Renal function – basic data for students and...
Transcript of Renal function – basic data for students and...
Renal function – basic data
for students and residents
Department of Paediatrics
Section for Pediatric Nephrology
University Hospital Motol, Prague
Functions of the kidney
regulation e.g. homeostasis,
water, acid/base
excretion e.g. urea, creatinine
endocrine e.g. renin,
erythropoietin,
1,25 dihydroxycholecalciferol-
conversion only in kidney!
Renal function tests
detect renal damage
monitor functional damage
help determine etiology
Laboratory tests of renal function
glomerular filtration
rate (GFR)
plasma creatinine
plasma urea
urine volume
urine urea
minerals in urine
urine protein
urine glucose
hematuria
osmolality
Kidney Function
A plumbers view
Filter
Processor
Input
Arterial
Output
Venous
Output
Urine
Kidney – basic data
Urine excreted daily in adults: cca 1.5L
Kidney only ca 1% of total body weight, despite it
The renal blood flow= 20% of cardiac output
Plasma renal flow= PRF ca 600 mL/Min./1.73 M2
Reflects two processes
Ultrafiltration (GFR): 180 L/day
Reabsorption: >99% of the amount filtered
How do you know it’s broken?
Decreased urine
production
Clinical
symptoms
Tests
Filter
Processor
Input
Arterial
Output
Venous
Output
Urine
Where can it break?
Pre-renal
Renal
(intrarenal)
Post-renal
(obstruction)
Filter
Processor
Input
Arterial
Output
Venous
Output
Urine
Causes of kidney functional disorders
Pre-renal e.g.
decreased
intravascular
volum
Renal e.g. acute
tubular necrosis
Postrenal e.g.
ureteral
obstruction
Tests of renal function
glomerular filtration
rate=GFR
plasma creatinine= Pcr
plasma urea-Purea
urine volume= V
urine urea- Uurea
cystatin C in plasma?
urine protein
urine glucose
hematuria
osmolality
Renal Function Tests-
Urine volumes
Adults:
1.5 L/24 h
typical in health,
oliguria < 400 mL,
anuria < 100 mL,
polyuria > 3000 mL
Children: ca 1.5 ml/Kg
of b.w./1 hour!
Principle of of Clearance
Some substances when filtered enter the tubules are not reabsorbed and so 100% excreted= GFR (inulin= gold standard for GFR, creatinine (but this one partially reabsorbed, particularly in uremia, then clearance <GFR
Some substances are filtered, enter tubules, and more of the substance is secreted enters the tubules by excretion. Clearance>GFR
Some substances are filtered, enter tubules, but are completely reabsorbed, so they did not reach the final urine (e.g. cystatin C)
Glomerular filtration rate
Glomerular filtration= major physiologic responsibility of kidney, GFR used as index of overall excretory function
Methods:
clearence of inulin, creatinine, EDTA and DTPA (=both derivates of acetic acid), cystatin C
GFR= Ux x V (V=volum of urine/ 1 minute or 1 second)
P x x= clearence of substance used
Glomerular filtration rate
Also service of nuclear medicine dptm.
Follow up the inulin clearence, EDTA or
DTPA clearence labelling the substances
with chromium or Tcm99
Where will you catch the activity with
detectors?
Never in the kidney or bladder area!!
Glomerular filtration rate
GFR in children, value always adapted to the
BSA!! Ideal BSA in adults is 1.73m2
Schwartz equation : GFR= v x 0.808
P
cr (umol/L)
How to assess easy if plasma creatinine is OK?
Pcr max= Vcm x 0.61 (v= body height in cm
Creatinine and Urea Plasma
Concentration- hyperbolic correlation
GFR 50%
pCr,
pUrea
140 mL/min
(100%) 0 mL/min
(0%)
Tendency in individual patients is
more important than the one value,
ever test if the hydration is OK. In
patients with CRI always note also
the BSA!
Lower limit today not 80 ml/Min.
/1.73 m2 but 90 ml/Min./1.73 m2
Normal
range->
Plasma urea (BUN)
= BUN (blood urea nitrogen)
Urea: product of protein catabolism
Synthesized by liver, majority excreted by kidney, partially reabsorbed in tubuli
Plasma concentration increases with decreased GFR
Urea cycle
CO2
NH3
aspartate
Urea
3 ATP
Urea
Cycle
Enzymatic conductivity rate
method for measuring urea
Urease
solution
Urea + 3H2O
HCO3¯ + 2NH4 + OH¯
urease
Urea in patients
with kidney diseases
Useful test but must be interpreted with great care, urea plasma level is more than creatinine dependent on protein intake
Most useful when considered along with creatinine
High in high protein intake, low in severe liver dysfunction
Urea EF may be useful in pts. on diuretics
Plasma creatinine and renal functions
Creatine: main storage compound of high
energy phosphate needed for muscle
metabolism.
Creatinine: anhydride of creatine!
Creatine Creatinine
(Waste product) H2O
Plasma creatinine vs. GFR
not linear, hyperbolic correlation!
GFR
[pCreat]
140 mL/min
(100%) 0 mL/min
(0%)
Change within an
individual patient is usually
more important than the
absolute value
Jaffe´ reaction for measuring
creatinine, simple, but better is
enzymatic method Creatinine + alkaline picrate solution
Bright orange/red colored complex
absorbs light at 485nm
(many interfering substances in blood
Can be minimized using rate method)
Analytical methods (Cr)
Normal range Pcr
Male 0.6-1.2 mg/dL,
Female 0.5-1.0 mg/dL
Be careful in children!!
Remember the max.
plasma creatinine
value!!
BUN: creatinine ratio
Pre-renal disorders
BUN:Cr ratio >20
Renal disorders
BUN: Cr nl but both
elevated
Post-renal
Filter
Processor
Input
Arterial
Output
Venous
Output
Urine
Osmolality of urine
Measures urine concentrating ability
Depends on # of particles, not size or charge
Largely due to ADH (anti-diuretic hormone)
Can reach maximum of 1200 mOsm/L
Normal range: 300-900mOsm/L, plasma 285+10
prior to collection, fluid intake restricted, first void submitted for evaluation
Measuring using the fact of freezing point depression
Standardized renal
concentration capacity test
1. Voiding completely at 9 p.m. (WC)
2. Desmopressin administration (since 2006 as
nasal spray). DDAVP is a Czech invention !!
3. Collection of urine (9 p.m. – 7 a.m.)
4. Testing of urine osmolality in this sample (not
the morning urine only!)
5. The lower limit of normal value= 950
mOsm/kg of urine
6. Short testing- Desmopressin, collection for 4
hours only= at least 900 mOsm/kg of urine
Urine dipsticks
Strip impregnated with reagents for the substances in
question within a urine sample
Substance level can be altered in the setting of pathology
within the urinary tract
Measured substances:
Modern dipsticks with multiplied zones:
Protein, hemoglobin, glucose, urobilinogen, nitrite,
leukocytes, specific gravity, and pH
Should be a tool everywhere on the level of primary
care!!!