Kidney Function Tests Difference

Clearance: no. of mL of plasma which the kidney can

⚫ Elimination of Metabolic waste products remove all of the given substance in 1 minute
through the formation of urine Plasma renal flow: no. of mL of plasma passing through
a. Glomerular filtration the kidney in 1 minute
b. Tubular reabsorption
c. Tubular secretion Laboratory Methods
Removal of unwanted substances from plasma includes Laboratory Methods refer to Measurement of waste
Excretion of waste products of protein metabolism, products in blood which accumulate when kidneys fail
Excretion of drugs and toxin to properly function
ANATOMY ⚫ Renal failure occurs when only 20% to 30% of
⚫ Each kidney has 1 million nephrons. the nephrons are functioning
⚫ Nephron =functional unit of 5 parts:
⚫ Glomerulus Tests for Glomerular Filtration
⚫ Proximal convoluted tubule
⚫ Loop of Henle A. Clearance Measurement
⚫ Distal convoluted tubule ⚫ Measurement of clearance detects much
⚫ Collecting duct earlier stages of renal disease.
⚫ Clearance refers to that volume of plasma from
which a measured amount of substance can be
completely eliminated into the urine per unit of
time. Clearance tests are also called tests for
glomerular filtration.

⚫ Formula for GFR = U X V

P
⚫ where: U =concentration in urine (mg/dL)
V= volume of urine (mL/min)
P= conc of substance in plasma

A.1. Inulin (Iothalamate) Clearance Test

1. Glomerulus is a tuft of capillaries surrounded by the ⚫ GFR or Cinulin = Uinulin X VmL/min
expanded end of a renal tubule known as Bowman’s P inulin
capsule. Inulin is the most ideal substance for GFR but is
2. Proximal convoluted tubule is located in the cortex. NOT commonly used because it requires IV infusions and
3. Long loop of Henle is composed of thin descending the procedure is labour extensive and time consuming.
limb, which spans the medulla, and the ascending limb, However, this test is considered as the reference method.
which is located in both the medulla and the cortex,
composed of a region that is thin and then thick A.2. Creatinine clearance
4. Distal convoluted tubule is located in the cortex. ⚫ is the standard laboratory test for determining
Shorter than the proximal convoluted tubule early renal failure.
5. Collecting duct=Formed by 2 or more distal ⚫ Formula:
convoluted tubules as they pass back down through the Ccr(mL/min)= Ucr (mg/dL) X Vur (mL/24h) X 1.73
cortex and medulla to collect urine that drains from Pcr (mg/dL) x 1440 min/24hrs A
each nepron. Merge and empty contents into renal
pelvis Where: Ccr= creatinine clearance; Ucr= urine
creatinine concentration; Vur= urine volume excreted in
24 hours; Pcr= serum creatinine concentration; 1.73/A=
normalization factor for body surface area
 A.3. Cclearance=ideal B.Modification of Diet in Renal Disease Formula
⚫ synthesized at a constant rate (MDRD)
⚫ cleared essentially only by glomerular filtration GRF (mL/min/1.73m )= 186 x Scr (mg/dL)-1.154 x age -0.203x
2

⚫ inexpensive X (1.212 if black)

Reasons why it is ideal for the measurement of X (0.742 if female)
clearance: MDRD
§ More accurate assessment of GFR than Cockcroft-
1. endogenous metabolic product synthesized at a Gault formula
constant rate § Does not require weight but corrected for body
2. cleared essentially only by glomerular filtration (It is surface area
NOT reabsorbed and is only slightly secreted by the § May underestimate GFR of healthy patients with GFR
proximal tubule) over 60 mL/min; may overestimate GFR in underweight
3. can be analyzed inexpensively by colorimetric patients
methods
CKD-EPI formula (Chronic Kidney Disease
Requirements essential for testing: Epidemiology Collaboration
⚫ 1. 24-hr urine collection eGFR (mL/min/1.73 m2) = 141 x min (Scr/K,1)a
⚫ 2. patient must maintain an adequate fluid
X max (Scr/K,1)-1.209 X 0.993age
intake to ensure a minimum urine rate flow of at
X ( 1.018 if female)
least 2 mL/min.
X (1.159 if black)
⚫ 3. patient is NOT allowed (patient restrictions):
coffee, tea, heavy exercise, medications, Less bias than MDRD in patients with higher GFR
recreational drugs. §K is 0.7 for females and 0.9 for males
§a is -0.329 for females and -0.411 for males
Estimated GFR (eGFR)
§min indicates the minimum of Scr/K or 1
Cockcroft-Gault formula
§ max indicates maximum of Scr/K or 1
Formula:
GFR (mL/min)= (140-age) x weight (kg) X (0.85 if
Urea Clearance
female)
72 x Scr ( mg/dL)
Types of Urea clearance:
1. Maximum Urea Clearance is obtained if the rate of
The recommendation of National Kidney Foundation
tubular fluid flow is > 2mL/min.
that eGFR be calculated each time a serum creatinine is
C= U X VmL/min X 1.33 X 1.73
reported.
P A
The equation predicts GFR based on serum creatinine,
⚫ Reference range: 64-99 mL/min ( average: 75
age, body size, race, and gender and does not require
mL/min)
urine creatinine.
⚫ Urea does not provide a full clearance
assessment because it is freely filtered in the
A. Cockcroft-Gault formula: Not corrected for body
glomerulus and about 40% is reabsorbed by the
surface area. Assumes that women have 15% lower
tubules.
creatinine clearance than men at the same level of
serum creatinine 2. Standard Urea Clearance is obtained if the rate of
tubular fluid flow is <2mL/min.
⚫ Reference range: 41-68 mL/min (average: 54
mL/min)

Standard Urea Clearance is more precise or consistent.

This is obtained if the rate of tubular fluid flow is
<2mL/min.
 Concentration and Dilution Tests
B. Cystatin C ⚫ Specific Gravity
Random urine: 1.003-1.035
⚫ Freely filtered by the glomerulus, reabsorbed, 24-hr urine: 1.015-1.025
and catabolized by the proximal tubule Serum : 1.010-1.012
⚫ Osmolality
Cystatin C is Freely filtered by the glomerulus,
reabsorbed, and catabolized by the proximal tubule Concentration and Dilution Tests are measurements for
Levels rise quickly than creatinine in acute kidney injury the functions of kidney tubules. The tests are based on
(AKI); levels is seen before decrease in GFR the degree of hydration or tonicity of ECF.
Levels unaffected by gender, diet, race, age, muscle A. Specific Gravity is due to the possible presence of
mass glucose and proteins in the specimen.
Reference range:
C. β2-microglobulin Random urine: 1.003-1.035
⚫ easily filtered in the glomerulus 24-hr urine: 1.015-1.025
⚫ 99% reabsorbed by proximal tubules Serum : 1.010-1.012
-Osmolality of serum is 92% because of electrolytes and
β2-microglobulin: easily filtered in the glomerulus; 99% 8% due to proteins, glucose and urea.
reabsorbed by proximal tubules. Used to assess renal
tubular function in renal transplant patients , with osmolality
elevated levels indicating organ rejection

D. Myoglobin
⚫ Early diagnosis and aggressive treatment of high
myoglobin may prevent or lessen the severity of
renal failure

Tests for Renal Blood Flow

Hyperosmolality can be seen in excessive water loss.
Hypoosmolality is seen in polypidsia. Reference range:
A. PAH (Para-amino Hippuric acid)
285-319 mOsmol/kg H2O
o reference method for ERPF
UPAH X V mL/min
Measurement of osmolality
RPF (mL/min) = PPAH

⚫ Osmometry: use of osmometer or cryoscope

Reference range for PAH: 600-700 mL/min
⚫ vapor pressure or dew point osmometer
PAH (Para-amino Hippuric acid) Clearance measures the
Osmolality can be directly measured using:
effective renal plasma flow (ERPF) in the absence of
1.Osmometry: use of osmometer or cryoscope
tubular functional impairment. It is the reference
2.vapor pressure or dew point osmometer
method for ERPF determination.

⚫ Delta osmolality is employed to evaluate acutely

B. PSP dye Excretion Test
ill or comatose patients.
⚫ use of Phenolsulfonphthalein
⚫ Reference range: >40 mOsmol/kg H20
⚫ test that detects ERPH
⚫ Reference range: 60-86% excretion in 2 hours (
Delta osmolality is employed to evaluate acutely ill or
20% of dye is secreted by the liver.
comatose patients.
It refers to the difference between the calculated
osmolality and the measured osmolality using the direct
method.
 ⚫ U/S Osmol is also used to differentiate etiologies
of polyuria.
⚫ Reference range: 1-3.
⚫ U/S Osmol ratio means urine over serum
osmolality. This is also used to differentiate
etiologies of polyuria. Reference range: 1-3.

RFI and FeNa test is used to differentiate pre-renal and

renal cause of acute renal failure

⚫ RFI = urine Na + Urine Crt/plasma Crl

Urine Na X plasma Crt X 100
⚫ FeNa = urine Crt X plasma Na

RFI and FeNa refer to the renal failure index and the
fractional sodium excretion. This test is used to
differentiate pre-renal and renal cause of acute renal
failure. It is better than osmolality or Na excretion test
alone.
RFI = urine Na + Urine Crt/plasma Crl
Urine Na X plasma Crt X 100
FeNa = urine Crt X plasma Na
RFI/FeNa<1.0 = pre-renal failure
RFI/FENA>2.0 = parenchymal renal failure

Osmol Clearance evaluates the concentration and

diluting ability of kidneys. This measures the amount of
water cleared from the plasma resulting in urine that
has the same osmolality as the plasma.

Uosmol X V
⚫ Cosmol= P osmol

⚫ Free water clearance is to test for the

concentration ability of the kidneys.
⚫ C water = V-Cosmol
⚫ Interpretation:
+ Cwater clearance =urine is dilute than serum.
- Cwater clearance = urine is concentrated than serum.

Free water clearance is used to test for the

concentration ability of the kidneys. C water = V-
Cosmol
Interpretation: + If free water clearance is positive, urine
is dilute as compared to serum.
- if free water clearance is negative, urine is
concentrated as compared to serum