Dr. Eny Rahmawati, M.Sc, Sp.

PK
Departemen/Bagian Patologi Klinik RSMH/FK
UNSRI
Blok 18, 2017
Structure of Renal
Glomerulus
Rana
corlax
-Cortical nephron
Rena tubula
Renal medulla
Papilla or Pyramid

• Each kidney contains

approximately 1 to 1.5 million functional units
called nephrons. The nephron is the functional
unit of the
kidney.
• There are two types of
nephrons, cortical and juxtaglomerular nephrons
Loop or
Henle Collecting
duat
utamedullar nephron
‫בחם‬
artery
slys
Renal vein
OX
Renal pelvis
Uretar
Urinary bladder
Urethra
Structure of Nephron
Juxtaglomerular
apparatus
Aferent arteriole Efferent arteriole
Bowman's
capsule Glomerulus
Distal convoluted tubule
Cortex
Proximal convoluted
tubule
Colecting
duct
Pertubular
capilaries -
>Vasa recta
Thick descending
loop of Henle
Medula
Vasa recta
Thick ascending loop of Henle Thin ascending loop of Henle
Thin descending
loop of Henle
Renal Function
Glomerular
Filtration
• Ultrafiltration of plasma in the glomerulus
producing cells and protein - free filtrate which passes to the Bowman's
capsule
Tubular Reabsorption
• Reabsorption of important molecules back to the blood (water, a.a.
glucose and ions).
Tubular Secretion
• Secretion of waste and toxic substances
into the tubules.
Glomerular Filtration
Aferent arteriole
Eferent arteriole
Hydrostatic
pressure
Oncotic pressure (unfiltered
plasma proteins
Visceral epithelium (podocyte)

Several factors influence the actual filtration process.

These include the cellular structure of the capillary walls
and Bowman's capsule, hydrostatic and oncotic pressures,
and the feedback mechanisms of the
reninangiotensinaldosterone system
-Endothelium
Foot processes of podocyte
Basement membrane
Bowman's
Space
Proximal convoluted tubule
Glomerular Filtration
FREELY FILTERED
NONE FILTERED
• H, - Na, K, Cl, Mg2+, HCO3;
PO4
· Glucose
Urea
• Creatinine
Inuline
• Protein BM>68 KDa
• Imunoglobulin
• Red blood cell
Feritin
Tubular Resorbtion
Table 2-2
Tubular Reabsorption
Substance
Location
/Pertubular
Сарагу

Active Liartsport
Glucose, amino acids, salts Chloride
Sodium
Passive transport
Water
Proximal convoluted tubule Ascending loop of Henle Proximal and distal convoluted
tubules Proximal convoluted tubule. descending loop of Henle and collecting duct
Proximal convoluted tubule and ascending loop of Henle Ascending loop of Henle
Reabsorption
TO 12000
Bowman's
caxulg Glomerular titrate
Tubule
Secretion
‫פחחם ס‬T
Urea

Sodium
Tubular Secretion
Tubular lumen

Renal tubular
cell
Pertubular
plasma

HPO, (filtered)
HPO4 +
HHHHCO; + HCO3
H 003
H PO
Carbonic anhydrase

• Function of Tubular
secretion : a. elimination of waste products not filtered by the
glomerulus b. regulation of the acid-base balance in the body
through the secretion of hydrogen ions.
H20+00,
co
Final urine

Figure 2-9 Excretion with phoxhate

secreted hydrogen ions combined
RENAL FUNCTION TEST
GLOMERULUS
TUBULUS
1. Glomerular Filtration
Rate a. Clearance
- Endogen substance
- Exogenous substance b. Estimated GFR 2. Measuring
endogen
substance in blood (reflect glomerular function)
1. Tubular reabsorption
test a. Osmolarity test b. Titrable acidity
c. Urinalysis 2. Tubular secretion test
PAH test
Glomerular Filtration Tests
• The standard test used to measure the filtering
capacity of the glomeruli is the clearance test.
• A clearance test measures the rate at which the kidneys are
able to remove (to clear) a filterable substance from the blood.
• To ensure that glomerular filtration is being
measured accurately, the substance analyzed must be one
that is neither reabsorbed nor secreted by the tubules.
Clearance
• It is defined as the volume of plasma that would
theoretically have to be "cleared" of the substance to account
for the amount of the substance excreted in the urine during a
given period.
Clearance Substances selection
• The stability of the substance in urine during
a possible 24-hour collection period.
• The consistency of the plasma level
• The substances availability to the body
• The availability of tests for analysis of the
substance (reproducibility)
Clearance Substances
• Cystatin C Endogenous. Creatinine
• Urea
Exogenous
• Inulin
• Radioisotop: 51Cr-EDTA, 99m Tc
DTPA, 125 l-Labelleed iothalamate. lohexol
Clearance Formula
The plasma and urine concentrations are determined by chemical
testing. The standard formula used to calculate the milliliters of
plasma cleared per minute (C) is:
UV
C=
P
C = renal clearance (ml/minutes) U = subtance level in urine
(mg/dl) V= 24 hour urine volume P= substance level in
plasma/serum (mg/dl) A= body surface area
UV, 1.73 PA
89

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area. N Engl Med Figure 2-13 A non con for the determination of body surface
area. (From Boothby WM and Sandiford, RB NomoTan for determination of body surt 185227, 1921,
with permission.)
High

Normogram
To estimate the body surface area →
information of patient height and weight
Creatinine Clearance
• Creatinine is an endogenous substance with a molecular
weight of 113 Da it is produced by the muscle from creatine
and creatine phosphate.
• Creatinine, a waste product of muscle metabolism that is
normally found at a relatively
constant level in the blood.
• Creatinine measurement → High reproducibility.
Creatinine Clearance
• Creatinine is the most widely used marker of GFR
for several reasons: a. It is an endogenous substance with a
fairly constant rate of production. b. Creatinine is not bound
to plasma proteins; therefore it is filtered freely by the
glomerulus. It is not reabsorbed by the renal tubules, and
only a small amount is secreted by the tubules.
Consideration of using Creatinine as clearance substance
1. Some creatinine is secreted by the tubules, and
secretion increases as blood levels rise. 2. Medications,
including gentamicin, cephalosporins,
and cimetidine, inhibit tubular secretion of
creatinine. 3. Bacteria will break down urinary creatinine
if
specimens are kept at room temperature for
extended periods. 4. Measurement of creatinine clearance
is not a
reliable indicator in patients suffering from musclewasting
diseases.
Classification of Kidney Diseases
Stages of Kidney Disease
Glomerular Filtration Rate (GFR)*
Stage
Description
Kidney damage (e.g., protein in the urine) with normal GFR
90 or above
Kidney damage with mild decrease in GFR

60 to 89
3
Moderate decrease in GFR
30 to 59
Severe reduction in GFR
15 to 29
Kidney failure
Less than 15
* Your GFR number tells your doctor how much kidney function you have.
As
chronic kidney disease progresses, your GFR number decreases.
• GFR declines with age.
• After age 20 to 30 years, GFR decreases by
approximately 1.0 mL/min/1.73 m per year.
Estimated GFR
• Formulas have been developed to provide
estimates of the GFR based on the serum creatinine without
the urine creatinine.
• Accurate urine collection is a major limitation
of creatinine clearance as a measure of GFR, attempts have
been made to mathematically transform serum creatinine to
estimate glomerular filtration rate.
Estimated GFR
Cockroft Gault Formula
(140 - age)(weight in kilograms)
72 X serum creatinine in mg/dL
Modification of Diet in Renal Disease (MDRD) system
GFR= 170 X serum creatinine-0.999 x age-0.176 X 0.822 (if
patient is female) x 1.1880 (if patient is black) X
BUN-0.170 X serum albumin +0.318
Estimated GFR
• Cockroft Gault eGFR → overestimates GFR in
individuals who have relatively low muscle mass in relation
to their body weight such as obese, edematous, or
chronically ill.
. Both Cockroft-Gault formula and MDRD
formula estimate GFR in adults and are not applicable to
measurement of GFR in children.
Estimated GFR
SCHWARTZ FORMULA
Schwartz Formula: GFR = 0.55 x height (cm)/serum
creatinine (mg/dL) GFR = 48 x height (cm)/serum creatinine
(umol/L)
(14-15A) (14-15B)
Estimated GFR for children
Renal Function Test
• Measuring some endogen substances in blood that reflect
renal function.
• Indirectly reflect renal function.
• Substances reflects renal function
a. Serum BUN/Ureum b. Serum Cystatin C c. Serum
Creatinin
Serum cystatin
• Cystatin C is a 122 amino acid protein with a molecular
weight of 13,000 Da; it is an
inhibitor of cysteine proteinase, produced by all nucleated
cells, and its production rate is relatively constant from age 4
months to 70 years.
• The rate of production is not affected by muscle mass, sex,
or race
Cystatin
Cystatin (→ measured in serum → can be calculated as
Cystatin Ce GFR
Cystatin CeGFR
Modified cystatin equation: GFR [mL.min.(1.73 m')'] =
84.69%
cystatin C (mg/L) 1.384 (if a child <14 years)
(14-18)
Serum Creatinine
• Not sensitive in detecting renal function →
increment of serum creatinine happened when renal function
less than 50%
Serum Urea
. Urea is the main waste product of nitrogen
containing chemicals in the body.
Serum urea is widely used as a measure of renal dysfunction,
but its value as a measure of GFR is not very good for
several reasons:
a. First, urea concentration in the serum depends not only on
renal function but also on the rate of urea production, which
depends largely on protein intake. b. The rate of protein
intake varies widely from individual to individual
Serum Urea
• Urea is freely filtered at the glomerulus but is
reabsorbed substantially in the proximal convoluted tubule
and the inner medullary collecting duct.
• Reabsorption of urea in the proximal tubule
occurs passively through the lipid membrane without the
help of urea transporters
Tubular Resorbtion Test
SPECIFIC GRAVITY - Urin SG - Concentration Test
| Osmolarity and Osmolality
Tubular Reabsorption Tests
• Measurement of the GFR is not a useful
indication of early renal disease, the loss of tubular
reabsorption capability is often the first function affected in
renal disease.
• Tests to determine the ability of the tubules
to reabsorb the essential salts and water that have been
nonselectively filtered by the
glomerulus are called concentration tests.
Tubular Reabsorption Tests
• The ultrafiltrate that enters the tubules has a
specific gravity of 1.010; therefore, after reabsorption one
would expect the final urine product to be more
concentrated.
Tubular Reabsorption Tests
Patient A

Patient B
Water (1 glass)
Water (4 glasses)
Glomerulus
Glomerulus
J 120 ml Water
Ultrafiltrate 1 300 mg Solute
Ultrafiltrate

TE
120 mL Water || 300 mg Solute
119 ml Water

Reabsorption | | 100 mg Solute

1 110 mL Waler Reabsorption
| 1 100 mg Solute
| 10 ml Water
si mL Water
Urine 1200 mg Solute
Unne 1 200 mg Salute

Figure 2–14 The effect of hydration on renal concentration.

Specific gially 1015
Specific gravity 1.005
Tubular Reabsorption Tests
· Fishberg and Mosenthal concentration tests,
which measured specific gravity.
• In the Fishberg test, patients were deprived of fluids for 24
hours prior to measuring
specific gravity.
• The Mosenthal test compared the volume
and specific gravity of day and night urine samples to
evaluate concentrating ability.
Tubular Reabsorption Tests
Fishberg concentration test the patients is given supper
with not more than 200 ml of fluid and nothing thereafter.
Urine voided during the night is discharded. The morning
urine is saved, the patient keept in bed and the urine of 1
hour and 2 hours later is saved. If the specific gravity of any
specimen is less than 1,024 there is impairment of renal
concentration.
Tubular Reabsorption Tests
• Mosenthal test The patients follows his usual eating and
drinking habbits. Collect urine every 2 hours from 8 am-8
pm. Collect night urine as one specimen. SG in one specimen
should not ecxeed than 1.020. A difference of 0.009 or more
should exist between the lowest and the highest SG. Volume
of 12-hours should not exceed 725 ml.
Tubular Reabsorption Tests
• All of concentration test is contraindicated in
uraemia and is unreliable in a case of heart failure and
edema.
Neither test (Fishberg and Mosenthal) is used now because
information provided by SG is more useful as screening,
quantitative measurement of renal concentrating ability is
best assesed through osmometry.
Tubular Reabsorption Tests
- Persons with normal concentrating ability
should have a specific gravity of 1.025 when deprived of
fluids for 16 hours.
opening vario
specific
Figura 42 Lots
Dades
Osmolality vs Osmolarity
• Osmolarity refers to the number of moles of solute in a liter
of solution.
• Osmolality refers to the number of moles of solute in a kg
of water (solvent).
Osmolality vs SG
• Osmolality measures only the number of
particles in a solution, whereas SG is influnced by the
number and density (molecular weight) of
the particles.
• Renal concentration is concerned with small
particles, primarily sodium and chloride. Large molecular-
weight molecules such as glucose and urea do not contribute
to the evaluation of renal concentration.
Osmolality vs Osmolarity
• Therefore osmolality is more accurate
evaluation of renal concentrating ability → Osmometry.
Serum osmolality = {serum Nat (mmol/L)x2} +
{glucose (mg/dL)/18} + {urea (mg/dL)/2.8}
(14-3)
Tubular Secretion Tests
• Tests to measure tubular secretion of nonfiltered
substances and renal blood flow are closely related in that
total renal blood flow through the nephron must be measured
by a substance that is secreted rather than
filtered through the glomerulus.
Tubular Secretion Tests
The test most commonly associated with tubular secretion
and renal blood flow is the paminohippuric acid (PAH) test.
Measurement of urine pH, titratable acidity, and urinary
ammonia can be used to determine the defective function of
tubular secretion.
Titrable acid: phosphoric acid, sulfuric acid which is
involved in renal physiology.
Microalbuminuria
• Microalbuminuria refers to an abnormally increased
excretion rate of albumin in the urine in the range of 30–299
mg/day.
protein
Stages of kidney involvement according to the urinary albumin level Stage of
Urine dipstick for Urine ACR 24 hour urine nephropathy
(mg/mmol) collection for
albumin Normal
Negative
< 2.0 (men)
< 30 mg/day
< 2.8 (women) Microalbuminuria Negative 2.0-20.0 (men) 30-300 mg/day
2.8-28.0 (women) Overt nephropathy Positive
> 20.0 (men) > 300 mg/day (Macroalbuminuria)
> 28.0 (women)
Laboratory exam on CKD
Screening
Diagnosis
Monitoring a. Progressivity b. Complication
GFR Renal impairment (albuminuria, proteinuria,
hematuria)
Serum creatinin, BUN,
eGFR, Urinalysis
Microlbuminuria
NGAL Cystatin C
Pemeriksaan urin lengkap:
- makroskopis: jumlah, warna, kejernihan,
BJ, bau, pH - mikroskopis: pemeriksaan
sedimen - kimia: protein, darah samar, nitrit,
glukosa, bilirubin, dll
URINALISIS: ®
bersih, kering, tertutup rapat,
berlabel identitas
®
KULTUR URIN: steril, kering, tertutup
rapat, berlabel identitas
Transport bahan pemeriksaan:
- kurang dari 2 jam harus sudah diperiksa -
bila > 2 jam: harus dg dry ice/coolbox pd
suhu 4 derajat C Tujuan: agar tak terjadi
pembiakan kuman.
 Warna ®
®
Kejernihan
®
Bau
®
Volume
Ayo Cek Warna Urine Anda
Anda terhidrasi dengan baik Pertahankan kecukupan cairan tubuh
dengan cukup minum air putih
Anda kurang terhidrasi dengan baik Dianjurkan segera minum air putih
yang mencukupi
Apakah Anda Sudah Minum hari
Cukup

Anda mengalami kekurangan cairan Segera minum & mencukupi cairan

tubuh/pertolongan medis
Minum Air Putih 2-3 Liter (8 gelas) sehari
fakualita.bdg
PEMERIKSAAN KIMIA
URIN
tysis URS - 2P
HE YERCON
L
. Paplace Done
w Yor Basics
20 PM D e Zone
Changon Paco T33
8531 Et forconate W e can .co EGREES
Beta Brusi
SO Registration
SYON Standard NO. YB 2005 Manufacturer Den JSE scx0001

LOK
EC
DOLL

CELLS UL Bload
ககககககககக
sen
Felone

1 ostrips
th

H0

CE
09
Specific Gravity
Densidad Densidade 60 sec/seg.
1.000
1.005
1.010
1.015
1.020
1.025
1.030
e cline 10
6.0
7.0
8.0
9.0

60 sec/seg. Leukocytes
Leucocitos 60–120 sec/seg.

Blood/Hemoglobin/ Sang(re)(ue)/Hemoglobina
60 sec/seg.
neg.
ca. 15
ca. 75
ca. 125
ca. 500
Leuko/uL
neg.
ca. 5-10ca. 10
ca. 25
ca. 25
ca. 50
ca. 50
ca. 250 Ery/UL

IVD
Nitrite/Nitrito/Nitritos
60 sec/seg.
 Ketones/ C.Cetónicos 60 sec/seg.
neg.
++
1
+30°C

+2°c. A
5(0.5)
15 (1.5)
50 (5)
150 (15) mg/dl (mmol/L)
neg.
+
++

++
+++
+++

Bilirubin/Bilirrubina/
60 sec/seg. Urobilinogen(o)/ Urobilinogênio
60 sec/seg. Protein/Proteinas/
Proteínas
60 sec/seg. Glucose/Glucosa/
Glicose 60 sec/seg.
normal
1(17)
4 (70)
8 (140)
12 (200) mg/dL (umol/L)

2011-02 23054941 LOT

neg.
15 (0.15) 30 (0.3)
100 (1)
300 (3)
1000 (10) mg/dL (g/L)
normal 100 (5.5) 300 (17) 1000 (55) mg/dl (mmol/L)
Sedimen organik:
○

Epitel
○

Eritrosit
○

Lekosit Sedimen anorganik

○

Kristal
○

Silinder
○

Mukus
○

Bakteri
EPITEL
ERITROSIT
8.80
Eritrosit
LEKOSIT
KRISTAL TRIPEL FOSFAT
KRISTAL OKSALAT
KRISTAL AMMONIUM BIURAT
SILINDER
7
Білет орг
Bahan: - urin steril porsi tengah
- urin aspirasi supra pubik - urin tampung
dari urin bag - urin aspirasi dari kateter
Penampung: pot steril, kering, dan tertutup
Persiapan pasien: sebaiknya pasien blm
mendapat terapi antibiotik selama 3 hari,
catat apabila sudah.
Cara mengambil
-
Urin porsi tengah: Wanita: - Cuci daerah vulva dg
sabun antiseptik - Bilas dg air mengalir - Lebarkan
labia mayora dg kedua jari
-
Pasien berkemih 30 ml pertama dibuang
-
Tampung porsi tengah 50 ml ke dalam pot steril
- Urin porsi terakhir tdk ditampung
Pada pria:
-
Gland penis dicuci dg sabun antiseptik dan
bilas dg air mengalir
-
Pasien berkemih dan urin porsi tengah
ditampung
Urin aspirasi supra pubik:
- pasien diminta untuk minum banyak dan
tdk boleh berkemih sampai kandung kemih
penuh - dilakukan pungsi kandung kemih dg
cara aseptik - dilakukan oleh Dokter Bedah
SUPRA PUBIC PUNCTION
Urin tampung dari urin bag: sering pd bayi
yg
tidak tahu kapan akan berkemih. Urin
aspirasi dari kateter: dilakukan tindakan
antiseptik seproksimal mungkin di daerah
kateter sampai ke uretra, kemudian dengan
jarum steril dilakukan pungsi pada daerah
tersebut.
URIN KATETER
k! ‫ دار السلبيان‬: ‫ای‬
HHH

in dhcher Oruclinta
LE
URIN TAMPUNG URIN BAG
Interpretasi pemeriksaan kultur urin:
-
Urin porsi tengah:
-
Jumlah kuman>100.000/mL, 1 jenis kuman:
infeksi saluran kemih - Jumlah
kuman>100.000/mL, >= 3 jenis kuman:
kontaminasi, perlu sampel baru - Jumlah kuman
10.000-100.000/mL: infeksi
saluran kemih, dilihat keadaan klinis yg
mendukung, ulangi pengambilan sampel - Jumlah
kuman< 10.000/mL: adanya kontaminasi
Urin supra pubik: adanya kuman sudah
menunjukkan adanya infeksi Urin
tampung dari urin bag dan urin aspirasi
dari kateter: kemungkinan kontaminasi
sangat besar→ interpretasi hasil perlu
dihubungkan dengan gejala klinis dan
pemeriksaan yg lain.
®
KUMAN ETIOLOGI:
▪
E. COLI (TERBANYAK)
▪ PROTEUS SP.
▪ KLEBSIELLA SP.
▪ PSEUDOMONAS SP.
▪
COCCUS (STAPH/ STREPTO)
▪
VIRUS, DLL
SEKIAN TERIMA
KASIH