Renal function test - II

Topics to be covered

• Complete urine analysis

• Abnormal constituents of urine

• Acute kidney injury

• Chronic kidney disease
 Specific learning objectives
Complete urine analysis:

• What are the components of a complete urine

analysis?

• What abnormalities can be detected by

examining the physical characteristics of a sample
of urine?
 Specific learning objectives
Complete urine analysis:

• What are some of the abnormal substances

present in urine in various diseases?
 Complete urine analysis
• General indicator of renal function

• Specimen collection – spot /24 hr urine

 Physical characteristics - urine

1. Volume
2. pH
3. Specific gravity
4. Appearance
5. Color
 Physical characteristics - Volume

Urine output Increased Decreased

Normal Polyuria Oliguria

1 – 1.5 litre/day >2.5 litre/day <400 mL/day

Diabetes insipidus Acute and chronic

Diabetes mellitus renal failure
Excess water intake
2. pH : 4.5 – 8.0

3. Specific gravity of urine: 1.003 – 1.032

4. Appearance
– Clear and transparent
– Turbid in the presence of phosphates (normal)
and WBC’s urinary tract infections
5. Color
– Normal urine is yellow or straw colored
– Color is due to the pigment urobillin

wikipedia.org
 Physical characteristics of urine: Color

RBC/Hemoglobin Obstructive jaundice: Alkaptonuria:

Red colored urine Dark yellow Black urine on exposure to air

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 Abnormal constituents of urine

1. Protein
2. Reducing sugar
3. Ketone bodies
4. Blood
5. Bile salts
6. Bile pigments
Renal handling of protein - Glomerulus
Glomerular filtration

• Glycosaminoglycans (GAGs) are present in the

glomerular basement membrane

• Negatively charged

• This restricts the movement of negatively

charged albumin (69 kDa)

Continued…
• Glomerular filtration barrier is size and charge
selective
• Thus, glomerular filtrate has minimal amounts of
albumin
 Renal handling of protein: tubules
• Small molecular weight proteins are present in
filtrate

– Retinol binding protein

– β2 microglobulin
– alpha-1-microglobulin

• Completely reabsorbed by the proximal tubule,

degraded
 Renal handling of protein: tubules

• Tamm Horsfall protein

– is produced by the distal tubular epithelial cell
– is the protein present in urine normally
Does normal urine contain protein?
Yes.
– Normal urine contains very small amounts of
protein

– Total protein in urine <150 mg/day

– Total albumin in urine <30 mg/day
 Proteinuria

• Proteinuria is defined as presence of

total urine protein >150mg/day

• Requires collection of urine specimen for 24 hours

Types of proteinuria
• Glomerular
– Benign
– Pathological

• Tubular
• Overflow
 Glomerular proteinuria
1. Benign proteinuria:
• Transient in nature
– Fever, exercise

– Orthostatic proteinuria
(proteinuria is seen while patient stands)

– Proteinuria of pregnancy
 Glomerular proteinuria
2. Pathological proteinuria
• Persistent in nature
• Presence of protein in urine is an important
indicator of renal disease
 Glomerular proteinuria
• Most common type of proteinuria
• Damage to the glomerular membrane

• Albumin is excreted in urine > 30 mg/day

• Seen in
– Diabetes mellitus
– Nephrotic syndrome ( >3 g/day)
– Glomerulonephritis
 Microalbuminuria
• Albumin levels in urine greater than normal and
in the range of 30-300 mg of albumin/day in
urine

• Seen in
– Early stages of renal disease in diabetes
– Important early indicator of diabetic
nephropathy
 2. Tubular proteinuria
• Proximal tubular damage results in inability to
reabsorb and degrade these proteins:
– β2-microglobulin
– Retinol binding protein

Seen in
• renal transplant rejection
• drug and heavy metal induced renal tubular
damage
 3. Overflow proteinuria
• Increased level of low molecular weight protein
in blood which is excreted in urine

– Multiple myeloma
– light chains of immunoglobulins
(Bence-Jones proteinuria)
– Hemoglobinuria
– massive intravascular hemolysis
– Myoglobinuria
– muscle injury
Types of proteinuria
• Glomerular
– Benign
– Pathological

• Tubular
• Overflow
 Nephrotic syndrome
• Group of disorders with loss of integrity or
damage to the glomerular basement membrane

• Accompanied by excretion of large quantities of

albumin in urine (>3g/day)
 Laboratory findings in nephrotic syndrome

• Massive albuminuria (> 3 g / day)

• Low serum albumin level
• Hypercholesterolemia (>400 mg/dL)

• Serum electrophoresis will show

– a faint albumin band
– prominent α – 2 band
Tests for abnormal constituents of
urine
 Abnormal constituents of urine
Constituent Test for detection Conditions

Protein Heat coagulation test Nephrotic syndrome

Sulphosalicylic acid test Diabetic nephropathy

Reducing sugar Benedict’s test Diabetes mellitus

Renal glycosuria

Ketone bodies Rothera’s test Starvation

ketoacidosis

Diabetic ketoacidosis
 Abnormal constituents of urine
Constituent Test for detection Conditions

Blood Benzidine test or Hematuria

Orthotoluidine test
Hemoglobinuria

Bile salts Sulphur test Obstructive jaundice

(Salts of bile acids)

Bile pigments Fouchet's test Obstructive jaundice

Bilirubin
Biliverdin
(From heme)
 Specific learning objectives
• What is acute kidney injury (AKI)?
• What are the causes for acute kidney injury (AKI)?
• How will you differentiate
pre- renal from renal causes of AKI?

• What is chronic kidney disease (CKD)?

• What are the important causes of CKD?
 Acute Kidney Injury - AKI
(Acute renal failure - ARF)

• Sudden and reversible loss of renal function

which develops over a period of days (< 48 hrs)

– GFR is decreased
– Increase in serum urea and creatinine levels
– Decrease in urine output
Oliguria (usually < 400 mL /day or 15mL/h)
 Acute renal failure: causes

Pre-renal Renal
•Decreased renal perfusion •Glomerular diseases
− Hypovolemia •Tubular diseases
− Hypotension
 Acute kidney injury: Pre-renal causes
• This includes any condition that decreases
effective renal perfusion

Hypovolemia
– severe dehydration, excessive vomiting,
diarrhea, burns
Hypotension
– Hemorrhage, shock
 Acute kidney injury: Renal causes

Glomerular injury
– Glomerulonephritis

Tubular injury
– Drugs, Toxins
– Prolonged decreased renal perfusion
 Comparison of laboratory findings
pre-renal & renal AKI
Indices Pre-renal Renal
BUN : creatinine ratio >20 10-20
Urine Sodium mmol/L <20 >20
Fractional excretion of <1 >1
sodium (FENa) %
BUN: Blood Urea Nitrogen = Serum urea x 28/60

FENa: Fractional excretion of sodium refers to the fraction of total

filtered sodium that is excreted in urine.

Sodium loss is more when kidney function is impaired (in renal causes)
 Chronic kidney disease

• Chronic kidney disease refers to an irreversible

deterioration in renal function which develops
over a period of years

• It is characterized by a steady, slow decline in GFR

over a period of years
Causes of chronic kidney disease
Leading cause for CKD
Diabetes mellitus
Hypertension

Infection
Glomerulonephritis

Congenital defects
Drug induced injury
 Investigations in CKD

• Focused on assessment of renal function – GFR

• Identification of underlying cause and treatment

any reversible causes

• Identification and management of complications

 Specific learning objectives
• What is acute kidney injury (AKI)?
• What are the causes for acute kidney injury (AKI)?
• How will you differentiate
pre- renal from renal causes of AKI?

• What is chronic kidney disease (CKD)?

• What are the important causes of CKD?