Renal function

tests

Dr. Nalini
Functions of kidneys :

Homeostasis
Secretion of hormones Renin,
Prostaglandin, Bradykinin
Red cell production
Calcium , phosphorus and bone
metabolism
Catabolism of peptide hormones
Synthesis of glucose
Excretory function
 Renal function tests are done

To screen and identify children

with asymtomatic renal disease
To determine etiology and
severity of renal disease and
function
To assess therapeutic response
and progress of illness
Renal function tests include -

Urine examination
Blood examination
Renal clearance tests
Miscelleneous
Urine examination

Non invasive diagnostic test.

Done on freshly voided early
morning midstream urine
examined within one hour of
voiding.
Can be maintained for 24hrs at
40C adding few drops of acetic
acid which preserves casts.
It includes-
Appearance
Quantity
Odour
Colour
Specific gravity , Osmolality , PH
Urinary proteins , glucose, ketones
Blood in urine
Microscopy cells , gram stain
Culture
Tests nitrite test , leucocyte
esterase test
Appearance:

Freshly voided clear yellow

Turbidity Pus cells
- Urates
-Phosphates
-Refrigeration
Quantity :
Depends on
Fluid intake
Environmental temperature
Body temperature
Type of food ingested
Exercise
Dress worn
Normal values for urine
output
Urine 1- 2ml/kg/hr Acceptable

More than Adequate

2ml/kg/hr

More than Polyuria

4ml/kg/hr

Less than 1ml/kg/hr Oliguria

Less than 0.5 Anuria

ml/kg/hr
Normal urine output per day at
different ages:
Age Frequency Vol in ml
1-2 days 2-6 30-60
3-10 days 2-6 100-300
10-60 days 5-30 250-450
2-12 mon 5-20 400-500
1-3 yrs 5-20 500-600
3-5 yrs 5-20 600-700
5-8 yrs 6-8 650-1000
8-14yrs 4-6 800-1400
Odour :

Normal aromatic
Bacterial infection foetid or
ammonical
Metabolic disorders
Colour :

It changes during the course

of the day and ingestion of
foods or drugs ,renal or
metabolic disorders.
Color of urine in various
conditions :
COLOR CAUSES
Amber Normal
Colorless Very dilute urine
Cloudy Phosphates
Milky Pyuria ,Chyluria
Yellow orange Concentrated urine
Urobilin in excess
Bilirubin
Color of urine in various
conditions contd..,
COLOR CAUSES
Red Hemoglobinuria
Myoglobinuria
Hematuria
Foods with Rhodamine
Drugs like pyridium,rifampicin
Brown Homogentisic acid
black
Methemoglobin
Blue green Pseudomonas infection
Specific gravity :

Normal 1.001- 1.030

Measured by Urinometer
-Refractometer
-Dipstick
Increased Low water intake
-Diabetes mellites
-Albuminuria
-Acute Nephritis
 Decreasesd Tubular damage
- Absence of ADH

Isothenuria fixed low specific

gravity
- Renal failure
Urine proteins
Normalsmall amounts of albumin &
LMW proteins are found
Excretion <150mgs/day
Proteinuria-postural or fixed
Turbidometry
Heat coagulaion test
Urine dip stick
Sulfosalicylic acid test
Reagent strips
Urine glucose & ketones

Glucose- dip stick

-Benedicts
Ketones- ketonemia
- prolonged fasting
Blood in urine

Positive dip stick reaction

indicates presence of RBCs &
free Hb

Positive test in the absence of

RBCs- haemoglobinuria &
myoglobinuria
microscopy
Clean fresh midstream early morning
sample collected.
10ml centrifuged at 3000rpm for 3mns &
the sediment resuspended in 0.5ml urine.
Cover slip placed- light microscopy
phase contrast- cell
morphology , urine sediments
Polarising filters-
crystals
1.cells

RBC-
>5RBC/HPF
Dysmorphic-glomerular or tubular
origin
Isomorphic distal to renal
pappillae
Haematuria > 80% dysmorphic
RBCs-glomerular disease
Leukocytes
Polymorphs infections
Sterile pyuria-glomerulonephritis ,
stones, inadequately treated UTI,
acute viral haemorrhagic cystitis
Eosinophilluria-acute interstitial
nephritis
 Tubular epithelial cells- acute tubular
necrosis, with
lipid droplets-oval fat bodies nephrotic
syndrome
Squamous epithelial cells-bladdder &
urethra
2. cast

Formed from proteinecious matrix

of tamm horsfall protein, secreted
in tubular lumen
Red cell cast- glomerulonephritis
 Leukocyte cast acute bacterial
pyelonephritis
- Tubulointerstitial
nephritis
Tubular epithelial cell cast- acute bacterial
pyelonephritis, Acute glomerulonephritis
 Fatty cast-nephrotic syndrome
Hyaline cast-fever after exercise
Granular cast-renal parenchymal damage
Broad waxy cast- chronic renal failure
Pigmented cast- Hb, myoglobin
3 .crystals

Uric acid- diamond or trepezoid

shape
cystine- flat hexagonal
Ca oxalate monohydrate-round disc
Ca oxalate dihydrate-pyramids
Triple phosphate-coffin lid shaped
Ca phosphate fan shaped
Urinary crystals. (A) Calcium oxalate crystals; (B) uric acid
crystals (C) triple phosphate crystals with amorphous
phosphates ; (D) cystine crystals.
4 .gram stain

Screening for UTI

1 organism/HPF in uncentrifuged
urine represents 105 colonies/ml of
urine.
Urine culture

Significant bacteuria->105
CFU/mm3
104- 105- significant poliuria,
partially treated UTI, catheter or
suprapubic samples
<10 4insignificant
Urine osmolality :

Newborn preterm -500

term -800
Early morning urine osmoality >800
,indicate normal concentrating ability.
Useful in hypo/hypernatremia,polyuria,
oliguria.
 Hyponatremia with low urine osmolality
water intoxication
Hyponatremia with high urine osmolality
water deprivation
- dehydration
Hypernatremia with low urine osmolality
polyuria
Hypernatremia with high urine
osmolality- excess salt ingestion with

water deprivation
Blood examination :
Blood urea -5-40mg/dl
-filtered at glomerulus and
reabsorbed at tubules
-end product of protein nitrogen
catabolism
Serum creatinine filtered by glomerulus
,secreted by tubules
-product of enzymatic
degradation of muscle
creatinine
-formula -0.004xHt(cm)
Normal creatinine values:

Age Value
Upto 1 yr 0.6mg/dl
2-3yrs 0.7mg/dl
4-7yrs 0.8mg/dl
8-10yrs 0.9mg/dl
11-12yrs 1.0mg/dl
13-17yrs 1.2mg/dl
18-20yrs 1.3mg/dl
Arterial blood gas:
Diagnose acid base disorders.
PH of urine is acidic 4.5-8
Bicarbonate estimation
-premature :18-
26
-term-2yrs:20-26
->2yrs:22-26
Persistently low bicarbonte with urine PH
> 6 renal tubular acidosis
 Anion gap
Serum electrolytes :
Serum sodium 135-145meq/l
Serum potassium 3.5-5.5meq/l
Serum calcium, serum phosphorus
Renal clearance tests :

Estimation of GFR :
Inulin clearance
Creatinine clearance
Ccr= Ucr V/Pcr
Ccr = clearance rate creatinine
Pcr = plasma concentration of
creatinine
Ucr= urine concentration of
creatinine
V = urine flow rate[volume in
ml/min]
Normal creatinine clearance in
various age groups:
Age GFR(ml/min/1.73mt
2)
preterm 47
Newborn 50
0-3mnths 60
3-6mnths 80
6-24mnths 100
2-12yrs 120
>12yrs 130
Equations for predicting GFR:
REFERENCE FORMULA
Creatinine based
Original schwartz 0.55Xht(cm)/Scr
CKiD study 0.413Xht
AIIMS delhi 0.42
Leger (0.641Xwt)/ScrX(0.00131Xht2)/Scr
Cystatin based
Filler 91.62XcysC-1.123
Grubb 84.69XcysCX1.680X1.384 if
<14yrs
Combined csystatin &
creatinine
CKiD study 39.1X(ht(mt)/Scr)0.516
X(1.8/cysC)0.294 X(30/BUN)0.169
X1.099m X(ht(m)/1.4)0.188
Tubular functions
Tubular proteinuria alpha and beta glolbulins
G lucose -10mg/100ml
Aminoacids Fanconi ,Cystinuria, Hartnups
Phosphaturia normally >85% reabsorbed
Tubular reabsorption of phosphate =
1 (urine PO4 S.Creatinine/Serum PO4urine

creatinine) 100
Tubular maximum of phosphorus (TMP) corrected
to GFR is appropriate
= S. PO4 U.PO4 S cr/U cr
 Fractional excretion of sodium:
= (urine sodiumplasma Cr/plasma
sodiumurine Cr) x 100
<1 renal dysfunction
>1 sodium wasting
Hypercalciuria
>4mg/kg
Spot urine calcium/ creatinine values measured.
>0.86 -<7mon
>0.6 = 7mon -18mon
>0.2 19mon -6yrs
>0.22 older child
 Transtubular potassium gradient
Urine dilution tests
- simple water loading test
Urine concentration tests
- water deprivation test
Miscellaneous :

Intravenous pyelography
Arteriography
Ultrasound KUB
Isotope perfusion studies
Renal biopsy
T
H
A
N
K
U