Renal Function test

Normal functions of the kidney

1. To maintain the constancy of the extra-cellular fluid by:

I. Excreting dietary surpluses and metabolic end-products e.g. urea, creatinine, urate, H+ II. Retaining necessary substances, either by not letting them be filtered (e.g. proteins) or by reabsorbing them in the tubules (e.g. glucose, amino-acids, HCO3-) 2. To act as an endocrine gland I. Erythropoietin II. Renin III. 1-alpha-hydroxylation of Vitamin D (to make 1:25 di-hydroxycholecalciferol, calcitriol)

Uses 20-25% of cardiac out put to filter 180L/day = 125ml/min

Overview of kidney functions

Regulation of blood ionic composition Regulation of blood pH Regulation of blood volume Regulation of blood pressure Maintenance of blood osmolarity Production of hormones (calcitrol and erythropoitin) Regulation of blood glucose level Excretion of wastes from metabolic reactions and foreign substances (drugs or toxins)

Each kidney has about 1 million nephrons

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Structures and functions of a nephron

Renal corpuscle Afferent arteriole Renal tubule and collecting duct

Glomerular capsule
Fluid in renal tubule Urine (contains excreted substances)

1 Filtration from blood plasma into nephron

Efferent arteriole

2 Tubular reabsorption from fluid into blood

3 Tubular secretion from blood into fluid

Blood (contains reabsorbed substances)

Peritubular capillaries

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Glomerular filtration
Glomerular filtrate fluid that enters capsular space
Daily volume 150-180 liters more than 99% returned to blood plasma via tubular reabsorption

Filtration membrane endothelial cells of glomerular capillaries and podocytes encircling capillaries
Permits filtration of water and small solutes Prevents filtration of most plasma proteins, blood cells and platelets 3 barriers to cross glomerular endothelial cells fenestrations, basal lamina between endothelium and podocytes and pedicels of podocytes create filtration slits Volume of fluid filtered is large because of large surface area, thin and porous membrane, and high glomerular capillary blood pressure
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Podocyte of visceral layer of glomerular (Bowmans) capsule Filtration slit Pedicel

Fenestration (pore) of glomerular endothelial cell: prevents filtration of blood cells but allows all components of blood plasma to pass through Basal lamina of glomerulus: prevents filtration of larger proteins Slit membrane between pedicels: prevents filtration of medium-sized proteins (a) Details of filtration membrane

Pedicel of podocyte

Filtration slit

Basal lamina

Lumen of glomerulus

Fenestration (pore) of glomerular endothelial cell (b) Filtration membrane

TEM 78,000x

Net filtration pressure

Net filtration pressure (NFP) is the total pressure that promotes filtration
NFP = GBHP CHP BCOP Glomerular blood hydrostatic pressure forcing water and solutes through filtration slits Capsular hydrostatic pressure is the hydrostatic pressure exerted against the filtration membrane by fluid already in the capsular space and represents back pressure Blood colloid osmotic pressure due to presence of proteins in blood plasma and also opposes filtration Why oliguria developed in shocked patients?
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1 GLOMERULAR BLOOD HYDROSTATIC PRESSURE (GBHP) = 55 mmHg

2 CAPSULAR HYDROSTATIC PRESSURE (CHP) = 15 mmHg 3 BLOOD COLLOID OSMOTIC PRESSURE (BCOP) = 30 mmHg Proximal convoluted tubule

Afferent arteriole

Efferent arteriole

NET FILTRATION PRESSURE (NFP) =GBHP CHP BCOP = 55 mmHg 15 mmHg 30 mmHg = 10 mmHg Glomerular (Bowman's) capsule Capsular space

Tubular reabsorption and tubular secretion

Reabsorption return of most of the filtered water and many solutes to the bloodstream
About 99% of filtered water reabsorbed Proximal convoluted tubule cells make largest contribution Both active and passive processes

Secretion transfer of material from blood into tubular fluid

Helps control blood pH Helps eliminate substances from the body
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Reabsorption routes and transport mechanisms

Reabsorption routes
Paracellular reabsorption
Between adjacent tubule cells Tight junction do not completely seal off interstitial fluid from tubule fluid Passive

Transport mechanisms

Transcellular reabsorption through an individual cell

Reabsorption of Na+ especially important Primary active transport

Secondary active transport Transport maximum (Tm)
Symporters, antiporters

Sodium-potassium pumps in basolateral membrane only

Obligatory vs. facultative water reabsorption

Upper limit to how fast it can work

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Reabsorption routes: paracellular reabsorption and transcellular reabsorption

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Reabsorption and secretion in proximal convoluted tubule (PCT)

Reabsorb what you need 80% water Na and water - K+ : 95% absorbed usually - phosphate : active reabsorption which is inhibited by PTH - HCO3- : mostly absorbed - glucose and amino acid absorption is normally nearly complete

Fanconi syndrome: is loss (inherited or acquired) of proximal tubular functions characterised by glycosuria, amino aciduria, and phosphaturia. May also have acidosis and polyuria.

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Reabsorption and secretion in the proximal convoluted tubule

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Reabsorption in the loop of Henle

Its counter-current multiplier effect (creating either dilute or concentrated urine) Key features are an active NaCl pump in the thick ascending limb water impermeability of the whole of the ascending limb. At end of the loop of Henle (hypotonic) About the osmolality of body fluids (~ 120-150 mosmoles/l, as compared with 250-300 mosmoles/l in plasma).

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Na+K+-2Cl- symporter in the thick ascending limb of the loop of Henle

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Reabsorption and secretion in the late distal convoluted tubule and collecting duct
Reabsorption on the early distal convoluted tubule
Na+-Cl- symporters reabsorb Na+ and Cl Major site where parathyroid hormone stimulates reabsorption of Ca+ depending on bodys needs

Reabsorption and secretion in the late distal convoluted tubule and collecting duct
90-95% of filtered solutes and fluid have been returned by now Aldosterone ( Renin-angiotensin system) causes sodium to be exchanged for K+ and/or H+. Conn's syndrome, Addisons disease, and RTA type I all affect DCT function.

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Hormonal regulation of tubular reabsorption and secretion

Angiotensin II - when blood volume and blood pressure decrease
Decreases GFR, enhances reabsorption of Na+, Cl- and water in PCT

Aldosterone - when blood volume and blood pressure decrease

Stimulates principal cells in collecting duct to reabsorb more Na+ and Cl- and secrete more K+

Parathyroid hormone
Stimulates cells in DCT to reabsorb more Ca2+

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Regulation of facultative water reabsorption by ADH

Antidiuretic hormone (ADH or vasopressin)
Increases water permeability of cells by inserting aquaporin-2 in last part of DCT and collecting duct

Atrial natriuretic peptide (ANP)

Large increase in blood volume promotes release of ANP Decreases blood volume and pressure by inhibiting reabsorption of Na+ and water in DCT and collecting duct, suppress secretion of ADH and aldosterone

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Diabetes insipidus
Pituitary form, where no ADH is synthesized due to damage to the pituitary. Nephrogenic form, where renal tubular cells do not respond to normal levels of ADH. Both forms give rise to polyuria with dilute urine. Syndrome of inappropriate secretion of ADH (SIADH): low output of inappropriately concentrated urine in the presence of hypervolaemia and dilutional hyponatraemia

Formation of dilute urine

Osmolarity of interstitial fluid of renal medulla becomes greater, more water is reabsorbed from tubular fluid so fluid become more concentrated Water cannot leave in thick portion of ascending limb but solutes leave making fluid more dilute than blood plasma Additional solutes but not much water leaves in DCT Low ADH makes late DCT and collecting duct have low water permeability

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Formation of concentrated urine

Urine can be up to 4 times more concentrated than blood plasma Ability of ADH depends on presence of osmotic gradient in interstitial fluid of renal medulla 3 major solutes contribute Na+, Cl-, and urea 2 main factors build and maintain gradient
Differences in solute and water permeability in different sections of loop of Henle and collecting ducts Countercurrent flow of fluid though descending and ascending loop of Henle and blood through ascending and descending limbs of vasa recta
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Summary of filtration, reabsorption, and secretion in the nephron and collecting duct

Copyright 2009, John Wiley & Sons, Inc.

EVALUATION OF RENAL FUNCTION

GLOMERULAR FUNCTION TESTS:

SERUM CREATININE: Filtered at the glomerulus and no

significant reabsorption or secretion in the tubules Derived from creatine phosphate in muscle. Serum levels are related to muscle mass ,dietary meat intake. CREATININE CLEARANCE (Cr Cl): Cr Cl provides a measure of the glomerular filtration rate (GFR). It is calculated as follows: Cr Cl. = (Urine Creatinine conc. x volume) / (Plasma Creatinine conc.) Normal Cr Cl. is about 120 ml/min.

 If the normal Creatinine clearance is 120 ml/min what would you suggest are likely values in patients with loss of: (i) 50 % (ii) 90% of renal functional mass? What sort of changes might you expect to see in plasma urea and/or creatinine?

Evaluation of kidney function

BLOOD UREA: Is a useful measure of decreased filtration. About 30-40 % is normally reabsorbed in tubules. Levels are affected by: High protein intake, catabolic states, post-surgery and trauma, and gastrointestinal haemorrhage GFR: calculated using the 4-variables (i.e. serum creatinine concentration, age, gender and ethnic origin).

CAUSES OF ABNORMAL SERUM UREA TO CREATININE RATIO

Increased High protein intake G.I. haemorrhage Hypercatabolic state Dehydration Urinary Stasis Muscle wasting or amputation Decreased Low protein intake Dialysis (urea crosses Severe liver disease

TUBULAR FUNCTION TESTS

Urinary Na+ concentration. Normally low relative to serum concentration unless on a dietary high salt intake. Concentration tests (usually after Pitressin), and Dilution tests, after a water load. Ratio of osmolality (or urea) in urine relative to that in plasma is a simple practical measure. Acidification tests, after administration of NH4Cl ( NH3 + H+ + Cl- ). Seldom done except in differentiation of type I and II renal tubular acidoses MISCELLANEOUS TESTS: Microscopy : look for casts, cells, or crystals

 Protein : :> 2.5 g/day: Nephrotic syndrome Bence-Jones Protein : Myeloma 2-microglobulin, small protein, filtered then absorbed by tubules, which is a sensitive test of tubular function (but also in some malignancies and inflammatory conditions). Mild increase can sometimes be normal (orthostatic, pregnancy).

 A 4 year old child presents with facial edema a few weeks after a flu-like illness?
What single test will be most informative?

34. 56 year old female. Symptoms : tiredness, weakness, developing over a long period. Several years previously she had developed backache due to lumbar disc prolapse, and had habitually consumed large quantities of analgesic tablets. serum: Na+ 140 (N 135-145) K+ 5.5 (N 3.5-5.5) Cl- 100 (N 97-107) Bicarbonate 16 (N 22-26) urea 33 mM (N 1.7-6.7) creatinine 900 M (N 75-115) calcium 1.9 mM (N 2.1-2.6) albumin 40 g/l (N 30-50) inorganic phos. 4.2 mM (N 0.8-1.4) urate 0.57 mM (N 0.12-0.5) urine: Na+ 50 mmol/l K+ 30 mmol/l urea 120 mmol/l creat 4.0 mmol/l (4000 moles/l) osmol. 330 mosm/kg urine output: 3 litres/24h The findings were similar 2 months previously at an outpatient clinic visit. i. Calculate the creatinine clearance. ii. The patient has a normal 24h urinary output of urea and creatinine, but markedly elevated plasma values. Explain this apparent paradox.

 iii. Comment on the plasma bicarbonate concentration. iv. Comment on the plasma urate and phosphate. v. Suggest a cause for the hypocalcemia. vi. Calculate the daily sodium output. What could happen if her sodium intake fell substantially below this value? vii. Comment on the plasma K+. Is it important to monitor this regularly?

 What would you expect the urinary Na+ concentration to be in: (i) A patient who has had a severe haemorrhage (low plasma volume) (ii) A patient who has impaired tubular function.
16. What is the value of measuring proteins in the urine? 17. What is the Fanconi syndrome, and what anatomical part of the kidney is affected?

 A mother donates one of her kidneys for transplant to one of her children who has a severe kidney disease. How will her own renal function be affected? What sort of changes might you expect to see in plasma urea and/or creatinine

RENAL DISORDERS

NEPHROTIC SYNDROME
Characterized by increased permeability of the glomerulus to proteins, with proteinuria of greater than 2.5 g/day, & oedema (why?), hypoproteinaemia, and increased serum lipids.

Selectivity index: which is the ratio of the clearance of a high M.W. protein such as IgG and
a low MW protein such as albumin:

UIgG/PIgG

Selectivity Index = ------------- x 100 This index will increase as the disease progresses. Ualb/Palb

 in 2 globulins (2 macroglobulin - too large to be filtered easily, and increased as part of an attempt by the liver to compensate for the protein loss by increasing overall synthesis of serum proteins) There is also hypercholesterolaemia and in other serum lipids (cause of elevated globulins above)

Clinical and biochemical features

CAUSES Minimal change GN Membranous GN SLE Diabetic nephropathy Other forms of GN Hyperlipidemia Increased apolipoprotein synthesis FEATURES proteinuria Oedema Thrombotic tendency MECHANISM Glomerular change Low plasma albumin 2ndry hyperaldosteronism Hyperfibrinogenemia Low antithrombin III

some of causes respond to steroid therapy.

ACUTE RENAL FAILURE (ARF)

Definition: Urine output less than 450 ml/day (in adult) with a rising blood urea (N = 1.7 - 6.7 mmoles/l) The blood urea typically rises by 5 mmoles/l/day, but in surgical, trauma, or gastro-intestinal bleeding it can rise by up to 15 mmoles/l/day. ARF has three different types : 1. Pre-renal failure (defect before the kidney) 2. Intra-renal failure (defect in the kidney e.g. acute tubular necrosis, glomerulonephritis) 3. Post-renal failure (defect after the kidney, e.g. prostatic enlargement, urolithiasis

).

Pre-renal

Intra-renal

Post-renal

Acute tubular necrosis (ischaemic or toxic)

Hypovolaemia

Bilateral ureteric obstruction

Decreased cardiac output Renovascular obstruction

Acute glomerulonephritis Interstitial nephritis Intrarenal vasoconstriction (e.g. sepsis) Tubular obstruction (e.g. uric acid crystals)

Urethral obstruction

Why urgency to differentiates

1.Pre-renal failure if not rapidly treated can progress to the much more serious intra-renal failure (acute tubular necrosis). 2. Some aspects of the treatment of intra-renal failure are the opposite of those for pre-renal failure.

Diagnostic strategy
Assess tubular function in a situation where glomerular malfunction is predominating Tubular function will be defective in Intra-renal failure but normal (for a while) in pre-renal failure. Appropriate tests to distinguish between these two are therefore: PRE-RENAL INTRA-RENAL
U Na conc * < 20 > 40 mmol/l Urine/plasma osmo ratio > 1.4 < 1.1 Urine/plasma urea ratio > 14 < 10 The urinary Na+ is low in pre-renal failure because the low blood volume causes a marked stimulation of aldosterone-mediated Na+ uptake. In Intra-renal failure the damaged tubules can't respond fully.

MANAGEMENT OF ACUTE RENAL FAILURE

1. Post-renal

- relieve the obstruction, but then watch out for subsequent polyuria . 2. Pre-renal - Restore blood volume, then blood pressure and GFR will return to normal levels. 3. Acute tubular necrosis Water : if blood volume is low, replace with care, since fluid overload can lead to cardiac failure, maintain balance with 500 ml/day for insensible loss, plus previous day's volume of urine output, monitor by weighing patient daily

 Na+ : if oliguric restrict, in diuretic phase - may need to administer Na+ ++. K+ :if oliguric - restrict - may even have to dialyse, in diuretic phase - administer if hypokalaemic. H+ :high anion gap metabolic acidosis, may need bicarbonate to neutralise a severe acidosis Dialysis is indicated if blood urea is greater than 50 mmol/l and rising bicarbonate is less than 10 mmol/l K+ is greater than 7.0 mmol/l (or ECG changes)

CHRONIC RENAL FAILURE (CRF)

It is a progressive loss in the number of functioning nephrons. Causes: The most common are glomerulonephritis, diabetes mellitus, and hypertension The key characteristic of well developed CRF is polyuria the opposite to the oliguria or anuria of ARF. Features : are those of decreasing glomerular function

Increase in urea ( azotaemia) Increase in creatinine and progressive decrease in Cr clearance Increase in urate, phosphate, sulphate, etc. Features of decreasing tubular function (Developed later): - Polyuria with fixed output - Loss of concentrating and diluting abilities - Metabolic acidosis with increased anion gap - Sodium instability - overload or deficiency can easily occur

MANAGEMENT OF CRF 1. Water intake is controlled by thirst since output is fixed. 2. Careful control of Na+, K+ and protein intake. 3. Treatment of anaemia with erythropoietin. 4. Oral bicarbonate if acidosis is severe. 5. In end-stage CRF : dialysis - haemodialysis or peritoneal dialysis , renal transplantation

RENAL ACIDOSIS
2 components to H+ excretion by the kidney: (i) Reabsorption of filtered bicarbonate in the proximal tubule (ii) H+ secretion in the distal tubule. 2 types of acidosis: 1. URAEMIC ACIDOSIS.
Seen in acute or chronic renal failure. Decreased H+ excretion due to both glomerular and tubular failure. Increased anion gap due to retention of phosphate, sulphate and other anions.

2- RENAL TUBULAR ACIDOSIS (RTA).

A group of disorders characterized by tubular dysfunction, with normal or perhaps slightly decreased glomerular function. Normal anion gap (i.e. hyperchloraemic) Metabolic acidosis, in the presence of a normal or near-normal plasma creatinine. The urine pH is often inappropriately high in the face of the systemic acidosis (but NOT always) 4 types

 Type 1 (distal) RTA: Due to inability of distal nephron to excrete H+. The urine pH is inappropriately high (pH > 5.5), but does not contain significant bicarbonate. Associated with hypokalemia, nephrocalcinosis and rickets. There are genetic and acquired forms (e.g. heavy metal toxicity). Type 2 (proximal) RTA: Due to defective proximal bicarbonate reabsorption. The renal threshold for bicarbonate is decreased (normal value 24 mmol/l).

 Plasma bicarbonate level exceeds the (lowered) renal threshold (e.g. 16 mmol/l) Urine pH is inappropriately high (called renal bicarbonate wasting). Associated with hypokalemia due to the increased delivery of Na+ to the distal tubule. Proximal RTA may be isolated or may be associated with other proximal tubular defects: glycosuria, phosphaturia and amino aciduria - the Fanconi syndrome. Can be genetic (e.g. with cystinosis) or acquired (e.g. toxins).

 (Type 3 RTA is a mixed form of types 1 and 2 - not recognised nowadays as a specific entity.) Type 4 RTA : The acidosis due to mineralocorticoid deficiency or to renal resistance to mineralocorticoid action is Associated with hyperkalemia. Mineralocorticoid resistance may be a specific genetic entity (pseudohypoaldosteronism) or may result from generalized tubular damage.

 A 6-month old male infant was investigated for poor feeding and failure to gain weight. There was occasional regurgitation of food but no diarrhoea. There were no problems during labour and the infant appeared normal after birth. The following biochemical results were obtained: Serum: Na+ 134 mmol/l, K+3.0mmol/l, Cl- 115mmol/l, HCO3- 12mmol/l, creatinine 75 mol/l, pH 7.2, pCO2 3.8 kPa, Bicarbonate 11 mmol/l, URINE pH 6.7 Discuss the biochemical findings in this case, and suggest a diagnosis. Would any further investigations be useful? Discuss treatment.

 30 year old male. 48 h after motor accident. Multiple injuries. Serum: urea 20.5 mmol/l, creat 450 mol/l, Na+ 140 mmol/l, K+ 6.0 mmol/l HCO3 15 mmol/l Urine:urea 74 mmol/l (N 250-600 mmoles/day), creat 1500 mol/l (N 7-17 mmoles/day), Na+ 90 mmol/l, Cl- 100 mmol/l, urine osmol 350 mosm/l, urine output 400 ml/24 h i. Comment on the urea and creatinine output. ii. What diagnosis is suggested, and by what specific tests ? iii. Why is the plasma potassium elevated?

 iv. What is the danger associated with hyperkalemia? v. What can be done to treat the hyperkalemia acutely?

vi. Comment on this patient's fluid requirements. Would an infusion of several litres of intravenous fluid be beneficial?