Renal Lab Tests

RENAL LABORATORY TESTS
PETER S. AZNAR, MD, FPSP, MHPE
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Basic Functional Unit of the Kidney:
• Nephron

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• Proximal Tubules- majority of solutes are reabsorbed.
• Descending Loop of Henle- permeable to water, so

water goes out.
• Ascending Loop of Henle- Impermeable to water, so

water stays.
• Distal Tubule – Aldosterone retains sodium (Na).
• Collecting Tubule – water is conserved by ADH.

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Polyuria
• Diabetes Insipidus
• Diabetes Mellitus

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Diabetes Insipidus
• associated with deficiency of antidiuretic

hormone (ADH)
• will result to severe polyuria
• associated with increase serum osmolality and

decrease urine osmolality
• urine will have low specific gravity

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H2O
ADH
URINE

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H2O
ADH
URINE

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Diabetes Mellitus
• associated with defect in carbohydrate
metabolism
• will also result to polyuria
• associated with increase urine osmolality

and decrease serum osmolality
• urine will have a high specific gravity

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H2O
RTG
180
URINE

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H2O
SERUM GLUCOSE
RTG
300 180
120

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KIDNEY FUNCTION TESTS
A1. Tests measuring Glomerular Filtration
Rate (GFR)
A2. Tests measuring Renal Blood Flow
A3. Tests measuring Tubular Function

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A1. Tests measuring Glomerular
Filtration Rate (GFR)
I. Creatinine Clearance Tests
II. Inulin Clearance Tests
III. Urea Clearance Tests

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A2. Tests measuring Renal Blood Flow
I. Creatinine
II. Urea
III. Blood Uric Acid (BUA)
IV. Ammonia
V. Amino Acids
VI. Creatine

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A3. Tests measuring Tubular Function
I. Excretory Tests
Ia. Para-Amino Hippurate Test (PAH)
Ib. Phenolsulfonphthalein (PSP) Dye
Excretion Test
II. Concentration Tests
IIa. Specific gravity
IIb. Osmolality
IIc. Fishberg Concentration Test

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A1.TESTS MEASURING GLOMERULAR
FILTRATION RATE
• Tests which measure the rate of

glomerular filtration are generally called
clearances.

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General Formula for Clearance
• C (ml/min) = U x Volume (ml/min) x 1.73
P A
• Where:
C- clearance of the substance expressed in ml/min.
U- concentration of substance in urine
P- concentration of substance in plasma (blood)
Volume (ml/min)- total volume of urine excreted in 24 hours
converted to ml/min.
1.73- generally accepted body surface area of an
individual in square meters
A- body surface area of patient whose value is obtained
from a nomogram (height and weight are needed)

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Given:
Urine creatinine = 120 mg/dL
Serum creatinine = 1.5 mg/dL
Total urine volume in 24 hours = 1800 mL
C (ml/min) = U x Volume (ml/min) x 1.73
P A
C (ml/min) = 120 x 1800 (ml/min) x 1.73
1.5 A
C (ml/min) = 120 x 1.25 (ml/min) x 1.73
1.5 A
C (ml/min) = 80 x 1.25 (ml/min) x 1.73
A
C (ml/min) = 100 (ml/min) x 1.73
A

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I. Creatinine Clearance Tests
• In product of muscle metabolism

derived from creatine
• Most commonly used substance for
clinical assessment of GFR
• Normal values: 107-139 ml/min (men)
87-107 ml/min (women)

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II. Inulin Clearance Tests
• Normally not present in the plasma,

therefore it is neither secreted or
reabsorbed by the renal tubules.
• Most accurate measure of GFR
• Not particularly pleasant to the patient, thus
it is not regularly used.

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III. Urea Clearance Tests
• Not commonly employed because of

variable results
• 1.33 constant for maximum urea clearance
• 1.85 constant for standard urea clearance

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A2. TESTS MEASURING RENAL BLOOD FLOW
NON-Protein Nitrogens (NPN)
GENERAL INFORMATION
All NPNs (urea, creatinine, uric acid and

ammonia) are increased in the plasma in renal
impairment; referred to as azotemia
In cases of suspected renal impairment, the best

laboratory evaluation is for glomerular filtration
rate (GFR).

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I. CREATININE
• Can also be measured to evaluate renal

function; NOT as sensitive as GFR
• Reference ranges
a) Men = 0.9-1.5 mg/dL
b) Women = 0.7-1.3 mg/dL

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I. CREATININE
Creatinine phosphate + ADP + H+
Creatine + ATP nonezymatic creatinine

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II. BLOOD UREA NITROGEN (BUN)
• End product of protein metabolism
• Increased in impaired renal function
• Rises more rapidly than serum creatinine
• BUN/Creatinine ratio is normally about 10:1-20:1

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III. URIC ACID
• End product of purine metabolism
• Increased in gout, renal failure and

leukemia

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IV. AMMONIA
• Derived from the action of bacteria on the

contents of the colon
• Metabolized by the liver normally
• Increased plasma ammonia is toxic to the

CNS

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IV. AMMONIA
• Hyperammonia (increased ammonia)
a) Advanced liver disease (most
common cause)
aa. Reye’s syndrome
ab. Cirrhosis
ac. Viral hepatitis
b) Impaired renal function
Blood urea is increased (increased
excretion into intestine, where it is
converted to ammonia)

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A3. TEST MEASURING TUBULAR FUNCTION
I. Excretory Tests
Ia. Para-Amino Hippurate Test (PAH)
Ib. Phenolsulfonphthalein (PSP) Dye

Excretion Test

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A3. TEST MEASURING TUBULAR FUNCTION
II. Concentration Tests
IIa. Specific gravity
IIb. Osmolality
IIc. Fishberg Concentration Test

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DIABETES WORK UP
PETER S. AZNAR, MD, FPSP, MHPE

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Cardinal signs of Diabetes Mellitus:
• Polyuria
• Polydipsia
• Polyphagia
• Pruritus

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Types of Diabetes Mellitus
Type I (Insulin dependent diabetes mellitus)
Type II (Non-insulin dependent diabetes mellitus)

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Diabetes Mellitus Type I
• Also known as Insulin Dependent Diabetes
Mellitus (IDDM) or juvenile onset
diabetes mellitus
• Main defect is decrease or absence of

insulin
• Associated with ketoacidosis
• Treatment: insulin

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Diabetes Mellitus Type II
• Also known as Non-Insulin Dependent

Diabetes Mellitus (NIDDM) or adult
onset diabetes mellitus
• Main defect is absence or decrease receptors
• Ketoacidosis not present
• Treatment: Sulfonylureas

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Diagnostic Criteria for DM:
• Random plasma glucose > 200 mg/dL
• Fasting plasma glucose > 126 mg/dL
• 2-hours plasma glucose > 200 mg/dL

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Impaired Glucose Tolerance*
– FBS more than 100mg/dL but less than 126mg/dL
– OGTT 2 hour value more than 140mg/dL but less

than 200mg/dL
*Latent or chemical diabetes

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Glucose Metabolism Tests
• 2- hour Postprandial Test
• Oral Glucose Tolerance Test (OGTT)

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2 hour Postprandial Test:
Patient is made to fast for 8 hours and sample is

collected
Patient is given 75 grams of oral glucose

Patient’s blood glucose is taken after 2 hours

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Result
s
Normal patients- glucose level is less than 140 mg/dL
Diabetic patients- glucose level is more than 200 mg/dL

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Oral Glucose Tolerance Test
• 75 grams of glucose is given
• blood samples and urine specimens are taken at

30, 60, 120 and 180 minutes

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Normal Neg Neg Neg Neg
Abnormal Pos Pos Pos/ Pos/

Neg Neg
Min 30 60 120 180

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200 Abnormal
180
160
140 Normal
120
100
Min 30 60 120 180

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Monitoring of Glucose Levels:
Daily: FBS, RBS
Weekly: Fructosamine (every 2 weeks)
Monthly: Hemoglobin A1C (every 3 months)

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Proinsulin Insulin
C-peptide

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• Increased in:
– Insulinoma
– Type II diabetes mellitus
• Decreased in:
– Exogenous insulin administration (eg., factitious
hypoglycermia)
– Type I diabetes mellitus

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Insulin/ C-Peptide Ratio
• Use
– To differentiate insulinoma from fractitious
hypoglycermia due to insulin
• Interpretation
– <1.0 in molarity units ( or>47.17 µg/ng in con. units)
– Increased endogenous insulin secretion (e.g., insulinoma,
sulfonylurea administration)
– Renal failure
– >1.0 in molarity units (or<47.17 ug/ ng in con. units)
– Exogenous insulin administration
– Cirrhosis

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Diabetes Mellitus, Gestational
Hyperglycemia that develops for the first time during

pregnancy: after ~4% of pregnant women; most have return
to normal glucose tolerance after delivery. 60% become
diabetic in next 16 yrs.
Infants of Diabetic Mothers

• Blood glucose less than 30mg/dL in 50% of diabetic
mothers.
• Associated with hypocalcemia, occurring 24-36 hrs. after
birth.
• Asymptomatic at birth but should be monitored every 6hrs.

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Diabetes Mellitus, Neonatal
• Blood glucose is often between 245 and 2300 mg/dL
• Metabolic acidosis of some degree is usually present
• Ketonuria is variable
• Laboratory findings due to dehydration

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Diabetes Mellitus, Neonatal
• Laboratory findings due to infection or CNS lesions,

which are present in one third of patients
• Has been detected as early as fourth day. Usually is

transient
• Increased association with postmaturity, low birth

weight, neonatal hypoglycemia, steroid therapy early
in neonatal period.

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Tumors of Pancreas
(Hormone-Secreting), Primary
• Cell Type Hormone Secreted Tumor

• B cell Insulin Insulinoma
• D cell Gastrin Gastrinoma
• A cell Glucagon Glucagonoma
• H cell VIP Vipoma
• D cell Somatostatin Somatostatinoma
• HPP cell Human Pancreatic HPP- Secreting Tumor
Poly- Peptide (very rare tumor)

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Thank You!

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RENAL LABORATORY TESTS

PETER S. AZNAR, MD, FPSP, MHPE

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• Descending Loop of Henle- permeable to water, so

• Ascending Loop of Henle- Impermeable to water, so

• Distal Tubule – Aldosterone retains sodium (Na).

• Collecting Tubule – water is conserved by ADH.

https://cdn.fbsbx.com/v/t59.2708-21/22286764_10210463021267101_8642777820910…S6uOv4niYqX3D624_g&oh=0a95d7d0c55ec7f3c62cdc79c9ac9e4f&oe=59FE77D5&dl=1 03/11/2017, 11P49 PM

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• associated with deficiency of antidiuretic

• will result to severe polyuria

• associated with increase serum osmolality and

• urine will have low specific gravity

https://cdn.fbsbx.com/v/t59.2708-21/22286764_10210463021267101_8642777820910…S6uOv4niYqX3D624_g&oh=0a95d7d0c55ec7f3c62cdc79c9ac9e4f&oe=59FE77D5&dl=1 03/11/2017, 11P49 PM

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• will also result to polyuria

• associated with increase urine osmolality

• urine will have a high specific gravity

https://cdn.fbsbx.com/v/t59.2708-21/22286764_10210463021267101_8642777820910…S6uOv4niYqX3D624_g&oh=0a95d7d0c55ec7f3c62cdc79c9ac9e4f&oe=59FE77D5&dl=1 03/11/2017, 11P49 PM

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A2. Tests measuring Renal Blood Flow

A3. Tests measuring Tubular Function

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II. Inulin Clearance Tests

III. Urea Clearance Tests

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• Tests which measure the rate of

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• In product of muscle metabolism

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• Normally not present in the plasma,

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• Not commonly employed because of

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NON-Protein Nitrogens (NPN)

All NPNs (urea, creatinine, uric acid and

In cases of suspected renal impairment, the best

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• Can also be measured to evaluate renal

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Creatinine phosphate + ADP + H+

Creatine + ATP nonezymatic creatinine

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• End product of protein metabolism

• Increased in impaired renal function

• Rises more rapidly than serum creatinine

• BUN/Creatinine ratio is normally about 10:1-20:1

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• End product of purine metabolism

• Increased in gout, renal failure and

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• Derived from the action of bacteria on the

• Metabolized by the liver normally

• Increased plasma ammonia is toxic to the

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Ia. Para-Amino Hippurate Test (PAH)