FUNCTIONS TEST

by
V. KUZHANDAI VELU

RENAL

K I D N E Y:

Functions of the kidney

REGULATION

Homeostasis, water, acid/base

EXCRETION

urea, creatinine

ENDOCRINE

renin,erythropoietin, 1,25 dihydroxycholecalciferol

OBJECTIVES of RFTs:

To detect possible renal damage

Assessment of its severity. To observe the progress of renal disease To monitor the safe and effective use of drugs which are excreted in the urine

CLASSIFICATION Of RFTs:

Urine Analysis

Physical examination Chemical examination Microscopic examination Renal clearance test Blood analysis of urea and creatinine Proteinuria and heamaturia

Test for Renal Plasma Flow

Para-aminohippurate test Urine concentration test Urine dilution test Glycosuria Amino aciduria Acid load test Phenosulfonpthalein test

Test for Tubular Function

Test for Glomerular Function

Physical examination:

Volume:
Normal output = 800 2,500 ml / day Polyuria > 2,500 ml / day Oliguria < 500 ml / day Anuria: complete cessation of urine

Appearance: Normal urine is transparent pale yellow or amber colour Blood Colour (haemoglobin, myoglobin,) Turbidity (infection, nephrotic syndrome)

pH

However depending on the acid-base status, urinary pH may range from as low as 4.5 to as high as 8.0. Normal 1.016 to 1.022 Average is 300 900 mosm/kg. Normal aromatic Foul smell Bacterial infection

Specific Gravity

Osmolality

Odour

Chemical examination

Chemical examination includes detection of the following

Glucose Protein Blood

Glucose

Normal urine contains small amount of glucose which can not be detected by routing test Excretion of detectable amounts of reducing sugar in urine is called glycosuria. It may be benign or pathological. It increased amount of protein in urine

Protein

Proteinuria increased glomerular permeability or reduced tubular reabsorption.

Most common type of proteinuria is due to albumin Renal stone, cancer, tuberculosis trauma of kidney or acute glomerulonephritis

Blood or Hematuria

Test for Glomerular Function

Renal clearance test Blood analysis of urea and creatinine Proteinuria and hematuria

Renal clearance test:

The renal clearance of a substance is defined as the volume of plasma from which the substance is completely cleared by the kidneys per minutes Depends on the plasma concentration of the substance and its excretory rate, which in turn, depends on the GFR and renal plasma flow. GFR can be measured by determining the excretion rate of a substance which is filtered through the glomerulus but subsequently, is neither reabsorbed nor secreted by tubules.

C = (U x V)/P

C is the clearance of the substance in ml/minutes U is the concentration of the substance in urine (mg/L) P is the concentration in plasma (mg/L) V is the volume of urine passed per minute.

Lower GFR Indicates:

Acute tubular necrosis Glomerulonephrosis Shock, Acute nephrotic syndrome

Acute and chronic renal failure

 Selected

substrate should be

Freely filtered by glomerulus Should not be reabsorbed or secreted Should not be metabolized by the kidney Should not be toxic Should not be affected by dietary intake
2

types of substance are used for GFR

Endogenous creatinine and urea Exogenous Inulin

CREATININE CLEARANCE TEST

Creatinine is freely filtered at the glomerulus and is not reabsorbed by the tubule.

A small amount of creatinine is secreted by tubules. Creatinine clearance is determined by collecting urine over 24-hr period and a sample of blood is during the urine collection period.

Creatinine from plasma directly related to the GFR.

 Clinical

interpretation:
90 120 ml/mints

Normal:

Decreased filtrated rate acute and chronic damage to the glomerulus, reduced blood flow

UREA CLEARANCE TEST

Normal Its

value 75 ml/min

less sensitivity

Conc. Of urea affected by dietary protein, fluid intake, infection, surgery, etc. Approximately 40 % of the filtered urea is normally reabsorbed by the tubules.

INULIN CLEARANCE TEST

Fructose polymer inulin satisfies the criteria as an ideal marker of glomerular filtration rate. Normal value 120 ml/min Disadvantages:

Need intravenous administration Difficulty of analysis

BLOOD ANALYSIS

Blood analysis may be more sensitive when the renal failure is advance Impairment of renal function results in elevation of blood urea and creatinine. Increase end products of these substances called Azotaemia.

Use of Formulae to Predict Clearance

Formulae have been derived to predict Creatinine Clearance (CC) from Plasma creatinine. Plasma creatinine derived from muscle mass which is related to body mass, age, sex. Cockcroft & Gault Formula CC = k[(140-Age) x weight(Kg))] / Creatinine (mol/L) k = 1.224 for males & 1.04 for females Modifications required for children & obese subjects Can be modified to use Surface area

PROTEINURIA
The glomerular basement membrane does not usually allow passage of albumin and large proteins. A small amount of albumin, usually less than 25 mg/24 hours, is found in urine. When larger amounts, in excess of 250 mg/24 hours, are detected, significant damage to the glomerular membrane has occurred. Quantitative urine protein measurements should always be made on complete 24-hour urine collections. Albumin excretion in the range 25-300 mg/24 hours is termed microalbuminuria

Normal < 200 mg/24h. Causes: overflow (raised plasma Low MW Proteins, Bence Jones, myoglobin) glomerular leak decreased tubular reabsorption of protein (RBP, Albumin) protein renal origin

Test for Tubular Function

Assessment of the concentration and dilution ability of the kidney can provide the most sensitive means of detection early impairment in renal function since the ability to concentrate or dilute urine is dependent upon

Adequate GFR Renal Plasma Flow Tubular mass Healthy tubular cells Vasopressin hormone

URINE CONCENTRATION TEST

The

ability of the kidney to concentrate urine is a test of tubular function that can be carried out readily with only minor inconvenience to the patient. This test requires a water deprivation for 14 hrs and has replaced the previous 24 hrs water deprivation test. The test should not be performed on a dehydrated patient.

URINE DILUTION TEST

This test is very simple, but because it is less sensitive than the water METHOD After an overnight fast the patient (who is not allowed to smoke) empties his

deprivation test as test of renal damage, its use is not often required.

bladder completely and is given 1000 ml of water to drink. Urine specimens are collected for the next 4 hours, the patient emptying bladder completely on each occasion.

INTERPRETATION Unless there is renal functional impairment, the patient will excrete at least 700 ml of urine in the 4 hours, and at least one specimen will have a specific gravity less than 1.004.

URINARY ACIDIFICATION TEST

This procedure tests the ability of the renal tubules to form an acidic urine and to excrete ammonia. It is useful if there is doubt whether a patient's acidosis (confirmed by plasma analyses) is due to a pre-renal cause, or to kidney damage as in renal tubular acidosis.

METHOD The patient fasts from midnight until the conclusion of the test, zero time. The patient empties his bladder completely. The urine is collected. The patient takes 0.1 g (1.9 m mol) of ammonium chloride/kg body weight and drinks a liter of water. A standard dose of 5 g is sometimes used. In children the dose should be proportional to the body surface area. At 2 hours, 4 hours, and 6 hours; complete urine specimens are collected.

INTERPRETATION

In a normal subject the urine will be acidified to pH 5.3 or less, and will contain more than 1.5 m mol of ammonia per hour, in at least one of the specimens.

K N A H U T O Y