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AUBF-Lec

GLOMERULAR FILTRATION

Clearance Test
- Measure rate at which the kidneys can remove a filterable substance from
the blood. Substance cannot be reabsorbed or secreted. Many require
accurately timed urine collection.
- Substances evaluated:
Urea earliest, no longer used, 40% is reabsorbed, results were
adjusted for this
Inulin
Polymer of fructose
No reabsorption or secretion
Original clearance reference method
Disadvantage: Requires infusion
Exogenous procedure = infusion
Endogenous procedure = body constituent
Not routinely used
Creatinine
Beta2 microglobulin
Cystatin C
Radioisotopes
Creatinine clearance
- Creatinine is current routine test substance
- Advantages:
Waste product of muscle destruction found at relatively constant
plasma level
Automated chemical tests
- Disadvantages:
Tubular secretion with high blood levels
Bacteria break down creatinine if urine is stored at room
temperature
Heavy meat diet during timed collection increases urine creatinine
Not reliable with muscle-wasting diseases
Gentamicin, cephalosporins, and cimetidine inhibit tubular secretion
- Normal values and additional notes:
Creatinine is produced as a result of muscle destruction; therefore,
normal values are based on size; the larger the person, the more
creatinine produced
Men: 107-139 mL/min
Women: 87-107 mL/min
Values are lower in older people
Nomograms are available to adjust for size
- Clinical significance:
Results are based on functioning nephrons

Nephrons can double their workload if needed


This is seen in persons with one kidney
Creatinine does not detect early disease
Monitor extent of known renal disease
Determine feasibility of administering medications that may build
up to toxic blood levels

Methods Not Requiring Urine Collection

Beta2 microglobulin
- Small protein that dissociates from human leukocyte antigens at a
constant rate
- Rapidly removed from the plasma by kidneys
- Measured by enzyme immunoassay
- Sensitive indicator of decrease in GFR
- Unreliable in patients with immunological disorders and malignancies
Cystatin C
- Small protein produced by all nucleated cells; filtered by glomerulus
- Absorbed by the renal tubules and broken down; no cystatin C is secreted
- Serum levels directly reflect GFR
- Monitors pediatric patients, diabetics, elderly, and critically ill patients
- Immunoassay procedures available
Radioisotopes
- Exogenous procedure measuring plasma disappearance of an injected
isotope
- 125I iothalamate
- Provides simultaneous visualization of the kidneys

Tubular reabsorption test


-

Good indicator of early renal disease


Measure renal concentrating ability
Often termed concentration tests
Baseline for determining concentration is the 1.010 specific gravity of the
original ultrafiltrate
Control of fluid intake is necessary for accurate results

Osmolarity
-

Osmolarity has replaced specific gravity as the test to assess renal


concentration
Specific gravity includes number and size of molecules
Osmolarity only includes number of small molecules; Na and Cl are both
equal to a large urea molecule
Clinical unit of measure is the milliosmole (mOsm)

Colligative Properties
-

Solution properties related to the number of molecules present in the


solvent
Lower freezing point (laboratory measure)

Higher boiling point


Increased osmotic pressure
Lower vapor pressure (laboratory measure)
Urine and plasma values are compared with those of pure water

Osmometry
-

Freezing point osmometers


Measured sample is supercooled and vibrated to form crystals; heat of
fusion raises temperature to freezing point; probe measures freezing point
Comparison: 1 mol (1000 mOsm) of nonionizing substance in 1 kg water
lowers freezing point to 1.86C
Clinical reference standard is NaCl

Vapor Pressure Osmometers


-

Actual measure is dew point (temperature at which water vapor


condenses to a liquid)
Microsamples on small filter-paper disks in sealed chamber; evaporating
sample forms vapor
Temperature lowered, vapor condenses, thermocoupler measures heat of
condensation that raised temperature to dew point.
Requires careful technique because of microsamples

TECHNICAL FACTORS
Lipemic serum
o Affects both instruments
o Insoluble lipids displace serum water
Lactic acid
o Elevates readings in both instruments
o Separate or refrigerate within 20 minutes
Volatile/ethanol
o Elevate results for freezing point osmometers, no effect on vapor
pressure instruments
NORMAL VALUES
Serum: 275 300 mOsm
Urine: depends on fluid intake or exercise
50 1400 mOsm
Ratio of serum to urine more accurate
Normal 1:1
Controlled fluid intake: 3:1
Tubular Secretion Renal Blood Flow

- Tests are related because secretion is dependent on renal blood flow


- Interpretation requires attention to both functions and their tests
- To measure secretion, the blood flow must be adequate
- To measure blood flow, the secretion must be adequate
P-Aminohippuric Acid (PAH)

Test for renal blood flow


PAH is secreted in proximal convoluted tubule, not by glomerular filtration
PAH is loosely bound to plasma proteins
PAH is completely removed from the blood each time it comes in contact
with functional renal tissue
- Exogenous procedure
Titratable Acidity/Urine Ammonia
- Tests for tubular secretion of H+ and NH4+
- Normal: 70 mEq/day of acid in form of H+, H2PO4-, NH4+
- Alkaline tide = first morning, postprandial 2-8 p.m. Lowest pH at night
- Renal tubular acidosis is inability to produce an acid urine = metabolic
acidosis
- PCT = secretion of H+
- DCT = secretion NH3

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