Kidney Function Tests

Kidney Function Tests

 The kidney function tests are physiologically
grouped into two broad categories:

1. The tests that assess glomerular functions

(glomerular function tests)

2. The tests that assess tubular functions (tubular

function tests).
 1.Glomerular function tests
1.Blood urea determination
2.Blood creatinine estimation
3.Inulin clearance test
4.Creatinine clearance test
5.Urea clearance test
6.PAH clearance test
7.Estimation of proteins in the urine
 2.Tubular function tests
1. Urine concentration test
2. Urine dilution test
3. Detection acid excretion
4. Test for acidification of urine
5. Test for alkalinisation of urine
6. Test for amino acids in urine
Clinically, kidney function tests are divided
into following categories
1.Routine tests:
Complete urine analysis, measurement of
BUN in blood, and measurement of serum
electrolytes.
2.Tests for further assessments:
Clearance test, determination of urine and
plasma osmolality, concentration and dilution
tests.
3.Specific tests:
Tests to assess renal acidification, tests to
assess renal handling of sodium,
measurement of renal plasma flow.

4.Specialtests:
Ultrasonography, CT scan, MRI, etc
1.ROUTINE URINE ANALYSIS
Routine urine analysis includes analysis of physical
and biochemical characteristics of urine.
Physical characteristics:
(i)Volume:
The normal volume of urine excreted is about 1 ­
1.5 liters per day.

Urine volume increases in excess water intake, high

protein diet, diuretic therapy, diabetes mellitus,
diabetes insipidus , and sometimes in chronic renal
diseases.
 (ii) Appearance:
Normally, urine is clear.
It becomes turbid when kept in a container for a long time
as urea is converted to ammonium carbonate by the action
of bacteria, which makes the urine alkaline and results in
precipitation of calcium and magnesium phosphates.

Urine may also be turbid if it contains more phosphates (as

in alkaline urine) .

 Pus as seen in infection of urinary tract.

Chyle as occurs in obstruction of lymphatics of the urinary

tract (for example, in filariasis).
 (iii) Odor:
Normally, the odor of urine is mildly aromatic due to
presence of volatile organic acids.

Ifkept for a long time, urine gives unpleasant ammoniacal

smell due to conversion of urea into ammonium
carbonate.

Diabetic urine gives acidotic-fruity odor due to the

acetone in the urine.

Excretion of different drugs in the urine also changes the

smell of urine.
 (iv) Color:
Normal urine is straw colored or amber-yellow in color,
which is due to the presence of the pigment urochrome in it.

Urine becomes yellow in bilirubinuria , as occurs in

jaundice.

Itbecomes dark in alkaptonuria , melanuria (seen in

malignant melanoma).

Red in hematuria, hemoglobinuria , myoglobinuria ,

porphyria or following intake of rifampicin (anti-tubercular
antibiotic).
 (v) Specific Gravity:
The normal specific gravity of urine is 1.005-1.030.

Specific gravity of urine is 1.010 normally corresponds to

urine osmolality of 285 m mol /kg.

Specific gravity decreases when urine is diluted (as seen in

diabetes insipidus) and increases when urine is concentrated
(as occurs in dehydration).

In chronic renal failure, specific gravity is fixed at 1.010.

 Biochemical characteristics
Reaction of Urine:
 Normally, urine is mildly acidic; the average pH being 6
(ranging between 4.5-7.5).

After a normal meal, urine becomes alkaline due to alkaline

tide that occurs with secretion of acid in the stomach, which
adds bicarbonate into the plasma.

If the meal is rich in protein, urine becomes acidic due to

formation of Sulphates and phosphates of amino acids in
tubular fluid.
If the meal is rich in vegetables then the urine becomes
alkaline as organic acids like citric and tartaric acids
extracted from vegetables are converted to bicarbonate in
the body.

Alkaline urine is also feature of urinary tract infection by

urease producing organisms, acetazolamide therapy and
following ingestion of alkali.
Proteins in Urine:
Normal, glomerulus is not permeable to substances with
molecular weight more than 69000.

Normally proteins are absent in urine.

Proteinuriaoccurs when glomerular filtering membrane

is damaged in various glomerular diseases.

Albumin being a smaller molecule passes easily through

the damaged glomerulus.

Therefore, in proteinuria, albumin predominates in urine

A very less amount (less than 100 mg per day) of proteins
is secreted in urine, which is secreted by the tubular
epithelial cells.

This trace quantity of protein is not detected by routine

urine analysis test.

Proteinuria is seen in strenuous exercise, pregnancy,

nephritis, nephrosis, eclampsia etc.

Normally, protein filtered is reabsorbed by the tubule.

Therefore, either in increased filtration or in diseases of

tubule, proteinuria occurs.
Blood in Urine:
Blood in urine is called hematuria.
Hematuria is seen in nephritis and injury to ureter,
urinary bladder or urethra.
It is detected by Benzidine test.
Reducing Sugars in Urine:
The presence of sugar in urine is called glycosuria .
Glycosuria occurs in conditions in which renal
threshold for glucose is exceeded as in diabetes
mellitus.
Glucose in urine is detected by Benedicts test.
 Ketone Bodies in Urine:
The ketone bodies are acetoacetate, β-hydroxybutyrate
and acetone.

Excretion of ketone bodies in urine is called ketonuria.


Ketonuria occurs in severe diabetes mellitus, starvation,
chronic vomiting etc.

Ketone bodies in urine are detected by Rothera's test

and Gerhardt's test.
Bile salts in Urine:
Bile salts appear in urine in the early phase of
obstructive jaundice.

Bile salts are detected by Hay's test.

Bile-Pigments in Urine:
Bile pigments (bilirubin and biliverdin) appear in urine
in obstructive jaundice.

Bilirubinuriais detected by modified Fouchet's test, and

van den Berg reaction .
 Urobilinogen in Urine
Normally, the main pigment in the urine is urochrome.

Small amounts of urobilinogen may also be present in

urine.

Urobilinogen excretion increases in persistent fevers, liver

diseases, diseases of biliary tract & hemolysis.

This is detected by Ehrlich test.

 Measurement of (NPN) in Urine:
The non-protein nitrogen (NPN) in urine includes urea, (15-
40mg%) creatinine(0.7-1.5male, 0.5-1.2 female)& uric
acid(2-4mg/dl).

Their concentration in urine increases in different

physiological and pathological conditions.

Determination of creatinine is an important test for renal

function.
 Measurement of (NPN) in Urine…
Urea level is altered in many conditions.

Even, increased intake of protein increases urea in

urine.

Urea estimation is a non-specific kidney function test.

However, blood urea concentration is good index of

renal functions.

Uric acid is increased in urine in conditions that are

associated with increased purine catabolism.
 2.Clearance tests
Clearance tests mainly determine the glomerular function.

GFR provides the most useful index for assessment of

severity of the renal disease.

Clearance is defined as the quantity of blood or plasma

cleared of a substance per unit time.

This is expressed as ml per minute.

 It is the ml of plasma, which contains the amount of that

substance excreted by the kidney within a minute.
Cs = Us × V
Ps
Cs = clearance rate of a substance ‘s’
Ps = plasma concentration of the substance
Us = urine concentration of that substance
V = urine flow rate[volume in ml/min]
Actually, it estimates the amount of plasma that passes
through the glomeruli per minute with complete removal
of that substance (to account for the substance actually
appears in the urine).

Measurement of the clearance is predominantly a test of

glomerular filtration rate (GFR).

The relation between clearance value and GFR shown in

next slide.
 Mechanism Result Example

Substances filtered but GFR = clearance Inulin

neither reabsorbed nor
excreted.

Substances filtered, GFR = clearance Uric acid

Reabsorbed & excreted

Substances filtered and Clearance< GFR Urea, &

partially reabsorbed. creatinine

Substances filtered, and Clearance > GFR PAH

secreted but not
reabsorbed
In normal practice, creatinine clearance test,
urea clearance test, and inulin clearance test
are used for determination of kidney functions
 TUBULAR FUNCTION TESTS
Determination of Specific Gravity:
The specific gravity depends on the concentration of solutes
whereas the osmolality detects the presence of osmotically
active particles in the urine.
Other tests:
Tubular functions are determined by concentration and
dilution tests
Concentration Test:
 The patient is advised to eat usual food at 6 PM but food intake is restricted
to 200 ml.

 He is further advised not to take anything throughout night.

 Next morning, at 7 AM, the bladder is emptied and this first specimen is
discarded.

 At 8 AM, urine is collected and this second specimen is obtained for

measuring specific gravity.

 If specific gravity is more than 1.022, the renal function is normal.

 If specific gravity is below this value, a third sample is collected at 9AM.

 Ifthis sample gives specific gravity less than 1.022, then the concentrating
ability of the kidney is considered to be impaired.
Determination of Urine Volume:

The measurement of the volume of urine passed in

24 hours is a simple test of tubular function.

 Normally, the volume of urine in night is half the

volume of urine excreted during day time.

An increased excretion of urine during night is an

early indication of tubular dysfunctions.
 Specific tests
Tests for urine acidification.

Ammonium chloride tablets are given to

subjects(0.1g/kg b. w)

Urine is collected every hour for 4-8 hrs for

determination of pH of urine & ammonia excretion
of each sample.

One sample should have pH of 5.3 or less &

ammonia excretion should be 30-90 mmole per hour
 PSP TEST
Phenol-sulfonphthalein (phenol red) test is used to
determine secretory capacity of tubule.

The subject is allowed to drink 600 ml of water following

which PSP is given IV (6 mg in 1ml solution).

Bladder is emptied after 15min,30min,60min & 120 min &

excretion of phenol red is noted in each sample.

Normally 35% of dye in first sample & 70% of dye should

be eliminated in two hours.