PRINCESS ALEN I.

AGUILAR, RMT
 RENAL FUNCTION TESTS
GLOMERULAR TUBULAR TUBULAR SECRETION
FILTRATION TESTS REABSORPTION TESTS: TESTS:
A. ENDOGENOUS: A. FISHBERG A. PHENOLSULFONA
1. CREATININE B. MOSENTHAL PHTHALEIN (PSP)
CLEARANCE B. P-AMINOHIPPURIC
C. OSMOLARIITY
2. UREA CLEARANCE ACID (PAH)
D. FREE WATER
3. BETA2- C. TITRATABLE
MICROGLOBULIN CLEARANCE
ACIDITY
4. CYSTATIN-C 1. FREEZING
POINT D. URINARY
B. EXOGENOUS: AMMONIA
1. INULIN 2. VAPOR
CLEARANCE PRESSURE
2. RADIOISOTOPES
 I. GLOMERULAR FILTRATION RATE TESTS
A. CREATININE CLEARANCE (ROUTINELY USED)
 SEVERAL DISADVANTAGES:
1. Some creatinine is secreted by the tubules, and secretion increases as blood level rise
2. Chromogens present in human plasma react in the chemical analysis.
3. Medications, including gentamicin, cephalosporins, and cimetidine (Tagamet), inhibit tubular
secretion of creatinine
4. Bacteria will break down urinary creatinine if specimens are kept at room temperature
for extended periods.
5. An increased intake of meat can raise the urine and plasma levels of creatinine during the
24-hour collection period.
6. Measurement of creatinine clearance is not a reliable indicator in patients suffering
from muscle-wasting diseases or persons involved in heavy exercise or athletes
supplementing with creatine.
7. Accurate results depend on the accurate completeness of a 24-hour collection.
8. It must be corrected for body surface area, unless normal is assumed, and must always be
corrected for children.
I. GLOMERULAR FILTRATION RATE TESTS
CREATININE CLEARANCE

CCR = UV x 1.74 Sample:

P A
WHERE:
CCR = Creatinine clearance
U= urine clearance (mg/dL)
P= (Plasma creatinine)
V=urine volme (mL/min)
A= Body surface area
* x 0.17 for pediatric
patient instead 1.73
Using urine creatinine of 120 mg/dL,
plasma creatinine of 1.0 mg/dL , and
urine volume of 1.4 L obtained from
a 24-hour specimen of an average
person, calculate the GFR.
NV:
M: 107-139ml/min
F: 87-107ml/min
plasma creatinine : 0.5 to 1.5 mg/dL
 I. GLOMERULAR FILTRATION RATE TESTS
CREATININE CLEARANCE

Calculated Glomerular Filtration The calculation for ideal body weight

Estimate using Formula (IBW) is:
Developed by: Males: 50 kg 2.3 kg for each inch
of height over 60 inches
Cockcroft & Gault! Females: 45.5 kg 2.3 kg for each
inch of height over 60
CCR= (140-age)(body weight in kg) inches
72 x serum creatinine (mg/dL) The calculation for adjusted body
weight (AjBW) is:
IBW 0.3 (ABW-IBW)
• Result multiply by 0.85 (female)
• Variables: AGE, WEIGHT, SEX
 I. GLOMERULAR FILTRATION RATE TESTS
CREATININE CLEARANCE

At the present time the formula recommended by the

National Kidney Disease Education Program (NKDEP) is
called the MDRD-IDMS-traceable formula when the
serum creatinine method is not standardized to
IDMS.
GFR = 173 × serum creatinine–1.154 × age–0.203
× 0.742 (if patient is female) × 1.212 (if patient is black)
I. GLOMERULAR FILTRATION RATE TESTS
B. B2-MICROGLOBULIN
 Molecular weight 11,800kD
 Dissociates from human leukocytes antigens at a
constant rate and is rapidly removed from the plasma
by glomerular filtration.
 Sensitive method: enzyme immunoassay
 Increase plasma level has > sensitivity as indicator of
a decrease in GFR than CCT.
 However test is not reliable in patients who has
immunologic history
I. GLOMERULAR FILTRATION RATE TESTS
C. CYSTATIN-C
 Is a small protein (13,359kD) produed at a constant
rate y all nucleated cells.
 It is readily filtered by the glomerulus and reabsorbed
and breakdown by the renal tubular cells.
 Thus, serum concentration level is directly related to
GFR.
 Monitoring levels is recommended for pediatric
patients, persons with DM, the elderly and critically ill
patients.
I. GLOMERULAR FILTRATION RATE TESTS
D. UREA CLEARANCE (OLD METHOD)
 Earliest glomerular filtration tests
 Because approximately 40% of the filtered urea is
reabsorbed, normal values were adjusted to reflect the
reabsorption, and patients were hydrated to produce a
urine flow of 2 mL/min to ensure that no more than
40% of the urea was reabsorbed.
I. GLOMERULAR FILTRATION RATE TESTS
E. INULIN CLEARANCE (GOLD STANDARD)
 A polymer of fructose, is an extremely stable
substance that is not reabsorbed or secreted by the
tubules.
 It is not a normal body constituent, however, and
must be infused by IV at a constant rate throughout
the testing period.
I. GLOMERULAR FILTRATION RATE TESTS
F. RADIONUCLEOTIDES
 Injecting radionucleotides such as
125Iiothalamate

 provides a method for determining glomerular

filtration through the plasma disappearance of the
radioactive material and enables visualization of the
filtration in one or both kidneys.
 This procedure can be valuable to measure the
viability of a transplanted kidney.
 II. TUBULAR REABSORPTION TEST
Concentration tests  used to evaluate tubular reabsorpion

A. OLD TESTS:
1. FISHBERG TEST
 The patient is deprived of fluid for 24 hours then
measure urine SG
 SG should be > 1.026
II. MOSENTHAL TEST
 Compare day and night urine in terms of volume
and SG
 II. TUBULAR REABSORPTION TEST
Concentration tests  used to evaluate tubular reabsorpion

B. NEW TESTS:
1. SPECIFIC GRAVITY
 Influence by the number and density of particles in
a solution
II. OSMOLARITY
 Influenced by the number of particles in a solution
 OSMOLARITY PROCEDURE AND
INTERPRETAION
1. Controlled intake procedures can include after
dinner overnight deprivation of fluid for 12 hours
followed by collection of a urine sample.
2. A urine osmolality reading of 800 mOsm or
higher is normal and the test can be discontinued.
3. If the urine test is abnormal, the fluid is restricted
for another two hours and both urine and serum
species are collected for osmolality testing. A urine
to serum ratio (U:S ratio) of 3:1 or greater or
a urine osmolality of 800 mOsm or greater
indicates normal tubular reabsorption.
 II. TUBULAR REABSORPTION TEST
OSMOLARITY
A. FREEZING POINT
OSMOMETERS
 Determine the freezing point of a
solution by supercooling a
measured amount of sample to
approximately 27O C.
 1 Osm or 1000mOsm/kg of H2O
will lower the freezing point of
H2O by 1.86oC
 Clinical osmometers use solutions
of known NaCl concentration as
their reference standards because
a solution of partially ionized
substances is more representative
of urine and plasma composition.
B.VAPOR PRESSURE
OSMOMETERS
 The depression of dew point
temperature by solute parallels the
decrease in vapor pressure, thereby
providing a measure of this
colligative property.
 The vapor pressure osmometer
uses microsamples of less than 0.01
mL; therefore, care must be taken to
prevent any evaporation of the
sample prior to testing.
 used primarily to analyze
serum and sweat microsamples
for disorders not related to
renal function, such as cystic
fibrosis.
 II. TUBULAR REABSORPTION TEST
III. FREE WATER CLEARANCE
 calculating the osmolar clearance using the
standard clearance formula:
COsm= UOsm X V
posm
 and then subtracting the osmolar clearance
value from the urine volume in mL/min.
Fwc = COsm- Urine volume
FWC sample:
 Using a urine osmolarity of 600 mOsm , a urine volume of 2
mL/min , and a plasma osmolarity of 300 mOsm , calculate the
free water clearance:

 NV:
 (-) NEGATIVE result indicates that less than the necessary
amount of water is being excreted, a possible state of
dehydration.
 If the value had been 0, no renal concentration or dilution
would be taking place;
 lf the value had been POSITIVE, excess water would have been
excreted.
 II. TUBULAR SECRETION TEST
& RENAL BLOOD FLOW

A. PHENOLSULFONAPHTHANLEIN (PSP)
 The PSP test is not currently performed because:
 Standardization and interpretation of PSP results are difficult
 interference by medications, elevated waste products in patients’
serum, the necessity to obtain several very accurately timed urine
specimens
 possibility of producing anaphylactic shock.
B. P-aminohippuric (PAH) acid Test

 normal values for the effective renal plasma

flow range from 600 to 700 mL/min, making the
average renal blood flow about 1200 mL/min
 II. TUBULAR SECRETION TEST
& RENAL BLOOD FLOW

C. TITRATABLE ACIDITY & URINARY AMMONIA

 The ability of the kidney to produce an acid urine depends on
the tubular secretion of hydrogen ions and production and
secretion of ammonia by the cells of the distal convoluted
tubule.
 A normal person excretes approximately 70 mEq/day of acid in the form
of titratable acid (H+), hydrogen phosphate ions (H2PO4–), or
ammonium ions (NH4+).
 In normal persons, a diurnal variation in urine acidity consisting of
alkaline tides appears shortly after arising and postprandially at
approximately 2 p.m. and 8 p.m.
 The lowest pH is found at night.
 By titrating the amount of free H+ (titratable acidity) and then the total
acidity of the specimen the ammonium concentration can be calculated
as the difference between the titratable acidity and the total acidity.
INTRODUCTION TO
URINALYSIS
 Urinalysis – marked the beginning of laboratory medicine;
included observations of color, turbidity, odor, volume,
viscosity, and even sweetness
 1140 AD – color charts were developed that described the
significance of 20 different colors
 1627 – Thomas Bryant wrote a book about charlatans
(pisse prophets) which inspired the passing of the first medical
licensure law in England
 1694 – Frederik Dekkers’ discovered albuminuria by boiling
urine
 17th century – microscope was invented which led to the
examination of urinary sediment and to the development by
 Hippocrates
• Credited as being
the Western
father of
modern
medicine
• 5th century BC-
wrote a book on
uroscopy
Richard Bright

1827 –
introduced the
concept of
urinalysis as
part of routine
patient
examination
 Henry
Bence-Jones

• Associated a
urine protein
with patients
suffering from
multiple
myeloma
• Published work
1848
 of methods for quantitating the
Thomas Addis
microscopic sediment
 Accurate count / assessment of urine
sediment
 Urine sediment is analyzed in a
hemacytometer an individual elements
reported as number per 24 hours.
 To aid in the diagnosis of diseases
 To screen asymptomatic populations for
undetected disorders
 To monitor the progress of disease and
the effectiveness of therapy
A. First morning – ideal specimen for routine screening,
pregnancy test, detection of orthostatic proteinuria , most
concentrated and acidic; for well preservaion of cell and cast
B. Random – routine and qualitative UA; done within 2 hours
C. 24-hour – quantitative chemical tests, hormone studies ,CCT, begin
and end the collection with an empty bladder
D. 12-hour (ex. 8am  8pm) – Addis count
E. Afternoon specimen (2-4 pm) – urobilinogen
determination(alkaline tide); protect from light
F. 4 hour- for nitrite determination; for bacteria to convert
nitrate to nitrite; urine remains in the bladder for atleast 4
hours before being collected
H. 5 hour urine- for determining D-xylose
I. Fasting/Second morning – second voided
urine, diabetic screening/monitoring
J. Midstream clean-catch – routine screening,
bacterial culture, (OPD)
K. 2-h Postprandial – diabetic monitoring
 L. Suprapubic aspiration (cystocentesis)

 urine is obtained from a needle through the

abdominal wall.
 bladder urine for anaerobic bacterial culture and
urine cytology
 M. Pediatric Specimen-
 use of soft, clear plastic bag with adhesive (wee bag)

N. Catheterization – bacterial culture

L. Three-glass collection – diagnosis of prostatic infection
1. First portion of vioded urine (less WBC/bacteria)
2. Middle portion of voided urine (control, must be no
bacteria/WBC, for bladder nad kidney infection) : if positive,
indicative of UTI, invalid 3rd tube
3. Urine after prostatic massage (prostatitis>WBC/bacteria);10x
greater than tube #1
M. Drug testing specimen
 COC: process that provides documentation of proper sample
identification from the time of collection to the receipt of laboratory
results
 Required urine volume: 30-40mL
 temperature (within 4 mins) should be within 32.5- 37.7ºC;
 blueing agent added to the toilet water reservoir in unwitnessed
collection to prevent adulteration
 Composition of Urine:
 95% water, 5% analytes
 a. Organic components – urea, creatinine, uric
acid, ammonia, undetermined nitrogen, others
 b. Inorganic components – Cl-, >Na+, >K+, Ca2+,
phosphates, sulfates
 Containers: for routine urinalysis should have a
wide mouth to facilitate collections from female
patients and a wide, flat bottom to prevent overturning.
 Specimens must be collected in clean, dry, leak-proof
containers and clear material to allow for determination of
color and clarity.
 The recommended capacity of the container is 50
mL, which allows 12 mL of specimen needed for
microscopic analysis, additional specimen for repeat
analysis, and enough room for the specimen to be mixed
by swirling the container.
 Labels must be attached to the container, not to
the lid, and should not become detached if the
container is refrigerated or frozen.
 A requisition form (manual or computerized)
must accompany specimens delivered to the
laboratory. The information on the form must match
the information on the specimen label.
1. Improperly labeled and collected specimens
2. Nonmatching labels and requisition forms
3. Specimens contaminated with feces or toilet
paper
4. Containers with contaminated exteriors
5. Specimens of insufficient quantity
6. Specimens that have been improperly
transported
Sodium benzoate Does not interfere with reagent strip for glucose
HCl Preservation for cathecolamines and 5-HIAA determination
 List of reference
 Lillian Mundt & Kristy Shanahan, Graff’s Textbook of Urinalysis and Body
Fluids, 2nd Ed.
 Susan Strassinger & Marjorie Di Lorenzo, Urinalysis and Body Fluids, 5th &
6th Ed.
 Roderick Balce, RMT-CEU Professor AUBF Notes
 Erol Coderres,RMT-AUBF notes
 Meryl Haber, MD, A Primer of Microscopic Urinalysis, 2nd Ed.
 Zenggang Pan, MD, PhD., Dept of Pathology, U of Alabama at Birmingham
 http://www.enjoypath.com/cp/Chem/Urine-Morphology/Urine-morphology.htm
 Department of the Army, Landstuhl Regional Medical Center
 http://www.dcss.cs.amedd.army.mil/field/FLIP%20Disk%204.2/FLIP42.html
 Nobuko IMAI, Central Laboratory for Clinical Investigation, Osaka
University Hospital
 http://square.umin.ac.jp/uri_sedi/Eindex.html
THANK YOU FOR LISTENING
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