcium Sedentary occupations Anatomical abnormalities of the urinary tract Analysis of the chemical composition of renal calculi plays an important role in patient management.