13.
Renal Function tests
Name the different tests to assess the kidney functions.
Explain Creatinine clearance & inulin clearance
Urinary acidification test
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The major and important functions of the Kidneys are;
To maintain water-electrolyte balance, pH regulation
Excretion of wastes-urea, creatinine, uric acid, sulphates, and
phosphates.
Hormone synthesis eg. Erythropoietin plays a role in haemoglobin
synthesis and RBC formation. Renin plays a role in the release of
aldosterone.
Calcitriol (1,25-dihydroxy cholecalciferol) the active form of Vitamin D is
produced in the kidney.
A decrease in kidney function is due to a reduction in the performance of
nephrons. The structural and functional units of the kidney is nephron, which is
composed of the Bowman’s capsule with glomerular tuft of capillaries, the
proximal convoluted tubule (PCT), loop of Henle, distal convoluted tubule (DCT)
and collecting tubules.
Classification of Renal Function Tests:
(1) Tests to assess glomerular function: Glomerular filtration rate,
clearance tests.
(2) Tests to assess tubular function: Urine concentration and dilution
tests, urine acidification test and secretion tests
(3) Analysis of blood/serum: Estimation of blood urea, serum creatinine,
protein and electrolytes.
(4) Complete urine analysis: Examination of urine for volume, pH, specific
gravity, osmolality and presence of any abnormal constituents.
Glomerular filtration rate (GFR): It is the volume of fluid filtered from the
renal glomerular capillaries into the Bowman’s capsule per unit time. More than
99% of glomerular filtrate is reabsorbed by the kidneys. The normal GFR is
120-125 ml per minute in a person with 70kg body weight.
GFR is decreased when Blood pressure is below 80 mmHg. The GFR is reduced
when there is obstruction to the renal flow (calculi, prostate enlargement, etc.).
It also decreases with age.
Clearance: it is defined as the volume of plasma that would be completely
cleared of a substance per minute. Clearance measures the GFR and is useful to
assess the severity of renal damage. It serves as an index to assess the degree
of renal damage. Clearance is calculated by the formula
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C= U x V
P
Where, C= clearance,
U= concentration of substance in urine,
V = volume of urine in ml excreted per minute.
P= concentration of the substance in plasma.
The value is expressed as mL/minute.
If the substance is freely filtered across the capillary wall, and neither
secreted nor reabsorbed, then its clearance is equal to GFR. A substance which
meets these requirements is an ideal filtration marker.
Creatinine Clearance Test
Creatinine is a waste product, formed from creatine phosphate by a
spontaneous, non-enzymatic reaction. The conversion depends on total muscle
mass of the body and it is not affected by diet, age, or exercise. Women and
children excrete less creatinine than men because of their smaller muscle mass.
Since the production of creatinine is continuous, the blood level will not
fluctuate. Therefore, it is an ideal substance for clearance test.
Creatinine is cleared only by glomerular filtration (not reabsorbed and only
slightly secreted by proximal tubules) and it can be analysed by colorimetric
method. Since creatinine is completely filtered at glomeruli, and there is little
of tubular handling , its clearance is closer to GFR.
Procedure: Both 24-hour urine sample and a serum sample, taken at the mid
point of the 24-hour urine collection are taken. The volume of urine is measured
and the concentration of creatinine in both serum and urine is estimated.
Creatinine clearance is calculated using the general clearance formula UV/P,
where, U= urine creatinine concentration, V=urine volume excreted in 24 hours,
P= serum creatinine concentration.
A correction factor for body surface area must be included in the formula
because creatinine excretion varies in relation to body mass. A correction
factor of 1.73/A is used, where 1.73 is the generally accepted average body
surface area in square meters and A is patient’s body surface area. Thereby,
modified formula is U x V/P x 1.73/A.
Reference values:The normal range for creatinine clearance is 100-125 mL/min
in males and 90-115 mL/min in females. When corrected for surface area,
creatinine clearance values becomes same for both male and female, which is
about 100ml/min.
Normal serum creatinine concentration in Adult males: 0.7 to 1.4 mg/dL, Adult
females: 0.6 to 1.3 mg/dL, Children: 0.4 to 1.2 mg/dL.
Significance: Values below normal indicates impairment of glomerular functions.
Thus, creatinine clearance is a very sensitive indicator, which can detect renal
impairment in the early stages.
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Inulin clearance
Inulin is a homopolysaccharide made up of fructose residues. It is not
appreciably metabolized by the body. It is neither absorbed nor secreted by
the renal tubules. Therefore, inulin clearance is equal to GFR.
In this test, there is a continuous infusion of inulin intravenously so as to
keep the plasma level adequate. Since it involves administration of an
extraneous compound, this procedure is not used routinely. It is more
convenient to estimate the clearance of substances already present in blood and
therefore, creatinine clearance is preferred over inulin clearance.
Inulin clearance (GFR) = 125mL/min and urea clearance =75mL/min.
Inulin clearance – urea clearance = 125-75 = 0.4
GFR 125
About 40% of urea present in the glomerular filtrate is reabsorbed in the
tubules.
Urinary acidification test: Acid loading test
It is the most useful test to study the capacity of the kidneys to produce acidic
urine following stimulation by giving ammonium chloride (or hydrochloric acid).
Procedure: To the overnight fasted subject a dose 0.1 g /kg body weight of
ammonium chloride is given orally. The ammonium chloride is dissociated into
NH4+ and Cl-. In the liver, the NH4+ is immediately converted into urea.
Therefore Cl- ions are counter balanced by H+ to produce HCl, a powerful acid.
It is then excreted through urine so as to produce acidification.
All the urine samples during next 6 hours are collected in sterile bottles and the
bladder is emptied at the end of that period. pH of the samples and total
ammonia of the combined urine is measured. At least one sample should have pH
of 5.3 or less and total ammonia excretion is between 30-90 µEq/min. In renal
tubular acidosis, the pH remains between 5.7 and 7.0 and the ammonia excretion
is also low.
QUESTIONS
1. Name different test to assess the kidney fucntions
2. Name the renal clearance tests.
3. Creatinine clearance test and its significance
4. Inulin clearance test
5. Urine acidification test
6. Glomerular filtration rate (GFR)
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