RENAL FUNCTION TESTS

By:
Dr: Mahmoud Gomaa Eldeib

Biochemistry Dept., Faculty of Pharmacy, Sinai

University
Biochemistry and molecular biology Dept.,
Faculty of Pharmacy , Al-Azhar University
 Functions of the kidneys: -
1- Excretory function: the excretion of waste products.
2- Homeostatic function: regulation of the ECF volume and composition
(regulation of water, electrolyte and acid–base balance)
3- Endocrine function: kidney perform the following
▪ Produce Rennin hormone that stimulate angiotensogen.
▪ Activates vitamin D by hydroxylation at C1 to produce 1,25 dihydroxy cholecalcifirol (Vit D3
active from).
▪ Produce Erythropiotin (stimulate erythropoiesis on the bone marrow).

In order to achieve these functions, they receive a rich blood supply, amounting to about 25% of the
cardiac output.
 Functional unit of the kidney (nephron)
Each kidney comprising about 1 million nephrons,
which act as independent functional units.
• The glomeruli act as filters which are permeable to water and low
molecular weight substances, but impermeable to macromolecules.
This impermeability is determined by both size and charge, with
proteins smaller than albumin (68 kDa) being filtered, and positively
charged molecules being filtered more readily than those with a
negative charge.
• The tubules return nutrients, fluids, and other substances that have
been filtered from the blood, but the body needs, back to the blood.
The remaining fluid and waste in the renal tubules become urine
 Impaired renal function
causes of impaired renal function
1- Pre-renal causes
- reduced renal perfusion due to:
A. Physiological response to hypovolaemia or a drop in blood pressure. this causes renal
vasoconstriction and a redistribution of blood such that there is a decrease in GFR, but
preservation of tubular function.
Stimulation of vasopressin secretion and of the renin–angiotensin–aldosterone system
causes the excretion of small volumes of concentrated urine with a low Na content.
B. Congestive cardiac failure (CHF)

If pre-renal causes are not treated adequately and promptly by restoring renal perfusion,
there can be a progression to intrinsic renal failure.
2- Renal causes
may be due to acute kidney injury or chronic kidney
disease, with reduction in glomerular filtration.
3- Post-renal causes
occur due to outflow obstruction, which may occur at
different levels (i.e. in the ureter, bladder or urethra), due to
various causes (e.g. renal stones, prostatism, genitourinary
cancer).
As with pre-renal causes, this may in turn cause damage to
the kidney.
 Renal function tests
• Tests of glomerular function
In acute and chronic kidney injury, there is effectively a loss of function of whole nephrons, and because the
process of filtration is essential to the formation of urine, tests of glomerular function are almost invariably
required in the investigation and management of any patient with kidney disease.

Measurement of glomerular filtration rate

• Clearance tests
• An estimate of the GFR can be made by measuring the urinary excretion of a substance that is completely
filtered from the blood by the glomeruli and is not secreted, reabsorbed or metabolized by the renal tubules.
• Experimentally, inulin (a plant polysaccharide) has been found to meet these requirements.
• The volume of blood from which inulin is cleared or completely removed in 1 min is known as the inulin
clearance, and it 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.
Creatinine clearance:
• The most widely used biochemical clearance test is based on measurements of creatinine in plasma and urine.
• Creatinine is an endogenous substance derived mainly from the turnover of creatine in muscle, and daily
production is relatively constant, being a function of total muscle mass.
• A small amount of creatinine is derived from meat in the diet.
• Creatinine clearance is calculated using the following formula:
• Clearance =U× V˙/P mL/min
• U = urine creatinine concentration (μmol/L)
• V = urine flow rate (mL/min or (L/24 h)
• P = plasma creatinine concentration (μmol/L)

Creatinine clearance in healthy adults is ∼120 mL/min, but a normal GFR for a small person will be lower than
for a large person.
Results can be corrected to a standard body surface area of 1.73 m2 using formulae that incorporate weight and
height; this allows easier comparison between individuals.
It should be noted that the clearance formula is valid only for a steady state, that is, when kidney function
is not changing rapidly.
• A larger amount, up to 10% of urinary creatinine, is actively secreted into the urine by the renal tubules and as
a result, the creatinine clearance is higher than the true GFR. The difference is of little significance
when the GFR is normal, but when the GFR is low (<10 mL/min), tubular secretion makes a major
contribution to creatinine excretion and creatinine clearance significantly overestimates the GFR.
• The effect of creatinine breakdown in the gut also becomes significant when the GFR is very low.
• Certain drugs, including spironolactone, cimetidine, fenofibrate, trimethoprim and amiloride, decrease
creatinine secretion and thus can reduce creatinine clearance.
• Measurements of creatinine clearance are potentially unreliable and no longer recommended in
routine practice.
• Alternative methods should be used if a reliable calculation of GFR is required, for example in the
assessment of potential kidney donors, investigation of patients with minor abnormalities of kidney
function and calculation of the initial doses of potentially toxic drugs that are eliminated from the
body by renal excretion.
• There are two main alternative approaches to determining the GFR in clinical practice.
1) derive an estimated GFR (eGFR) from the plasma creatinine concentration
2) use exogenous markers of clearance.
Estimated GFR:
• Estimated GFR (eGFR) is now widely reported on laboratory report forms. This is a calculated estimate
based on creatinine and gets around some of the problems associated with creatinine, by incorporating
age and sex in the calculation.
• A number of formulae exist for predicting creatinine clearance (or GFR) from plasma [creatinine] and other
readily available information, such as age, sex and weight. e best known of these is that of Cockcroft and
Gault (1976):

This equation has been shown to be as reliable an estimate of creatinine clearance as its actual
measurement, since it avoids the inaccuracies inherent in timed urine collections.
Plasma creatinine

Creatine is synthesized in the liver, kidneys and pancreas, and is transported to its sites of usage, principally
muscle and brain. About 1–2% of the total muscle creatine pool is converted daily to creatinine through the
spontaneous, nonenzymatic loss of water.
• Creatinine is an end-product of nitrogen metabolism, and as such undergoes no further metabolism, but is
excreted in the urine.
• Creatinine production reflects the body’s total muscle mass.
• Plasma creatinine concentration is the most reliable simple biochemical test of glomerular function.
Ingestion of a meat-rich meal can increase plasma creatinine concentration by as much as 20 μmol/L for up to
10 hours afterwards, so ideally blood samples should be collected after an overnight fast.
• Strenuous exercise also causes a transient, slight increase.
• Reference range of serum [creatinine] in adults is 55–120 μmol/L.
• Plasma creatinine concentration is related to muscle bulk, and therefore, a value of 100 μmol/L could be
normal for an athletic young man but would suggest renal impairment in a thin 70-year-old woman.
The plasma creatinine concentration is inversely related to the GFR.
GFR can decrease by 50% before plasma creatinine concentration rises beyond the reference range;
plasma creatinine concentration doubles for each further 50% decline in GFR.
• Consequently, a normal plasma creatinine concentration does not necessarily imply normal
kidney function.
 Creatinine clearance or plasma [creatinine]?

• Measurement of plasma [creatinine] is more precise than measurement of creatinine clearance, as there are
two extra sources of unaccuracy in clearance measurements, that is, timed measurement of urine volume and
urine [creatinine].

• Low plasma [creatinine]

• A low [creatinine] is found in subjects with a small total muscle mass. A low plasma [creatinine] may
therefore be found in children, and values are, on average, normally lower in women than in men.
• Abnormally low values may be found in wasting diseases and starvation, and in patients treated with
corticosteroids, due to their protein catabolic effect.
• Creatinine synthesis is increased in pregnancy, but this is more than off- set by the combined effects of the
retention of fluid and the physiological rise in GFR that occurs in pregnancy, so plasma [creatinine] is usually
low.
High plasma [creatinine]
Nonrenal causes
➢Plasma [creatinine] tends to be higher in subjects with a large muscle mass
➢A high meat intake can cause a temporary increase.
➢Transient, small increases may occur after vigorous exercise.
➢Some analytical methods are not specific for creatinine. For example, plasma [creatinine]
will be overestimated by some methods in the presence of high concentrations of
acetoacetate or cephalosporin antibiotics.
➢Some drugs (e.g. salicylates, cimetidine) compete with creatinine for its tubular transport
mechanism, thereby reducing tubular secretion of creatinine and elevating plasma
[creatinine].
If nonrenal causes can be excluded, an increased plasma [creatinine] indicates a fall
in GFR, which can be due to pre-renal, renal or post-renal causes.
Plasma urea

• Urea is formed in the liver from ammonia released by deamination of amino acids.
• Over 75% of nonprotein nitrogen is excreted as urea, mainly by the kidneys; small amounts are lost
through the skin and the GI tract.
• Urea measurements are widely available, and have come to be accepted as giving a measure of
renal function.
• However, as a test of renal function, plasma [urea] is inferior to plasma [creatinine], since 50% or
more of urea filtered at the glomerulus is passively reabsorbed through the tubules, and this
fraction increases if urine flow rate decreases, such as in dehydration.
• It is also more affected by diet than [creatinine].
Low plasma [urea]
• Less urea is synthesized in the liver if there is reduced availability of amino acids for deamination, as in the case of
starvation or malabsorption However, in extreme starvation, plasma [urea] may rise, as increased muscle protein
breakdown then provides the major source of fuel.
• In patients with severe liver disease (usually chronic), urea synthesis may be impaired leading to a fall in plasma [urea].
• Plasma [urea] may fall as a result of water retention associated with syndrome of inappropriate vasopressin secretion
(SIAD) or dilution of plasma with IV fluids.
High plasma [urea]
• Increased production of urea in the liver occurs on high protein diets, or as a result of
increased protein catabolism (e.g. due to trauma, major surgery, extreme starvation). It
may also occur after haemorrhage into the upper GI tract, which gives rise to a ‘protein
meal’ of blood.
• Plasma [urea] increases relatively more than plasma [creatinine] in pre-renal impairment
of renal function. This is because the reduced urine flow in turn causes increased passive
tubular reabsorption of urea whereas relatively little reabsorption of creatinine occurs. Thus
shock, due to burns, haemorrhage or loss of water and electrolytes (e.g. severe diarrhoea),
may lead to a disproportionately increased plasma [urea] in comparison with [creatinine].
• Back-pressure on the renal tubules enhances back difusion of urea, so that plasma [urea]
rises disproportionately.
Cystatin C

• Cystatin C is low molecular mass peptide (13 kDa) that is produced by all nucleated cells. It is cleared from
the plasma by glomerular filtration, and its plasma concentration reflects the GFR more accurately than
creatinine.
• It is not much influenced by sex or muscle mass but may be increased in malignancy, hyperthyroidism and
by treatment with corticosteroids.
• Although not widely available in routine laboratories, measurement may have a role in the detection of early
renal impairment in patients in whom creatinine is affected by unusual muscle bulk (e.g. body builders,
teenage boys, the frail elderly [especially women] and patients with wasting muscle disorders).
 Tests of tubular function
• Specific disorders affecting the renal tubules may affect the ability to concentrate urine or to
excrete an appropriately acidic urine, or may cause impaired reabsorption of amino acids, glucose,
phosphate, etc.
• Renal tubular disorders may be congenital or acquired, the congenital disorders all being very rare.
• The healthy kidney has a considerable reserve capacity for reabsorbing water, and for excreting H+
and other ions, only exceeded under exceptional physiological loads.
• Moderate impairment of renal function may reduce this reserve, and this is revealed when loading
tests are used to stress the kidney.
Urine osmolality and renal concentration tests

• Urine osmolality varies widely in health, between 50 and 1250 mmol/kg, depending upon the
body’s requirement to produce a maximally dilute or a maximally concentrated urine.
• The failing kidney loses its capacity to concentrate urine at a relatively late stage.
• Formal tests of renal concentrating power measure the concentration of urine produced in response
either to fluid deprivation or to intramuscular (IM) injection of 1-deamino,8-D-arginine
vasopressin (DDAVP), a synthetic analogue of vasopressin.
• If the patient is receiving drugs that affect the renal concentrating ability (e.g. carbamazepine,
chlorpropamide, DDAVP), these should be stopped for at least 48 h before testing.
• A fluid deprivation test is performed first.
• If the patient is unable to concentrate the urine adequately following fluid deprivation, then a
DDAVP test follows immediately.
Fluid deprivation test
• There are a number of ways of performing a fluid deprivation test, differing in detail but all
involving fluid deprivation over several hours, ensuring that the patient under observation takes no
fluid, and that excessive fluid losses do not occur.
• Local directions for test performance should be followed.
• For instance, beginning at 10 pm, the patient is told not to drink overnight, and urine specimens are
collected while the patient continues not to drink between 8 am and 3 pm the next day. During the
test, the patient should be weighed every 2h, and the test should be stopped if weight loss of 3–5%
of total body weight occurs. Blood and urine specimens are collected for measurement of osmolality.
• Normally, there is no increase in plasma osmolality (reference range 285–295 mmol/kg) over the
period of water deprivation, whereas urine osmolality rises to 800 mmol/kg or more.
• A rising plasma osmolality and a failure to concentrate urine are consistent with either a failure to
secrete vasopressin or a failure to respond to vasopressin at the level of the distal nephron.
• When this pattern of results is obtained, it is usual to proceed immediately to perform the DDAVP
test.
 DDAVP test
• The patient is allowed to drink a moderate amount of water at the end of the fluid deprivation test, to alleviate
thirst. An IM injection of DDAVP is then given, and urine specimens are collected at hourly intervals for a
further 3 h and their osmolality measured.
• Interpretation of tests of renal concentrating ability
• These tests are of most value in distinguishing among hypothalamic–pituitary, psychogenic and renal causes of
polyuria
• Patients with diabetes insipidus of hypothalamic– pituitary origin produce insuificient vasopressin; they should
therefore not respond to fluid deprivation, but should respond to the DDAVP.
• As a rule, these patients show an increase in plasma osmolality during the fluid deprivation test, to more than
300 mmol/kg, and a low urine osmolality (200–400 mmol/kg). There is a marked increase in urine osmolality,
to 600 mmol/kg or more, in the DDAVP test.
• Polyuria of renal origin may be due to inability of the renal tubule to respond to vasopressin, as in nephrogenic
diabetes insipidus. In this condition, there is failure to produce a concentrated urine in response either to fluid
deprivation or to DDAVP injection, the urinary osmolality usually remaining below 400 mmol/kg; in these
patients, plasma osmolality increases as a result of fluid deprivation.
• Patients with psychogenic diabetes insipidus should respond to both fluid deprivation and DDAVP.
• Glycosuria
• Glucose is most commonly found in the urine in patients with diabetes, when the plasma [glucose]
exceeds the renal threshold.
• Glycosuria in the presence of a normal plasma [glucose] occurs in proximal tubular malfunction
causing a reduced renal threshold. This can be a benign isolated abnormality, may occur during
pregnancy or may be part of a more generalised disorder (the Fanconi syndrome).
The amino acidurias
• Amino acids can be categorised into four groups – the neutral, acidic and basic amino acids, and
the imino acids proline and hydroxyproline.
• Each has its own specific mechanism for transport across the proximal tubular cell.
• Normally, the renal tubules reabsorb all the filtered amino acids except for small amounts of
glycine, serine, alanine and glutamine.
• Amino aciduria may be due to disease of the renal tubule (renal or low threshold type), or to raised
plasma [amino acids] (generalised or overflow type).
• Renal amino aciduria may be due to impairment of one of the specific transport mechanisms. For
example, in cystinuria there is a hereditary defect in the epithelial transport of cystine and the basic
amino acids lysine, ornithine and arginine; it is a rare cause of renal (cystine) stones.
• Renal amino aciduria may also occur as a nonspecific abnormality due to generalized tubular
damage, together with reabsorption defects affecting glucose or phosphate, or both.
• Fanconi syndrome
• Fanconi syndrome may be inherited or secondary to a number of other disorders
(e.g. heavy metal poisoning, multiple myeloma).
• The syndrome comprises multiple defects of proximal tubular function. There are
excessive urinary losses of amino acids (generalised amino aciduria), phosphate,
glucose and sometimes HCO−3, which gives rise to a proximal renal tubular
acidosis.
 Renal failure

• Renal failure is the cessation of kidney function.

• In acute renal failure (ARF), the kidneys fail over a period of hours or days.
• Chronic renal failure (CRF) develops over months or years and leads eventually
to end-stage renal failure (ESRF).
• ARF may be reversed and normal renal function regained, whereas CRF is
irreversible.
 Acute renal failure
Aetiology
• Pre-renal: the kidney fails to receive a proper blood supply.
❖ Dehydration
❖ Hypotension
❖ Hemorrhage
❖ Low cardiac output (CHF)
❖ Severe burns
• Post-renal: the urinary drainage of the kidneys is impaired because of
an obstruction.
❖ Bilateral obstructing kidney stones
❖ Prostatic enlargement (benign or malignant)
❖ Other urinary tract neoplasms
• Renal:
Intrinsic damage to the kidney tissue. This may be due to a variety of
diseases, or the renal damage may be a consequence of prolonged pre-renal
or post-renal problems.
 Usually, urine output falls to less than 400 mL/24 hours, and the patient is said to be oliguric.
The patient may pass no urine at all, and be anuric.
Occasionally urine flow remains high when tubular dysfunction predominates.

• AKI is characterized by rapid loss of kidney function, with

retention of urea, creatinine, hydrogen ions and other metabolic
products and, usually but not always, oliguria
• The severity of the injury can be graded according to changes in
plasma creatinine concentration and urine output

• The terms ‘uraemia’ (meaning ‘urine in the blood’) and

‘azotaemia’ (increase in concentration of nitrogenous compounds)
have been used as synonyms for kidney disease
 Biochemical changes in plasma in acute kidney injury
Serum urea and creatinine are increased. Urea is increased disproportionately more Increased
than creatinine because of its reabsorption by the tubular cells, particularly at low urine potassium
flow rates. This leads to a relatively higher serum urea concentration than creatinine, urea
which is not so readily reabsorbed. creatinine
phosphate
Hyponatraemia is common. It is due primarily to an excess of water relative to sodium magnesium
hydrogen ion
urate
Hyperkalaemia occurs as a result of decreased renal excretion of potassium and
Decreased
transcellular shift (retained hydrogen ions are taken up by cells in exchange for sodium
potassium). bicarbonate
calcium
Hyperphosphataemia Retention of phosphate and leakage of intracellular phosphate
into the interstitial fluid leads to hyperphosphataemia, which inhibits the 1α-
hydroxylation of 25-hydroxycholecalciferol to calcitriol. The resulting decreased
plasma concentration of calcitriol causing hypocalcaemia
• Hypermagnesaemia is also often present as a result of decreased magnesium excretion.
• Metabolic acidosis: because of the inability of the kidney to excrete hydrogen ions.
Changes in urine:
❖Oligourea
❖A high urine osmolality.
❖Proteinuria is always present, and the urine may be dark because of the presence of haem
pigments from the blood.
❖It may be difficult to decide the reason for a patient’s oliguria. The biochemical features that
distinguish pre-renal uraemia from intrinsic renal damage are shown in this table:
 Chronic renal failure
• Chronic renal failure (CRF) is the progressive irreversible destruction of kidney tissue if not treated by
dialysis or transplant, will result in the death of the patient.
• Causes:
• Many disease processes can lead to progressive, irreversible impairment of kidney function.
• Glomerulonephritis
• Diabetes mellitus
• Hypertension
• Pyelonephritis,
• Renovascular disease and polycystic kidneys account for the majority of cases where a cause can be
determined.
• Patients may remain asymptomatic until the GFR falls to <15 mL/min.
Classification of CRF
Consequences of CRF
Sodium and water metabolism
Most CRF patients retain the ability to reabsorb sodium ions, but the renal tubules
may lose their ability to reabsorb water and fail to concentrate urine. polyuria is
never gross (not >4 L/day), because the GFR is so low.