Renal Diseases
By
Dr. Marwa Abd el-Haq
Assistant Professor
Faculty of Medicine
University of Tabuk
Overview
Functions of the kidney include:
1. Maintenance and regulation of fluid
balance, acid/base and electrolyte
balance (eg, sodium, potassium,
chloride, bicarbonate, calcium,
phosphate).
2. Excretion of waste substances.
3. Production of hormones as
erythropoietin and 1,25-
dihydroxyvitamin D.
Overview
An important example of undesirable
substances is the end products of
protein metabolism (called non-protein
nitrogenous substances NPN), as:
- Urea and Creatinine (The most
commonly used in investigations).
- Others: Uric acid, amino acids,
creatine, nucleotides … etc.
Indications for assessment
of renal function
To asses the functional capacity of
kidney before operation or in hospital
admitted patients.
Early detection of possible renal
impairment (No symptoms until 50-75%
of kidney function is lost).
Severity and progression of the
impairment.
Monitor response to treatment.
Monitor the safe and effective use of
drugs which are excreted in the urine.
Types of renal investigations:
Decreased:
- Pathologically: As in paraplegia,
muscular dystrophy, amputation,
rhabdomyolysis … etc.
- Physiologically: As in elderly patients.
Measurement of plasma creatinine
provides a more accurate assessment
than urea because there are many
non renal factors that affect urea level.
BUN/creatinine ration
It is performed in:
1. If either the creatinine or BUN
concentrations are increased above
the upper normal range.
2. In conditions associated with elevated
levels of blood urea (uremia or
azotemia) to differentiate between
them.
Azotemia (Uremia)
1. Prerenal (due to kidneys
hypoperfusion): as in dehydration,
severe hemorrhage, shock.
2. Renal (primary kidney damage): as in
GN, ATN, interstitial nephritis …).
3. Postrenal (due to blockage of urine
flow): as in prostate enlargement,
stones, congenital anomalies.
The normal BUN/Creatinine ratio is
between 10:1-20:1. The ratio is helpful
in determining the cause of renal
impairment.
BUN/creatinine ration
Pre-renal azotemia leads to increased
urea level, while creatinine level
remains within the normal range (ratio is
20:1 or higher).
In renal azotemia both urea and
creatinine levels rise proportionate to
one another (ratio near 10:1)
Post-renal azotemia both urea and
creatinine levels rise, but creatinine in a
smaller extent.
BUN/creatinine ration
Increased:
• Pathologically in:
1. Pre-renal azotemia
2. Post renal azotemia:
3. Increased protein catabolism: as in
bleeding in the digestive tract, severe
tissue injury (as burns, trauma and
infarctions …)
4. Intraperitoneal extravasation of urine
and urinary enteric fistulas: urea goes
back to blood.
• Physiologically in:
Increased protein intake.
BUN/creatinine ration
Decreased:
• Pathologically in:
1. Renal azotemia: both are increased in blood
but creatinine> urea due to decreased
tubular urea reabsorption.
2. Decreased urea synthesis: as in Liver
cirrhosis.
3. Increased protein loss: as in nephrotic
syndrome.
4. Hemodialysis: semi membranes are more
leaky for urea.
• Physiologically in:
Decreased protein intake.
Overhydration
Glomerular Function Test
The glomerulus is investigated by
determining:
1. Glomerular filtration rate
2. Creatinine clearance
Glomerular filtration rate
GFR is the volume of plasma filtered from
glomerulus to Bowman’ capsule per unit time
(mL/min).
Reference Range:
Male = 117 ± 20 mL/min.
Female = 95 ± 20 mL/min.
GFR can be calculated by measuring a
substance that has a steady level in the
blood, freely filtered and neither reabsorbed
nor secreted by the kidneys.
Creatinine is freely filtered.
10% of the total excreted creatinine is
secreted by the tubules.
Negligible amounts of creatinine are
reabsorbed.
Methods to measure GFR
1. Inulin difficult to perform routinely.
2. Most commonly used method is by
measuring creatinine clearance (Ccr )
• Ccr: Creatinine clearance (ml/min)
Ucr: Creatinine urine concentration
(mg/dl).
Pcr: Creatinine plasma concentration
(mg/dl).
V: Urine volume (mg/dl).
Stage GFR Comment
Serum:
- Normal serum creatinine, SUN, serum
SUN/creatinine ratio, creatinine
clearance, GFR, and uric acid.
- Leukocytosis.
Urine: