Renal Function Tests –required for……

 Older age
 Family history of Chronic Kidney disease (CKD)
 Decreased renal mass
 Low birth weight
 Diabetes Mellitus (DM)
 Hypertension (HTN)
 Autoimmune disease
 Systemic infections
 Urinary tract infections (UTI)
 Nephrolithiasis
 Obstruction to the lower urinary tract
 Drug toxicity
RFTs give information regarding…….
Functions of KIDNEY
 Maintenance of homeostasis:
The kidneys are responsible for the regulation
of water, electrolyte & acid-base balance in
the body.
 Excretion of metabolic waste products:
The end products of protein & nucleic acid
metabolism are eliminated from the body.
These include urea, creatinine, creatine, uric
acid, sulfate & phosphate.
 Retention of substances vital to body:
The kidneys reabsorb & retain several
substances of biochemical importance in the
body e.g. glucose, amino acids etc.
 Hormonal functions:
The kidneys also function as endocrine
organs by producing hormones.
 Erythropoietin:
A peptide hormone, stimulates hemoglobin
synthesis and formation of erythrocytes.
 1,25-Dihydroxycholecalciferol (calcitriol):
The active form of vitamin D is finally
produced in the kidney.
It regulates calcium absorption from the gut.
 Renin:
A proteolytic enzyme liberated by kidney,
stimulates the formation of angiotensin II
which, in turn, leads to aldosterone
production.
 Angiotensin II & aldosterone are the
hormones involved in the regulation of
electrolyte balance.
 Nephron is the functional unit of kidney.
Each kidney is composed of approximately
one million nephrons.
Nephron, consists of a Bowman's capsule
(with blood capillaries), proximal convoluted
tubule (PCT), loop of Henle, distal convoluted
tubule (DCT) & collecting tubule.
The blood supply to kidneys is relatively
large.
About 1200 ml of blood (650 ml plasma) passes
through the kidneys, every minute.
About 120-125 ml is filtered per minute by the
kidneys & this is referred to as glomerular
filtration rate (GFR).
With a normal GFR (120-125 ml/min), the
glomerular filtrate formed in an adult is
about 175-180 litres/day, out of which only 1.5
litres is excreted as urine.
More than 99% of the glomerular filtrate is
reabsorbed by the kidneys.
Urine formation basically involves two steps-
glomerular filtration & tubular reabsorption.
 Glomerular filtration:
This is a passive process that results in the
formation of ultra filtrate of blood.
All the (unbound) constituents of plasma,
with a molecular weight < 70,000, are passed
into the filtrate.
The glomerular filtrate is almost similar in
composition to plasma
 Tubular reabsorption:
The renal tubules (PCT, DCT & collecting
tubules) retain water & most of the soluble
constituents of the glomerular filtrate by
reabsorption.
This may occur either by passive or active
process.
 There are certain substances in the blood
whose excretion in urine is dependent on their
concentration.
 Such substances are referred to as renal
threshold substances.
 At the normal concentration in the blood, they
are completely reabsorbed by the kidneys.
 The renal threshold of a substance is defined
as its concentration in blood (or plasma)
beyond which it is excreted into urine.
 The renal threshold for glucose is 180 mg/dl;
ketone bodies 3 mg/dl; calcium 10 mg/dl
bicarbonate 30 mEq/l.
 Tubular maximum (Tm):
 The maximum capacity of the kidneys to
absorb a particular substance.
 Tubular maximum for glucose is 350 mg/min.
 Kidney function tests may be divided into 4 groups.

› Urine examination:

Routine examination of urine - volume, pH, specific

gravity, osmolality & presence of certain abnormal
constituents (proteins, blood, ketone bodies, glucose
etc).
› Analysis of blood/serum:

Estimation of blood urea, serum creatinine, protein &

electrolyte are useful to assess renal function.
 Glomerular function tests:
› All the clearance tests (inulin, creatinine, urea)
are included in this group.
 Tubular function tests:
› Urine concentration or dilution test, urine
acidification test.
 Colour
 Normal- clear and ranges from pale
yellow to deep gold in colour due to
pigments urochrome,urobilin and
uroerythrin.
 Cloudiness may be caused by excessive
cellular material or protein, crystallization
or precipitation of salts upon standing at
room temperature or in the refrigerator.
 If the sample contains many red blood
cells, it would be cloudy as well as red.
Blue Green Pink-Orange- Red-brown-black
Red
Methylene Blue Haemoglobin Haemoglobin
Pseudomonas Myoglobin Myoglobin
Riboflavin Phenolpthalein Red blood cells
Porphyrins Homogentisic Acid
Rifampicin L -DOPA
Melanin
Methyldopa

 Color of urine depending upon it’s constituents.

 Volume
 Normal- 1-2.5 L/day
 Oliguria- Urine Output < 400ml/day
Seen in
›Acute glomerulonephritis
›Renal Failure
 Polyuria- Urine Output > 2.5 L/day
Seen in
›Increased water ingestion
›Diabetes mellitus and insipidus.
 Anuria- Urine output < 100ml/day
Seen in renal shut down (Complete cessation of
urine)
Acute tubular Necrosis
Bilateral renal stones
Prostate enlargement
 Specific Gravity
 Measured by urinometer or refractometer.
 It is measurement of urine density which
reflects the ability of the kidney to concentrate
or dilute the urine relative to the plasma from
which it is filtered.
 Normal :- 1.001- 1.040.

S.G Osmolality (mosm/kg)

1.001 100
1.010 300
1.020 800
1.025 1000
1.030 1200
1.040 1400
 Increase in Specific Gravity seen in
 Low water intake
 Diabetes mellitus
 Albuminuruia
 Acute nephritis.
 Decrease in Specific Gravity is seen in
 Absence of ADH
 Renal Tubular damage.
 Isosthenuria-Persistent production of fixed
low Specific gravity urine isoosmolar with
plasma despite variation in water intake.
 pH
 Urine pH ranges from 4.5 to 8
 Normally it is slightly acidic lying
between 6 – 6.5.
 After meal it becomes alkaline.
 On exposure to atmosphere,urea in
urine splits causing NH4+ release
resulting in alkaline reaction.
 May indicate proteus infection or
azetazolamide use
 Urine osmolality depends on the state of
hydration.
 After excessive fluid intake the osmotic
concentration may fall as low as 50 m
osm/kg, where as with restricted fluid intake,
it is up to 1,200 m osm/kg. On average fluid
intakes, 300 to 900 m osm / kg are found
 Fresh urine is normally aromatic. Foul smell
indicated bacterial Infection.
 Glucose: Normal urine contains small amounts
of glucose, which cannot be detected by
routine test. Presence of detectable amounts
of glucose in urine is called glycosuria – DM
 Protein: The glomerular basement membrane
does not usually allow passage of albumin
and large proteins. Increased amounts of
protein in urine is called proteinuria.
Proteinuria – Indication of leaky glomerulli.
Most common type of proteinuria is due to
albumin.
 Glomerular proteinuria:
› The glomeruli of kidney are not permeable to
substances with molecular weight more than 69,000
& plasma proteins are absent in normal urine.
› When glomeruli are damaged or diseased, they
become more permeable & plasma proteins may
appear in urine.
› The smaller molecules of albumin pass through
damaged glomeruli more readily.
› Albuminuria is always pathological.
› Large quantities of albumin are lost in urine in
nephrosis.
› Small quantities are seen in urine in acute
nephritis, strenuous exercise & pregnancy.
 It is also called minimal albuminuria
 It is identified, when small quantity of albumin (30-300
mg/day) is seen in urine.
 The test is not indicated in patients with overt proteinuria
(+ve dipstick).
 Micro albuminuria is an early indication of nephropathy
in patients with diabetes mellitus & hypertension.
 All diabetics & hypertensive should be screened for
microalbuminuria.
 It is an early indicator of onset of nephropathy.
 The test should be done at least once in an year
 It is expressed as albumin-creatinine ratio.
 Normal ratio being
 Males < 23 mg/gm of creatinine
 Females < 32 mg/gm of creatinine
 Presence of ketosis can be established by
detection of ketone bodies in urine using
Rothera’s test, strip tests are also available.
 Normally do not appear in urine
 Three ketone bodies are
› - hydroxybutyric acid (80%)
› Acetoacetic acid (20%)
› Acetone –a small %
 Ketonuria – uncontrolled DM, starvation low
carbohydrate diet
 Urine sample is collected
 Subjected to centrifugation for 5-10 minutes
which produces a concentration of sediment
(cellular matter) at the bottom of the tube.
 Microscopic Examination of the centrifuged
 Urinary sediment defects the following.
› Cells – RBC, WBC, pus cells
› Crystals – Calcium phosphate, Calcium
oxalate, Amorphous phosphate
› Casts – Hyaline casts, granular casts, Red
blood casts. Casts" are plugs of material
which came from individual tubules
 Then, examination is carried out at high power to
identify crystals, cells, and bacteria.
 The various types of cells are usually described as
the number of each type found per average high
power field (HPF). For example: "1-5 WBC/HPF."
 Epithelial cells and 1-2 WBC or pus cell/HPF is
normally seen
 If more leukocytes per each high power field appear in
non-contaminated urine, the specimen is probably
abnormal showing pyuria. Leukocytes have lobed nuclei
and granular cytoplasm.
 Usually, the WBC's are granulocytes. White cells from the
vagina, in the presence of vaginal and cervical
infections, or the external urethral meatus in men and
women may contaminate the urine.
 Presence of Granular Casts, RBC, bacteria, Glucose, Albumin and
Ketone bodies is abnormal.
 Hematuria is the presence of abnormal numbers of red cells in
urine due to any of several possible causes.
› glomerular damage,
› tumors which erode the urinary tract anywhere along its
length,
› kidney trauma,
› urinary tract stones,
› acute tubular necrosis,
› upper and lower urinary tract infections,
› nephrotoxins
 Red blood cells may stick together and form red blood cell casts.
Such casts are indicative of glomerulonephritis, with leakage of
RBC's from glomeruli, or severe tubular damage.
 White blood cell casts are most typical for acute pyelonephritis,
but they may also be present with glomerulonephritis. Their
presence indicates inflammation of the kidney.
Crystals
 Tyrosine crystals with congenital tyrosinosis
 Leucine crystals in patients with severe liver disease
or with maple syrup urine disease.

Urinary crystals. (A) Calcium oxalate crystals; (B) uric acid

crystals (C) triple phosphate crystals with amorphous
phosphates ; (D) cystine crystals.
Done to measure substance in blood that are
normally excreted by kidney.

Their level in blood increases in kidney dysfunction.

As markers of renal function creatinine, urea,uric

acid and electrolytes are done for routine analysis
Estimation of Plasma Proteins:
 Normal Value : 6.4 to 8.3 gm%
 Components :
› Albumin : 3 – 5 gm%
› Globulin : 2 – 3 gm %
› Fibrinogen : 0.3 gm%
› A/G ratio : 1.7:1
Estimation of Non – Protein Nitrogenous Substances
 Normal Value : 28 to 40 mg%
 Components:
› Urea : 20 to 40 mg%
› Uric acid : 2 to 4 mg %
› Creatinine : 0.6 to 1.2 mg%
 Normal blood levels of these substances are ↑sed in case of
impairment of renal function.
 An Increase of these end products in blood - Azotaemia.
 Serum creatinine
 Creatinine is a breakdown product of creatine
phosphate in muscle, and is usually produced at a
fairly constant rate by the body depending on
muscle mass
 Creatinine is filtered but not reabsorbed in kidney.
 Normal range is 0.8-1.3 mg/dl in men and 0.6-1 mg/dl
in women.
 Not increased above normal until GFR<50 ml/min .
 The methods most widely used for serum creatinine
are based on the Jaffe reaction. This reaction occurs
between creatinine and the picrate ion formed in
alkaline medium (sodium picrate); a red-orange
solution develops which is read colorimetrically at
520 nm .
 Increased serum creatinine:
› Impaired renal function
› Very high protein diet
› Anabolic steroid users
› Vary large muscle mass: body
builders, giants, acromegaly patients
› Rhabdomyolysis/crush injury
› Athletes taking oral creatine.
› Drugs:
• Probenecid
• Cimetidine
• Triamterene
• Trimethoprim
• Amiloride
 Blood urea
 Urea is major nitrogenous end product of protein
and amino acid catabolism, produced by liver and
distributed throughout intracellular and
extracellular fluid.
 Urea is filtered freely by the glomeruli .
 Many renal diseases with various glomerular,
tubular, interstitial or vascular damage can cause
an increase in plasma urea concentration.
 The reference interval for serum urea of healthy
adults is 10-40 mg/dl.
 Plasma concentrations also tend to be slightly
higher in males than females. High protein diet
causes significant increases in plasma urea
concentrations and urinary excretion.
 Measurement of plasma creatinine provides a more
accurate assessment than urea because there are
many non renal factors that affect urea level.
 Nonrenal factors can affect the urea level (normal
adults is level 10-40mg/dl) like:
 Mild dehydration,
 high protein diet,
 increased protein catabolism, muscle wasting as in
starvation,
 reabsorption of blood proteins after a GIT haemorrhage,
 treatment with cortisol or its synthetic analogous
 States associated with elevated levels of urea in
blood are referred to as uremia or azotemia.
 Causes of urea plasma elevations:
 Prerenal: renal hypoperfusion
 Renal: acute tubular necrosis
 Postrenal: obstruction of urinary flow
 Blood urea is normally doubled when the GFR is halved.
 Parallel determination of urea and creatinine is
performed to differentiate between pre-renal and post-
renal azotemia.
 Pre-renal azotemia leads to increased urea levels, while
creatinine values remain within the reference range. In
post-renal azotemias both urea and creatinine levels
rise, but creatinine in a smaller extent.
 Enzymatic Berthelot Method is used for blood urea
estimation:
 Principal:
 Urea + H2O Urease > Ammonia + CO2
 Ammonia + Phenolic Chromogen + Hypochlorite >
Green Colored Complex whoose absorbance is read
at 570nm
 Serum Uric Acid
 In human, uric acid is the major product of the
catabolism of the purine nucleosides, adenosine and
guanosine.
 Purines are derived from catabolism of dietary nucleic
acid and from degradation of endogenous nucleic
acids.
 Overproduction of uric acid may result from increased
synthesis of purine precursors.
 In humans, approximately 75% of uric acid excreted is
lost in the urine; most of the reminder is secreted into
the GIT
 Renal handling of uric acid is complex and involves
four sequential steps:
› Glomerular filtration of virtually all the uric acid in
capillary plasma entering the glomerulus.
› Reabsorption in the proximal convoluted tubule of
about 98 to 100% of filtered uric acid.
› Subsequent secretion of uric acid into the lumen of
the distal portion of the proximal tubule.
› Further reabsorption in the distal tubule.
 Hyperuricemia is defined by serum or plasma uric
acid concentrations higher than 7.0 mg/dl (0.42mmol/L)
in men or greater than 6.0 mg/dl (0.36mmol/L) in
women
 The GFR is the best measure of glomerular function.
 Normal GFR is approximately 125 mL/min
 When GFR decreases to 30% of normal
moderate renal insufficiency. Patients remain
asymptomatic with only biochemical evidence of a
decline in GFR
 As the GFR decreases further severe renal
insufficiency characterized by profound clinical
manifestations of uremia and biochemical
abnormalities, such as acidemia; volume overload;
and neurologic, cardiac, and respiratory
manifestations
 When GFR is 5% to 10% of normal ESRD
 Clearance is defined as the volume of plasma
that would be completely cleared of a
substance per minute.
 A renal clearance test is employed to assess the rate
of Glomerular filtration and renal blood flow
 Renal clearance is defined as the volume of plasma
from which the substance is completely cleared by
the kidneys per minute. (ml/min)
 Clearance = U x V
P
› Where, U - Concentration of substance in urine
(mg/dl)
› V - Volume of urine excreted (ml/min)
› P - Concentration of substance in plasma (mg/dl)
 The maximum rate at which the plasma can be
cleared of any substance is equal to the GFR.
 This can be calculated by measuring the clearance of
a plasma compound which is freely filtered by the
glomerulus & is neither absorbed nor secreted in the
tubule.
 Inulin (a plant carbohydrate, composed of fructose
units) and 51Cr-EDTA satisfy this criteria.
 Inulin is intravenously administered to measure GFR.
 Inulin clearance and creatinine clearance are used
to measure the GFR.
Creatinine Clearance:
 A simple, inexpensive bedside estimate of GFR.
 GFR= Ccr = {Ucr * Urinary flow rate(ml/min)} / Pcr
Normal 100-120ml/min
Dec.Renal reserve 60-100ml/min
Mild Renal imp 40-60ml/min
Moderate insuff. 25-40ml/min
Renal failure <25ml/min
ESRD <10ml/min
 Creatinine is an excretory product derived
from creatine phosphate.
 The excretion of creatinine is rather
constant & is not influenced by body
metabolism or dietary factors.
 Creatinine is filtered by the glomeruli & only
marginally secreted by the tubules.
 Creatinine clearance may be defined as the
volume (ml) of plasma that would be
completely cleared of creatinine per minute.
 Procedure:
 In the traditional method, creatinine content
of a 24 hr urine collection & the plasma
concentration in this period are estimated.
 The creatinine clearance (C) can be calculated
as follows:

UxV
C = ______
P

 U = Urine concentration of creatinine.

 V = Urine output in ml/min (24 hr urine
volume divided by 24 x 60)
 P = Concentration of creatinine.
 Modified procedure:
 Instead of a 24 hr urine collection, the
procedure is modified to collect urine for 1 hr,
after giving water.
 The volume of urine is recorded.
 Creatinine contents in plasma & urine are
estimated.
 The creatinine clearance can be calculated by
using the formula.
 Reference values:
 The normal range of creatinine clearance is
around 120-145 ml/min.
 These values are slightly lower in women.
 Serum creatinine normal range:
 Adult male: 0.7-1.4 mg/dl
 Adult female: 0.6-1.3 mg/dl
 Children: 0.5-1.2 mg/dl
 Cockroft Gault Formula
Creatinine Clearance =(140-age) × weight in kg / S.creat.
× 72
(multiplied by 0.85 for females)
 MDRD Nomogram
GFR(ml/min)=170 × S.creat.-0.999 × age-0.176 × BUN-0.170 ×
albumin0.318
(multiplied by 0.742 if female)
 Creatinine coefficient:
 It is the urinary creatinine expressed in
mg/kg body weight.
 The value is elevated in muscular dystrophy.
 Normal range is 20–28 mg/kg for males & 15–
21 mg/kg for females.
 Urea clearance is defined as the volume (ml)
of plasma that would be completely cleared
of urea per minute.
 It is calculated by the formula:

UxV
Cm = ______
P

 Cm=Maximum urea clearance.

 U = Urea concentration in urine (mg/dl).
 V = Urine excreted per minute in ml.
 P = Urea concentration in plasma.
 Diagnostic importance:
 A urea clearance value below 75 % of the
normal is serious, since it is an indicator of
renal damage.
 Blood urea level is found to increase only
when the clearance falls below 50% normal.
 Normal level of blood urea: 20-40 mg/dl
 Urine Concentration Test:
(i) Fluid intake is withheld for 15 hours.
(ii) Early morning urine sample is collected.
(iii) Specific gravity is measured.
(iv) It specific gravity exceeds 1.025, the renal
concentrating ability is considered normal.
If not, indicates renal impairment.
(v) Clinically, the loss of concentrating ability
is manifested by nocturia (passage of urine
at night)
 Bladder is Emptied.
› (ii) 1,000 to 1,200 ml of water is given to the patient.
› (iii) Urine sample is collected every hour for the
next 4 hours.
 Specific gravity is measured
› (v) If the functioning of renal tubule is normal, the
urinary specific gravity should fall to 1.005 or less.
 It the renal tubules are diseased, the concentration
of the solutes in urine will remain constant
irrespective of excess water intake.
 Acid load test is used for the diagnosis of renal tubular
acidosis.
› (ii) Ammonium chloride is administered orally in a
gelatin capsule (0.1g/kg body wt)
› (iii) Ammonium chloride Dissociates into:
 NH4 + Cl-
(liver) ↓ ↓ (counted balanced by H+)
 Urea Hcl
↓
› urine acidification)
Urine is collected 2 –8 hours after ingestion
PH below 5.5 : Normal
 Between 5.5 to 7.0 : Renal tubular acidosis
 Non –toxic dye
 Excreted by kidneys
(iii) Intravenous injection of 6mg of PSP in /ml of
saline is given.
(iv) Urine specimen collected at 15,30,60 and 120
minutes
(v)Rate of excretion of the dye is measured.
(iv) 15 minutes urine : 25% PSP
1st hour urine : 40 –60 5 PSP
2nd hour urine: 20 to 25% PSP
 Excretion less than 23% in 15 minutes urine sample
indicates impaired Renal excretory function.
 Para –Aminohippurate Test
› (i) PAH: Filtered and secreted
› (ii) Not reabsorbed
› (iii) PAH clearance is defined as the amount of
plasma passed through kidneys.
› (iv) Known amount of PAH is injected into the body
› (v) Concentration of PAH in plasma and urine
volume of urine Excreted.
 RPF = U x V
P
 Normal Value: 700ml/min
 ACUTE RENAL FAILURE  CHRONIC RENAL FAILURE
CAUSES:  CAUSES:
 (i) Acute Nephritis  (i) Chronic Nephritis
 (ii) Acute Tubular  (ii) Polycystic kidney
Necrosis  (iii) Renal calculi
 (iii) Renal calculi  (iv) Urethral constriction
 (iv) Damage of Renal
Features
tissue

(i)Uremia
Features
(ii)Acidosis
› (i) Oliguria
(iii)Edema
› (ii) Anuria
(iv)Anemia
› (iii) Proteinuria (
(v)Hyperparathyroidism
› (iv) Hematuria
› (v) Edema (v)
 (vi) Acidosis
Laboratory Findings in Specific Syndromes:
1.Nephrotic Syndrome
•proteinuria > 3 g/day
•hypoproteinemia and consequent edema; the protein loss may be
selective (predominantly albumin loss), or
nonselective (both large and small proteins lost)
•hyperlipidemia
•azotemia is not a necessary component of the syndrome, but may be present
2.Nephritic Syndrome
•hematuria, proteinuria ( < 2 g/day)
•red cell casts
•azotemia
3.Tubulointerstitial Disease
•cloudy urine from high WBC
•white cell casts
•proteinuria ( < 1 g/day)
•azotemia
4.Acute Renal Failure
•sudden oliguria
•rapidly developing azotemia (serum creatinine increases at a maximum rate of about 2
mg/dl per day)
•broad waxy casts (renal failure casts)
•serum urea/creatinine ratio ~ 15
•urine sodium concentration > 40 mEq/L