B.

Tests Measuring Glomerular Filtration Rate

Tests, which measure the rate of glomerular filtration, are generally called CLEARANCES. These group of tests (renal clearance tests) are useful in measuring the actual excretory capacity of the kidney since they measure the amount of substance excreted in the urine, as compared to the concentration in the plasma

Estimation of Glomerular Filtration

How much plasma that courses through the kidneys is filtered per minute? This could be calculated if we have a substance having the following essential characteristics. a) Freely filtered or allowed to pass easily through the filtering apparatus. b) Neither secreted nor reabsorbed from the filtrate as it comes along nephritic tubules. c) Neither synthesized nor altered by the kidneys (not metabolized) d) Easily detected or analyzed chemically in both plasma and urines

General Formula For Clearance:

U 1.73

C (ml/min) =
Where:

------------ x Volume (ml/min)

----------------

C = Clearance of the substance expresses in ml/min U = Concentration of substance in urine P = Concentration of substance in plasma (blood) Volume (ml/min) = Total volume of urine excreted in 24 hours converted to ml/min A = Body surface area of patient whose value is obtained from a nomogram (Height and weight) are needed 1.73 = Generally accepted body surface are of an individual in square meters

Types of Clearances

Creatinine Clearance Test:

Creatinine is the end product of muscle metabolism derived from Creatine. It is freely filtered by the glomeruli but no reabsorbed by the tubules However, it is secreted by the renal tubules resulting in an over estimation of the actual GFR. Creatinine is the most commonly used endogenous substance in the Clinical assessment of GFR. Creatinine occurring through metabolic production is eliminated from plasma by glomerular filtration therefore a measurement of its rate of clearance affords a measure of the process. Normal Values: Men: 107-139 ml/min

Women:

87-107ml/min

The most sensitive chemical method of assessing renal function Provides an estimate of the amount of plasma that must have flowed through the kidney glomeruli per minute with complete removal of its content of Creatinine to account for Creatinine per minute actually appearing in the urine. The test requires the complete collection of the urine formed in an accurately recorded time period for the calculation of the rate of urine flow and quantitation of the Creatinine concentration in both serum and urine.

Inulin Clearance Test and Iothalmate Clearance

Inulin freely passes the glomeruli but is neither secreted nor reabsorbed by nephric tubules. Since Inulin or Iothalmate is not present in the plasma it must be introduces in a suitable concentration in order to allow its clearance by the kidneys to be measured. Thus, considered to be the most accurate measure of GFR, particularly in children, patients with renal disease and noncompliant patients. This is done by giving a priming dose (25 ml of 10% Inulin solution) by intravenous injection to produce a satisfactory plasma level and then maintaining this level throughout the tests period by slow, continuous infusion of a less concentrated solution In actual clinical setting, this is not commonly requested due to lack of flexible procedure. Therefore it is not regarded as a regular clearance test. Normal Value: Men: Women: 125 ml/min 110 ml/min

Urea Clearance Test

Urea is freely filtered by the glomeruli but variably reabsorbed in the tubules depending upon the transit time (rate of urine flow along the course of nephric tubules) of urea filtrate. The faster the rate of urine flow, the less urea is reabsorbed. If the rate of urine flow is 2ml/min or more, less urea is reabsorbed and the normal clearance is 64-99 ml/min or an average of 75 ml/min. This is known as the Maximum Urea Clearance.
C (ml/min) = U ------------ x Volume (ml/min) P x 1.33 x 1.73 ---------------A

1.33 constant for standard urea clearance

If the rate of urine flow is less than 2 ml/min, more urea is reabsorbed and the average normal clearance is 54 ml/min (41-68 ml/min) This is known as the Standard Urea Clearance Test.
U -----------P

C (ml/min) =

x Volume (ml/min)

x 1.85 x

1.73/A

1.85 constant for standard urea clearance

C. Test Measuring Renal Blood Flow Excretory Tests: o o The test most commonly associated with tubular secretion and renal blood flow is the paminohippuric acid (PAH) test. Historically excretion of the dye phenolsolfonphtalein (PSP) was used to evaluate this functions

PAH Test o To measure the exact amount of blood flowing through the kidney, it is necessary to use a substance that is completely removed from blood each time it comes in contact with functional renal tissues. The principle is the same as in the clearance test for glomerular filtration. However to ensure measurement of blood flow through the entire nephrons, the substance must be removed from the blood primarily in the peritubular capillaries rather being removed when the blood reaches the glomerulus. Although it has the disadvantage of being exogenous the chemical PAH meets the criteria needed to measure the renal blood flow. This non-toxic substance does not bind strongly to plasma proteins, which permits its complete removal as the blood passes through the peritubular capillaries. Except for a small amount of PAH contained in plasma that does not come in contact with functional renal tissue all the plasma PAH is secreted by the proximal convoluted tubules. The standard clearance Formula:
C PAH (ml/min) = U (mg/dl PAH) ------------------------ x Volume (ml/min P (mg/dl PAH)

o o o

Effective renal plasma flow ranges from 600-700 mL/min.

Concentration Tests:
o o o Specific gravity Osmolality Fishberg Concentration Tests: