KIDNEY FUNCTION

TESTING
An Introduction to the Urinary System

Produces urine

Transports urine
towards bladder

Temporarily store
urine

Conducts urine
to exterior
 The Function of Urinary System
)A  Excretion & Elimination:
removal of organic wastes products
from body fluids (urea, creatinine,
uric acid)

)B  Homeostatic regulation:
Water -Salt Balance
Acid - base Balance
)C  Enocrine function:
Hormones
 )A The excretory function

 excretion of excess electrolytes, nitrogenous wastes and organic acids

 The maximal excretory rate is limited or established by their plasma

concentrations and the rate of their filtration through the glomeruli

 The maximal amount of substance excreted in urine does not exceed the

amount transferred through the glomeruli by ultrafiltration except in the

case of those substances capable of being secreted by the tubular cells.

 B) Homeostatic Functions
1) Water -Salt Balance
Blood volume is associated with Salt volume.
The greater the blood volume the greater the blood pressure.
Removing water lowers blood pressure

 Regulate blood volume and blood pressure:

 by adjusting volume of water lost in urine
 releasing renin from the juxtraglomerular apparatus

• Regulate plasma ion concentrations:

 sodium, potassium, and chloride ions (by controlling quantities lost in urine)
 calcium ion levels
 B) Homeostatic Functions
Acid-Base Balance )2 (Help stabilize blood pH)

The kidneys control this by excreting H+ ions and

reabsorbing HCO3 (bicarbonate).

If plasma pH is low (acidic). If plasma pH is high (alkaline).

   
H+ secretion in the urine and H+ secretion in the urine and HCO3¯
HCO3¯ reabsorption back to the reabsorption back to the plasma
plasma increases decreases
   
thus urine becomes more acidic, thus urine becomes more alkaline,
and the plasma more alkaline. and the plasma more acidic.
C) The endocrine function
 Kidneys have primary endocrine function since they produce hormones
(erythropoietin, renin and prostaglandin).
 Erythropoietin is secreted in response to a lowered oxygen content in the
blood. It acts on bone marrow, stimulating the production of red blood cells.
 In response to low blood pressure, the juxtaglomerular cells of the kidneys
secrete an enzyme called renin, which converts angiotensinogen (synthesized
by the liver) into angiotensin I  converted into angiotensin II in the lungs.
 Angiotensin II causes constriction of efferent arterioles that lead away from
the glomerulus, which causes glomerular blood pressure to increase 
normal filtration pressure in the glomerulus.
 The kidneys are primarily responsible for producing vitamin D3
 In addition, the kidneys are site of degradation for hormones such as
insulin and aldosterone,
KIDNEY STRUCTURE

AND

URINE FORMATION
Each kidney consists of one million functional
units: Nephrone

Nephron structure
A) Glomerulus
B) Glomerular Capsule
C) Renal Tubule
 proximal convoluted tubule
• loop of Henle
• distal convoluted tubule
D)  Collecting Duct
 
 The Glomerulus

 
 
Blood pressure inside of the glomerulus is very high.
 
Because of differences in the resistance between the afferent and efferent arterioles.
Forces the fluids and some solids out of the blood into the glomerular capsule.
 Urine Formation
: Urine formation requiers
)a Glomerular Filtration
Due to differences in pressure water, small molecules
move from the glomerulus capillaries into the
glomerular capsule

)b Tubular reabsorption
  many molecules are reabsorbed from the nephron
into the capillary (diffusion, facilitated diffusion,
osmosis, and active transport)
i.e.  Glucose is actively reabsorbed with transport
carriers.
If the carriers are overwhelmed glucose appears in the
urine indicating diabetes

)c Tubular secretion
Substances are actively removed from blood and
added to tubular fluid (active transport)
ie.  H+, creatinine, and some drugs are moved by
active transport from the blood into the distal
convoluted tubule
 Urine Formation

Glomerular Filtration
The first step in the production of urine is called
glomerular filtration.
Filtration: the forcing of fluids and dissolved
substances through a membrane by pressure
occurs in the renal corpuscle of the kidneys
across the endothelial capsular membrane
(Bowman's) capsule.
- The resulting fluid is called the filtrate.
- Filtration is a passive process.
- The total filtration rate of the kidneys is mainly
determined by the difference between the blood
pressure in the glomerular capillaries and the
hydrostatic pressure in the lumen of the nephron
 Glomerular Filtration Rate

The amount of filtrate that flows out of all the renal corpuscles of both kidneys every minute
is called the glomerular filtration rate (GFR).
In the normal adult, this rate is about 120 ml/min; about 180 liters/Day

Glomerular Filtration Rate (GFR) Affected by:

1). Total filtration surface area
2). Membrane permeability
3). Net Filtration Pressure
Biochemical Tests of Renal Function

 Measurement of GFR
 Clearance tests
 Plasma creatinine
 Urea, uric acid and β2-microglobulin

 Renal tubular function tests

 Osmolality measurements
 Specific proteinurea
 Glycouria
 Aminoaciduria
 Urinalysis
 Appearance
 Specific gravity and osmolality
 pH
 osmolality
 Glucose
 Protein
 Urinary sediments
When should you assess renal function?

 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
Biochemical Tests of Renal Function

 Measurement of GFR
 Clearance tests
 Plasma creatinine
 Urea, uric acid and β2-microglobulin
 Biochemical Tests of renal function
In acute and chronic renal failure, there is effectively a loss of
function of whole nephrons
 Filtration is essential to the formation of urine  tests of
glomerular function are almost always required in the
investigation and management of any patient with renal disease.
The most frequently used tests are those that assess either the
GFR or the integrity of the glomerular filtration barrier.
 Measurement of glomerular filtration rate
GFR can be estimated by measuring the urinary excretion of a substance that is completely filtered
from the blood by the glomeruli and it is not secreted, reabsorbed or metabolized by the renal
tubules.
 Clearance is defined as the (hypothetical) quantity of blood or plasma completely cleared of a
substance per unit of time.
(Uinulin  V)
GFR = V is not urine volume, it is urine flow rate
Pinulin
 Clearance of substances that are filtered by the glomeruli but neither reabsorbed nor secreted
by other regions of the nephron can be used to measure GFR.
 Inulin (a plant polysaccharide) can be used.
The Volume of blood from which inulin is cleared or completely removed in one minute is
known as the inulin clearance and is equal to the GFR.
Measurement of inulin clearance requires the infusion of inulin into the blood and is not
suitable for routine clinical use
Biochemical Tests of Renal Function

 Measurement of GFR
 Clearance tests
 Plasma creatinine
 Urea, uric acid and β2-microglobulin
 Creatinine
1 to 2% of muscle creatine spontaneously converts to creatinine
daily and released into body fluids at a constant rate.
Endogenous creatinine produced is proportional to muscle
mass, it is a function of total muscle mass the production
varies with age and sex
 Dietary fluctuations of creatinine intake cause only minor
variation in daily creatinine excretion of the same person.
 Creatinine released into body fluids at a constant rate and its
plasma levels maintained within narrow limits  Creatinine
clearance may be measured as an indicator of GFR.
 Creatinine clearance and clinical utility
The most frequently used clearance test is based on the
measurement of creatinine.
 Small quantity of creatinine is reabsorbed by the tubules and
other quantities are actively secreted by the renal tubules  So
creatinine clearance is approximately 7% greater than inulin
clearance.
The difference is not significant when GFR is normal but when
the GFR is low (less 10 ml/min), tubular secretion makes the
major contribution to creatinine excretion and the creatinine
clearance significantly overestimates the GFR.
 Creatinine clearance clinical utility
An estimate of the GFR can be calculated from the creatinine content of a 24-hour
urine collection, and the plasma concentration within this period.
The volume of urine is measured, urine flow rate is calculated (ml/min) and the
assay for creatinine is performed on plasma and urine to obtain the concentration in
mg per dl or per ml.

Creatinine clearance in adults is normally about of 120 ml/min,

The accurate measurement of creatinine clearance is difficult, especially in outpatients,
since it is necessary to obtain a complete and accurately timed sample of urine
 Creatinine clearance and clinical utility

The 'clearance' of creatinine from plasma is directly related to the

GFR if:
The urine volume is collected accurately
There are no ketones or heavy proteinuria present to interfere with
the creatinine determination.
It should be noted that the GFR decline with age (to a greater extent
in males than in females) and this must be taken into account when
interpreting results.
 Use of Formulae to Predict Clearance

Formulae have been derived to predict Creatinine

Clearance (CC) from Plasma creatinine.
Plasma creatinine derived from muscle mass which is
related to body mass, age, sex.
Cockcroft & Gault Formula
CC = k[(140-Age) x weight(Kg))] / serum Creatinine (µmol/L)
k = 1.224 for males & 1.04 for females
Modifications required for children & obese subjects
Biochemical Tests of Renal Function

 Measurement of GFR
 Clearance tests
 Plasma creatinine
 Urea, uric acid and β2-microglobulin
 Measurement of nonprotein nitrogen-
containing compounds
Catabolism of proteins and nucleic acids results in formation of
so called nonprotein nitrogenous compounds.
Protein
 Proteolysis, principally enzymatic
Amino acids
 Transamination and oxidative deamination
Ammonia
 Enzymatic synthesis in the “urea cycle”
Urea
 Plasma Urea
Urea is the major nitrogen-containing metabolic product of protein
catabolism in humans,
 Its elimination in the urine represents the major route for nitrogen
excretion.
 More than 90% of urea is excreted through the kidneys, with losses
through the GIT and skin
 Urea is filtered freely by the glomeruli
 Plasma urea concentration is often used as an index of renal glomerular
function
 Urea production is increased by a high protein intake and it is decreased
in patients with a low protein intake or in patients with liver disease.
 Plasma Urea
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 5-39 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 factors that affect urea level.
Nonrenal factors can affect the urea level (normal adults is level 5-39 mg/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
 Clinical Significance
 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

 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 (nucleated cells,
like meat) 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
 Uric acid
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
 Plasma β2-microglobulin
β2-microglobulin is a small peptide (molecular weight 11.8 kDa),
It is present on the surface of most cells and in low concentrations in the
plasma.
It is completely filtered by the glomeruli and is reabsorbed and catabolized
by proximal tubular cells.
The plasma concentration of β2-microglobulin is a good index of GFR in
normal people, being unaffected by diet or muscle mass.
It is increased in certain malignancies and inflammatory diseases.
Since it is normally reabsorbed and catabolized in the tubules, measurement
of β2-microglobulin excretion provides a sensitive method of assessing
tubular integrity.
Biochemical Tests of Renal Function

 Renal tubular function tests

 Osmolality measurements
 Specific proteinurea
 Glycouria
 Aminoaciduria
 Renal tubular function tests
 To ensure that important constituents such as water, sodium, glucose and
a.a. are not lost from the body, tubular reabsorption must be equally
efficient
 Compared with the GFR as an assessment of glomerualr function, there
are no easily performed tests which measure tubular function in
quantitative manner
 Investigation of tubular function:
1. Osmolality measurements in plasma and urine; normal urine: plasma
osmolality ratio is usually between 1.0-3.0
2. Specific proteinuria
3. Glycosuria
4. Aminoaciduria
 Assessment of glomerular integrity
Proteinuria may be due to:
1. An abnormality of the glomerular basement membrane.
2. Decreased tubular reabsorption of normal amounts of filtered proteins.
3. Increased plasma concentrations of free filtered proteins.
4. Decreased reabsorption and entry of protein into the tubules consequent to tubular epithelial
cell damage.
Measurement of individual proteins such as β2-microglobulin have been used in the early
diagnosis of tubular integrity.
With severe glomerular damage, red blood cells are detectable in the urine (haematuria), the red
cells often have an abnormal morphology in glomerular disease.
 Haematuria can occur as a result of lesions anywhere in the urinary tract,
 Proteinuria
The glomerular basement membrane does not usually allow passage of
albumin and large proteins. A small amount of albumin, usually less than 25
mg/24 hours, is found in urine.
Urinary protein excretion in the normal adult should be less than 150
mg/day.
When larger amounts, in excess of 250 mg/24 hours, are detected,
significant damage to the glomerular membrane has occurred.
Quantitative urine protein measurements should always be made on
complete 24-hour urine collections.
Albumin excretion in the range 25-300 mg/24 hours is termed
microalbuminuria
 Proteinuria
 Normal < 150 mg/24h.
 TYPES OF PROTEINURIA 
 Glomerular proteinuria 
 Tubular proteinuria 
 Overflow proteinuria 
 Glomerular proteinuria

 Glomerular proteinuria — Glomerular proteinuria

is due to increased filtration of macromolecules
(such as albumin) across the glomerular capillary
wall. The proteinuria associated with diabetic
nephropathy and other glomerular diseases, as well
as more benign causes such as orthostatic or
exercise-induced proteinuria fall into this category.
Most patients with benign causes of isolated
proteinuria excrete less than 1 to 2 g/day
 Tubular proteinuria
  Low molecular weight proteins — such as ß2-
microglobulin, immunoglobulin light chains, retinol-
binding protein, and amino acids — have a molecular
weight that is generally under 25,000 in comparison to
the 69,000 molecular weight of albumin. These smaller
proteins can be filtered across the glomerulus and are
then almost completely reabsorbed in the proximal
tubule. Interference with proximal tubular reabsorption,
due to a variety of tubulointerstitial diseases or even
some primary glomerular diseases, can lead to increased
excretion of these smaller proteins
 Overflow proteinuria 

  Increased excretion of low molecular weight

proteins can occur with marked overproduction of a
particular protein, leading to increased glomerular
filtration and excretion. This is almost always due
to immunoglobulin light chains in multiple
myeloma, but may also be due to lysozyme (in
acute myelomonocytic leukemia), myoglobin (in
rhabdomyolysis), or hemoglobin (in intravascular
hemolysis
Biochemical Tests of Renal Function

 Urinalysis
 Appearance
 Specific gravity and osmolality
 pH
 Glucose
 Protein
 Urinary sediments
 Urinalysis
Urinalysis is important in screening for disease is routine test for every patient, and not just
for the investigation of renal diseases
Urinalysis comprises a range of analyses that are usually performed at the point of care rather
than in a central laboratory.
Urinalysis is one of the commonest biochemical tests performed outside the laboratory.

 Examination of a
patient's urine should
not be restricted to
biochemical tests.
 Urinalysis using disposable strips
Biochemical testing of urine involves the use of commercially available disposable strips
When the strip is manually immersed in the urine specimen, the reagents react with a
specific component of urine in such a way that to form color
 Colour change produced is proportional to the concentration of the component being tested
for.
To test a urine sample:
fresh urine is collected into a clean dry container
the sample is not centrifuged
 the disposable strip is briefly immersed in the urine specimen;
The colour of the test areas are compared with those provided on a colour chart
Chemical Analysis
Urine Dipstick
Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
 Urinalysis
 Fresh sample = Valid sample.
 fresh urine is collected into a clean dry container
 the sample is not centrifuged
Blue Green Pink-Orange- Red-brown-black
Red
Methylene Blue Haemoglobin Haemoglobin
Pseudomonas Myoglobin Myoglobin
Riboflavin Phenolpthalein Red blood cells
 Appearance: -
Porphyrins Homogentisic Acid
 Blood
 Colour (haemoglobin, myoglobin,) Rifampicin L -DOPA
 Turbidity (infection, nephrotic syndrome) Melanin
Methyldopa
 Urinalysis: Specific gravity
– This is a semi-quantitative measure of concentration.
– A higher specific gravity indicates a more concentrated urine.
– Assessment of urinary specific gravity usually just confirms the impression gained by
visually inspecting the colour of the urine. When urine concentration needs to be
quantitated,
Urinalysis: Osmolality measurements in
plasma and urine
– Osmolality serves as general marker of tubular function. Because the ability
to concentrate the urine is highly affected by renal diseases.
– This is conveniently done by determining the osmolality, and then
comparing this to the plasma.
– If the urine osmolality is 600mosm/kg or more, tubular function is usually
regarded as intact
– When the urine osmolality does not differ greatly from plasma (urine:
plasma osmolality ratio=1), the renal tubules are not reabsorbing water
 Urinalysis
 pH
 Urine is usually acidic
 Measurement of urine pH is useful in suspected drug toxicity, abuse.., or where there is
an unexplained metabolic acidosis (low serum bicarbonate or other causes…).
 Urine sediments
 Microscopic examination of sediment from freshly passed urine involves looking for
cells, casts, fat droplets
 Blood: haematuria is consistent with various possibilities ranging from malignancy
through urinary tract infection to contamination from menstruation.
 Red Cell casts could indicate glomerular disease
 Crystals
 Leucocytes in the urine suggests acute inflammation and the presence of a urinary tract
infection.
 Urinary casts

are cylindrical structures produced by the kidney and present in the urine
in certain disease states.
 They form in the distal convoluted tubule and collecting ducts of
nephrons, then dislodge and pass into the urine, where they can be
detected by microscope.
 They form via precipitation of Tamm-Hrsfall mucoprotein which is
secreted by renal tubule cells, and sometimes also by albumin.
Red blood cell cast in urine
White blood cell cast in urine

Urinary casts. (A) Hyaline cast

(200 X); (B) erythrocyte cast (100
X); (C) leukocyte cast (100 X);
(D) granular cast (100 X)
 Crystals

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

crystals (C) triple phosphate crystals with amorphous
phosphates ; (D) cystine crystals.
 Urine volume
- Water homeostasis is determined by several interrelated processes:
1. Water intake and water formed through oxidation of food stuffs.
2. Extra-renal water loss: insensible water loss the via faeces, and sweating.
3. A solute load to be excreted that is derived from ingested minerals and
nitrogenous substances.
4. The ability of the kidneys to produce concentrated or dilute urine.
5. Other factors such as vomiting and diarrhoea become important in various
disease states;
loss of ability to produce concentrated urine is a feature of virtually all types
of chronic renal diseases.
 Urine volume
To maintain water homeostasis, the kidneys must produce urine in a volume
precisely balances water intake and production to equal water loss through extra
renal routes.
 Minimum urine volume is determined by the solute load to be excreted whereas
maximum urine volume is determined by the amount of excess water that must be
excreted
Causes of polyurea

Increased osmotic load, e.g due to glucose

Increased water ingestion
Diabetes insipidus: - Failure of ADH production results in
marked polyuria (diabetes insipidus), which stimulates thirst
and greatly increases water intake
Nephrogenic diabetes insipidus: The kidneys’ lack of
response to ADH has similar effect ( failure of the tubules to
respond to Vassopressin (ADH
MAJOR CAUSES OF KIDNEY DISEASE 

  The causes of acute or chronic kidney disease are traditionally

classified by that portion of the renal anatomy most affected by the
disorder. Renal function is based upon four sequential steps, which
are isolated to specific areas of the kidney or surrounding structures:
 First, blood from the renal arteries and their subdivisions is delivered to the
glomeruli.
 The glomeruli form an ultrafiltrate, nearly free of protein and blood
elements, which subsequently flows into the renal tubules.
 The tubules reabsorb and secrete solute and/or water from the ultrafiltrate.
 The final tubular fluid, the urine, leaves the kidney, draining sequentially
into the renal pelvis, ureter, and bladder, from which it is excreted through
the urethra.
Prerenal disease
  The two major causes of reduced renal perfusion are
volume depletion and/or relative hypotension. This
may result from true hypoperfusion due to bleeding,
gastrointestinal, urinary, or cutaneous losses, or to
effective volume depletion in heart failure, shock, or
cirrhosis.
 Prerenal disease is most commonly associated with an
acute time course. However, among patients with
chronic kidney disease, the addition of a prerenal
process may result in acute renal dysfunction
Glomerular disease 
  There are numerous idiopathic and secondary (due to neoplasia,
autoimmunity, drugs, genetic abnormalities, and infections)
disorders that produce glomerular disease. Two general patterns
(with considerable overlap in some diseases) are seen:
 A nephritic pattern, which is associated with inflammation on
histologic examination and produces an active urine sediment with
red cells, white cells, granular and often red cell and other cellular
casts, and a variable degree of proteinuria.
 A nephrotic pattern, which is not associated with inflammation on
histologic examination and is associated with proteinuria, often in
the nephrotic range, and an inactive urine sediment with few cells or
casts.
Tubular and interstitial disease 
  As with vascular disease, the tubular and
interstitial diseases affecting the kidney can be
divided into those that produce acute and chronic
disease: Hereditary, systemic, toxic, and drug-
induced causes predominate.
 The most common acute tubulointerstitial disorders are
acute tubular necrosis, which typically occurs in
hospitalized patients.
 The major chronic tubulointerstitial disorders are
polycystic kidney disease
Obstructive uropathy
 Obstruction to the flow of urine can occur
anywhere from the renal pelvis to the urethra. The
development of renal insufficiency in patients
without intrinsic renal disease requires bilateral
obstruction (or unilateral obstruction with a single
functioning kidney) and is most commonly due to
prostatic disease (hyperplasia or cancer) or
metastatic cancer. The time course can be acute or
chronic
Nephrotic syndrome
  The nephrotic syndrome is caused by renal diseases that
increase the permeability across the glomerular filtration
barrier. It is classically characterized by four clinical
features, but the first two are used diagnostically because
the last two may not be seen in all patients:
 Nephrotic range proteinuria — Urinary protein excretion
greater than 50 mg/kg per day
 Hypoalbuminemia — Serum albumin concentration less than
3 g/dL (30 g/L)
 Edema
 Hyperlipidemia