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BY- MANINDER KAUR B.Sc.

(MLT) third year


MODERATOR-Dr. SEEMA

DEFINITION Glomerular filtration rate (GFR) is a measure of kidney function. It is the volume of fluid filtered from the renal glomerular capillaries into the Bowmans capsule per unit time. It is a test used to check how well the kidneys are working.

Specifically, it estimates how much blood passes through the tiny filters in the kidneys, called glomeruli, each minute.

NORMAL RANGE :- 90-120mL/minute.


Older people have lower normal GFR levels, because GFR decreases with age. Levels below 60mL/minute for 3 or more months are a sign of chronic kidney disease. Level below 15mL/minute are a sign of kidney failure.

(a) Urea clearance (b) Endogenous creatinine clearance (c) Inulin clearance test (d) Cr51-EDTA clearance test

TESTS TO MEASURE RENAL PLASMA FLOW :

(a) Para-amino hippurate test (b) Filtration Fraction

WHAT IS MEANT BY CLEARANCE TEST?

The rate of excretion of a given substance by the kidney is called its clearance. The renal clearance of a substance is defined as the volume of plasma from which the substance is completely cleared by the kidneys per unit time.

The clearance of a substance S is given by the equation Cs = (Us x V)/Ps

Where: Cs = clearance in units of ml of plasma cleared of a substance per minute. Us = urinary concentration of the substance(mg/dl). V = volumetric flow rate of urine in ml per minute. Ps = plasma concentration of the substance(mg/dl).

Blood urea clearance is an expression of the number of ml of blood/plasma which are completely cleared of urea by the kidney per minute.

MAXIMUM UREA CLEARANCE- It is defined as volume of plasma that would be completely cleared of urea per minute. A urea clearance of 75 does not mean that 75ml of blood have passed through the kidneys in one minute and were completely cleared of urea.

But it means that the amount of urea excreted in the urine in one minute is equal to the amount found in 75ml of blood. The clearance which occurs when the urinary volume exceeds 2mL/minute is termed as MAXIMUM UREA CLEARANCE. AVERAGE NORMAL RANGE:- 75ml+/-10.

Formula= U x V/ B

Where, U= concentration of urea in urine (mg/100ml) V= volume of urine in ml/minute B= concentration of urea in blood (mg/100ml)

STANDARD CLEARANCE- When the urinary volume is less than 2ml/minute, then the rate of urea elimination is reduced because of relatively more urea is reabsorbed in tubules and is directly proportional to square root of urinary volume.

INTERPRETATION OF THE TESTUrea clearance of 70% or more of average function indicates that the kidneys are excreting satisfactorily.

Values between 40 to 70% indicates mild impairment, between 20 to 40% moderate impairment and below 20% indicates severe impairment of renal function.

At normal levels of creatinine, this metabolite is filtered at the glomerulus but neither secreted nor reabsorbed by the tubules. Excretion of creatinine is constant and is not influenced by body metabolism or dietary factors.

Hence its clearance gives the GFR. This is a convenient method for estimation of GFR sinceI. It is a normal metabolite of the body. II. It does not require the intravenous administration of any test material . III. Estimation of creatinine is simple.

Measurement of 24 hour excretion of endogenous creatinine is convenient. This longer collection period minimizes the timing error. RESULT: Ccr=U x V/ P where, U= urine creatinine concentration in mg/dl. P= serum creatinine in mg/dl. V= volume of urine in ml/minute.

NORMAL VALUES FOR CREATININE CLEARANCE VARIES FROM 95 TO 105 ML/MINUTE.

Inulin, a homopolysaccharide , polymer of fructose is an ideal substance as :Not metabolised in the body. Following IV administration, it is excreted entirely through glomerular filtration, being neither excreted nor reabsorbed by renal tubules.

I.

II.

CALCULATION AND RESULT:Values obtained of two samples of blood is averaged. Cin=U x V/P where, U= mg of inulin/100ml of urine. V=ml. of urine/minute. P=mg of inulin/dl of plasma(average of two samples).

NORMAL AVERAGE:- inulin clearance in an adult(1.73 sqm)=125ml of plasma cleared of inulin per minute. RANGE=100 to 150 ml. DETERMINATION OF Cr51- EDTA CLEARANCE Currently simplified single injection method for determination of Cr51- EDTA plasma
clearance is widely used, for routine assessment of glomerular filtration rate in adults as well as in children. 4.5 ci(0.17MBq)/kg body weight of Cr51- EDTA is injected IV. Capillary blood samples are drawn at 5, 15 ,60,90 and 120 minutes after the injection and simultaneously the haematocrit is determined.

The radioactivity is calculated as measured activity in 0.2ml capillary blood/1-hct. The Cr51- EDTA plasma clearance is determined as the ratio between the injected amount of the tracer (Q o) and the total area under the plasma activity curve C(+) which is resoluted into two mono-exponential functions.

The plasma clearance (Cl) is then calculated as Cl= Qo/(c1/b1+c2/b2)

Para-amino hippurate (PAH) is filtered at the glomeruli and secreted by the tubules. At low blood concentrations (2mg or less/100ml) of plasma PAH is removed completely during a single circulation of the blood through the kidneys. Thus, the amount of PAH in the urine becomes a measure for the value of plasma cleared of PAH in a unit time, i.e. PAH clearance at low blood levels measures renal plasma flow (RPF).

RPF (for a surface =574ml/minute.

area

of

1.73

sqm)

FLITRATION FRACTION: The filtration fraction (FF) is the fraction of plasma passing through the kidney which is filtered at the glomerulus. It is obtained by dividing the inulin clearance by the PAH clearance. FF= Cin/CPAH = GFR/RPF

NORMAL RANGE=0.16 TO 0.21 IN AN ADULT.

INTERPERTAIONS:1. The FF tends to be normal in a early essential hypertension , but as the disease progresses the decrease in RPF> than the decrease in the GRF. This produces an increase in FF. 2. In the malignant phase of hypertension, these changes are much greater, consequently the FF rises considerably. 3. In glomerulonephritisa progressive decrease in FF is characteristic. 4. A rise in FF is also observed early in congestive cardiac failure.

It is a condition when proteins appear in urine in detectable quantities. There is increased glomerular permeability, as in the nephrotic syndrome. Albumin is usually the prominent protein in the urine, hence the term proteinuria is also called as albuminuria.

The albumin molecules are the smallest, so it easily passes the glomerular epithelium, next are globulins and fibrinogen is least readily absorbed. LABORATORY INVESTIGATIONS: Qualitative tests for albumin: HEAT TEST: PRINCIPLE: Proteins in urine are coagulated by heat and the degree of coagulation is directly proportional to the amount of proteins present. Coagulation can be further enhanced when drops of acetic acid are added.

SULPHOSALICYLIC ACID TEST:


PRINCIPLEUrine proteins are precipitated by sulphosalicylic acid, which gives a white precipitate and the degree of the precipitate is directly proportional to the protein level.

SEMI QUANTATITIVE METHOD:


ALBUSTIX METHOD: PRINCIPLE: It is based on the protein error of the pH indicator. At a constant pH, the presence of protein leads to the development of any green color. Colors range from yellow for negative through yellow green and green to green blue for positive reactions.

QUANTITATIVE TEST: ESBACHs TEST: To determine the proportion of albumin per thousand, Esbachs albuminometer is used. This tubes bears two markers: one, U indicating the point to which the urine must be added ; and one, R the point to which the reagent is added. The lower portion of the tube upto U bears a scale reading from 1 to 7. At the expiration of time albumin and others proteins settle down, the amount per ml in grams, may be directly read from the scale.

RESULT: evaluation of protein severity:


Mild <1 gm/day(causes-physiologic protein uria, urinary tract infections, kidney stones ) Moderate : 1 to 3 gm / day (causesglomerular and tubule interstitial nephropathies) Severe > 3.5 gm / day (nephrotic syndrome)

Thank you