Chapter 3: Renal Function
Analysis of Urine and Other Body Fluids
Renal Physiology
Nephron
Functional unit of kidney
1-1.5 million in the kidney
Two (2) types of nephrons
1. Cortical nephrons
2. Juxtamedullary nephrons
Cortical Nephrons
85% of nephrons
Situated in the cortex
Function:
o
Removal of waste products
o
Reabsorption of nutrients
Juxtamedullary nephrons
Longer loops of Henle
Deep into the medulla
Function:
o
Concentration of urine
Function of Kidneys
1. Clear waste products from blood
2. Maintain water and electrolyte balances
Renal Blood Flow
Hydrostatic Pressure Differential
Important for glomerular filtration
Maintain consistency of glomerular capillary pressure and
renal blood flow
Peritubular Capillaries
Surround proximal and distal CT
Function:
o
Immediate reabsorption of essential substances
(from Proximal CT)
o
Final adjustment of urinary composition (in Distal
CT)
Vasa Recta
Adjacent to ascending and descending loops of Henle in
juxtamedullary nephrons
Major exchanges of water and salts take place between
blood and medullary interstitium
o
Maintains osmotic gradient (salt concentration)
Total Renal Blood Flow: 1,200 mL/min based on 1.73m 2 average
body size
Bowmans capsule
Covers the glomerulus
Forms the beginning of renal tubule
Factors that influence Filtration
1. Cellular structure of Bowmans and capillary walls
2. Hydrostatic pressure
3. Osmotic pressure
4. Feedback mechanisms of RAAS
Cellular Structure of Glomerulus
**Age groups should be considered when evaluating renal function
studies
Increase BP
Constricts afferent arteriole
Prevent over filtration
Prevent glomerular damage
Renin-Angiotensin-Aldosterone System
Glomerulus
Nonselective filter
Coil of approximately 8 capillary lobes
Glomerular Filtration Barrier
Hydrostatic Pressure
Enhances filtration
Overcome the opposition of pressures from the fluid within
Bowmans capsule and oncotic pressure of unfiltered plasma
Autoregulatory mechanism
Within juxtaglomerular apparatus
Maintains glomerular blood pressure at constant rate
Decrease BP
Dilates afferent arteriole
Constricts efferent arteriole
Prevents of blood in kidney
Prevents toxic waste in blood
Renal Blood Flow
Blood enters the capillaries of the nephron through the afferent
arteriole glomerulus efferent arteriole peritubular capillaries
vasa recta cortex and medulla of the kidney Renal vein
Glomerular Filtration Barrier Layers
1. Capillary wall membrane
2. Basement membrane
3. Visceral epithelium of Bowmans capsule
Endothelial cells
Fenestrated
o
Increase capillary permeability
Podocytes
Inner layer of Bowmans capsule
Forms the filtration slits
Filtration slits
Covered by basement and thin membranes
Shield of Negativity
Repels molecules with positive charge
Important because of Albumin
o
Albumin has positive charge
Glomerular Pressure
Total Renal Plasma Flow: 600-900 mL/min
Glomerular Filtration
Walls of glomerulus
Renal Artery
Supplies blood to the kidneys
** Varying sizes of the arterioles help create hydrostatic pressure
differential
RAAS
Regulates flow of blood to and within the glomerulus
Responds to changes in blood pressure and plasma sodium
content
Juxtaglomerular apparatus
Monitors blood pressure changes and plasma sodium
content
Consists of:
o
Juxtaglomerular cells (afferent arterioles)
o
Macula densa (of Distal CT)
Renin
Enzyme produced by juxtaglomerular cells
Convert angiotensinogen angiotensin I
Angiotensin-converting enzyme (ACE)
Angiotensin I Angiotensin II
Chapter 3: Renal Function
Analysis of Urine and Other Body Fluids
RAAS Summary
Low Blood Pressure, Plasma Sodium
Angiotensinogen
(Renin)
Angiotensin I
(ACE)
Angiotensin II
1.
2.
3.
4.
5.
Vasodilation (Afferent arteriole)
Vasoconstriction (Efferent arteriole)
Na reabsorption in Proximal convoluted tubule
Aldosterone (Adrenal cortex) sodium reabsorption in Distal CT
ADH (Hypothalamus) Water reabsorption in Collecting ducts
Renal Concentration
Beings in the descending and ascending loop of Henle
** Maintenance of this osmotic gradient is essential for the final
concentration of filtrate when it reaches the collecting duct
Collecting Duct Concentration
Reabsorption
Depends on:
o
Osmotic gradient in medulla
o
Vasopressin/ ADH
** Dilute filtrate + Osmotic concentration of medullary interstitium =
passive reabsorption of water
Chemical Balance
Final determinant of urine volume and concentration
Body Hydration = ADH = Urine Volume
Tubular Secretion
** BP, Plasma Na = Renin
Tubular Reabsorption
** The body cannot lose 12o mL of water containing essential
substances every minute
Active
Transport
Passive
Transport
Tubular Reabsorption Summary
Definition
Substance
Location
Substance to be Glucose,
Proximal CT
reabsorbed must AA, salts
Ascending LH
combine
with Chloride
Sodium
Proximal and Distal
carrier protein
CT
Movement
of Water
Proximal CT
molecules
Descending LH
across
Collecting duct
Proximal CT
membrane as a Urea
Ascending LH
result
of
Ascending LH
differences
in Sodium
** Medications cannot be filtered by the glomerulus
Gradients
Physical differences
Concentration or electrical potential on opposite sides of the
membrane
** When plasma concentration of a substance reaches an abnormally
high level; the filtrate concentration exceeds the maximal reabsorptive
capacity (Tm) and substance begins appearing in the urine.
Renal Threshold
Plasma concentration at which active transport stops
RT of Glucose = 160-180 mg/dL
Normal Blood pH: 7.4
To maintain acid base balance of blood:
1. Buffer
2. Eliminate excess acid formed by dietary intake and
metabolism
Bicarbonate ions (HCO3-)
Readily filtered by glomerulus
When buffering capacity depends
Hydrogen ions (H+)
Readily filtered and reabsorbed
Excretion depends on tubular secretion
Ammonia
Produced from breakdown of glutamine
Proximal CT, Distal CT, Collecting duct
Reacts with H+ to form Ammonium (NH4+), then excreted in
urine
Results of disruption of Secretory Functions
1. Metabolic acidosis
2. Renal Tubular acidosis inability to produce acid in urine
** Knowledge of renal threshold and plasma concentration can be used
to distinguish between excess solute filtration and renal tubular
damage.
** Glucose appearing in the urine of a person with normal glucose is a
result of a tubular damage and NOT diabetes mellitus.
Tubular Concentration
Countercurrent Mechanism
Selective reabsorption
Maintain the osmotic gradient of the medulla
Proximal Convoluted Tubule
Major site for removal of unfiltered substances
Acid-Base Balance
gradients
CT = convoluted tubule; LH = Loop of Henle
Tubular Secretion
Involves passage of substances from the blood in the
peritubular capillaries to the tubular filtrate
Functions:
o
Eliminate waste products not filtered by
glomerulus
o
Regulate acid-base balance in the body (Secrete
H+)
Renal Function Tests
Glomerular Filtration Tests
Clearance Tests
Standard tests used to measure the filtering capacity of the
glomerulus
Measures the rate at which the kidneys are able to remove a
filterable substance from the blood
Chapter 3: Renal Function
Factors to consider in selecting a clearance test substance
1. Must be neither reabsorbed nor secreted by the tubules
2. Stability of substance in 24-hour urine
3. Plasma level consistency
4. Substances availability to the body
5. Availability of tasks to analyze the substance
Analysis of Urine and Other Body Fluids
To adjust clearance for body size:
C=
UV 1.73
P
A
Clearance Tests
Primary substances used in clearance tests
1. Creatinine
2. Beta-2 microglobulin
3. Cystatin C
4. Radioisotopes
Exogenous Procedure
Requires an infused substance
Seldom method of choice
Endogenous Procedure
Substance is already present in the body
Urea Clearance
Earliest glomerular filtration test
Because urea is present in all urine specimens
Inulin Clearance
Original reference method
Not a normal body constituent
Polymer of fructose
Extremely stable
Not reabsorbed/secreted by tubules
Must be infused by IV at constant rate
Where: A = Actual Body Size
log A = (0.425 x log weight) + (0.725 x log height)
Normal Reference Range of Plasma Creatinine = 0.5-1.5 mg/dL
Estimated Glomerular Filtration Rate
Estimated clearances
Used for routinely screening patients as part of metabolic
profile
Monitor patients already diagnosed with renal disease or at
risk for renal disease
Modification of Diet in Renal Disease (MDRD)
Most frequently used formula
MDRD-IDMS-Traceable formula
Recommended by National Kidney Disease Education
Program (NKDEP)
1.154
GFR=175 serum creatinine
Creatinine Clearance
Creatinine
Waste product of muscle metabolism that is produced
enzymatically by creatine phosphokinase
Endogenous procedure
Disadvantages:
o
Creatinine = Blood Levels
o
Chromogens react in chemical analysis
o
Medications inhibit tubular secretion of creatinine
o
Bacteria break down creatinine
o
A diet heavy in meat influence results of plasma
specimen is drawn before the collection period
o
Not reliable indicator
Muscle-wasting disease
Atheletes or with heavy excercise
o
Accurate results depents of completeness of 24hour collection
o
Must always be corrected for children
** Greatest source of error = Improperly timed specimen
Glomerular Filtration Rate
Reported in mL cleared/min
Urine Volume
Calculated by dividing the number of mL in specimen by
number of minutes used to collect specimen
mL
UV =
min
Original MDRD Calculation
When serum creatinine is not standardized to IDMS
1.154
GFR=173 serum creatinine
if
0.203
age
0.742 ( if fem
Cystatin C
Cystatin C
-
Most frequently used formula
Small protein produces at a constant rate by all nucleated
cells.
Readily filtered by the glomerulus and reabsorbed and
broken down by the renal tubular cells.
** No cystatin C is secreted by the tubules, and the serum
concentration can be directly related to the
GFR.
** Measurement of serum cystatin C has been shown to provide a
good procedure for screening and monitoring GFR.
Monitoring levels of cystitin C is recommended for:
1.
2.
3.
4.
Plasma cleared per minute:
UV
C=
P
if
age0.203 0.742 ( if fem
pediatric patients
persons with diabetes
elderly
critically ill patients
*Recent studies also have shown that measuring both serum or
plasma cystatin C and creatinine can provide even more accurate
information on a patients GFR.
Beta2-Microglobulin
Chapter 3: Renal Function
-
Dissociates from human leukocyte antigens at a constant
rate and is rapidly removed from the plasma by glomerular
filtration.
plasma level (more sensitive indicator of a GFR than
creatinine clearance.
** Test is not reliable in patients who have a history of immunologic
disorders or malignancy.
Radionucleotides
Exogenous procedures and more labor intensive and costly
-
125
I-iothalamate
injection 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.
Analysis of Urine and Other Body Fluids
Abnormal
Fluid is restricted for another two hours and both urine and
serum species are collected for osmolality testing.
3:1 (Urine:Serum ratio) / Urine osmolality of 800 mOsm or greater
- normal tubular reabsorption.
**If the test continues to be abnormal, additional testing is performed to
determine wherether the failure to concentrate the urine is cause by
diabetes insipidus
Diabetes insipidus
occurs as the result of a problem with the production or the
response of the kidney to ADH.
The patient is injected with ADH and serum and urine specimens
are collected in 2 and 4 hours.
Normal
Patient is not capable of producing ADH (neurogenic
diabetes insipidus)
Abnormal
Renal tubules are not responding to ADH (nephrogenic
diabetes insipidus)
**Procedure of injecting this radio nucleotide can be valuable to
measure the viability of a transplanted kidney.
o
Clinical Significance:
1.
2.
3.
Although the GFR is a frequently requested laboratory procedure,
its value does not lie in the detection of early renal disease.
Instead, it is used to:
Determine the extent of nephron damage in known cases of renal
disease
Monitor the effectiveness of treatment designed to prevent further
nephron damage
Determine the feasibility of administering medications, which can
build up to dangerous blood levels if the GFR is markedly
reduced.
Tubular Reabsorption Tests
Osmolality
Osmolality
Measures only the number of particles in a solutions
Performed for a more accurate evaluation of renal
concentrating ability.
** Specific gravity is influenced by the number and density (molecular
weight) of the particles
Renal concentration
concerned with small particles (sodium and chloride
molecules
** Loss of tubular reabsorption capability is often the first function
affected in renal disease.
Concentration Tests
Tests to determine the ability of the tubules to reabsorb the
essential salts and water that have been nonselectivelyfiltered by the glomerulus
Freezing Point Osmometers
** Urine concentration is largely determined by the bodys state of
hydration
Fishberg and Mosenthal concentration Tests
measured specific gravity
Fishberg Test
patients were deprived of fluids for 24 hours before
measuring specific gravity.
Mosenthal Test
compared the volume and specific gravity of day and night
urine samples to evaluate concentrating ability.
** Neither test is used now because the information provided by
specific gravity measurements is most useful as a screening
procedure.
Osmometry
assess quantitative measurement of renal concentrating
ability
Urine osmolality reading of 800 mOsm or higher
Normal
Test can be discontinued.
-
Freezing Point Osmometers
Determine the freezing point of a solution by supercooling a
measured amount of sample to approximately 27C
Supercooled sample: vibrated to produce crystallization of
water in the solution
Heat of fusion produced by the crystallizing water :
temporarily raises the temperature of the solution to its
freezing point.
Thermistor
temperature-sensitive probe
(resistance decreases as temperature increases)
measures temperature increase (corresponds to the freezing
point of the solution
information is converted into milliosmoles.
1 mol (1000 mOsm) of a nonionizing substance dissolved in 1
kg of water
- known to lower the freezing point 1.86C
**By comparing the freezing point depression of an unknown solution
with that of a known molal solution, the osmolarityof the unknown
solution can be calculated.
**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.
Chapter 3: Renal Function
Vapor Pressure Osmometers
Vapor Pressure Osmometers
The actual measurement performed is that of the dew point
Samples are absorbed into smaller filter paper disks that are
placed in a sealed chamber containing a tempreaturesensitive thermocoupler.
Sample evaporates in the chamber, forming a vapor.
When the temperature in the chamber is lowered, water
condenses in the chamber and on the thermocoupler
Heat of condensation produced raises the temperature of the
thermocoupler to the dew point temperature
Dew point temperature is proportional to the vapor
pressure from the evaporating sample
Temperatures are compared with those of the NaCl
standards and converted into milliosmoles.
The vapor pressure osmometer uses microsamples of less
than 0.01 mL
Dew Point
Temperature at which water vapour condenses to a liquid.
**The depression of dew point temperature by solute parallels the
decrease in vapor pressure, thereby providing a measure of this
colligative property.
Technical Factors
Factors influencing true osmolarity readings:
1. lipemic serum
serum water displacement by insoluble lipid produces
erroneouss result with both vapour pressure and freezing
point osmometers
2. lactic acid
falsely elevated values if serum samples are not
separated or refrigerated within 20 minutes
3. volatile substances (ethanol)
cannot be detected by vapour pressure osmometers,
as they become a part of the solvent phase.
Analysis of Urine and Other Body Fluids
- ratio of urine to serum osmolality after controlled fluid intake
Free Water Clearance
The ratio of urine to serum osmolarity can be further expanded by
performing the analyses using:
1. Water deprivation
2. Timed urine specimen
3. Calculating the free water clearance
Free Water Clearance
Used to determine the ability of the kidney to respond to the
state of body hydration.
Determined by first calculating the osmolar clearance using
the clearance formula:
*Calculating osmolar clearance indicates how much water must be
cleared each time to produce a urine with the same osmolality as
the plasma.
Osmotic differences in the urine are the results of:
1. Renal concentrating
2. Diluting mechanisms
** By comparing the osmolar clearance with the actual urine volume
excreted per minute, it can be determined whether the water being
excreted is more or less than the amount needed to maintain an
osmolality the same as that of the ultrafiltrate.
Tubular Secretion and Renal Blood Flow Tests
**Tests to measure tubular secretion of nonfiltered substances and
renal blood flow are closely related in that total renal blood flow
through the nephron must be measured by a substance that is
secreted rather than filtered through the glomerulus.
Causes of abnormal results:
1. Impaired tubular secretory ability
2. Inadequate presentation of the substance to the capillaries
owing to decreased renal blood flow
Clinical Significance
Major
Clinical
Uses of Osmolarity
1. initially
evaluating
renal
concentrating
ability
2. monitoring the
course of renal disease
3. monitoring fluid and
electrolyte therapy
4. establishing the differential diagnosis of hypernatremiaand
hyponatremia
5. evaluating the secretion of and renal response to ADH.
PAH (p-aminohippuric acid) Test
PAH (p-aminohippuric acid) Test
-
Test most commonly associated with tubular secretion and
renal blood flow.
Disadvantage: exogenous
Nontoxic substance that is loosely bound to plasma proteins, which permits its complete removal as the blood
passes through the peritubular capillaries
Secreted by the proximal convoluted tubule.
Reference Serum Osmolality Values: 275 to 300 mOsm.
*Reference values for urine osmolality are difficult to establish,
because factors such as fluid intake and exercise can greatly
influence the urine concentration. (50 to 1400 mOsm.)
*Determining the ratio of urine to serum osmolality can provide a more
accurate evaluation.
1:1
- the ratio of urine to serum osmolality under normal random conditions
3:1
and then subtracting the osmolar clearance value from the
urine volume in mL/min.
Chapter 3: Renal Function
** The volume of plasma flowing through the kidneys determines the
amount of PAH excreted in the urine.
The standard clearance formula can be used to calculate the effective
renal plasma flow:
Based on normal hematocrits readings:
Reference Values for the effective renal plasma flow
- 600 to 700 mL/min
Average Renal Blood Flow
- 1200 mL/min
Analysis of Urine and Other Body Fluids
In normal persons, a diurnal variation in urine acidity:
Alkaline tides - appears shortly after arising and postprandially at
approximately 2 p.m. and 8 p.m
Lowest pH - night.
Renal Tubular Acidosis
Inability to produce an acid urine in the presence of
metabolic acidosis
May result from impaired tubular secretion of hydrogen ions
associated with the proximal convoluted tubule or defects in
ammonia secretion associated with the distal convoluted
tubule.
Determinants: Urine pH, titratableacidity, and urinary
ammonia measurements
Ammonium concentration
Difference between the titratable acidity and the total acidity.
Titratable Acidity and Urinary Ammonia
**A normal persons excretes approx. 70 mEq/day of acid in the form
of:
1. Titratable acid (H+)
2. Hydrogen phosphate ions (H2PO4-)
3. Ammonium ions (NH4+)
