Notes on Clinical Pathology Renal function tests By Dr. Ashish Jawarkar Consultant Pathologist Vadodara
OVERVIEW 1. Indications 2. Classification a. Tests for glomerular function i. Clearance tests 1. Inulin clearance 2. creatinine clearance 3. cystatin c clearance 4. urea clearance ii. Blood biochemistry 1. BUN 2. Sr. Creatinine 3. BUN/Sr. Creatinine ratio 4. Urine proteins b. Tests for tubular function i. Tests for proximal tubular function 1. Glycosuria, aminoaciduria, LMW proteinuria 2. Urinary concentration of Na+ 3. Functional excretion of Na+ ii. Tests for distal tubular function 1. Specific gravity 2. Urine osmolality 3. Water deprivation test 4. Water loading ADH suppression test 5. Ammonium chloride loading test 3. Each test in detail
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
* Indications for RFT 1. To identify early renal impairment in patients at risk, such as i. Diabetes mellitus ii. Hypertension iii. SLE iv. UTI v. UT obstruction vi. Older age To diagnose certain renal disorders to asses response to treatment in renal disorders to adjust dosage of chemotherapeutic drugs To plan renal replacement therapy in advanced renal diseases
2. 3. 4. 5.
* Classification
Tests for glomerular function 1. For GFR clearance tests, indirect clearance 2. Blood biochemistry S. Creatinine, Bl Urea, BUN/S Creat ratio, Proteinuria (Albuminuria and microalbuminuria)
Tests for tubular function For Proximal Tubules For distal tubules i. Glycosuria, i. Specific gravity and Phosphaturia, osmolality Uricosuria, ii. water deprivation test aminoaciduria, LMW iii. water loading test Proteinuria iv. Ammonium chloride ii. Urinary excretion of test sodium iii. fractional sodium excretion
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
*Tests to measure GFR GLOMERULAR FILTERATION RATE: Definition: Rate at which a substance is cleared from the plasma in unit time by the glomeruli (in ml/min) Rationale: i. ii. iii. iv. v. vi. vii. Best for assessing excretory renal function Varies according to age/sex/body surface area (BSA) Also depends on renal blood flow and pressure Normal GFR = 120ml/min/1.73m2 GFR declines with age after 40 @1ml/min/year due to progressive glomerular arteriosclerosis Fall in GFR leads to accumulation of waste products GFR <15ml/min indicates uremia GFR <60ml/min/1.73m2 indicates >50% loss of renal function
Classification of chronic kidney diseases based on GFR: Stage Stage I Stage II Stage III Stage IV Stage V Disease Kidney disease with Kidney disease with Kidney disease with Kidney disease with Renal Failure GFR Normal GFR Mild decreased GFR Moderate dec GFR Severe dec GFR Value (ml/min/1.73m2) >90 60-89 30-59 15-29 <15
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
(i) CLEARANCE TESTS: Volume of plasma that is completely cleared of that substance per minute
C = UV/P
C = clearance (ml/min), U=Concentration of substance in urine (mg/dl), V=Volume of urine per min (ml/min), P=concentration of substance in plasma (mg/dl) Ideal agent for clearance studies: No ideal agent has been found, however the agent used should fulfill most of the following criteria: i. Should not bind to plasma proteins ii. should be freely filtered across glomeruli iii. should not be reabsorbed iv. should not be metabolized by kidney v. should be excreted only through the kidney Agents used: Exogenous i. ii. iii. iv. Inulin radiolabelled EDTA Radiolabelled 125I thiocynate 99 Tc-DTPA i. ii. iii. Endogenous Creatinine Urea Cystatin C
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
As we can see from the graph, as the creatinine clearance decreases, the remaining nephrons in the kidney decrease Also the dotted line shows that the serum creatinine begins to rise only after 50% of the nephrons are damaged, i.e. serum creatinine though useful is a less sensitive indicator of renal function.
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
Disadvantages: 1. small amounts of creatinine secreted by renal tubules can increase even further in advanced renal failure 2. Creatinine level is affected by intake of meat and muscle mass 3. collection of urine is incomplete often 4. Creatinine levels are affected by drugs such as cimetidine, probenecid and trimethoprim that block tubular secretion
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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Clearance tests are more helpful in this scenario of detection of early renal impairment
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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Creatinine clearance
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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*Blood Biochemisty
Amino acids
Energy
Ammonia
Urea Cycle
Urea
Excretion in urine Rationale: 1. Completely filtered by glomeruli and 30-40 % is reabsorbed 2. State of hydration affects estimation 3. Affected by non renal factors such as - high protein diet - upper g.i. hemorrhage 4. Less sensitive considerable destruction of renal parenchyma has to occur before urea is elevated
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Methods: 1. Direct method (Di acetyl monoxamine method) Urea + DAM High temp, strong acid, oxidizing agent Yellow diazine derivative
2. Indirect method (Urease Bertholet reaction) 37 C Urea Urease Ammonia Phenol Alkaline hypochlorite Iodophenol
Normal levels: Normal Adults 7-18 mg/dl Adults > 60 years 8-21 mg/dl
Causes of increased BUN: Azotemia increase in level of BUN/urea Uremia clinical syndrome resulting from azotemia Pre renal shock CHF dehydration high protein diet, trauma, burns, g.i. hemorrhage Renal Impairment of renal function Post renal Obstruction of urinary tract
1. 2. 3. 4.
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The dotted line shows that the serum creatinine begins to rise only after 50% of the nephrons are damaged, i.e. serum creatinine though useful is a less sensitive indicator of renal function.
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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Methods: 1. Jaffes method Creatinine + Picric acid Alkaline reagent Colored product
Spectrophotometer Picric acid also reacts with glucose, protein and fructose, hence actual level is 0.2 to 0.4 mg /dl lower 2. Enzymetic method
Creatinine enzymes
Colored product
Causes of: Increased serum creatinine 1. Azotemia 2. dietary meat 3. Acromegaly, gigantism Decreased serum creatinine 1. Pregnancy (hemodilution) 2. Old age (decreased muscle mass)
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Ratio >20:1 INCREASED BUN WITH NORMAL CREATININE 1. 2. 3. 4. High protein diet Increased protein catabolism G.I. Hemorrhage Dehydration decreased renal perfusion (Pre renal azotemia)
Ratio <12:1 INCREASED CREATININE WITH NORMAL BUN 1. Starvation 2. Low protein diet 3. severe liver disease In these three conditions, there is increased creatine breakdown in muscles to synthesize proteins increased creatinine BUN is normal
In these conditions there is increased protein break down increased BUN Muscle creatine is not broken down hence no increase in serum creatinine INCREASED BUN AND INCREASED CREATININE BUT INCREASE IN BUN IS MORE 1. Post renal azotemia (obstruction) In this condition there is obstruction to urine flow which pushes urea back into circulation - increase in BUN is more than that of creatinine
INCREASED BUN AND CREATININE BUT INCREASE IN CREATININE IS MORE 1. Acute tubular necrosis
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(iv) Proteinuria
Rationale: 1. Normally a very small amount of albumin is excreted in urine. 2. Earlest evidence of glomerumlar damage in diabetes mellitus is occurrence of microalbuminuria (albuminuria in range of 30 to 300 mg/24 hrs) 3. Albuminuria >300mg/24 hour is termed clinical or overt proteinuria and indicates significant glomerular damage. For details see notes on urine analysis Protein in urine
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2. Generalised aminoaciduria i. many aminoacids are excreted in urine due to proximal tubular dysfunction 3. Tubular proteinuria (Low molecular weight proteinuria) i. substances such as beta 2 microglobulin, retinol binding protein, lysozyme and alpha 1 microglobulin are completely reabsorbed by tubules ii. Detected by urine protein electrophoresis.
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Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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Hence to avoid this we can measure the exact quantity of Na+ reabsorbed as a fraction of amount of Na+ filtered to amount excreted
As with above test, this test is used to differentiate between pre and renal azotemia Method: F Na+ = Urine Na+ Plasma Na+ x x Plasma Creatinine Urine Creatinine x 100
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Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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Method:
0.1 M sucrose
Semipermeable Membrane
Water
Simple osmometer
Notes on renal function tests By Dr. Ashish Jawarkar Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes
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Factors affecting osmolality: 1. depends only on number of dissolved particles 2. it doesnot depend on nature or molecular weight of dissolved particles like specific gravity does Normal: Urine osmolality (24 hour)
500 - 800 mOsm/kg of water With restricted fluid intake - >800 mOsm/kg of water
Application: (Urine : plasma osmolality ratio is calculated, used to differentiate pre renal and renal azotemia) Decreased urine:plasma osmolality ratio (either urine osmolality is decreased or plasma osmolality is increased) Seen in Acute tubular necrosis (decreased concentrating ability) Increased urine:plasma osmolality ratio (either urine osmolality is increased or plasma osmolality is decreased) Pre renal azotemia preserved concentrating ability
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(iii) Water deprivation test for urine osmolality and specific gravity
Rationale: Measures concentrating ability of kidney with fluid restriction Method: Measurement of urine osmolality and specific gravity
Measurement of urine osmolality and specific gravity and comparison with earlier values
Rise in specific gravity and urine osmolality (>800 mOsm/kg of water, >1.025)
Administer desmopressin
No rise
Nephrogenic DI
* false positive result is obtained in case of low salt, low protein diet or major electrolyte disturbances
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1. 2. 3. 4.
Measure Specific gravity urine volume osmolality (serum and urine) plasma levels of ADH
Scenario 1 1. >90% of fluid load excreted in 4 hours 2. specific gravity <1.003 after 4 hours 3. Urine osmolality <100 mOsm/kg after 4 hrs 4. ADH level decreased with decreased osmolality
* False negative seen in 1. dehydration 2. cirrhosis 3. Malabsorption 4. adrenocortical insufficiency 5. congestive heart failure
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Renal tubular acidosis is the most likely diagnosis This test is done to confirm or rule out renal tubular acidosis
If results are inconclusive , we administer ammonium chloride which increases urinary pH and remeasure