CLINICAL BIOCHEMISTRY

Lecture (5)
Kidney Function Tests
& Kidney Disorders Part I

Dr. Emad Gamil, PhD

Objectives

■ By the end of this session you should be able to:

■ 1- Describe functions of the kidney,
■ 2- Identify tests of assessment of renal function
■ 3- Describe tests of kidney function and assessment of kidney integrity.
■ 4- Analyze the differential diagnosis of prerenal, renal, and postrenal
diseases.
The Kidneys
Position of the kidneys:
-Two kidneys are located against the
posterior abdominal wall on either side
of vertebral column.
-The left kidney is related interiorly to the stomach,
pancreas, spleen and descending colon.
-The right one is related to the liver, second part of the
duodenum and the ascending colon.
- The suprarenal (adrenal) glands cover the superior poles
of kidneys.
Kidney Structure and Functions
▪ Each kidney consists of one million
functional units: Nephron, each
nephron can be divided into:

a) The glomerulus (filtration)

b) Tubules (reabsorption &

secretion)

1. Proximal tubule (reabsorption).

2. Loop of Henle (concentration).

3. Distal tubule (secretion).

4. Collecting duct (H2O

reabsorption).
Functions of the kidneys:
1- Excretory function:
- This includes the urine formation; it serves to rid the
body of most of the undesirable end (waste) products of
metabolism, as well as any excess of inorganic
substances ingested in the diet.
Waste products include:
1- The non-protein nitrogenous compounds (uric acid,
urea, creatinine), that are formed as metabolic end
product.

2- A number of organic acids including the amino acids

are excreted in small quantities.
3- The excessive supply of sodium, potassium, chloride,
calcium, phosphate, magnesium, sulphate and
bicarbonate.

4- Water, as daily intake of water is also variable and

may exceed the requirements of the body, so it
becomes additional waste material requiring
excretion.

5- Drug excretion that is excreted as its original form or

after being transformed into another structure.
2- Regulatory function:
■ This function is the main function of the kidney.
■ It is called homeostasis to maintain the constant optimal
chemical composition of the blood and it includes:
1- Retention of biologically active substances (glucose,
amino acids, minerals and vitamins).

2- Kidneys are the principal organs for regulating the total

water content of the body.

3- Kidneys, together with lungs are responsible for keeping

pH of the blood constant. (Acid-Base Balance) by
excreting H+ ions and reabsorbing HCO3-.
3-Endocrine functions (Hormonal function):
Kidneys act as an endocrine gland, secreting many
hormones
a) Erythropoietin, Formation of blood cells.
b) Renin, Regulates blood pressure.
c) Vit-D3, Kidneys activate vit D3.
Urine Formation
▪ Urine is composed of:
1. Water (95%).
2. Nitrogen containing waste (Urea, Uric acid, Ammonia, and Creatinine).
3. Electrolytes.
▪ Urine is formed in nephron by 3 processes;

1. Glomerular Filtration: process by which cells and large proteins are

retained while materials of smaller molecular weights are filtered from
the blood to make a filtrate that will eventually become urine.

2. Tubular Reabsorption: which is the transport of molecules needed by

body from filtrate into the blood e.g. glucose and amino acids.

3. Tubular Secretion: which is the reverse process of reabsorption, in

which molecules are transported from the blood directly to the urine
through tubules.
Classification of renal function tests:
- Normal renal function depends on a normal glomerular
filtration rate (GFR) and a normal tubular function.
- For simplicity, renal function testes can be classified:
A- Glomerular function tests:
1- Simple examination of urine (full urine report).
2- Blood urea and serum creatinine estimation.
3- Cystatin C estimation.
4- Glomerular filtration rate (GFR).
5- Creatinine clearance test.
6- Albumin to creatinine ratio (ACR).
7- Plasma β2-microglobulin.
B- Tubular function tests:
1- Urine concentration test.

2- Vasopressin test.

3- Urine dilution test.

4-Maximal tubular capacity to reabsorb glucose

and secrete para-amino hippuric acid (PAH).
A- Glomerular Function Tests

I- Simple Examination of urine (Full urine report):

- This is the most important initial test for suspected renal
damage.
A) Physical Examination:
1- Volume:
- The normal 24 urine volume of an adult is between 750
and 2000 ml with a physiological variation of renal
excretion that depends on fluid intake, climate and on
the loss of fluids by other routes particularly sweating.
-The minimal 24 hour output of urine needed to
remove the waste products of normal
metabolism is about 500 ml.
-A marked alteration in the output of urine may
be a prominent sign in disease of the kidney.

- Excretion of less than 500 ml urine per day is

called Oliguria.
- Excretion of more than 2000 ml urine per day
is called Polyuria.
2- Specific Gravity:
- The normal specific gravity of 24 hour urine sample is
between 1015 and 1025 with a normal considerable
physiological variation.

- Disorders associated with oliguria leads to urine with

high specific gravity.

- Polyuria tends to lead to urine of low specific

gravity except in diabetes mellitus where there is
polyuria with a high specific gravity.
3- Reaction:
- On a normal mixed diet the urine is usually acidic, but
with high vegetables and fruits intake, it becomes
alkaline.

4- Appearance (Aspect):
- Normal urine is clear.

- Turbidity may be due to:

1-precipitation of excessive urates in acid urine.
2-excessive phosphates in alkaline urine.
3- presence of pus, red blood cells,... etc
5- Color:
- The normal color is amber yellow due to the presence of
urinary pigments collectively known as urochromes and
urobilin.
- Colored urines occur in certain diseases of metabolic
disorders and after administration of many drugs e.g.:
1- Red-brown: hemoglobin and its derivatives.
2-Green-yellow: Bile pigments in jaundice.
3-Brown black on standing: melanin (malignant
melanoma)
4-Black: parenteral iron therapy.
6- Odor:
- Normal odor is aromatic (uriniferous).
- Distinct-unpleasant odor: urine infected with gram-
negative organisms.
- In case of ketonuria, the urine is characterized by
specific acetone odor.
Fermented urine (Old urine) has ammoniacal odor.
B) Chemical Examination of urine:
1- Proteins:
- Normal urine contains a very small amount of protein
(40-150 mg/day) and this concentration is undetectable
by simple tests.

- Proteins appear in urine in abnormal amounts

(proteinuria) in many renal disease e.g., acute
nephritis, nephrotic syndrome,...etc.
-  Appearance of proteins in urine is referred as
Proteinuria
2- Glucose:
- Normal fasting blood glucose level is 70-100 mg %.
- Normal renal threshold of glucose is 180 mg%:
It is the blood glucose level above which , glucose
appears in urine.

- Glucosuria: is a pathological condition characterized

by excessive excretion of glucose in urine.

- These are many causes of glucosuria such as:

1-Diabetes mellitus
2-Renal glucosuria
3- In pregnancy
3- Ketone bodies (ketonuria):
- Normally, less than 18 mg of ketone bodies are
excreted per day.
- Ketonuria is the presence of ketone bodies in the urine
in abnormal concentrations.

- Ketonuria may occur associated with ketosis in any

condition where carbohydrate utilization is impaired
e.g. starvation, carbohydrate poor diet and diabetes
mellitus.
4- Bilirubin and Bile salts
- Increased in liver diseases and jaundice.
- Bile salts are increased in intestinal obstruction

C) Microscopical Examination of urine

1- Cells:
- The examination of fresh urine for erythrocytes, pus cells is
an important part of the testes of renal function.
- In case of glomerulonephritis the urine will contain red
blood cells; pus cells.
2- Crystals:
- Uric acid and calcium oxalate may be found in acid urine
and phosphates in alkaline urine
II) Blood Urea and Serum Creatinine Estimation
- The normal blood urea is 20 - 45 mg/dl.
- The normal serum creatinine is 0.5 - 1.4 mg/dl.

- In renal failure: all non-protein nitrogenous (NPN)

compounds of plasma are raised (including urea and
creatinine).

- Analysis of serum creatinine (or blood urea) can be used

as a quantitative measure of known glomerular damage.
- Blood urea estimations are frequently performed as a test
of renal function, but the causes of a raised plasma urea
are many.
- Blood urea level is affected by diet.
- Significantly high blood urea above 80 mg/dl almost
indicates impaired renal function.
- Serum creatinine is preferable as index for renal
function than serum urea??
Because creatinine does not affected by diet and its level
is constant per day as it is produced endogenously by
creatine breakdown in a constant rate.
At high protein diet, the plasma urea increases while a
low protein diet, or dialysis, will lower the plasma urea,
so serum creatinine can be used as a true measure of the
renal damage (because endogenous creatinine production
remains, relatively constant).
III) Cystatin C
■ a low m.wt peptide, produced by all nucleated cells and
removed from the bloodstream by glomerular filtration
in the kidneys.
■ When glomerular filtration rate declines → the blood
levels of cystatin C rise.
■ Serum levels of cystatin C are a more precise test of
kidney function than serum creatinine levels??
As its plasma concentration is a more sensitive index of
mild renal impairment than that of creatinine and not
affected by gender or muscle mass.
Measurement of cystatin c may have a role in the
detection of early renal impairment.
Cystatin C
■ Its greatest drawback is that it has to be measured by
immunoassay, which is much more expensive than the
usual colorimetric or enzymatic techniques used to
measure creatinine.

■ Although not widely available in routine laboratories,

measurement may have a role in the detection of early
renal impairment in patients with extremes of muscle
bulk (such as body builders) and muscle wasting
disorders (such as small elderly women).
IV) Glomerular filtration rate (GFR)
Properties of substances used to assess glomerular filtration rate
■ Freely filtered by glomerulus.
■ Neither secreted nor absorbed in nephron.
■ Produced endogenously at constant rate.
■ Easily measured.
* Estimation of GFR can be done by clearance tests.
Clearance tests measure the volume of blood which could be completely cleared of a
substance per minute.
- Clearance can be calculated from the following equation:

Clearance = U.V/P
Where: U = Concentration in urine by mg/dl.
V = Urine flow rate (ml/min).
P = Plasma concentration by mg/dl.
- The clearance will be expressed in ml/min.
V) Creatinine clearance (CCr or CrCl) :
is the volume of blood that is cleared of creatinine per unit time
and is a useful measure for approximating the GFR.
* This is the practical and most convenient method of obtaining a
fairly accurate estimate of the GFR.
* Normal creatinine clearance = 120 ml/min.
* Values below 90 ml/min. are indicative of diminished GFR.
Problem:
The accurate measurement of creatinine clearance is difficult,
especially in outpatients, as it is necessary to obtain a complete
and accurately timed sample of urine.
▪ Alternative methods should be used if a reliable
calculation of GFR is required (Estimated GFR or eGFR)
▪ This approach has the advantage that a urine collection is not
required.
▪ Several formulae have been derived from the Modification
of Diet in Renal Disease (MDRD) to calculate eGFR.
The ‘four-variable’ formula is: (Cr, Age, Sex, Race).
eGFR (mL/min per 1.73m2) =
186 x (Scr)-1.154 x (age)-0.203 x (0.742 if female) X (1.21 if black)
(Scr) = Serum creatinine expressed in mg/dL and age is
expressed in years
VI) Albumin to creatinine ratio (ACR):

It is the recommended method to evaluate albuminuria

as a marker of kidney damage
Calculation of ACR in spot urine samples was done by
dividing the value of urinary albumin (g/dL) by the value
of urinary creatinine (mg/dL)
Normal: ˂ 30 g/mg.
Microalbuminuria: 30-300 g/mg.
Macroalbuminuria: ˃ 300 g/mg.
VII) Plasma β2-microglobulin (β2M)
■ β2M is a protein that is found on the surface of nucleated
cells and functions as part of the human immune system.
This protein is routinely shed by cells into the blood and is
present in most body fluids, with highest levels in the
blood, and trace levels in urine.
■ In the kidneys, β2M passes through the glomeruli and is
then reabsorbed by the renal proximal tubules. Normally,
only small amounts of B2M are present in the urine.
■ β2M test may be used when known physical or suspected
kidney damage occurs to distinguish between glomerular
and tubular disorders of the kidney.
■ When the glomeruli in the kidneys are damaged, they are
unable to filter out β2M, so the level in the blood rises.
■ when the renal tubules become damaged , β2M level in
urine increases due to the decreased ability to reabsorb
this protein.
B- Tubular function tests:
1- Urine concentration test.

2- Urine dilution test.

3- Plasma electrolytes determination.

4- Maximal tubular capacity to reabsorb glucose and

secrete para-amino hippuric acid (PAH).