CLINICAL CHEMISTRY LEC

LECTURE 1: RENAL FUNCTION

Prof. Isaac Edron J. Orig, RMT
November 7, 2021
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Introduction glomerulus
● Kidneys are important organs in the body because they ■ Efferent = Exiting the glomerulus
excrete the waste products of the body’s metabolism ● Efferent arteriole will go to
● When we don’t have our kidneys, the toxic substances in the tubules and then will
the body will accumulate and becomes deadly for us become capillaries
(Peritubular capillaries)
RENAL ANATOMY ● Leaves the nephron to
become the renal vein
Kidneys: General Characteristics ○ Bowman’s capsule and space
● Paired, bean-shaped organs found retroperitoneally in ● PCT (Proximal Convoluted Tubule)
either side of the spinal column ● Loop of Henle (LoH) - hairpin (u-turn)
○ Retro - at the back ○ Thin Descending LoH
○ Peritoneal cavity - abdomen ○ Thin Ascending LoH
● About the size of a fist (10-12 cm) ○ Thick Ascending LoH
● Between T12-L3 ● DCT (Distal Convoluted Tubule)
○ 12 thoracic vertebrae and the 3rd lumbar ● Collecting Duct
vertebra
● Urine will form sa kidneys, then will go to the ureters and
will go to the urinary bladder where it will be stored
● The bladder will contract and the urine will go throughout
the urethra and then will go to the penis/urethral orifice

Kidneys: Macroscopic Characteristics

● Renal cortex
○ Outside part of the kidney
○ Surrounded by a fibrous connective tissue that
supports the kidney
● Renal medulla
○ Heart-shaped
● Renal pelvis
○ The urine will go to the renal medulla and will
be collected in the renal pelvis and will go to the
ureters then bladder
RENAL PHYSIOLOGY

Kidney Functions
● Urine formation
○ Most important function
○ Filters unwanted substances in the body
● Fluid and electrolyte balance
○ Kidneys secretes and reabsorbs water
● Regulation of acid-base balance
○ Kidneys can also secrete acids (hydrogen) or
base (bicarbonate)
● Excretion of the waste products of protein metabolism
Kidneys: Microscopic Characteristics ● Excretion of drugs and toxins
● Kidneys are made up of nephrons ● Secretion of hormones
● Functional unit: nephrons ○ Renin
○ Can’t be seen in the naked eye ○ Erythropoietin
● Glomerulus - filter the substances needed to be filtered) ■ Hormone responsible for production
○ Made up of tuft of capillaries and covered by of RBC
the Bowman’s capsule and the space inside it ■ Kidney is also involved in production
is called Bowman’s space of RBC
○ Afferent arteriole→ tuft of capillaries → efferent ■ Renal function < anemia < decreased
arteriole EPO < bone marrow cant produce
○ Site of filtration of the substances RBC needed
○ Substances come from the blood vessels since ■ Kidney failure < rickets (osteomalacia)
the blood carries the substances that need to ● Active form of Vitamin D is
be filtered to the kidneys produced in the kidney
○ Fromm the different parts of the body, it will go ● Decreased Vit D = Rickets
to the renal artery from the heart and will ○ 1,25-Dihydroxy vitamin D3
eventually become the afferent and efferent ○ Prostaglandins
arteriole
■ Afferent = Approaching the BASIC RENAL PROCESSES
● Glomerular Filtration
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 ○ Process of the substances from the glomerulus ● Bilirubin
to the Bowman’s space to the urine ○ Not that big but it is carried by albumin
○ Glomerulus filters unwanted substances CAN pass through the glomerulus:
● Tubular Absorption ● Water
○ Reabsorbs rom the tubules to the capillaries ● Electrolytes
back to the blood (back to the circulation) ● Glucose
● Tubular Secretion ● Amino acids
○ ● Urea
● Renal Blood Flow ● Creatinine
CANNOT pass through the glomerulus:
● Plasma proteins
○ Albumin, hemoglobin
● Cellular elements
○ RBC, WBC, PLT
● Protein-bound molecules (lipids, bilirubin)

Tubular Reabsorption
● Happens when the substances from the tubular lumen
are moved to the peritubular capillary plasma
○ Reabsorb from the tubules to the capillaries
● Happens mostly at the PROXIMAL CONVOLUTED
TUBULE (90%)
● 75% of the sodium, chloride, water
● 100% of the glucose
○ There should be no sugar found in the urine
Glomerular Filtration ● Almost all of the amino acids, vitamins, proteins
● Variable amounts of urea, uric acid, ions (Ca, Mg, K,
What are the factors that make the glomerulus the best site for
HCO3)
filtration?
● 98-100% of uric acid is reabsorbed, only to be secreted
● High pressure in the glomerulus - brought upon by the
at the DCT
position of the glomerular tuft of capillaries.
● There is tubular reabsorption because kailangan pa ng
○ Kasi galing sha sa renal artery
body yung mga na filter
■ Blood from the artery is mabilis ang
kanyang flow
■ That's why there is high pressure in
the glomerulus.
○ Bowman's space
■ Low pressure kasi walang laman
● Semi-permeability of the glomerulus - molecular cutoff
value of about 66,000 Da or 66 kDa
○ Cut off value
■ Dictates if the substance will be
filtered in the glomerulus.
■ Dapat below 66,000 Da ang isang Renal Threshold
substance for ot to be filtered . ● REMEMBER: If a substance’s concentration exceeds the
● Basement membrane is negatively-charged. renal threshold for tubular reabsorption, it will appear in
○ If the substance is negative and the basement the urine.
membrane is also negative = it will repel ● Example: Glucose 160-180 mg/ dL
○ Negative molecules will not be filtered in the ○ All of the glucose will be filtered and
glomerulus. reabsorbed by the
■ Ex: albumin is small (↓ 66K Da) PCT.
● Negatively charged. ○ What if the px has
● Cannot penetrate to the wall diabetes mellitus?
of the capillary. There will be a lot of
● Renal Blood Flow glucose in the blood.
○ 1,200 - 1,500 mL/min Hence, if it exceeds
● Glomerular Filtrate the renal threshold, it
○ 130 - 150 mL/min will be excreted in the
● GLOMERULAR FILTRATION RATE urine.
○ volume of blood filtered per minute.
○ Kapag ↑ ang glomerular filtration rate, marami
kang na fifilter sa glomerulus.

What can pass through the glomerulus?

Red = can pass through
● Water
● Sodium
● Glucose
○ Very small
● Glycine
○ Are also very small
● Urea
● Albumin
○ Small but negatively charged
● Red blood cells
○ Cellular elements: very big
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 Tubular Reabsorption ■ Sodium in urine = decreased
Substance Location ■ Sodium in blood = increased
● Addison’s Disease?
Active transport Glucose, amino Proximal convoluted ○ Deficiency of aldosterone
acids, salts tubule ○ Sodium will not be reabsorbed
Chloride Ascending loop of ■ Sodium in urine = increased
Henle ■ Sodium in blood = decreased
Sodium Proximal and distal ● Syndrome of Inappropriate ADH secretion (SIADH)?
convoluted tubules ○ Excess in ADH
Passive transport Water ● Proximal ○ Water will be reabsorbed from the tubule to the
convoluted tubule blood
● Descending loop ○ Water in the urine will be decreased
of Henle ○ Urine will be more concentrated
● Collecting duct ○ Water in the blood will increase
● Diabetes Insipidus?
Urea ● Proximal
○ Decrease in ADH
convoluted tubule
○ Water will be freely flowing and will not be
● Ascending loop of
reabsorbed
Henle
○ Water in the urine will increase
Sodium Ascending loop of ■ Urine will be more dilute
Henle ○ Water in blood will decrease
● Active transport
○ uses energy, transport mechanisms, carriers, Tubular Secretion
proteins to transport the substance from the ● Movement of the substances from the peritubular
tubules back to the capillaries capillary plasma to the tubular lumen
● Passive transport ○ From the blood to the tubules
○ Freely flowing ○ Baliktad ng tubular reabsorption
● Tubular cells secrete products of their own cellular
metabolism to the filtrate in the tubular lumen
● The tubules are made up of cells and these cells have
metabolic wastes
● Secrete waste products na hindi kaya ifliter ng
glomerulus
● Can contribute to acid base balance, fluid balance, and
electrolyte balance

● Substance A
○ Some of the solute is filtered and most are
*blue = passive transport; red = active transport secreted to the urine
● Proximal convoluted tubule ● Substance B
○ GAAs-WU ○ Substance is filtered but reabsorbed
■ Glucose ● Substance C
■ Amino acids ○ A lot of the substance is filtered in the
■ Salts glomerulus and all of the substance is
■ Water reabsorbed
■ Urea
● Descending loop of Henle RENAL FUNCTION TESTS
○ ONLY water is reabsorbed ● Tests that determine of the kidneys are functioning well
● Ascending loop of Henle
○ CloUrs 1. Glomerular Filtration Tests
■ Chloride 2. Tubular Reabsorption Tests
■ Urea 3. Tubular Secretion Tests
■ Sodium 4. Renal Blood Flow Tests
● Distal convoluted tubule
○ Sodium is reabsorbed but controlled by ● Why should we perform renal function tests?
aldosterone ● These rely on the measurement of the waste products in
■ When there is aldosterone, sodium the blood (usually urea and creatinine) which accumulate
will be reabsorbed in the DCT when the kidneys begin to fail
● Collecting duct ○ Urea and creatinine are waste products of the
○ ADH controlled H20 reabsorption blood
■ Water will only be reabsorbed when ○ Waste products should be excreted by the
there is antidiuretic hormone (ADH) kidney
■ kidney problems = increase in urea
What will happen to the Sodium and Water Balance? and creatinine in the bloof\d
● Conn Syndrome? ● There should be 20%-30% of the nephrons still
○ Excess of aldosterone functioning (advanced renal failure) before concentration
○ If there will be excess of aldosterone, sodium of these product begin to accumulate in the blood
will be reabsorbed. ○ 70%-80% of the nephrons ang masisira before
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 these product accumulate ○ Urinary Ammonia
○ Not sensitive markers to test for renal failure, ➢ These are not done in the present
but if it is vast, it can accumulate in the blood
and diagnosed as having kidney failure

Glomerular Filtration Tests

Clearance Tests
● Standard test used to measure the filtering capacity of
the glomeruli
● Measures the rate at which the kidneys are able to
remove a filterable substance from the blood
● Substances that can be filtered by the glomerulus:
○ Urea clearance test
○ Creatinine clearance test
○ Inulin clearance
○ Cystatin C
● To ensure accuracy of the test, substance to be analyzed
must:
1. Be neither reabsorbed nor secrete
○ Because it is the glomerular filtration NON-PROTEIN NITROGEN COMPOUNDS
that we want to test ● Urea
2. Be stable in the urine during a possible 24-hour ● Uric acid
collection period ● Creatinine
○ In testing GF, urine should be 24 ● Ammonia
hours old
3. Have a consistent plasma level UREA
4. Be available to the body (not toxic) ● NPN with the highest concentration in the blood
5. Be available for chemical analysis (can be ● Major excretory product of protein metabolism
tested) ○ When the proteins in the body are
○ There must be a test that is standard metabolized or broken down, it becomes urea
to measure the analyte ● BUN → Blood Urea Nitrogen
○ Obsolete term because we have to measure
Tubular Reabsorption Tests urea as a whole not just
the nitrogen in the urea
Concentration Tests ● BUN x 2.14 = Urea
● Often the first function to be affected in renal disease ● Has 2 amino groups and 1 carboxyl
● Tests to determine the ability of the tubules to reabsorb group
the essential salts and water that have been
non-selectively filtered by the glomerulus
● Sodium, chloride, & water will be filtered by the Urea Cycle
glomerulus but the body needs these, so the tubules will
reabsorbed those substances
● Osmolality and osmolarity - measures the “concentration”
of analytes in the urine
○ If there are a lot of analytes in the urine, it want
reabsorbed by the tubules = there is a defect
● Free water clearance - measures the amount of
solute-free water excreted in the kidney
● Obsolete tests:
○ Fishberg Test - 24 hours fluid deprivation
○ Mosential Test - Day vs Night concentration
function
● To ensure accuracy of the test, substance to be analyzed
must:
1. Be neither reabsorbed nor secreted
2. Be stable in the urine during possible 24 hour
collection period
3. Have a consistent plasma level
4. Be visible to the body
5. Be available for chemical analysis (can be
tested) ● Urea is formed in the liver from CO2 and ammonia (from
the deamination of proteins)
Tubular Secretion and Renal Blood Flow Tests ○ The major waste product of protein metabolism
● To measure the exact amount of blood flowing through ○ Exogenous or endogenous protein will undergo
the kidney, it is necessary to use a substance that is: proteolysis which is broken down into amino
○ How to measure the blood flowing to the acids and the amino acids are deaminated to
kidney? form ammonia
■ Use a substance that is completely ○ Ammonia will be combined with CO2 to form
removed from the blood (peritubular urea
capillaries) rather than being removed ○ Happens in the liver
when the blood reaches the ● Excreted by the kidneys
glomerulus ○ 90% excretion and appears in the urine
● To be secreted in the urine ● <10% are excreted in the GI tract and skin
○ PAH Test (para-aminohippuric test) ● Concentration of urea in the blood is affected by
○ Titratable Acidity ○ Protein content of the diet
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 ■ Product of protein
metabolism/catabolism
○ Rate of protein metabolism
■ Increased levels of urea because of
protein metabolism from the muscles
○ Renal function and perfusion
■ When there is a failure of renal
function, the urea will not be excreted
from the urine and will accumulate in
the blood lading to increased levels

Urea Disorders: Pathophysiology

● Azotemia - elevation of urea in the blood
● Uremia - azotemia + renal failure
○ Elevation of urea with renal failure
● Causes of azotemia in the blood
○ Prerenal
■ Before the kidney
○ Renal
■ Kidney
○ Postrenal
■ After kidney
CAUSES OF ABNORMAL PLASMA UREA CONCENTRATION
INCREASED CONCENTRATION
Prerenal (causes of Congestive heart failure - heart can’t
azotemia) pump the blood to the kidneys; no
blood in the kidneys = can't filter blood
(urea will stay in the circulation)
Failure of blood to be perfused to the
liver to be filtered
Shock, hemorrhage - loss of blood
(lower blood volume); lower perfusion
in the kidneys (increased urea in the
blood)
Dehydration
Increased protein catabolism
High-protein diet
Renal (causes of Acute and chronic renal failure -
azotemia) kidney can’t filter urea (urea will
- Can be causes of accumulate in the blood)
uremia due to renal
Renal disease, including glomerular
failure
nephritis and tubular necrosis
Postrenal Urinary tract obstruction - after the
kidney (ureter, urinary bladder)
Stones in the ureter may cause
backflow of urine to the kidneys =
kidneys can't filter (no storage) =
increase urea in the blood
DECREASED CONCENTRATION
Low protein intake
Severe vomiting and diarrhea
Liver disease - body cant produce
urea in the liver
Pregnancy - increase blood flow =
increase urea
How do we differentiate the different types of causes of
azotemia?
● urea/creatinine ratio (normal - 10:1 to 20:1)
● Prerenal azotemia - high urea/ creatinine ratio
○ Low creatinine
● Renal azotemia/ uremia - normal urea/ creatinine ratio
● Postrenal azotemia - high urea/ creatinine ratio with high
creatinine
● Low urea/ creatinine ratio - low protein intake, severe
liver disease
○ No urea due to lack of protein in the liver
● Ex. A patient with azotemia
○ Remove urea in the blood through dialysis
CREATININE
● Formed from creatine and creatine phosphate in the
muscle
● Released to the plasma in proportion to muscle mass
○ If bigger muscle mass = more creatine and
creatine phosphate = more creatinine
● Plasma creatinine is an indirect measure of GFR (MW =
113 Da)
○ GFR - Glomerular Filtration Rate
○ 113 Da is less than 60000 Da or 60 kDa (dapat
mafilter ng glomerulus ang creatinine)
○ Increased plasma creatinine = renal failure
(glomerulus can’t filter the creatinine)
● Diet?
○ Cannot affect the creatinine levels
○ Depends on the muscle mass
● Creatine is synthesized in the liver from arginine, glycine,
and methionine
● Becomes creatine phosphate(phosphocreatine) in the
muscle
○ creatine phosphate
■ High energy compound.
■ Ginagamit ng ating muscle
● Creatine phosphate and creatine become creatinine
○ Becomes creatinine if they are used by the
muscle as energy.
○ Creatine will become creatinine when it loses
water.
○ Creatine - water = creatinine
○ Phosphocreatine - phosphoric acid = creatinine
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 ● Creatinine is released to the circulation in a relatively
constant rate in proportion to muscle mass.
○ Men have more creatine level than women
■ Men have more muscle mass.
● It is filtered by the glomerulus into the urine.

Clinical Application of Creatinine Measurement

● Determine the sufficiency of kidney function
● Determine the severity of kidney damage
● Monitor the progression of kidney disease.
○ Hypertension can cause kidney damage,so,
his/her creatinine levels will be measured from
time to time
● CREATININE CLEARANCE
○ amount of creatinine eliminated from the blood
by the kidneys (usually a 24-hour sample
● CrCI = UV/P x 1.73/A
● U = urine creatinine (mg/dL)
● V = volume of the 24-hour urine per minute = V/1440 =
ml/min
● P= plasma creatinine (mg/dL)
● A= body surface area (in m^2)

Creatinine Disorders
PATHOPHYSIOLOGY RNA or DNA → Purines → Hypoxanthine & Guanine → Xanthine
● When there is INCREASED plasma creatinine what does → (xanthine oxidase) → Uric acid → Excreted in the urine
it tell about the patient's renal function? ● Uric acid can form crystals in joints (Gout)
● It is an insensitive marker and is not measurably
increased until the renal function is decreased by 50% Biochemistry
○ 70-80% ● Purines (Guanine and Adenine) from the breakdown
● Muscle diseases? ingested of nucleic acids and tissue destruction are
○ If there are muscle diseases = ↑ in creatine converted to uric acid
■ Bcoz marelease niya yung creatine ● 98-100% of filtered uric acid is reabsorbed in the PCT
from the muscles. ● 70% excreted in the kidneys, others excreted in the GI
■ creatine → creatinine tract
○ Muscular dystrophy ● Most uric acid in the plasma is in the form of
○ Poliomyelitis monosodium urate
○ Trauma ○ Basic/neutral pH
○ Measurement of Creatine Kinase? ● At the pH of plasma (about ~7), urate is relatively
■ CK will convert creatine to creatine insoluble
phosphate ○ If urate or uric acid is increased, it will be
● Also found in the muscle deposited in the joints and tissue
■ ↑ creatine kinase =muscle destruction ● At concentrations >6.8 mg/dL, the plasma is saturated
forming urate crystals
● In acidic urine (pH <5.75), uric acid predominates and
URIC ACID is seen as uric acid crystals

GENERAL CHARACTERISTICS
● Product of the catabolism of purine nucleic acids
○ Urea = protein
○ creatinine = muscle
○ Uric acid = nucleic acid
■ Purine nucleic acid
● Guanin
● Adenine
● Relatively insoluble in plasma and, in high
concentrations, can be deposited in the joints and tissue
causing pain and inflammation
○ Gout - increased in uric acid Clinical Application of Uric Acid Measurement
● Diagnosis and monitoring of treatment of gout
● Prevent uric acid nephropathy during chemotherapeutic
treatment
○ In chemotherapy, there is increased destruction
of cells, RNA and DNA of the cells will be
released causing an increased uric acid
● Assess inherited disorders of purine metabolism
● Detect kidney function
● Assist in the diagnosis of renal calculi
○ Renal calculi - kidney stone
○ Uric acid stones

Pathophysiology
● Increased Uric Acid
○ Gout
○ Increased catabolism of nucleic acids
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 ○ Renal disease
■ Hindi kaya ifliter ng glomerulus ang
uric acid
Gout
● Found primarily in men (30-50 years old)
● Pain and inflammation of the joints (due to precipitation
of monosodium urates)
● Plasma uric acid is usually greater than 6.0 mg/dL
● Can form renal calculi
● Postmenopausal women are prone to gout
● TOPHI formation
○ Precipitations in the join = tophi/tophus
○ Caused by increased uric acid
Other causes of increased uric acid
● Increased metabolism of cell nuclei (chemotherapy)
● hemolytic/megaloblastic anemia
○ Increased destruction of red blood cells causing
release of rna and dna = increase in uric acid
● Renal disease
● Toxemia of pregnancy
● Lesch-Nyhan Syndrome
○ X-linked genetic disorder caused by the
complete deficiency of HGPRT (hypoxanthine
guanine phosphoribsyl transferase)
○ Mostly boys are affected
○ No HGPRT
● From purines, it will become hypoxanthine and guanine
and will be salvaged by HGPRT to become purines and
gagawin ulit na RNA or DNA
● HGPRT will decrease uric acid
Hyperuricemia
● Decrease in uric acid in the blood
● Causes
○ Liver disease
○ Defective tubular reabsorption (Fanconi
Syndrome)
■ Defective tubular reabsorption of the
uric acid
○ azathioprine/6-mercaptopurine (inhibitors of de
novo purine synthesis)
■ Konti and purine, konti ang uric acid
○ Overtreatment with allopurinol
■ Drug used to lower uric acid
■ Inhibits the enzyme xanthine oxidase
Ammonia
General Characteristics
● Produced from the deamination of amino acids during
protein metabolism
● Converted to urea in the liver
○ Protein → amino acid → AA will be deaminated
to ammonia = urea
● Free ammonia is toxic
● Deamination of NH2= ammonia
Clinical Application of Ammonia Measurement
● Hepatic failure
○ The ammonia cannot be converted to urea
○ Increased in the ammonia, decreased in the
urea
● Reye’s syndrome
● Inherited defects in the urea cycle
○ Will stay as ammonia, thus it is increased and
is toxic
Reye’s Syndrome
● Serious and fatal disease
● Occurs mostly in children
● Preceded by viral infection and administration of aspirin
○ Damage the liver of the child
● Acute metabolic disorder of the liver
Ammonia Neurotoxicity
● How can ammonia be toxic to the body?
○ Ammonia will go to the brain and be added with
glutamate to be glutamine by glutamine
synthase
○ Glutamine will cause:
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 ■ Cerebral edema
■ Intracranial Hypertension
■ Neuronal dysfunction
➢ Causing hepatic
encephalopathy

Hepatic Encephalopathy
● The patient will just be sleeping, very confused, or in
coma (in severe cases)