Assessment of Renal Function

Nor Asyikin Mohd Tahir, Ph.D., R.Ph.

Faculty of Pharmacy
Universiti Kebangsaan Malaysia
 Glomerular Filtration Rate (GFR)
 GFR = the _______ of water filtered from the plasma per
unit of _______.
 Gives a rough measure of the number of functioning
nephrons.

 Normal GFR:
 Men: ______mL/min./1.73m2
 Women: ______ mL/min./1.73m2

 Cannot be measured directly, but can be estimated by

using serum creatinine (SCr) and creatinine clearance
CLCr.
 Creatinine
 A naturally occurring _______________
 Predominately found in skeletal muscle
 Freely filtered in the glomerulus, excreted by the kidney
and readily measured in the plasma.
 As plasma creatinine (SCr) increases, the GFR exponentially
decreases.
Factors influencing the levels of SCr
 Limitations of SCr in estimating GFR:
 Patients with decrease in _______________, liver disease,
malnutrition, advanced _____, may have low/normal
creatinine despite underlying kidney disease
 15-20% of creatinine in the bloodstream is not filtered in
glomerulus, but secreted by renal tubules (giving
overestimation of GFR)
 ____________ may artificially elevate creatinine:
 Trimethroprim (Bactrim)
 Cimetidine
 Estimating GFR

 Based on Creatinine Clearance (CLCr)

 Best way to estimate GFR
 GFR = CLCr x (__________________in m2/1.73)
 Estimating CLCr
 24-hour urine creatinine:
CLCr = (UCr x Uvol) / SCr

 Cockcroft-Gault Equation:
G (140 - age) x weight [kg]
CLCr (mL/min) = ———————————————
SCr in μmol/L

where G; male = 1.23, female = 1.04

 Limitations: Based on white men with non-diabetes kidney

disease
 Estimating CLCr
 Cockcroft-Gault Equation:
What to remember!
 Weight [kg] ;
 BMI ≤25, use ________ Body Weight (ABW)
 BMI 25 – 30, use ________ Body Weight (IBW)
 BMI >30, use ___________ Body Weight (AdjBW)*

 IBW; Male = 50 + 0.9(Ht in cm – 152)

Female = 45.5 + 0.9(Ht in cm – 152)
 AdjBW = IBW + 0.4(ABW-IBW)

 If SCr value < ____μmol/L; use the value of ____ for

estimation (exception in Augmented Renal Function!)
*recommended but debatable
 Estimating CLCr
 Augmented Renal Function

Udy et al. Critical Care 2013, 17:R35

 Estimating CLCr
 Augmented Renal Function

Udy et al. Critical Care 2013, 17:R35

 Estimating CLCr
 Modification of Diet in Renal Disease (MDRD)
Equation:

 GFR (mL/min/1.73m2) = 186 SCr - 1.154 Age - 0.203GR

Where G; male =1, female = 0.742

R; African-American = 1.210, others = 1
 Estimating CLCr
 CKD-EPI Equation:

 eGFR = 140 x
(mL/min/1.73m2) min (SCr/κ or 1)α x
max (SCr/κ or 1)-1.209 x
0.993Age x
1.018 (if female) x
1.159 (if Black, ‘african’)

Age, in years Constant Male Female

κ 0.9 0.7
α -0.411 -0.329
 Major causes of Kidney Disease
 Prerenal Disease
 Vascular Disease
 Glomerular Disease
 Interstitial/Tubular Disease
 Obstructive Uropathy
 Prerenal Disease
 Reduced renal perfusion due to _________
depletion and/or decreased ________
 Caused by:
 __________
 Volume loss (bleeding)
 Heart failure
 Shock
 Liver disease
 Stages of Chronic Kidney Disease
= a GFR of < 60 for _________or more
Stage Description GFR (mL/min/1.73 m2)

1 Kidney damage with normal or ≥ 90

increased GFR
2 Kidney damage with mildly 60-89
decreased GFR
3a Mildly to moderate decreased 45-58
GFR
3b Moderately to severely decreased 30-44
GFR
4 Severely decreased GFR 15-29
5 Kidney Failure < 15
[KDIGO 2012, Clinical Practice Guideline for the Evaluation and Management of CKD]
 Acute Renal Failure
 An _________ decrease in renal function sufficient to
cause _________ of metabolic waste such as urea
and creatinine.
 Frequently have:
 Metabolic acidosis
 Hyperkalemia
 Disturbance in body fluid homeostasis
 Secondary effects on other organ systems
 Acute Renal Failure
 Most ___________ acquired acute renal failure (70%)
is prerenal
 Most _________ acquired acute renal failure (60%) is
due to ischemia or nephrotoxic tubular epithelial
injury (acute tubular necrosis).
 Mortality rate 50-70%
Urine Output in Acute Renal failure
 Oliguria
 = daily urine output _________
 When present in acute renal failure, associated with a
mortality rate of 75% (versus 25% mortality rate in non-
oliguric patients)
 Most deaths are associated with the underlying disease
process and infectious complications
 Anuria
 ________ urine production
 Uh-oh, probably time for _________
Assessing the patient with acute renal
failure – Physical examination
 Vital Signs:
 Elevated BP: Concern for malignant hypertension
 Low BP: Concern for hypotension/hypoperfusion (acute tubular
necrosis)
 Neuro:
 Confusion: hypercalcemia, uremia, malignant hypertension,
infection, malignancy
 HEENT:
 Dry mucus membranes: Concern for dehydration (pre-renal)
 Abd:
 Ascites: Concern for liver disease (hepatorenal syndrome), or
nephrotic syndrome
 Ext:
 Edema: Concern for nephrotic syndrome
 Skin:
 Tight skin, sclerodactyly – Sclerodermal renal crisis
 Malar rash - __________
Assessing the patient with acute renal
failure – Laboratory analysis
 Fractional excretion of sodium:

(UrineNa+ x PlasmaCreatinine)
FENa= ______________________ x 100
(PlasmaNa+ x UrineCreatinine)

 FENa < 1% → Prerenal

 FENa > 2% → Epithelial tubular injury (acute tubular necrosis),
obstructive uropathy
 Assessing the patient with acute renal
failure – Urinalysis
 Hematuria
 Non-glomerular:
 Urinary sediment: _______ red blood cells
 Causes:
 Infection
 Cancer
 Obstructive Uropathy
 Rhabdomyolysis
 myoglobinuria; Hematuria with _________
 Glomerular:
 Urine sediment: ______________ red blood cells, red cell casts
 Causes:
 Glomerulonephritis
 Vasculitis
 Atheroembolic disease
 Thrombotic microangiopathy
 Assessing Patient with Acute Renal
Failure – Urinalysis (cont.)
 Protein
 Need microscopic urinalysis to see microalbuminuria
 Can check 24-hour urine protein collection
 Nephrotic syndrome ≥ 3.5 g protein in 24 hours
 Albuminuria
 Glomerulonephritis
 Atheroembolic disease
 Thrombotic microangiopathy
 Nephrotic syndrome
 Tubular proteinuria
 Tubular epithelial injury (acute tubular necrosis)
 Interstitial nephritis
Assessing patient with acute renal failure
– Urinary Casts
Red cell casts Glomerulonephritis
Vasculitis

White Cell casts Acute Interstitial

nephritis

Fatty casts Nephrotic syndrome,

Minimal change
disease
Muddy Brown casts Acute tubular necrosis
Assessing patient with acute renal failure
– Renal Biopsy
 If unable to discover cause of renal disease, renal
biopsy may be warranted.
 Renal biopsy frequently performed in patient’s with
history of _________________with worsening renal
function.
THANK YOU!

Further information:
syikin.tahir@ukm.edu.my

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