RENAL FUNCTION TEST

Introduction:-

Renal function test is a group of test that may be performed together to

evaluate kidney or renal function. The kidneys play a vital role in the
excreation of waste product and toxins such as urea , creatinine , uric acid
and electrolyte concentrations . If the kidneys are not functioning properly ,
waste products can accumulate in the blood and fluid level can increase to
dangerous volume , causing damage to the body or a potentially
life-threatening situation.

Purpose : -

● To assess functional capacity of kidneys

● To diagnose renal impairement .
● To assess the severity and progression of renal impairement
● To assess the effectiveness of treatment.

Parameters :-

The following parameters are commonly included in assessing the renal

function -
● Urea
● Creatinine
● Uric acid
● Electrolytes - a) Sodium (Na+)
b) Potassium (K+)
c) Bicarbonate(total CO2)
1)Urea:-

Urea is the end product of protein catabolism produced from the amino group
of the amino acids and is produced in the liver by the urea cycle. This nitrogen
containing compound is filtered by the glomerulus and 40 -60% of urea is
reabsorped in the collecting tubule. About 85% of urea is eliminated via
kidneys and the rest is excreted via GI (gastrointestinal) tract .
Serum level is increased in conditions where renal clearance is decreased
below 50% .
Normal value : 20 -45 mg/ dL .

Urea may also increased in non renal disease such as -

Dehydration, upper GI bleeding , high protein diet etc .

It may be decreased in conditions such as -

Starvation, severe liver disease , low protein diet etc .
Urea also reliable indicator of renal dysfunction as it affected by many other
factors .

Clinical Significance : -

Serum urea level increases in acute and chronic renal disease .

GFR (Glomerular filtration rate ) equations are used to determine the
presence of renal disease , stage of CKD (chronic kidney disease) and to
monitor response to treatment.

BUN( Blood Urea Nitrogen) :

Nitrogen in the blood that comes from urea (a substance comes from
breakdown of protein in liver). The kidneys filter the urea out of the blood and
into urine . A high level of urea nitrogen may be a sign of kidney problem .
Also called BUN or urea nitrogen.
A BUN, or blood urea nitrogen test, can provide important information about
the kidney function. The main job of our kidneys is to remove waste and extra
fluid from body. If someone have kidney disease, this waste material can build
up in the blood. Over time, this may lead to serious health problems, including
high blood pressure, anemia, and heart disease.

The BUN test measures the amount of urea nitrogen in blood. Urea nitrogen is
a waste product that the kidneys remove from the blood. Higher than normal
BUN levels may be a sign that the kidneys aren't working well.

People with early kidney disease may not have any symptoms. A BUN test
can help uncover kidney problems at an early stage when treatment can be
more effective.

Other names for a BUN test: Urea nitrogen test, serum BUN.

A BUN test is often part of a series of tests called a 'comprehensive

metabolic panel'. It can help diagnose or monitor a kidney disease or
disorder.

Normal level is 5- 26 gm / dL.

Increased in Intrinsic renal dysfunction.

A rise in blood nitrogen level is known as azotamia .
Pre- renal azotamia- CCF , shock , vomiting.
Post-renal azotamia : bilateral uretal obstruction, bladder outlet obstruction
and bladder dysfunction.

Decreased in fluid overload , malnutrition, severe liver disease.

2) Creatinine :-

Creatine is a small tripeptide found in the muscles . It releases energy for any
burst of muscular activity and released from the muscles during regular wear
and tear . Everyday upto 20% of total muscle creatine dehydrates and cycle to
form the waste product creatinine . Creatinine readily filtered by the
glomerulus. So any problem with glomerular filtration has a significant effect
on the excretion of creatinine resulting in a much substantial rise in serum
creatinine level. Serum creatinine is a better indicator of renal function and
more specifically GFR.

Normal value : 0.7- 1.2 mg /dL

Increased in: • kidney injury

•Elevated by some drugs such as trimetoptin and cimetidine in
hyperthyroidism .

Decrease in : •Reduce muscle mass

•Pregnancy

Creatinine Clearence Test -

The best currently available method for measuring kidney function is the
creatinine clearance test . It is also known as ' Measurement of glomerular
filtration rate (GFR) for creatinine ' . It estimates the amount of blood which
passes through the glomerulus in 1 min with complete removal of creatinine .
That amount of creatinine is then measured in a timed collection of urine . The
method is sensitive and can be easily followed in any laboratory with facilities
to measure creatinine . Decreased GFR is associated with worsening renal
failure .

The expression of GFR is 'millilitres per minute' indicates the amount of

substance cleared by the kidney during a period of 1 min . Ideally the GFR is
determined by measuring the clearance of a completely filterable substance
that is neither absorbed nor excreted by the renal tubules , such as inulin.
Creatinine is the best clinically useful substance . Urea clearance is of no
value as a measure of GFR , because it is influenced by too many variables .
It is measured over a period of 24 hours . For this urine is collected over a 24
hour period and blood sample is also collected. The concentration of
creatinine is measured both in the urine as well as the serum sample.

Normal value :-

Male : 100 - 120ml / min

Female : 95 - 105 ml / min

Calculation of clearance rate :-

Clearance calculated without considering the body weight is uncorrected.

Except for children , the correction is not ordinarily done .

Uncorrected-

Clearance (uncorrected) can be mathematically expressed by the following

formula :
Uncorrected clearance (ml/min) =
Ucr ×V
Pcr

U= Concentration of creatinine in urine .

P= Concentration of creatinine in plasma /serum .

V= Volume of urine passed per minute , expressed in mL .

Corrected

The GFR is roughly proportional to the size of the kidney and the body surface
area of the individual . Therefore , the calculation for the clearance if any given
substance should provide for correction for deviation from the average adult
body surface . This is done by multiplying the clearance by the factor 1.73/A,
where 1.73 is the average body surface in square metres and A is the body
surface of the patient under investigation . The formula for calculating the
renal clearance, therefore , expands as follows :
Corrected clearance rare (mL/min) = Ucr × V × 1.73
P cr A
The body surface area may be determined conveniently from the nomogram .

Example
A patient discharged 228 mL of urine in a 5 h period . The plasma
concentration of creatinine was found to be 2.1mg /dL and that of urine was
110mg/dL . If the weight and height of the patient are 70 kg and 150 cm (A
=1.65) respectively , calculate the creatinine clearance rate .

Calculation-

V= 228 × 1
5 60
= 0.76 mL/ min
U = 110 , P = 2.1

Uncorrected GFR

110 × 0.76
2.1
= 39. 8 mL/ min

Corrected GFR

39.8 × 1.73
1.65
= 41. 7 mL / min

Thus with the average weight and height , the uncorrected value is not too
difficult from the corrected value . Hence it is not necessary. However, the
same data for a child will be much higher , as shown in the following example .

Example

If the body weight of an infant is 4 kg and the height is 37 cm , the body

surface will be 0.17 .
Corrected clearance rate(mL / min) = 39.8 × 1.73
0.17
= 405
This shows that the correction for body surface is absolutely mandatory if the
body surface of the patient differs greatly from that of the average adult
person . The error otherwise introduced is substantial in case of infants.

Clinical Significance :-

Serum creatinine is elevated when there is a significant reduction in the GFR

or when urine elimination is obstructed . About 50% of kidney function must be
lost before a rise in serum creatinine can be detected . Thus serum creatinine
is a late marker of acute kidney injury .

3) Uric acid -

Uric acid is a normal waste product that is made when the bone breaks down
chemicals called purine . Purines are substances found in our own cells and
also in some foods . Uric acid is the final oxidation product of purine
metabolism and is really excreted . It is readily filtered by the glomerulus, but
then it undergoes cycle of reabsorption. Only filtered uric acid is finally
excreted . Therefore elevated serum uric acid levels are seen in patients with
reduced glomerular filtration rate (GFR) . However , in recent years it has
been proposed that uric acid itself plays a casual role in chronic kidney
disease and possibly in acute kidney injury .

Normal value :-

Male : 3.4 - 7.0 mg/dL

Female : 2.4 - 6.0 mg/dL

It may increase in chronic kidney disease but not sufficient to cause gout.
However raised uric acid is a bad progonostic indicator for chronic renal
disease .
4) Electrolyte :-

Electrolytes are positively and negatively charged molecules , called ions .

These are found within cells , between cells , in the bloodstream, and in other
fluids through the body in the form of dissolved salts . Electrolytes help to
move nutrients into and waste out of the body's cells maintain a healthy water
balance and help stabilize the body's pH level .
Electrolytes panel consists of electrolytes with a positive charge sodium (N+) ,
potassium ( K+) , bicarbonate (total CO2).

•Sodium :

Sodium is primarily extracellular cation in the human body . It plays a major

role in the body by maintaining fluid balance . Its major function is in nerve and
muscle function. The body obtain sodium from the food and drink and loses it
in sweat and urine . Kidneys when functioning normally, maintain a consistent
level of sodium by adjusting the amount excreted from the body . Sodium
balance in the body controlled only through secretion . When sodium intake
and excretion are not in balance , it may lead to either 'Hypernatremia ' (high
sodium ) or ' Hyponatremia' ( low sodium) .

Normal value - 120 - 135 mEq/L

Increased in -

•Dehydration
•Salt - rich diet
•Low blood volume

Decreased in -

Retention of water or excessive loss of sodium .

•Potassium:

Unlike sodium , potassium is the major intracellular cation of the body . Within
the cells , it plays an important role in maintanance of acid - base balance ,
osmatic pressure and water retention . Intracellular potassium is essential for
several important metabolic reaction catalyzed by enzymes . It is also very
important constituent of extracellular fluid because it influences muscle activity
notably the cardiac muscle .

The kidneys are primarily responsible for the excretion of potassium from the
body and alter the extent of potassium excretion according to the current
concentration in the blood .
An individual with acute kidney failure may not be able to excrete as much
potassium as usual . Imbalances in potassium can lead to 'Hyperkalemia'
(high potassium) or 'Hypokalemia' (low potassium) .

Normal value : 3.6 - 5.2 mmol / L

Increased in : • Kidney disease

•Dehydration
• High potassium diet

Decreased in : • Alkalosis or low pH

•Diarrhoea
• Vomiting

•Bicarbonate :

Bicarbonate is a substance called a base , which the body needs to help keep
a normal acid - base (pH) balance . This balance prevents the body from
becoming too acid , which can cause many health problems . The lungs and
kidneys keep a normal blood pH by removing excess acid .
Serum bicarbonate mostly travels through out the body as carbon dioxide
(CO2) , a gas that's dissolved in the blood . That is why the amount of CO2 in
blood is used to measure serum bicarbonate (base) , and it therefore check
the acid -base balance . If CO2 is too low in blood , then that means serum
bicarbonate is low and the body has too much acid , this condition is called
'Metabolic acidosis '.

Healthy kidneys remove acid from the body through urine and they keep the
right amount of bicarbonate in the blood . But in CKD ( Chronic Kidney
Disease ) , the kidneys cannot remove enough acid , which can lead
metabolic acidosis .

Normal value- 22 -29 mEq / L

Increased in -
•Metabolic alkalosis
•Dehydration
•Vomiting

Decreased in -

•Kidney disease
•Liver failure
•Diarrhoea

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