INTEGRAL UNIVERSITY,LUCKNOW

Session:2019-2020

Assignment on: Renal function test

Submitted by:. Submitted to:

Kausal Verma. Dr.Mohd.Afroj Ahmad
Pharm.d 4th year. Assistant professor
1601096009. Faculty of pharmacy

KIDNEY FUNCTION TEST :-

The kidneys play a vital role in the excretion of waste products and toxins such as urea,
creatinine and uric acid, regulation of extracellular fluid volume, serum osmolality and
electrolyte concentrations, as well as the production of hormones like erythropoietin and
1,25 dihydroxyvitamin D and renin. The functional unit of the kidney is the nephron which
consists of the glomerulus, proximal and distal tubules, and collecting duct. Assessment of
renal function is important in the management of patients with kidney disease or
pathologies affecting renal function. Tests of renal function have utility in identifying the
presence of renal disease, monitoring the response of kidneys to treatment, and
determining the progression of renal disease.
There are a number of clinical laboratory tests that are useful in investigating and evaluating
kidney function. Clinically, the most practical tests to assess renal function is to get an
estimate of the glomerular filtration rate (GFR) and to check for proteinuria (albuminuria).

Glomerular Filtration Rate

The best overall indicator of the glomerular function is the glomerular filtration rate (GFR).
The normal GFR for an adult male is 90 to 120 mL per minute. GFR is the rate in milliliters
per minutes at which substances in plasma are filtered through the glomerulus, in other
words, the clearance of a substance from the blood.
As no such endogenous marker currently exists, exogenous markers of GFR are used.
Assessment of GFR using inulin, a polysaccharide, is considered the reference method for
assessment of GFR. It involves the infusion of inulin and then measurement of blood levels
after a specified period to determine the rate of clearance of inulin. Other exogenous
markers used are radioisotopes such as chromium-51 ethylene-diamine-tetra-acetic acid (51
Cr-EDTA), and technetium-99-labeled diethylene-triamine-pentaacetate (99 Tc-DTPA). The
most promising exogenous marker is the non-radioactive contrast agent, iohexol, especially
in children.
The inconvenience associated with the use of exogenous markers, specifically that testing
has to be performed in specialized centers, and the difficulty to assay these substances, has
encouraged the use of endogenous markers.
. GFR is classified into the following stages based on the kidney disease.
Improving Global Outcomes (KDIGO) stages of chronic kidney disease (CKD):
Stage 1 GFR greater than 90 ml/min/1.73 m
Stage 2 GFR-between 60 to 89 ml/min/1.73 m
Stage 3a GFR 45 to 59 ml/min/1.73 m
Stage 3b GFR 30 to 44 ml/min/1.73 m
Stage 4 GFR of 15 to 29 ml/min/1.73 m
Stage 5-GFR less than 15 ml/min/1.73 m (end-stage renal disease)

Albuminuria and Proteinuria

Albuminuria refers to the presence of urine albumin 30 to 300 mg per day. Microalbumin,
considered an obsolete term as there is no such biochemical molecule, is now referred to
simply as urine albumin. Albuminuria is used as a marker for detection of incipient
nephropathy in diabetics; it is an independent marker for the cardiovascular disease since it
connoted increased endothelial permeability and is also a marker of chronic renal
impairment. Urine albumin may be measured in 24-hour urine collections or early
morning/random specimens as an albumin/creatinine ratio. Presence of albuminuria on two
occasions with the exclusion of a urinary infection indicates glomerular dysfunction. The
presence of albuminuria for 3 or more months is indicative of chronic kidney disease. Frank
proteinuria is defined as greater than 300 mg per day of protein. Normal urine protein up to
150 mg per day (30% albumin; 30% globulins; 40% Tamm Horsfall protein).

Inulin test
Inulin test is considered to be ‘gold standard’ for determining renal function.
Though it is considered as ‘gold standard’, CLcr may yield better results for pharmacokinetic
dosing, since most kinetic studies use creatinine to estimate drug clearance and to develop
dosing strategies
Methods:

 Blood urea nitrogen

 Measurement of plasma creatinine
 Renal plasma clearance

 Blood urea nitrogen

Normal range: 8 – 20 mg /dl or 2.9 - 7.1 mmol/L
Increase BUN may reflex decrease GFR. It is the serum concentration of nitrogen (within
urea)
BUN test can be used to monitor hydrational status, renal function,protein tolerance and
catabolism in numerous clinical settings.
Serum concentration depends upon:
- filtration
- production (in liver)
- tubular reabsorption
BUN elevation seen in:
- high protein diet
[including AA infusion]
- upper GIT bleeding
[blood is digested as dietary proteins]
- administration drugs
[corticosteroids, tetracycline and drugs with anti
anabolic effect]
BUN reduction seen in:
- malnutrition
- profound liver damage
- fluid overload

 Measurement of plasma creatinine

Creatine is the precursor of the creatinine.
It is synthesized in liver – poured into blood –picked up by skeletal muscle – stored as,
creatinine phosphate, high energy form Creatine phosphate acts as a readily available
source of phosphorous for the production of ATP

Creatinine is an spontaneous decomposition product of creatine and creatine phosphate

The daily production of creatinine is 2% of total body creatine, which remains constant if
muscle mass is not changed significantly
Reference range:
Adults: 0.7 – 1.5 mg/dl
Children: 0.2 – 0.7 mg/dl
If the level rises above the reference range it is an indication of poor renal function.

Concomitant serum BUN and creatinine

Simultaneous BUN and serum creatinine can furnish valuable information
In acute renal failure both are altered. However, BUN : Scr ratio is often 20:1 or higher

Patients with GI bleeding and renal insufficiency, both BUN and Scr increases. The ratio of at
least 36 suggest GI bleeding
Usually, BUN:Scr ratio greater than 20:1 suggest pre renal causes
Ratios from 10:1 to 20:1 suggest intrinsic renal damage.
However, both types may occur simultaneously,confounding typical interpretation.
Furthermore, the ratio greater than 20:1 is not clinically important if the values of BUN and
Scr under the reference range .

 Renal plasma clearance

Expresses how effectively the kidneys remove a substance from blood plasma
High renal clearance – efficient removal of substance from plasma into urine
Low renal clearance – less efficient removal of substance from plasma into urine
Creatinine Clearance is expressed in ml / minute / each1.73 m2of the patients BSA.

Creatinine clearance(ml/min)= [140-age] X body weight (Kg)/7.2*Scr(mg/dl)

In case of female, the value is multiplied by 0.85

Tests of Tubular Function

The renal tubules play an important role in reabsorption of electrolytes, water, and
maintaining acid-base balance. Electrolytes, sodium, potassium, chloride, magnesium,
phosphate can be measured in urine as well as glucose. Measurement of urine osmolality
allows for assessment of concentrating ability of urine tubules. A urinary osmolality greater
than 750 mOsmol/Kg H2O implies a normal concentrating ability of tubules. A water
deprivation test can be used to exclude nephrogenic diabetes insipidus. Also in distal renal
tubular acidosis (dRTA), an ammonium chloride test can be used to confirm the diagnosis of
distal RTA with failure to acidify the urine to a pH less than 5.3. In Fanconi’s syndrome, there
is aminoaciduria, glycosuria, and phosphaturia and bicarbonate wasting (proximal RTA).

Urine Analysis
Urine analysis involves assessment of urine characteristics to aid in disease diagnosis and
consists of physical observation, chemical, and microscopic analysis. Physical observation
involves assessing color and clarity. The normal color of urine is straw colored in the
presence of dehydration urine is a darker color. Red urine may indicate hematuria or
porphyria or represent the dietary intake of food like beets. Cloudy urine may be seen in the
presence of pyuria due to urinary tract infection. Specific gravity is an indicator of renal
concentrating ability may be measured using refractometry or chemically by use of urine
dipstick. The physiologic range for specific gravity is 1.003 to 1.030 and is increased with
concentrated urine and decreased with dilute urine.
Urine dipstick provides qualitative analysis of different analytes in urine using chemical
analysis.Dipstick uses dry chemistry methods to detect for the presence of protein, glucose,
blood, ketones, bilirubin, urobilinogen, nitrite, and leukocyte esterase. These may be
performed as a point-of-care test near a patient. The color changes following interaction of
the urine with the chemical reagents impregnated on the paper of the dipstick are
compared to the color chart guide to interpret the results.

References:-

1) Ganong (2016). "Renal Function & Micturition". Review of Medical Physiology, 25th
ed. McGraw-Hill Education. p. 677. ISBN 978-0-07-184897-8.

2) ^ Levey AS, Coresh J, Tighiouart H, Greene T, Inker LA (2020). "Measured and

estimated glomerular filtration rate: current status and future directions". Nat Rev
Nephrol. PMID 31527790.

3) ^ Rose GA (1969). "Measurement of glomerular filtration rate by inulin clearance

without urine collection". BMJ. 2 (5649): 91–3. doi:10.1136/bmj.2.5649.91. PMC
1982852. PMID 5775456.

4) ^ Hsu, CY; Bansal, N (August 2011). "Measured GFR as "gold standard"--all that
glitters is not gold?". Clinical Journal of the American Society of Nephrology. 6 (8):
1813–4. doi:10.2215/cjn.06040611. PMID 21784836.