BIOCHEM-PLENARY-KIDNEY

FUNCTIONTEST
Dra. Alvarado
Feb 27, 2019
INORGANIC CONSTITUENTS mmol/day

Tubular Secretion Cl- 120-240

-Involves the passage of substances from the blood in Na+ 100-150

the peritubular capillaries to
the tubular filtrate. K+ 60-80

SO4 2- 30-60
Amount Secreted = Amount
Excreted- Amount Filtered NH4+ 30-50
Two major functions: HPO4 2- 10-40
1. Eliminating waste products not filtered by the Ca2+ 4-11
glomerulus
Mg 2+ 3-6
2.Regulating the acid–base balance in the body through
the secretion of hydrogen ions. RENAL FUNCTIONS;

Substances usually secreted by active transport are: • Urine Formation

• H+ and K+ ions • Fluid and Electrolyte Balance

• Urea • Acid-Base Balance

• Creatinine • Excretion of Waste Products

• Drug metabolites • Excretion of Drug Metabolites and Toxins

Urine Constituents; • Hormonal Function

ORGANIC CONSTITUENTS Grams/day • Gluconeogenesis

Urea 20-30 Urine Formation

Creatinine 1-1.5 The rates at which different substances are excreted in

the urine represent the sum of three renal processes:
Uric Acid 0.3-2.0
(1) Glomerular filtration
Hippurate 0.15
(2) Reabsorption of substances from the renal tubules
Glucose <0.16
into the blood, and
Ketone bodies <3
(3) Secretion of substances from the blood into the
Amino acids <1-3 renal tubules.

Proteins <0.15 Urinary excretion rate = Filtration rate − Reabsorption

rate + Secretion rate

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 BIOCHEM-PLENARY-KIDNEY
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Inhibits NaCl and water reabsorption in the collecting
duct.
NOTE, under constant tubular reabsorption:
Uroguanilyn and Guanilyn
Increase in glomerular filtration rate (GFR) of only 10%
(from 180 to 198 L/day) would a. Produced by neuroendocrine cells in GI tract
raise urine volume 13-fold
b. Inhibit NaCl and water reabsorption
(from 1.5 to 19.5 L/day).

Regulation of NaCl and Water Reabsorption in kidneys is Norepinephrine and Epinephrine

led by a number of hormones and substances: a. Stimulate reabsorption of NaCl and water.

• Angiotensin II b. Released from the sympathetic nerves and

adrenal medulla.
• Aldosterone
Dopamine
• Atrial Natriuretic Peptide
a. Inhibits NaCl and water reabsorption.
• Brain Natriuretic Peptide
b. Stimulated by an increase in ECF volume.
• Urodilatin
Adrenomedullin
• Uroguanylin and guanylin
a. Increases GFR and renal blood flow.
• Norepinephrine and Epinephrine
b. Indirectly stimulate the excretion of NaCl and
• Dopamine water.
• Adrenomedullin Antidiuretic Hormone

• ADH Most important hormone that regulates reabsorption of

water
Angiotensin II
Secreted by: posterior pituitary gland
NaCl and water reabsorption in the proximal
tubule . Stimulated by: increase in plasma osmolality, decrease
in ECF volume
Aldosterone
Function: Increases the permeability of the collecting
Reabsorption of NaCl in the thick ascending limb
of the loop of Henle, distal tubule*, and collecting duct to water.
duct*. Electrolytes:
ANP and BNP Sodium- Major extracellular cation

Inhibit NaCl and water reabsorption. • Concentration depends greatly on the intake and
excretion of water.
Urodilatin

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 BIOCHEM-PLENARY-KIDNEY
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Feb 27, 2019
• 60-75% is Waste products:
reabsorbed in the proximal tubule.
Blood Urea Nitrogen,Creatinine,Uric
Potassium- Major intracellular cation Acid,Bilirubin,Sodium,Potassium,Drugs,Toxins and
Metabolites.
Regulates neuromuscular
excitability, contraction of the Non-Protein Nitrogen Compounds (major waste
heart, ICF volume, and H+ products)
concentration.
Blood Urea Nitrogen
Chloride-Major extracellular anion
Amino alpha-group of all amino acids broken down end
Involved in maintaining osmolality, blood volume, and up as urea compound
electric neutrality.
• Urea appears in glomerular filtrate
Phosphate-Major intracellular anion
• 40% of urea is reabsorbed
Renal regulation affected by vitamin D, calcitonin,
growth hormone, acid-base balance, and PTH. Blood Urea Nitrogen

Calcium-Essential for myocardial contraction

Serum calcium is regulated by PTH, vitamin D, and

calcitonin.

Magnesium-Fourth most abundant cation in the body

Overall regulation is controlled largely by the kidney

which can reabsorb magnesium in deficiency states or
Serum concentration of urea is affected strongly by the
readily excrete excess magnesium. degree of protein catabolism.
Acid-Base Balance; In the case of diet, a change to high protein diet can
The kidneys regulate extracellular fluid H+concentration double the serum urea, and a low protein intake can
through three fundamental reduce it by half.

Mechanisms: Creatinine

1.Secretion of H+ • Waste product formed in muscle from high

energy storage compound, phosphocreatine.
2.Reabsorption of filtered HCO3-
• Small amount of creatinine is ingested as meat
3.Production of new HCO3- constituent.

Renal Excretion It is considered as the best indicator of renal function

for two reasons:
Wanted substances: Kept or reabsorbed

Unwanted substances: Filtered and excreted

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 BIOCHEM-PLENARY-KIDNEY
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• Amount of • Active secretion is an enzyme (transporter)-mediated
creatinine excreted daily is a function of the process that is saturable.
muscle mass.
• Although reabsorption of drugs is mostly a passive
• It is not affected by process, the extent of reabsorption of weak acid or
diet, age and sex. weak base drugs is influenced by the pH of the urine
and the degree of ionization of the drug.
Uric Acid
• In addition, an increase in blood flow to the kidney,
• Uric acid is a purine compound that circulated which may be due to diuretic therapy or large alcohol
in plasma as sodium urate and is excreted by consumption, decreases the extent of drug reabsorption
kidney. in the kidney and increases the rate of drug excreted in
the urine.
• It is derived from the breakdown of nucleic acid.
Properties of Renal Drug Elimination Processes
• Urate appears in the glomerular filtrate and
partially reabsorbed in tubules.

• Urate deposition in the kidney may lead to renal

failure.

• There is a danger of precipitation of uric acid

crystal where there is local rise in H+
concentration.

Renal Gluconeogenesis;
Renal Drug Excretion
Major gluconeogenic tissues:
In summary, renal drug excretion is a composite of:
• ~90% - liver
• passive filtration at the glomerulus.
• 10%- kidneys
• active secretion in the proximal tubule.

• passive and/or active reabsorption in the distal tubule

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Feb 27, 2019
collection else requires refrigeration

• Macroscopic or physical examination

• Chemical examination

• Microscopic examination of the Sediments

Examination of physical characteristics:

1. Volume

RENAL FUNCTION TEST 2. Specific gravity

URINALYSIS 3. Colour (affected by drugs, food, general condition).

• General evaluation of health 4. Turbidity (clear; cloudy, particles)

• Diagnosis of disease or disorders of the kidneys or 5. Odour (affected by infection, diet)

urinary tract
VOLUME
• Diagnosis of other symptomatic disease that affect
kidneys function Normal – 1-2.5 L/day

• Monitoring the patient with diabetes Oliguria – urine output <400ml/day

• Screening for drug use -seen in cases of : Dehydration , shock,

Improper collection may invalidate the results acute glomerulonephritis , renal failure

• Containers used for collection of urine should be Polyuria - urine output > 2.5 L/day

wide mouthed clean and dry -seen in cases of : increased water

• Urine should be analyzed within 2 hours of ingestion diabetes mellitus and insipidus

Anuria - urine output <100ml/day

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 BIOCHEM-PLENARY-KIDNEY
FUNCTIONTEST
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Feb 27, 2019
SPECIFIC GRAVITY

COLOR Normal - 1.002-1.030

• Normal – pale yellow in color due to pigments • It is measurement of urine density which reflects the
ability of the kidney to concentrate or dilute the urine
like urochrome, urobilin and relative to the plasma from which it is filtered

uroerythrin
• Measured by urinometer, refractometer and dipsticks
• Cloudiness may be caused by
excessive cellular material or protein, crystallization or SPECIFIC GRAVITY
precipitation of non pathological salts upon standing at
room temperature or in the refrigerator

• Hyposthenuria: Consistently low specific gravity

<1.002
ODOR
• Hypersthenuria: Consistently high specific gravity
• Normal – aromatic due to the volatile fatty acids >1.030

• On long standing -ammonical (decomposition of urea • Isothenuria: Fixed specific gravity at 1.010 ( occurs in
forming ammonia which gives a strong ammoniacal chronic
smell )
kidney disease)
• Foul- pus or inflammation
● Usually done with reagent strips.
• sweet- diabetes
● Used to determine body processes such as
•Fruity – ketonuria carbohydrate metabolism, liver or kidney function.

• maple syrup- MSUD or maple syrup urine disease ● Used to determine infection.

• Rancid- Tyrosinemia

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 BIOCHEM-PLENARY-KIDNEY
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Feb 27, 2019
● Can be used to •The chemical reaction results in a specific colour
determine presence of drug or toxic environmental change.
substances.

The chemical analysis of urine

undertaken to evaluate the
levels of the following
components:

1. Ketones

2. pH

3. Blood

4. Bilirubin (urobilinogen)

•Glucose in the urine is referred to as glycosuria

5. Glucose
•If severe, glycosuria can lead to an osmotic diuresis
6. Protein
and dehydration
7. Nitrates
•Glucose is detectable in urine in patients with
8. Leukocytes hyperglycemia, proximal tubule dysfunction ( eg
fanconi’s syndrome)
9. Drugs
Proteins in urine:
10. Phenylketones
•Detected by heat coagulation or dipstick method

•Detection of protein dipstick is most sensitive

toalbumin

•Sensitivity is highly dependent on urine concentration

•Healthy individuals excrete <150 mg/dl of total protein

and <30 mg/d of albumin.

•Proteins are detectable in cases of glomerular

diseases, overflow proteinuria and also due to UTI or

urinary tract infectionspH
•The presence of normal and abnormal chemical
• Reflects ability of kidney to maintain normal hydrogen
elements in the urine are detected using dry ion concentration in plasma and ECF

reagent strips called dipsticks.

•When the test strip is dipped in urine the reagents are • Urine pH ranges from 4.5 to 8
activated and a chemical reaction occurs.

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 BIOCHEM-PLENARY-KIDNEY
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• Normally it is > 5 leukocytes
acidic lying between 6-6.5
> 2 renal tubular cells
• Tested by :
> 10 bacteria
-litmus paper , pH paper,
dipsticks Abnormal Findings

Per Low Power Field (LPF) (200x)
• Acidic urine – ketosis
(diabetes, starvation, fever), systemic acidosis, UTI- > 3 hyaline casts or > 1 granular cast
E.coli, acidification therapy .
> 10 squamous cells (indicative of
● Used to examine the elements not visible without a
microscope. contaminated specimen)

● Centrifuge spins the urine to separate substances. Any other cast ( RBCs, WBCs)

A sample of well-mixed urine (usually 10-15 ml) is Presence of :

centrifuged in a test tube at relatively low speed (about
1. Fungal hyphae or yeast, parasite, viral inclusion
2000-3000pm) for 5-10 minutes which produces a
concentration of sediment (cellular matter) at the 2. Pathological crystals (cysteine, leucine , tyrosine)
bottom of the tube
3. Large number of uric acid or calcium oxalate crystals
A drop of sediment is poured onto a glass slide, a thin
slice of glass (a coverslip) is place over it and observed 1. Hematuria is the presence of abnormal
under microscope.
numbers of red cells in urine due to any of
A variety of normal and abnormal cellular elements may
several possible causes.
be seen in urine sediment such as:
2. Glomerular damage.
1. Red blood cells
3. Tumors which erode the urinary tract
2. White blood cells
anywhere along its length
3. Mucus
4. Kidney trauma
4. Various epithelial cells
5. Urinary tract stones
5. Various crystals
6. Acute tubular necrosis
6. Bacteria
7. Upper and lower urinary tract infection
7. Casts
8. Nephrotoxins
Abnormal Findings

Per High Power Field (HPF) (400x)

> 3 erythrocytes

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 BIOCHEM-PLENARY-KIDNEY
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Feb 27, 2019
9. WBC in high Normal range of creatinine in serum: adult male: 0.7 -
number indicate inflammation or infection somewhere 1.4 mg/dl
along the urinary or genital tract.
female: 0.6 - 1.3 mg/dl
Casts
children: 0.4 - 1.2 mg/dl
● Urinary casts are cylindrical
Increase concentration
aggregation of particles that
form in the distal nephron, A) Prerenal factors: Congestive heart failure
dislodge, and pass into the urine. In urinalysis they Shock
indicate kidney disease. Salt and water depletion
● They form via precipitation of Tamm-Horsfall B) Renal factors:Involve damage to glomeruli,
tubules, renal blood vessels
mucoprotein which is secreted by renal tubule cells.

Types of cast seen: C) Postrenal factors:

•Acellular cast: Hyaline casts, Granular casts, Waxy • Prostatic hypertrophy

casts, Fatty casts, Pigment casts, Crystal casts. • Neoplasms compressing the ureters
• Calculi blocking the ureters
•Cellular cast: Red cell casts, White cell casts, Epithelial • Congenital abnormalities of ureters
cell cast
Decrease concentration
•The most common type of cast – hyaline casts, are
solidified Low serum creatinine concentration has no
clinicalsignificance
Tamm-Horsfall mucoprotein secreted from the tubular
epithelial cells and seen in fever, strenuous exercise, *Urine creatinine : The concentration of creatinine in
damage to the glomerular capillary urine is much higher than in serum (about 1mg/ml).

Red blood cells may stick together and form red blood Serum Urea/Blood Urea Nitrogen
cell casts. Such casts are indicative of
Conversion factor: 0.357
glomerulonephritis, with leakage of RBCs from
glomeruli or severe tubular damage Principle: Urea with diacetylmonoxime and
thiosemicarbazide in acidic solution produces pink
White blood cell casts are most typical for acute
color.
pyelonephritis, but they may also be present.
Normal range of urea in serum: 15-45 mg/dL
Serum creatinine

Conversion factor:88.4

Principle: Creatinine is treated with an alkaline picrate

solution to yield a bright orange-red complex.

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 BIOCHEM-PLENARY-KIDNEY
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Uric Acid Kidneys: The two kidneys function to excrete most of
the waste products of metabolism.
Conversion factor: 0.059
Reddish brown paired organs that lie on the posterior

wall of the abdomen behind the peritoneum on either
Principle (Folin-Wu Reaction): side of the vertebral column.

Sodium carbonate and dilute
Major role in controlling the water and electrolyte
phosphotungstic acid are balance within the body and in maintaining the acid–
added to protein free filtrate (PFF) of serum to produce
base balance of the blood.
blue color by reducing action of the acid upon
phosphotungstate (measured photometrically). The functional unit of the kidneys is the nephron. Each
human kidney contains approximately 1.2 million
Normal range ofuric acid in serum:
nephrons, which are essentially hollow tubes composed
of a single epithelial cell layer.
• adult male: 3.5 - 7.5 mg/dl
• female: 2.5 - 6.5 mg/dl
• children: 2.0 - 5.5 mg/dl
Ureters- narrow tubes that carry urine from kidneys to
Increased concentration: bladder

• Gout disease - muscles tighten and relax forcing urine downward,

• Renal disease away from the kidneys.
• After increased breakdown of nucleic acid and
nucleoprotein (leukemia, polycythemia, Bladder - triangle shaped, hollow organ, located in the
toxemia of pregnancy and after irradiation of x- lower abdomen.
ray sensitive carcinomas)
- it is held in place by ligaments that are attached to
Decreased concentration: other organs and pelvic bones.

• After administration of ACTH or cortisol-like Urethra - this tube allow urine to pass outside the
steroids body.
• Certain drugs that decrease the reabsorption of *The brain signals the bladder muscles to tighter
urate by renal tubules (aspirin, probenecid,
penicilamine) by drugs that block a step in – squeezing urine out of the bladder
formation of uric acid.
2. What are the general functions of the kidneys?

RESEARCH QAUESTIONS: (1) Urine Formation

(2) Fluid and Electrolyte Balance

1. How does the anatomy of the renal system correlate
with its intricate function? (Discuss briefly the basic (3) Acid-Base Balance
anatomy and physiology of the kidneys and the rest of
the urinary tract) (4) Excretion of Waste Products

(5) Excretion of Drug Metabolites and Toxins

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 BIOCHEM-PLENARY-KIDNEY
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(6) Hormonal Tests for renal blood flow
Function
(1) BUN

Increase: chronic renal disease, stress, burns, high
(7) Gluconeogenesis protein diet, dehydration

3. What are the components Decrease: poor nutrition, hepatic disease, impaired
of a kidney function test? absorption, pregnancy

Cite clinical conditions where these tests are indicated. (2) Creatinine

Tests for GFR Increase: renal function, chronic nephritis, congestive

heart failure
(1) Clearance tests : removal of substrate from plasma
to urine- Decrease: decreased muscle mass, advanced and
severe liver disease, pregnancy and inadequate dietary
a) Insulin protein
b) Creatinine clearance
(3) Blood uric acid
c) Urea clearance Increase: gout, increased nuclear metabolism,
Increase in clearance:
chronic renal disease, Lesch-Nyhan syndrome,
secondary to glycogen storage disease, toxemia of
• high cardiac output
pregnancy and lactic acidosis, increased dietary intake
• pregnancy
ethanol conception
• carbon monoxide
• poisoning Decrease: Fanconi syndrome, Wilson’s disease,
• burns Hodgkin’s disease

Decrease in clearance: Tests measuring tubular function

• impaired kidney function A. Excretion tests/ secretion test

• shock
• dehydration (1) Para- aminohippurate test — measures renal plasma
• hemorrhage (2) Titratable acidity and Urinary Ammonia
• congestive heart failure
clinical significance : renal tubular acidosis
(2) Serum cystatin C
B. Concentration tests: reflects function of collecting
Increase: acute and chronic renal failure, diabetic tubule and loop of Henle
nephropathy
(1) Specific gravity [SG]
(3) B- trace protein
(2) Osmolality [serum]
Increase: renal disease
Urine : SG ratio = <1.1 Diabetes Insipidus

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 BIOCHEM-PLENARY-KIDNEY
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Urine : SG ratio
= >1.1 Glomerular Disease

increase soluble solution in

every filtrate

Serum Osmolarity = >2.1 –

2.3x value of serum Na+

~ Hyperglycemia, uremia, anion gap acidosis

(3) Free water clearance

[-] value – dehydratiiom

o value - no renal concentration / dilution

[+] value - excess water excreted

4. What are the different diseases which could give

abnormal results on kidney function tests?

a. Acute kidney injury

b. Chronic kidney disease

c. Chronic nephritis

d. Glomerular disease

e. Acute and chronic renal failure

f. Tubular disease [eg. Renal tubular acidosis]

g. Urinary tract obstruction

5. Kidney function tests may be affected by certain

drugs. Give examples of such drugs that can lead to
falsely abnormal results and explain briefly why

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 BIOCHEM-PLENARY-KIDNEY
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•Low protein diet

•Acute tubular necrosis

•Repeated dialysis

•Hepatic disease

High BUN : Crea Ratio (>20:1 with normal creatinine)

•Pre-renal azotemia

•Dehydration

•Catabolic states

•Gastrointestinal hemorrhage

•High protein diet

High BUN : Crea Ratio (>20:1 with increased creatinine)

•Pre-renal azotemia

•Post-renal azotemia

•Renal failure

7. What is Chronic Kidney Disease (CKD)? Explain its

etiology (causes) and pathogenesis (emphasis on
6. What is the significance of getting the
molecular and biochemical mechanisms). Describe the
BUN:Creatinine ratio? Enumerate conditions that can
lead to increase or decrease in such ratio. three stages of Chronic Kidney Disease.

CKD (Chronic Kidney Disease)

BUN : Creatinine Ratio

•Used to determine acute kidney injury or dehydration - encompasses a spectrum of

pathophysiologic process associated with

•Prediction of volume status is based on the constancy
of urea and creatinine production abnormal kidney function and a
•In volume depletion, urea clearance decrease more progressive decline in glomerular
than creatinine does
filtration rate
•Creatinine is decreased only by reduced filtration
Etiology
•Urea is decreased by both reduced filtration and
increased reabsorption. - Diabetic Nephropathy

Low BUN : Creatinine Ratio (<10:1) - Glomerulonephritis

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- Hypertension- Stage 3b: GFR (30-44) – moderately to severely
associated CKD Diabetic nephropathy (includes vesicular decreased
and ischemic kidney disease with associated
Stage 4: GFR (15-29) – severely decreased
hypertension)

- Autosomal dominant Stage V CKD

polycystic kidney disease
End Stage Renal Disease - term for Stage 5 CKD where
- Other cysts and tubulo- accumulation of toxin levels to death happen.
interstitial nephropathy Resolved by renal replacement therapy using dialysis
Pathophysiology of CKD members two sets of or kidney transplantation. As toxins accumulate,
damage mechanism: patients usually experience a marked disturbance in
their activities of daily living, well-being, nutritional
(1) initiating mechanisms specific to the underlying status and rates and electrolytes homeostasis,
etiology eventually in the severe syndrome.

(2) hyperfiltration and hypertrophy at the remaining JOURNAL ARTICLE

viable nephrons that are common consequence
Prujim, et. al. (2018). Reduced cortical oxygenation
following long term reduction of renal mass,
irrespective of underlying etiology and lead to further predicts a progressive decline of renal function in
decline in kidney function. patients with chronic kidney disease. Kidney
International, 93(4), 765.
Stage I and II CKD
Background
Usually asymptomatic, recognition of CKD occurs more
Renal tissue hypoxia is the final pathway in the
often as a result of laboratory testing in clinical setting.
development and progression of chronic kidney disease
Stage 1: GFR (> 90) – normal/high (CKD).

Stage 2: GFR (60-89) = mildly decreased However, measurement of kidney oxygenationhas not
yet been performed in humans until the development
Stage III and IV CKD
of blood oxygenation-level dependent magnetic
- Clinical and laboratory complications become more resonance imaging (BOLD-MRI).
prominent. What is BOLD-MRI?
•All organs are affected, most evident compliant
- BOLD-MRI is developed to assess renal tissue
include anemia, associated easy fatigability, decreased oxygenation ideal for measurement in CKD patients.
appetite with progressive malnutrition, abnormalities in
Calcium, Phosphorus and mineral regulating hormones - It uses paramagnetic properties of deoxyhemoglobin
such as calcitriol, PTH, FGF-23; abnormalities in Na, K, to assess renal tissue oxygenation. Higher local
water and acid-base hemostasis. deoxyhemoglobin levels: Higher R2* (apparent
relaxation rate → THUS, tissue and blood oxygenation is
Stage 3a: GFR (45-95) – mildly to moderately decreased
in equilibrium in NORMAL individuals

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Objective the higher cortical R2* is (corresponding to lower
oxygenation), the larger the decline in yearly eGFR is.
To assess whether renal tissue oxygenation as
measured with BOLD-MRI is associated with renal In addition, the yearly change in eGFR correlated
function decline in a cohort of positively with the R2* slope (b, 0.45 0.17, P ¼ 0.010);
CKD patients, hypertensive hence, the flatter the slope, the larger the declinein
patients without CKD and eGFR.
normotensive controls.
CKD patients with the lowest cortical oxygenation were
3 times more likely to experience a major renal event
(e.g. transplantation or 30% increase in serum
creatinine) than those with
Methods
preserved renal tissue oxygenation. Therefore, lower
A 3-year prospective study was done with the following renal tissue oxygenation suggests decline in renal
sample population: function as measured using BOLD-MRI.

(1) 120 CKD patients

(2) 62 hypertensive patients

without CKD

(3) 44 normotensive patients

• Furosemide (diuretic) was administered to block

an oxygen-consuming active transporter which
is NKCC2 cotransporter.
• Medullary R2* levels were measured.
• Change Estimated Glomerular Filtration Rate

(eGFR) is statistically analyzed with R2* levels
change to correlate oxygenation with renal
function.

Results

Throughout the 3-year follow-up:

(1) 15 participants were excluded due to inability to
undergo BOLD-MRI

(2) 7 participants were excluded due to insufficient

image quality

(3) 10 hypertensive and 11 normotensive patients
refused to undergo follow-up and thus, excluded.Hence,

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