RENAL FUNCTION TESTS

Functions of kidney
1) Urine Formation:
• removal of potentially toxic waste products.
• it involves 3 processes
- filtration
- reabsorption
- secretion

2) Regulation of fluid & electrolyte balance.

3) Regulation of acid base balance.

.
4) Excretion of waste product of protein
metabolism

5) Hormonal function -Vit D metabolism

- Renin & angiotensin
- Erythropoietin.
 Preliminaries:

History & Physical Examition:

- oliguria
- polyuria
- nocturia
- frequency of urination
- appearance of oedema.
 Renal Function Tests
Classification:
I . Complete Examination of urine:
II. Biochemical examination of serum:
III. Tests based on glomerular filtration:
i. Urea clearance test
ii. Creatinine clearance test
iii. Inulin clearance test

IV. Test to measure renal plasma flow:

i. Para Amino Hippurate test
ii. Filtration Fraction
V. Test based on tubular function:
i. Concentration & dilution tests.
ii. 15 min PSP excretion test.
iii. Measurement of tubular secretory mass.

VI. Miscellaneous tests:

i. Intravenous pyelography
ii. Radio active Renogram
iii. Radio active Scanning
 I. Urine Examination
• Physical
• Biochemical
• Microbiological
• Urine Electrophoresis
A. Physical Examination
1. Colour
2. Appearance
3. Odour
4. Volume
5. pH
6. Specific Gravity.
 A. Physical Examination
Parameter Normal Variation & Associated Conditions

Volume 1- 2.5 L/ day Polyuria ( >3L/day): Diabetes mellitus (DM), DI, or

(average 1.5 diuretic therapy
L/ day) Oliguria (<400 ml/day): Fever, diarrhoea
Anuria (<100 ml/day): Mismatched blood transfusion,
shock, ATN
Colour Pale yellow Dark yellow: dehydration, Deep yellow: Jaundice, Milky
(due to white: chyluria, Black: alkaptonuria, Reddish: Hematuria
urochrome)
Appear Clear/ Cloudy/turbid: Pyuria due to urinary tract infection
ance transparent (UTI)
Odour Aromatic Foul or fishy: UTI, Fruity: DKA, Mousy:
Phenylketonuria
pH Average: 6.0 Acidic: protein rich diet, fever and metabolic acidosis
(4.5- 8)
Alkaline: Heavy vegetarian diet, antacid & met. alkalosis
Specific Average- 1.020 Increased with concentrated urine (dehydration, DM), NS
gravity (1.016-1.025) and decreased with dilute urine (Polyuria). Fixed (1.010) in
chronic glomerulonephritis (CGN)
 B. Chemical Examination:
• Urine dipstick provides qualitative analysis of analytes in
urine which are normally absent.
• Abnormalities detected by dipstick in urine are

Analytes Interpretations (found in)

Glucose Diabetes mellitus, pregnancy, renal glycosuria & Fanconi's
syndrome
Blood Injury, stone, tumor or infection of renal tract,
glomerulonephritis (GN), hemolysis and hemoglobinuria
Protein Fever, exercise, nephrotic syndrome (NS),
glomerulonephritis and UTI
Ketones Starvation, severe vomiting, or diabetic ketoacidosis. Only
detects acetoacetate and acetone.
Bilirubin Conjugated form in hepatitis and obstructive jaundice.
Urobilinogen Absent in conjugated hyperbilirubinemia and high in
prehepatic jaundice and hemolysis.
Nitrite & Indicators of urinary tract infection
c. Microscopic Examination:
i. Hematuria- microscopic hematuria:
ii. Cells –
RBCs:
- heavy exercise
- menstrual blood contamination
- renal trauma
- renal/bladder calculi
- pyelonephritis , cystitis
WBCs:
- AGN
- UTI
Epithelial cells:
vaginal epi. cells: female pt.
renal epi. Cells: active tubular injury.
Urothelial cells: ( in large no. )- bladder catheterization
- bladder inflammation
- bladder neoplasia
Yeast cells: vaginal moniliasis
Parasitic cells: E. vermicularis – children
T. vaginalis - female
iii. Bacteria: > 20 organism / hpf or 105 in colony count
is abnormal
usually gm –ve rods like E.coli , proteus etc.

iv. Casts: type of cast association

• hyaline normal , fever ,

prolonged standing ,
dehydration , emotional stress
• waxy renal tubular disorder

• broad CRF
 Type of casts Associations

 RBCs cast glomerulonephrits

vasculitis
 WBCs cast interstitial nephritis
pyelonephritis
 Epithelial cell acute tubular necrosis
interstitial nephritis
glomerulonephritis
 Granular pyelonephritis
chr. Lead poisoning
 Fatty cast heavy proteinuria
iv. Urine Electrophoresis:
• Done to distinguish between acute glomerular
nephropathy & tubular proteinuria from mono &
polyclonal globulinemia.
 BIOCHEMICAL PARAMETERS:

- Non protein Nitrogenous (NPN) constituents :

Their step wise ↑ reflect the deteriorating renal
function.
- Azotemia - ↑ in NPN in blood
- Uremia - ↑ in NPN in blood, along with clinical
symptoms of renal failure.
Estimation of Serum Urea:
 Synthesized in the liver .
 Constitutes ½ of NPN.
 Normal Serum urea= 13-45 mg/dl,
 Urea nitrogen = Urea/2.14
 ↓ serum urea - ↓ protein intake (malnutrition)
severe liver disease
pregnancy
early infancy
 ↑ serum urea – Physiological :↑ protein intake
Old age
Pre Renal: stress
CCF
shock , dehydration
haemorrhage
 Renal – ARF, CRF
glomerulonephritis
renal trauma, tubular necrosis
 Post renal – Urinary tract obstruction
stones , stricture
BHP , Ca prostrate
 Methods of estimation :
Diacetyl monoxime
Urease
GLDH kinetic
Nesslerization
Estimation of serum creatinine:
 More sensitive & specific than other NPN
 muscle creatinePO4 undergoes spontaneous
dehydration to form creatinine.
 Normal = 0.6-1.2 mg/dl (M), 0.5-1.1 mg%(F)
 In renal disease creatinine is retained & blood level
rises
 Methods of estimation :

JAFFE alkaline picrate ,Enzymatic method

Estimation of serum uric acid:
 final breakdown product of purine metabolism
 Metabolised mainly in liver , excreted through
kidney
 normal blood value: 3.0- 7.0 mg/dl
 ↑ - gout
- CRF
- toxemia of pregnancy
- lactic acidosis
 ↓ - 2ndary to severe liver ds
- defective tubular reabsorption
 Methods: phosphotungstic acid , uricase , HPLC
Cystatin C –
Extracellular cysteine protease inhibitor
Excellent GFR marker, better than Crea
Blood level not not depended on age, sex,
muscle mass, inflammatory processes.
Can detect mild renal impairment
Normal blood value – 0.8-1.2 mg/L
 GLOMERULAR FILTRATION TESTS:

CLEARANCE: Defined as a volume of blood or plasma

which contains that amount of substances
which is excreted in urine in 1 minute.

 C = UV/P, where U= conc. In urine

P= Plasma/Serum conc.
V= Urine output in ml per min

 Value expressed as ml/min (ml of plasma per min)

UREA CLEARANCE TEST: It is the expression of ml
of blood/plasma which are completely cleared of
urea by kidney per minute.
CU=UV/P
U= conc of urea in urine(mg/dl)
V= volume of urine in ml/min
P= conc of urea in blood (mg/dl)
Maximum Urea Clearance:
• The clearance which occurs when the urinary
volume exceeds 2ml/min is termed so.
• It is proportional to conc. of urea in blood.
• Avg value Cm= 75 ml/min (75±10)

Standard Urea Clearance:

• When urinary volume is <2 ml/min the urea
clearance is called so.
• Cs= U √ V =54 ml/min (54±10)
P
• CLu 40-60% of normal - mild impairment
20-40% - moderate impairment
< 20% - severe impairment

• Conditions of ↓ CLu - ARF (< ½ of normal)

- Chronic Nephritis
(progressive ↓)
- Terminal uremia (↓ to 5% of
Normal )

• Very low protein diet can lead to low CL value in

normal persons & in mild renal impairment.
ENDOGENOUS CREATININE CLEARANCE:
• At the normal levels of Cr , this metabolite is filtered at
the glomerulus but neither secreted nor reabsorbed.
• Hence its CL gives the GFR.
 This is convenient since
- it’s normal metabolite of body
- doesn’t need IV administration
- estimation is simple
- longer collection period minimizes timing error.
 C cr(ml/min)= Ucr(mg/dl)Vu(ml/min) 1.73/A
Pcr(mg/dl)
Ccr- Creatinine clearance , Ucr- urine Cr conc.
Pcr- plasma Cr , Vu – vol of urine/min,1.73/A-correction for BSA
C cr – 85-125ml/min/1.73m2(m), 80-115 ml/min/1/73m2(f)
• ↓ with age, renal failure
INULIN CLEARANCE TEST:
• It’s superior to other clearance as
- not metabolised in body
- following IV administration entirely excreted through
glomerular filtration , being neither secreted nor
reabsorbed.
• But the procedure is tedious
• C in= UV/P
• Normal value 100-150ml/min (avg-125)
Cr51-EDTA CLEARANCE:
 Single injection is required
 Particularly convenient for children where 24 hr
urine collection is not easy
 Can be used in infants.

Sodium[ I125] Iothalamate clearance:

 Radioactively lebeled filtration marker
 Simple to administer
Estimated GFR (eGFR)
• Simple technique of estimating Cr clearance
& there by GFR from Serum Cr.
• No need for timed urine collection
• Cockcroft-Gault equation:
Ccr=(140-age in years) x weight in Kg (0.85 in
F)/72 x Pcr in mg/dl
 TEST FOR RENAL BLOOD FLOW
Measurement of Renal Plasma Flow:

 Para Amino Hippurate (PAH) is filtered at the

glomerulus & secreted at the tubules
 At low plasma conc. of plasma , PAH is removed
completely during a single circulation through
kidney.
 So PAH CL measures renal plasma flow (RPF).
 RPF = 700 ml/min
Filtration Fraction: (FF)

• It’ s the fraction of plasma passing through the

kidney which is filtered at the glomerulus.
• Obtained by dividing the Inulin clearance by
PAH clearance.
• FF = C in/ CPAH = GFR/RPF

• Normal FF = 125/700= 0.18 (18%)

 TESTS FOR TUBULAR FUNCTION

Concentration Test:
• Sp gr measured after 12 hrs of fast.
• Sp gr > 1.022 – adequate renal function

Ratio of day and night urine volume- at least 2:1 or 3:1

• renal tubular diseases this ratio is decreased or
reversed
 Dilution Test:
• Bladder emptied at 7 am, water load given
• Hourly urine sample collected for next 4 hrs
• Normal person excretes all most all water, sp gr of
at least 1 sample is ≤ 1.003
• More sensitive and safe

Urinary acidification test:

• Most useful
• After giving a dose of NH4Cl, urine is collected
hourly for 2-8 hrs, pH & acid excretion of each
sample was noted.
Test of tubular excretion & reabsorption
15 min Phenol sulphthalein ( PSP ) test:
 0.1 ml of PSP (6 mg ) injected Ivly.
 Normal kidney excretes 30-50% of dye during 1st 15
min.
 Excretion < 23% during this period → impaired
kidney function

Tests to determine tubular secretory mass:

 by using Diodrast or PAH.
 MISCELLANEOUS TESTS

Intravenous Pyelography:
 Gives information about size , shape , functioning of
kidney.
 Commonly used substances are - Iodoxyl
- Diodrast
Radio active Renogram:
 15-60 µci of Hippuran given slow IV ly
 Information regarding - major assymetry in
function between 2 kidneys.
- presence of any obstruction

to urinary flow.
Radio active Scanning:
 Dimercaptosuccinicacid scan (DMSA Scan):
detects any structural abnormalities in kidney

 Diethylene triamine penta acetic acid scan

(DTPA):
Tc 99m DTPA scan determines overall renal
function
Renal biopsy:
Renal ultrasound:
CT, MRI :