CLINICAL

PATHOLOGY
 GROUP 6
• ANJUM HAFEEZ
• MOIZ AHMED
• ARSALAN LATIF
• RANA UMAR FAROOQ
• MAZHAR ALI
• SYED SHAHBAZ
• MALIK NOOR HUSSAIN
• SHEHARYAR AMEEN
• ZIA ULLAH
• ZAHEER ABBAS
 PRESENTATION

RFTS
(RENAL FUNCTION TEST)
 The Kidney

• Kidneys are bean shaped organs, located

near the Middle of The back, Just below
The Ribs cage.
• It play an important role in maintains our
body fluid.
 Functions of the Kidney
Urine formation:

 There are four process in urine formation.

 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, glucose and ions).

 Tubular Secretion:
• Secretion of waste and toxic substances
into the tubules.
 Excretion

• Removal of harmful/toxic substances

• Nitrogenous substances.
• Bilirubin
• Metabolites
• Drugs/Toxins.
• Non-protein nitrogenous NPN substance
• Urea*Creatinine *Uric Acid.
Excretion
 RESPONSIBILITIES
Production of Hormone
1.Erythropoietin (EPO):
Secreted in response to low blood oxygen
content. It acts on bone marrow,
stimulating the production of RBCs.

2.Renin :
Regulates blood pressure and fluid and
electrolyte balance.
3.Homeostasis:
Through Acid/Base Balance and Electrolytes
Balance.

Glomerular filtration tubular reabsorption, and

tubular secretion permit rapid removal of toxic
substances and entire plasma filtration about 60
times/day.
Each of these processes is regulated according
to the body needs.
 Signs and Symptoms of Kidney
Disorders

Early e. Headache
Symptoms f. Frequent hiccups
a. Weight loss
b. Nausea, vomiting
c. Feeling General
illness
d. Fatigue
 Late Symptoms

a. Increased or decreased urine output

b. Need to urinate at night
c. Easy bruising or bleeding
d. Decreased alertness Muscle cramps
e. Decreased sensation in the Hands and feet.
 Types of Renal Disorders

 Acute Renal Failure(ARF):

• Occurs quickly and suddenly as a result of
kidney injures.
• It results from pre-renal or post-renal
causes.
• May lead to permanent loss of kidney
function.
• Can be reversed if kidneys are not
seriously damaged.
 Physiologic impact includes:

• Retention of water (edema), electrolytes

(hypertension) and metabolic bi-
products(neurotoxicity).

• In severe cases, complete anuria occurs.

• Death may occur in 8 to 14 days.

 Pre-renal causes:

 Reduced perfusion due to:

• Blood loss(hemorrhage).
• Cardiac failure.
• Peripheral vasodilation resulting in
hypotension(e.g. anesthesia).
• Renal artery Obstruction.
• Stenosis embolism or thrombosis.
 Renal causes:
Acute Glomerulonephritis due to:

1.Infections(e.g. post-streptococcus
infection)

2.Autoimmune disorders (e.g.systemic

lupus erythematous SLE)
 Acute Tubular Necrosis Due to:

1.Renal Ischemia (↓O2).

2.Hemolysis(Hb degradations)

3.Toxins or Medications (e.g.carbon

tetrachloride CCl4 etc.)
 Post-renal causes:
• Obstruction of renal flow due to:
• Renal Calculi(stone formation)
• Benign or malignant masses(e.g. BPH, bladder
and prostate cancer)
• Chronic obstruction of the urinary tract, lasting for
several days or weeks, can lead to irreversible
kidney damage.
 Chronic Renal Disease(CRD)

• Occurs gradually and slowly as a result of a

long-term disease such as high blood pressure
or diabetes which slowly damages the kidneys
and reduces their function over time.

• May remain asymptomatic for years.

 Physiologic Impact:
• Anaemia (↓EPO hormone).
• Metabolic acidosis(Accumulation of acids).
• ↓ Active form of Vit . D→ ↓Ca intestinal absorption.
• Osteomalacia.
 End-Stage Renal Disease(ESRD):

• If CRD cannot be controlled, total or nearly total

permanent loss of kidney function will occur.

• Dialysis Or Transplantation Is necessary at this

stage.
 Classes of Renal Function Tests

 Glomerular Function:
• Serum
• Urea, Creatinine and Uric acid
• Clearance Tests
• Proteinuria
• Hematuria
Tubular Function:
• Determine by Specific Gravity.

Urine Analysis:
• Physical Chemical and Microscopic Examination
of urine.
 Biochemical Tests of Renal Function

Blood Urea Nitrogen (BUN):

• Urea is produced in the liver as a result of

protein metabolism.
• It is transported in the blood to the
kidneys, where it is excreted.
High Blood Urea Nitrogen(BUN):
• Renal impairment
• Glomerulonephtitis
• Obstructive uropathy
• High protein diet
• Dehydration(increase tubular reabsorption of
urea)
 LOW BLOOD UREA NITROGEN(BUN)

• Diet inadequate in protein.

• Liver failure.
• Malnutrition

 Value of Serum uric acid:

• Male 3.6-8.5mg/dL
• Female 2.3-6.6mg/dl
• Uric acid is produced by the breakdown of
purines,chemical that that are the building block
for DNA and RNA.

• Excess serum uric acid can become deposite in

joints and soft tissues, causing gout,an
inflammatory response to the deposition of the
urate crystals.
High serum uric acid:

• Condition of rapid turnover of cell due to cell

damage (e.g Malignant condition-leukemias)
• Gout.
• Glomerulonephritis.
• Chronic renal disease.
Serum creatinine level:
• For male 0.8-1.4mg/dL
• For female 0.6-1.2mg/dL
• For children 0.2-1.0mg/dL

Creatinine:
It is the waste product of creatine phosphate a
compound found in the skeletal muscle tissue.
• it is excreted entirely by the kidneys.
High serum creatinine:
Increase levels of creatinine indicate a slowing of
the glomerular filtration rate which indicates to a
renal disorder.

Decrease serum creatinine:

show muscle Atrophy.
Although BUN and creatinine are routine test of
kidney function,their value start to abnormally
increase only when more than 60% of kidney
function is impaired.
Estimation of Glomerular Filtration Rate
GFR

1.GFR is the volume (mL) of fluid filtered from the

glomeruli into Bowman's capsule per unit time (min).
2.Avg Normal Value: “100 ml/min” in average- sized
(70kg).
3.GFR is directly proportional to number of intact
nephrons.
4.GFR can be estimated by Clearance Tests.
 Clearance Tests:
• “Clearance” means the blood volume (ml) from
which a marker substances is totally cleared in
unit time (minute) “ml/min”
• GFR = Clearance of a Substance
= (USubs/SSubs) x Urine flow rate (Urine Vol.
(ml)/24 h USubs = Conc. of the marker
substance in Urine mg/dl SSubs = Conc. of the
marker substance in Plasma mg/dl
Ideal Marker for GFR
Measurement:
• Constant rate of production (endogenous) or of
delivery (i.v.) (exogenous).
• Freely filtered in the glomerulus i.e. no protein
binding.
• Metabolically inactive
• No tubular reabsorption
• No tubular secretion
• Can be estimated in the Lab
 Inulin Clearance:
• Inulin is a fructose polysaccharide that gives
very accurate estimations of GFR since it
meets all the criteria mentioned above.
• A loading dose of inulin can be administered
iv, followed by a sustaining infusion (usually
for 3 hr)
• Inulin concentration in urine and plasma is
determined and hence GFR can be
calculated.
• Inulin clearance is infrequently used in clinical
lab.
Creatinine Clearance:
• male 95–135 mL/min
• female 85–125 mL/min
• Creatinine clearance test is a more sensitive
indicator of kidney function than serum
creatinine and BUN alone.
• Creatinine clearance normally decreases with
aging due to a decline in the glomerular filtration
rate (Above age 30 y, normal range decreases
• 6.5 ml/min every 1decade).
Creatinine clearance test consists of 2
components:
I. 24 -hour urine sample to:
• Determine Urinary creatinine (mg/dl)
• Determine Urine flow rate (Urine volume/1440
min)
II. Blood sample to:
• Determine Serum creatinine (mg/dl)
• Creatinine Clearance (ml/min)=Ucreat /
Screat x Urine flow rate (Vol. /1440 min)
Hematuria
• It is the presence of Red blood cells (RBCs)
in urine detected by microscopic
examination of urine.
Proteinuria (Albuminuria)
• It is the presence of protein (albumin) in
urine.
• It can be detected by several ways that differs in
their accuracy:
• Dipsticks (qualitative)
• Microalbuminuria (MA) (Normal: < 30 mg/l)
• Albumin/Creatinine ratio (UACR)
• UAlbumin mg/dl/Ucreat g/dl → (mg/g creatinine)
• The urinalysis is a routine screening test which
is usually done as a part of a physical
examination, during preoperative testing, and
upon hospital admission.

• It is used in the diagnosis of infections of the

kidneys and urinary tract and also in the
diagnosis of diseases unrelated to the urinary
system.
 Urine Analysis

It involves 3 examinations:
1.Physical Exam.
2.Chemical Exam.
3.Microscopic Exam.
 Physical Examination

1.Appearance (Normal: Clear A)

2.Cloudy (turbid) B: bacteria and/or pyuria→UTI-
urinary tract infection
3.Smoky C: red blood cells→ Hematuria
“Crystalluria/renal calculi”
 Chemical Examination

Specific Gravity → Normal: 1.010–1.025

• The specific gravity is a measure of the

concentration of the urine compared to the
concentration of water, which is 1.000. The value
of this test is an indication of the kidney tubules
ability to concentrate and excrete urine.
• ↓Sp.Gr (Diluted urine) → Causes include: High fluid
intake, Diuretics,
• ADH deficiency (diabetes insipidus), and
Chronic pyelonephritis.
• ↑Sp.Gr (Concentrated urine) → Causes include: Fluid
loss, DM, ↑ADH and acute glomerulonephritis.
• pH → Normal: Acidic
• Alkaline → UTI and Chronic renal failure.
• Protein → Normal: Nil (i.e. not found)
• Proteinuria → renal dysfunction (e.g.
glomerulonephritis)
• “Detection of proteinuria (albuminuria) was
previously mentioned page 12”
 Microscopic Examination

1.Red blood cells (Hematuria) → Urinary tract

injury

2.Leukocytes (Pyuria) → Urinary tract infection

3.Crystals (Crystaluria) → Renal stone

-The accumulation of certain substances in the
urine leads to the formation of crystals resulting in
the formation of renal stones.
For example,numerous calcium oxalate crystals,
resulting from hypercalcemia, may form calcium
oxalate stones.