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Renal Function Tests

Renal function tests estimate the glomerular filtration rate (GFR) using endogenous markers like urea and creatinine, or exogenous markers like inulin. An ideal marker would be completely filtered by the kidneys, not secreted or reabsorbed. While tests for endogenous markers roughly correlate with GFR, tests for exogenous markers provide a closer correlation. Clinicians must determine whether actual GFR or surrogate clearance would provide more useful information. Common renal function tests include measuring blood urea nitrogen, plasma creatinine, and calculating renal plasma clearance.

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Harshini Makkena
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115 views

Renal Function Tests

Renal function tests estimate the glomerular filtration rate (GFR) using endogenous markers like urea and creatinine, or exogenous markers like inulin. An ideal marker would be completely filtered by the kidneys, not secreted or reabsorbed. While tests for endogenous markers roughly correlate with GFR, tests for exogenous markers provide a closer correlation. Clinicians must determine whether actual GFR or surrogate clearance would provide more useful information. Common renal function tests include measuring blood urea nitrogen, plasma creatinine, and calculating renal plasma clearance.

Uploaded by

Harshini Makkena
Copyright
© © All Rights Reserved
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Renal Function Tests

Introduction
Tests that estimate GFR use

 Endogenous markers
- urea and creatinine

 Exogenous markers
- inulin, EDTA, diethylenetriamine penta acetic acid
Introduction
Ideal marker should undergo:

 Complete filtration
 No secretion
 No reabsorption
Introduction

 Tests for endogenous markers clearance correlate


roughly with the GFR, whereas test for exogenous
marker clearance provides much closer correlations

 Clinicians should determine whether the actual


GFR (inulin clearance) or surrogate clearance (any
substance other than inulin) would give the most
useful information
Introduction
 Inulin test is considered to be ‘gold standard’ for
determining renal function.

 Though it is considered as ‘gold standard’, CLcr


may yield better results for pharmacokinetic dosing,
since most kinetic studies use creatinine to estimate
drug clearance and to develop dosing strategies
Methods:

Blood urea nitrogen


Measurement of plasma creatinine
Renal plasma clearance
Blood Urea Nitrogen (BUN)
Normal range: 8 – 20 mg /dl or 2.9 - 7.1 mmol/L

It is the serum concentration of nitrogen (within


urea)

Serum concentration depends upon:


- filtration
- production (in liver)
- tubular reabsorption
Blood Urea Nitrogen (BUN)

Increase BUN may reflex decrease GFR

It is not the ideal GFR marker


[it undergoes tubular reabsorption to an extent of 50% of filtered urea]
Blood Urea Nitrogen (BUN)
BUN elevation seen in:
- high protein diet
[including AA infusion]

- upper GIT bleeding


[blood is digested as dietary proteins]
- administration drugs
[corticosteroids, tetracycline and drugs with anti
anabolic effect]
Blood Urea Nitrogen (BUN)
BUN reduction seen in:

- malnutrition
- profound liver damage
- fluid overload

BUN test can be used to monitor hydrational status, renal function,


protein tolerance and catabolism in numerous clinical settings
Measurement of plasma creatinine
Creatine is the precursor of the creatinine

It is synthesized in liver – poured into blood –


picked up by skeletal muscle – stored as, creatinine
phosphate, high energy form

Creatine phosphate acts as a readily available


source of phosphorous for the production of ATP

Creatinine is an spontaneous decomposition


product of creatine and creatine phosphate
Measurement of plasma creatinine
The daily production of creatinine is 2% of total
body creatine, which remains constant if muscle
mass is not changed significantly

Reference range:
Adults: 0.7 – 1.5 mg/dl
Children: 0.2 – 0.7 mg/dl

If the level rises above the reference range it is an


indication of poor renal function
Measurement of plasma creatinine
However, clinicians should not depend solely on
serum creatinine because serum creatinine elevation
seen in

Dehydration
Renal dysfunction
Urinary tract obstruction
Excess catabolism
Excess exercise
Muscular dystrophy
Myasthenia gravis
Measurement of plasma creatinine
Drugs [cimetidine, triamterene, amiloride, spiranolactone,
trimethoprim, probecid, aspirin inhibit the tubular secretion of creatine.
Although they may increase serum creatinine these increase are not
from a decreased GFR]

Moreover , since serum creatinine is by-product of


muscle metabolism, severely decreased muscle mass
or activity may be reflected by low serum creatinine

Thus patients with spinal card injuries and muscle


inactivity have decreased creatinine production
Measurement of plasma creatinine

Conversely, very muscular patients occasionally


have slightly elevated serum creatinine with
elevated creatinine excretion and normal GFR

Therefore, as long as no abnormalities exist in


muscle mass, an increase serum creatinine almost
always reflects decrease GFR
Measurement of plasma creatinine
The converse is always not true because a normal
serum creatinine does not necessarily imply a
normal GFR. As a part of aging process, both
muscle mass and renal function decline. Therefore,
serum creatinine remains normal range because as
the kidneys became less capable of filtering and
excreting creatinine

Thus clinicians should not rely solely on serum


creatinine as an index of renal function. They
should obtain or estimate the creatinine clearance
Concomitant serum BUN and
creatinine
Simultaneous BUN and serum creatinine can
furnish valuable information

In acute renal failure both are altered. However,


BUN : Scr ratio is often 20:1 or higher

Patients with GI bleeding and renal insufficiency,


both BUN and Scr increases. The ratio of at least 36
suggest GI bleeding
Concomitant serum BUN and
creatinine
Usually, BUN:Scr ratio greater than 20:1 suggest pre
renal causes

Ratios from 10:1 to 20:1 suggest intrinsic renal


damage

However, both types may occur simultaneously,


confounding typical interpretation. Furthermore, the
ratio greater than 20:1 is not clinically important if
the values of BUN and Scr under the reference range
Renal plasma clearance
Expresses how effectively the kidneys remove a
substance from blood plasma

High renal clearance – efficient removal of


substance from plasma into urine

Low renal clearance – less efficient removal of


substance from plasma into urine

Clearance is expressed in ml / minute / 1.73 m2


Renal plasma clearance
Can be calculated from:

a) Estimating creatinine clearance from urinary


creatinine

UV 1.73
Renal clearance = X
P BSA

U- concentration of substance in urine (mg/ml)


P – concentration of substance in plasma
V – urine flow rate (ml/minute)
BSA – body surface area
Renal plasma clearance
Clearance depends on three process:

Filtration
Reabsorption
Secretion

If the substance is filtered and neither reabsorbed


nor secreted, then its clearance is equal to GFR
[E.g inulin (iv infusion) – GFR = 125 ml /minute]
Renal plasma clearance

If the substance is filtered and secreted but not


reabsorbed, then its clearance is more than GFR
[E.g creatinine – GFR = 140 ml / minute]

It is helpful to know the renal blood flow –


[Clearance of para amino hippuric acid (PAH) is equal to
the renal blood flow]
Renal plasma clearance
b) Estimating creatinine clearance without urine
collection

In clinical practice. CLCr is usually estimated from


the plasma creatinine concentration rather than
measured

The Cockcroft and Gault equation is widely used


which considers age, sex and body weight
Renal plasma clearance

[140-age] X body weight (Kg)


CLCr (ml/minute) =
7.2 X Ccr (mg/dl)

In case of female, the value is multiplied by 0.85


Renal plasma clearance
If SI units are used (if expressed in micromol/L)

[150-age] X body weight (Kg)


CLCr (ml/minute) =
CLCr (micromol/L)

In males : 10% is added to the value estimated

In females: 10% is subtracted from the value estimated

[1 mg / dl = 88.4 micromol/L] ; It gives similar results to previous equation


Thank you

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