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#74.

Indication laboratory tests in diseases of the uropoietic system

Examination methods of kidney function:


Serum creatinine concentration
A basic examination of urine in daily praxis to examine the function of the kidneys is a plasmatic
examination (serum) aka serum creatinine test. In decreases of GFR, serum concentration of creatinine
rises. The relationship is hyperbolic.
- Decrease of GFR to lower values leads to fast increase in serum creatinine.
- The hyperbolic association can be attributed to significant decrease in renal function.
- The upper level of creatinine in healthy people is dependent on gender and used analytic methods
o Commonly used kinetic method with alkaline picrate = normal serum creatinine in adult
men 105 and women 90 umol/l
o In elderly individuals there isn’t a rise in creatinine despite GFR decrease with age.
o This discrepancy is due to muscle mass loss and with it decreased production of
creatinine.
o In asthenic individuals even a slight creatinine serum level increase can indicate very
serious decreases in renal function.
Tests of GFR
- higher indicator of kidney function than serum creatinine level is renal creatinine clearance.
- This value is given by the ration between urinary excretion of creatinine and its serum
concentration.
- Clearance of substance (ml/s) = Cu/Cs x V/t
- Cs = concentration of substance in serum
- Cu = concentration of substance in urine
- Value of creatinine clearance is considered indicator of value of GFR.
- From physiology of kidneys we know that creatinine isn’t excreted only by glomerular filtration
but also partially from tubular secretion. In individuals with normal renal function, overall
creatinine clearance is higher than GFR creatinine clearance only by 10-20%.
- In decrease of number of functional nephrons, residual nephrons increase tubular secretion of
creatinine.
- In these conditions, creatinine clearance can be 50-100% > GFR clearance.
- Normal creatinine clearance range: 2ml/s/1.73m3, lower limit being 1.3.
- Testing creatinine clearance requires accurate urine collection in defined time periods, usually
24hr.
- Due to the fact that patient cooperation can get in the way of this, other methods of creatinine
calculation were developed:
o Cockcroft and Gault: CLkr (ml/s) = (140 – age) x body mass/49 x P-kr
 Age in years, body mass in kg and P-kr in umol/l
 Can be used for men ages 20-80
 In women multiply result by 0.85
o Modification of Diet in Chronic Renal Disease formula: need only serum conc of
creatinine and age, in women multiply by 0.742.
 MDRDzkr = 3.1(0.0113 x Skr) -1.154 x age -0.203
o GFR values figured out on basis of formulas are used to classify levels of GFR decrease.
5 stages of GFR decrease based on Kidney disease outcome quality initiative scale:
o
o more precise measurements of GFR requires testing renal clearance of substances that are
excreted only though glomerular filtration.
 Inulin, polyfructose, or some radionucline labeled substances (DTPA, EDTA)
o GFR can be evaluated based on serum concentration of cystatin C.
 Normal cystatin serum concentrations should be interpreted from the perspective
of used analytic methods.
 In use of immunophelometric methods, adult values range: 0.70 – 1.21 mg/l

Testing concentration capabilities of kidneys


- some kidney diseases can first affect tubular function and only progressively affect GFR
(decreasing it). Testing of concentration and acidification abilities of the kidneys belongs to test
that give information about kidney tubular function.
- Concentration abilities: examined using classic concentration experiments or antidiuretic tests.
- Classic concentration test:
o Test runs over course of 24-36 hours. Withholding of fluids and fluid rich foods (fruit,
vegetables)
o After 12 hours, urine collection in 4 hour intervals, measure volume and osmolality.
o In these conditions, healthy individuals create urine with high osmotic concentration.
o Urine osmolality is dependent on age.
- Adiuretin (DDAVP) test
o Adiuretin is an analog of normal ADH.
o Similar to ADH, it increases tubular resorption of water in the distal portion of the
nephron.
o Test is done that after nighttime abstinence from liquids, each nostril is filled with 2 drops
of ADH.
o Afterward, 4-5 collections of urine in 1hr intervals.
o Osmolality values in healthy individuals under these conditions are:
 Age 15-20 > 970 mmol/kg H2O
 Age 21-50 > 940 mmol/kg/H2O
 Age 51-60 > 830 mmol/kg/H2O
 Age 61-70> 790 mmol/kg H2O
 Age 71-80 > 780 mmol/kg H2O
o Tests of concentrative abilities of kidneys should be part of every in depth kidney
function testing exam.

Testing acidification abilities of kidneys


- problems in acidification abilities of nephrons can be expressed by various tubular defects or can
accompany individual kidney disease.
- For practical purposes pH testing of morning urine is often used.
- For this test to get accurate results, the following conditions must be met:
o Patient cant have UTI
o pH must be tested right after urinating
o correct pH meter
- healthy adult has morning urine < pH 6.0.
- in findings of a lower value, it is a sign of pathology.

Testing tubular transport processes


- defect of kidney function can present in tubular transport defects of certain substances.
- In clinical practice we evaluate intensity of tubular excretion of a watched substance (electrolyte
e.g.) on basis of excretion fraction that gives ratio between excreted and pro-filtered amount of the
substance.
- Often this value is expressed in percentages
- If EF > 1 (resp. 100%)  tubular secretion of substance
- EF < 1 (resp. 100%)  resorption
- Expression of tubular transport on basis of EF is often used for evaluating renal excretion of
electrolytes.
Testing diluting ability of kidneys
- we evaluate the ability of the kidneys to create urine with an osmolality lower than the osmolality
of plasma.
- 20-22 ml H2O/kg, ingested within 30 minutes
- in 30min intervals over course of 4 hours, collect urine.
- Healthy individual excretes about ¾ of the ingested amount over course of 4 hrs and osmolality of
urine decreases minimally to 100mmol/kg/H2O.
- This test is important for differential diagnosis of polyuric states.