Biochemistry of kidney

BY: Elias

02/04/25 1
Objectives
Upon completion of lectures, students should be
able to:
1. know the physiological functions of the
kidney.
2. identify the biochemical kidney function tests
with special emphasis on when to ask for the
test, the indications and limitations of each
kidney function tests.
3. interpret the kidney function tests
4. Regulation acid –base balance

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Introduction
KIDNEY
 paired organs in abdominal cavity
 held firmly by peritoneum
 embedded in fat
 solid, dark red & bean shape
 below stomach
 The functional unit of the kidney is called a
nephron. It consists of two main parts, the
glomerulus and the tubular system.
Functions of the Kidney
 Regulation of the water and electrolyte
content of the body.
 Maintenance of acid/base balance.
 Excretion of waste products, water soluble
toxic substances and drugs.
 Endocrine functions

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 Kidney Function Tests
(KFTs)

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 Kidney Function Tests
 The components of the Kidney function test
can be broadly divided into two categories.
 Tests that measure glomerular function
 Tests that measure tubular function

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 Why Do Test Renal Function?
 To identify renal dysfunction.
 To diagnose renal disease.
 To monitor disease progress.
 To monitor response to treatment.
 To assess changes in function that may impact on
therapy (e.g. Digoxin, chemotherapy).

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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 /kidney stone
 Obstruction to the lower urinary tract
 Drug toxicity

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Biochemical Tests of Renal
Function
 Measurement of GFR
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

 Glucose

 Protein

 Urinary sediments
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 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
02/04/25
barrier. 10
 Measurement of glomerular
GFR can be estimated by measuring the urinary excretion of a
filtration rate
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.
It could be calculated from the following equation:
Clearance (ml/min) = U  V
P
U = Concentration of creatinine in urine mol/l
V = Volume of urine per min 11
 Creatinine
 Product of muscle metabolism
 Some creatinine is of dietary origin
 Freely filtered, but also actively secreted into
urine
 Secretion is affected by several drugs
 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.

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 Serum Creatinine
 Increase  Decrease
 Male  Age
 Meat in diet
 Female
 Malnutrition
 Muscular body
 Muscle wasting
type  Amputation
 other medications
Serum Creatinine Concentration
 Normally 0.7-1.4 mg/dl, depending on
muscle mass
 Inversely proportional to GFR
 Good way to follow changes in GFR
 BUT also elevated by  muscle mass, 
tubular secretion
 Creatinine clearance and clinical
The most frequently used clearance test is based on the
utility
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 insulin
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.

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Cont’d…
 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 insulin clearance requires the infusion of
inulin into the blood and is not suitable for routine clinical
use
 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.

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Creatinine Clearance
 Timed urine collection for creatinine measurement
(usually 24h)
 Blood sample taken within the period of collection.
 Normal range = 120-145ml/min
Problems: -
 Practical problems of accurate urine collection and
volume measurement.
 Within subject variability = 11%

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Plasma Creatinine Concentration
Difficulties: -
 Concentration depends on balance between input
and output.
 Production determined by muscle mass which is
related to age, sex and weight.
 High between subject variability but low within
subject.
 Concentration inversely related to GFR.
 Small changes in creatinine within and around the
reference limits = large changes in GFR.

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Cockcroft-Gault
Cockcroft-Gault Formula
Formula
for
for Estimation
Estimation of
of GFR
GFR
 As indicated above, the creatinine clearance is measured
by using a 24-hour urine collection, but this does
introduce the potential for errors in terms of completion
of the collection.
 An alternative and convenient method is to employ
various formulae devised to calculate creatinine clearance
using parameters such as serum creatinine level, sex, age,
and weight of the subject.

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Serum Cr is a better KFT than creatinine
clearance because:
•Serum creatinine is more accurate.
•Serum creatinine level is constant throughout adult life

Creatinine clearance is only recommended in the

following conditions:
• Patients with early ( minor ) renal disease.
• Assessment of possible kidney donors.
• Detection of renal toxicity of some nephrotoxic drugs.

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Normal adult reference values:
Urinary excretion of creatinine is 0.5 - 2.0 g per 24 hours in a
normal adult, varying according to muscular weight.
- Sérum creatinine : 55 – 120 mol/L
- Creatinine clearance: 90 – 140 ml/min (Males)
80 – 125 ml/min (Females)
A raised serum creatinine is
a good indicator of impaired renal function

But normal serum creatinine

does not necessarily indicate normal renal function as
serum creatinine may not be elevated until GFR has fallen
by as much as 50%
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 Measurement of non-protein
nitrogen-containing compounds
Catabolism of proteins and nucleic acids results in formation of so
called non-protein nitrogenous compounds.
Protein
 Proteolysis, principally enzymatic
Amino acids
 Transamination and oxidative deamination
Ammonia
 Enzymatic synthesis in the “urea cycle”
Urea 02/04/25 23
 Plasma
Urea is the major nitrogen-containing metabolic product of protein
catabolism in humans, Urea
 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.
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 Plasma Urea cont’d…
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.
Non-renal 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,
02/04/25 treatment with cortisol or its synthetic analogous
25
 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

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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
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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.
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 The 3 stages of urine analysis

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Normal values of Internal Chemical Environment
:controlled by the Kidneys

SODIUM 135 to 145 mEq/L

POTASSIUM 3.5 to 5.5 mEq/L
CHLORIDES 100 to 110 mEq/L
BICARBONATE 24 to 26 mEq/L
CALCIUM 8.6 to 10 mg/dl
MAGNESIUM 1.6 to 2.4 mg/dl
PHOSPHORUS 3.0 to 5.0 mg/dl
URIC ACID 2.5 to 6.0 mg/dl
pH 7.4
CREATININE 0.8 to 1.4 mg/dl

BUN02/04/25
(Blood Urea Nitrogen) 15 to 20 mg/dl 30
Acid-base Balance
 pH affects all functional proteins and
biochemical reactions, so closely regulated
 Normal pH of body fluids
 Arterial blood: pH 7.4

 Venous blood and IF fluid: pH 7.35

 ICF: pH 7.0

 Alkalosis or alkalemia: arterial pH >7.45

 Acidosis or acidemia: arterial pH <7.35
 Acid-base Balance…..
 Most H+ produced by metabolism
 Phosphorus-containing protein breakdown

releases phosphoric acid into ECF

 Lactic acid from anaerobic respiration of

glucose
 Fatty acids and ketone bodies from fat

metabolism
 H+ liberated when CO converted to HCO –
2 3
in blood
 Acid-base Balance
 Concentration of hydrogen ions regulated
sequentially by
 Chemical buffer systems: rapid; first line of

defense
 Brain stem respiratory centers: act within 1–3

min
 Renal mechanisms: most potent, but require

hours to days to effect pH changes

 Buffer Systems
 Buffer systems prevent major changes in the pH
of body fluids by removing or releasing H+; they
can act quickly to prevent excessive changes in
H+ concentration.
 Hydrogen ions are buffered by both intracellular
and extracellular buffers.
 The body’s major extracellular buffer system is
the bicarbonate-carbonic acid buffer system.
 This is the system that is assessed when arterial
blood gases are measured.
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 Buffer Systems cont’d…
 Normally, there are 20 parts of bicarbonate
(HCO3−) to one part of carbonic acid (H2CO3).
 If this ratio is altered, the pH will change.
 It is the ratio of HCO3− to H2CO3 that is
important in maintaining pH, not absolute values.
 Carbon dioxide (CO2) is a potential acid; when
dissolved in water, it becomes carbonic acid
(CO2 + H2O = H2CO3).

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 Buffer Systems cont’d…
 Thus, when CO2 is increased, the carbonic acid
content is also increased, and vice versa.

 If either bicarbonate or carbonic acid is increased

or decreased so that the 20:1 ratio is no longer
maintained, acid–base imbalance results.

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 Kidneys
 The kidneys regulate the bicarbonate level
in the ECF; they can regenerate bicarbonate
ions as well as reabsorb them from the renal
tubular cells.

 In respiratory acidosis and most cases of

metabolic acidosis, the kidneys excrete
hydrogen ions and conserve bicarbonate
ions to help restore balance.
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 Kidneys cont’d….
 In respiratory and metabolic alkalosis, the
kidneys retain hydrogen ions and excrete
bicarbonate ions to help restore balance.
 The kidneys obviously cannot compensate
for the metabolic acidosis created by renal
failure.
 Renal compensation for imbalances is
relatively slow (a matter of hours or days).

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Kidney Mechanisms of Acid-Base
Balance
 Most important renal mechanisms are
 Conserving (reabsorbing) or generating

new HCO3–
 Excreting HCO3–
 Generating or reabsorbing one HCO3– is
equivalent to losing one H+
 Excreting one HCO – is equivalent to gaining
3
one H+
 Slide 1
Reabsorption of filtered HCO3– is coupled to H+ secretion.
1 CO2 combines with water 2 H2CO3 is quickly split, forming
within the tubule cell, forming H+ and bicarbonate ion (HCO3−).
H2CO3.
3a H+ is secreted
Filtrate in Nucleus
into the filtrate.
tubule Peri-
lumen PCT cell tubular 3b For each H+ secreted,
capillary
a HCO3− enters the
ATPase peritubular capillary
blood either via symport
with Na+ or via antiport
with CI−.
3a 3b 4 Secreted H+
2
4 ATPase combines with HCO3− in
the filtrate, forming
5 CA * 1 CA carbonic acid (H2CO3).
6 HCO3− disappears from
the filtrate at the same
rate that HCO3− (formed
Tight within the tubule cell)
junction enters the peritubular
capillary blood.
Primary active transport Transport protein
6 CO diffuses into the tubule 5 The H2CO3 formed in
Secondary active transport 2
CA Carbonic anhydrase
Simple diffusion cell, where it triggers further H+ the filtrate dissociates to
secretion. release CO2 and H2O.
Hormones of the kidney
 Erythropoietin
 Calcitriol
 Angiotensin

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Erythropoietin
 Polypeptide hormon that is formed predominantly
by the kidney (also by the liver)
 It controls the differentiation of the bone marrow
stem cells
 The release is stimulated by hypoxia (low pO2)
 The hormon ensures that the bone marrow cells
are converted to erythrocytes, so that their
concentration in the blood increases

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Calcitriol
 1-alpha,25-dihydroxycholecalciferol is a
steroid-related hormon involved in calcium
homeostasis.
 It is formed in the liver from calcidiol by
hydroxylation at C-1
 The activity of hydroxylase (calcidiol-1-
monooxygenase) is regulated by the
hormone parathyrin (parathormone).

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Renin – angiotensin system
 Renin is an enzyme which converts the plasma
protein angiotensinogen to angiotensin I.
 Angiotensin converting enzyme (ACE) which is
formed in the lungs converts angiotensin I to
angiotensin II which causes vasoconstriction and
an increase in blood pressure.
 Angiotensin II also stimulates the aldosterone
production (water and sodium retention which
together increase blood volume).
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Renin increases the production of angiotensin II
which is released when there is fall in intravascular
volume and dehydration. This leads to:
 Constriction of the efferent arteriole to
maintain GFR, by increasing the filtration
pressure in the glomerules.
 Release of aldosterone.
 Increased release of ADH.
 Thirst
 The opposite occurs when fluid overload
occurs.

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