Hello friends...! Exactly a year from today, i made my google slideshare account...and started publishing my ppts in it..... Today, I am publishing my 25th ppt........ And the first ppt in CLINICAL PHARMACY!! This is regarding RENAL FUNCTION TESTS...... Hope it may help anyone who refer this. God bless :) @rxvichu-alwz4uh! :) :)

1. PRESENTED TO : SEBIHA MAM, AND MY CLASS 
PRESENTED BY : VISHNU.R.NAIR,
4TH YEAR PHARM.D,
NATIONAL COLLEGE OF PHARMACY(NCP)

2. “Tests, that include INTERPRETATION of LABORATORY
TESTS, used in the ASSESSMENT of KIDNEY FUNCTION;
in order to diagnose possible renal diseases”…………………

3. RFTs are needed to :
1. ASSESS FUNCTIONAL CAPACITY of KIDNEY
2. DETECT(in early stages), possible RENAL IMPAIRMENT
3. ASSESS SEVERITY & PROGRESSION of IMPAIRMENT
4. MONITOR RESPONSE to TREATMENT
5. MONITOR SAFE & EFFECTIVE USE of DRUGS, that are excreted in
urine……………………….

4. RFTs should be assessed in the following conditions:
1. Older age 11. Obstruction to lower urinary tract
2. Family history of CKD 12. Drug toxicity……………….
3. Decreased renal mass
4. Reduced birth weight
5. DM
6. HTN
7. Autoimmune diseases
8. Systemic infections
9. UTI
10. Nephrolithiasis

5. A. TESTS, USED TO ASSESS KIDNEY FUNCTION
B. URINALYSIS
C. CHEMICAL ANALYSIS(SEMIQUANTITATIVE TESTS)

6. Classified into:
I. EXOGENOUS MARKERS:
Includes :
- Inulin clearance - Iodothalamate & Cr-EDTA clearance
II. ENDOGENOUS MARKERS :
Includes:
- Cystatin C
- Serum creatinine
- Urea(BUN)
- BUN: Scr ratio
- Creatinine clearance

7. 1. INULIN CLEARANCE:
- NORMAL RANGE :
a.127 mL/min/meter square(male)
b. 118 mL/min/meter square(female)
- Inulin is a FRUCTOSE POLYSACCHARIDE
- Regarded as GOLD STANDARD for measuring GFR in ADULTS & OLDER
CHILDREN
- This is restricted/ practical application is limited due to 1 reason :
a. Requires special analytical methods, and thus, is COSTLY

8. II. IODOTHALAMATE & Cr-EDTA CLEARANCE:
- NORMAL RANGE :
a. 127 ml/min/meter square(males)
b. 118 ml/min/meter square (females)
- I-IODOTHALAMATE is a RADIOACTIVE MARKER
- Marker  injected intravenously  take multiple blood samples, along with
urine samples, to check its CLEARANCE
- Highly COSTLY thus sometimes replaced by Cr-EDTA………………….

9. 1. CYSTATIN C :
- CYSTATIN C is a PROTEASE INHIBITOR
- Mainly produced by NUCLEATED CELLS
- Serum CYSTATIN concentration is INVERSELY PROPORTIONAL to GFR
Thus, changes in CYSTATIN C concentration is an INDIRECT INDICATIVE of
GFR ……………….

10. 2. SERUM CREATININE (SCr):
- NORMAL VALUES:
a. For ADULTS : 0.7-1.5 mg/dl
b. For YOUNG CHILDREN : 0.2-0.7 mg/dl
- CREATININE is a NON-PROTEIN, NITROGENOUS
COMPONENT(BIOCHEMICAL) of BLOOD
- CREATINE  Synthesized in LIVER  Diffuses into bloodstream  taken up
by MUSCLE CELLS  Stored in the form of CREATINE PHOSPHATE  Helps
in ATP REGENERATION  Used to transform CHEMICAL ENERGY to
MUSCLE ACTION
- CREATININE is produced in MUSCLE
- It is a SPONTANEOUS DECOMPOSITION PRODUCT of CREATINE &
CREATINE PHOSPHATE

11. - CREATININE  Neither REABSORBED nor SECRETED by NEPHRONS 
Thus, GFR is responsible for SCr levels
- Since CREATININE is derived from MUSCLE TISSUE  Serum levels vary,
depending on the MUSCLE MASS of the individual.
HIGH LEVELS OF SCr FOUND
IN:
LOW LEVELS OF SCr FOUND IN:
AMINOGLYCOSIDE USAGE REDUCED MUSCLE MASS (as in
amputees)
DIABETIC NEPHROPATHY MUSCULAR DYSTROPHY
URINARY TRACT
OBSTRUCTION
MYASTHENIA GRAVIS
GLOMERULONEPHRITIS
PYELONEPHRITIS

12. 3. UREA (BUN):
- NORMAL VALUE : 8-20 mg/dl
- BUN refers to CONCENTRATION of NITROGEN (as UREA) in serum
- BY-PRODUCT of PROTEIN CATABOLISM, produced by LIVER
- FILTERED by GLOMERULUS
- BUN is INVERSELY PROPORTIONAL to GFR
- BUN is affected by :
a. AMOUNT OF PROTEIN IN DIET
b. HEPATIC FUNCTION
- Used to assess:
a. Hydration
b. Renal function
c. Protein tolerance, etc.

13. - BUN is INCREASED in the following conditions:
PRE-RENAL CAUSES INTRA-RENAL CAUSES POST-RENAL CAUSES
DEHYDRATION NEPHROTOXIC DRUGS URETER OBSTRUCTION
SHOCK DM BLADDER NECK
OBSTRUCTION
SEVERE HEART
FAILURE
GLOMERULONEPHRITI
S
PYELONEPHRITIS
TUBULAR NECROSIS

14. - BUN levels are decreased in :
a. Malnourishment
b. Liver damage(due to inhibition of liver’s ability to SYNTHESIZE
UREA)……………

15. 4. BUN:SCr RATIO:
- BUN:SCr ratio is mainly used to assess KIDNEY FUNCTION(especially in ARF)
- In ARF volume depletion occurs  increases levels of BUN & SCr
- If BUN:SCr ratio > 20:1  suggests PRE-RENAL CAUSES of RENAL
IMPAIRMENT
- If BUN:SCr ratio is in between 10:1 – 20:1  suggests INTRINSIC KIDNEY
DAMAGE……………………….

16. 5. CREATININE CLEARANCE (CrCl):
- Refers to the amount of CREATININE excreted through URINE
- Calculated by THREE EQUATIONS:
A. BASIC EQUATION:
- CrCl = [(UCr * V) / (SCr * T)] * (1.73/BSA), where
a. CrCl = Creatinine clearance (in mL/min)
b. UCr = Urine creatinine concentration (in mg/dl)
c. V = Volume of urine produced, during the COLLECTION INTERVAL (in mL)
d. SCr = Serum creatinine concentration ( in mg/dL)
e. T = Time of collection interval (in minutes)
f. BSA : Body surface area (in metre square)

17. - BSA is calculated by MOSTELLER EQUATION:
BSA = [square root of ( height (in cm) *
weight (in kg) ) ] / 3600………….

18. B. COCKCROFT- GAULT EQUATION:
- Here, CrCl is estimated, based on the following patient details:
a. Age b. Weight c. SCr concentration
- There are 2 equations:
I. CrCl = {[(140-age) * weight (in kg) ] / [72 * SCr
] } * 0.85 (if female)
II.CrCl = {[ (140-age) * weight(in kg) ]/ [72 * SCr]
} * 0.85 (if female) * [1.73 meter square / BSA]

19. C. FOR PEDIATRIC PATIENTS:
- The NATIONAL KIDNEY FOUNDATION KIDNEY DISEASE OUTCOME
QUALITY INITIATIVE( NKF-KDOQI) GUIDELINES, suggest use of either
SCHWARTZ / COUNAHAN- BARRATT EQUATIONS to estimate kidney
function, in patients>12 years of age
- SCHWARTZ FORMULA:
CrCl = k * [(height, in cm) / SCr]
For infants < 1 year of age  k = 0.45
For children and adolescent females  k = 0.55
For adolescent males  k = 0.7
- COUNAHAN- BARRATT FORMULA:
GFR ( in ml/min/1.73 metre sq.) = 0.43 * [(height) / SCr)]………………..

20. There are 5 stages of CKD, based on KDOQI guidelines:
STAGE OF CKD GFR VALUE(in
ml/min/1.73 m sq.)
INTERPRETATION
1 >90 Normal/slight kidney
damage, normal GFR
2 60-89 Slightly diminished
GFR, Kidney damage
3 30-59 Moderately reduced
GFR, Kidney damage
4 15-29 Significantly reduced
GFR, Kidney damage
5 <15 Kidney failure, requires
immediate dialysis

21. - Defined as “Clinical tool, that is used to evaluate various RENAL & NON-
RENAL PROBLEMS(Endocrine, metabolic & genetic), using URINE SAMPLE
TESTING”.
- Classified into:
I. MACROSCOPIC ANALYSIS
II. MICROSCOPIC ANALYSIS

22. I. MACROSCOPIC ANALYSIS :
- Focusses on GENERAL APPEARANCE & COLOUR of URINE
- Colour of urine varies, based on the solute concentration inside it
- Colour of urine is derived from 2 pigments:
a. UROCHROME
b. UROBILIN
- Fresh normal urine is neither CLOUDY nor HAZY
- TURBIDITY may occur if large amounts of RBCs/ WBCs are there
- FOAMING may be due to presence of PROTEIN/ BILE ACIDS………………

23. COLOUR SIGNIFIES
PRESENCE OF
POSSIBLE
CAUSES
RED- ORANGE HEMOGLOBIN, RBCs,
MYOGLOBIN
Electric shock, malaria,
kidney stones, drugs
(rifampin, doxorubicin)
BLUE- GREEN BILIVERDIN,
BACTERIA, etc
Pseudomonas/ Proteus
infection in UTI, drugs
(amitriptyline,
triamterene)
BROWN- BLACK MYOGLOBIN, BILE
PIGMENTS,
PORPHYRINS, etc
Electric shock, liver
disease, hemolysis,
porphyria, drugs
(metronidazole, NTU, etc)

24. II. MICROSCOPIC ANALYSIS:
- Mainly used to check the presence of FORMED ELEMENTS, like :
a. CELLS
b. CRYSTALS
c. CASTS…………………..

25. A. CELLS:
- Usually, 1-2 cells may be found
- Cells include:
i. MICROORGANISMS:
- Normal range : 0-trace
- Presence of FUNGI, BACTERIA, SINGLE-CELL ORGANISMS, suggests UTI/
COLONIZATION……….
ii. RBCs:
- Normal range : 1-3 / hpf
- HAEMATURIA : “Abnormal renal excretion of RBCs”
- Few RBCs are seen in the urine of a healthy woman/man, especially after
FEVER, EXERTION, TRAUMA, etc

26. - Increased levels of RBC are seen in:
a. GLOMERULONEPHRITIS
b. PYELONEPHRITIS
c. RENAL INFARCTION
d. TUMORS
e. STONES……………
iii. WBCs:
- Normal range : 0-1/ hpf
- Increased levels of WBCs are seen in:
a. UTI
b. GLOMERULONEPHRITIS
c. INTERSTITIAL NEPHRITIS…………………

27. iv. TUBULAR EPITHELIAL CELLS:
- Normal range : 0-1/ hpf
- Increased amounts of epithelial cells are found in:
a. ACUTE TUBULAR NECROSIS
b. GLUMERULONEPHRITIS
c. INTERSTITIAL NEPHRITIS…………………….

28. B. CASTS:
- CASTS are CYLINDRICAL SHAPED GLYCOPROTEINS
- Formed in TUBULES
- In some conditions  Casts are released into urine  This condition is known as
CYLINDURIA
- Different types of casts include:
i. HYALINE CASTS
ii. CELLULAR CASTS
iii. GRANULAR CASTS
iv. WAXY CASTS
v. BROAD CASTS………………

29. i. HYALINE CASTS:
- Difficult to observe under microscope
- Seen in :
• Concentrated urine
• Diuretic usage………….
ii. CELLULAR CASTS:
- Cellular casts include RBC casts, WBC casts & EPITHELIAL CELL casts
CASTS TYPE POSSIBLE INDICATION/S
WBC Pyelonephritis, Acute interstitial
nephritis
RBC Glomerulonephritis
EPITHELIAL CELL Glomerulonephritis

30. iii. GRANULAR & WAXY CASTS:
- Older, degenerated forms of (i) and (ii)
- Found in:
• Acute tubular necrosis
• Glomerulonephritis………………………….

31. C. CRYSTALS:
- Presence of CRYSTALS in urine, depends on 3 factors:
i. Urine PH
ii. Degree of saturation of urine, by the substance, that forms crystals
iii. Presence of other substances in urine, that promote crystallization
CRYSTAL TYPE INDICATES
CYSTINE CYSTINURIA
STRUVITE (Magnesium ammonium
phosphate)
STRUVITE STONES
CALCIUM OXALATE, CALCIUM
PHOSPHATE & URIC ACID
STONES

32. C. CHEMICAL ANALYSIS
(SEMIQUANTITATIVE TESTS):
- Here, main focus is on BIOCHEMICAL ANALYSIS of urine, for the detection of
PROTEIN, URINE PH, BILIRUBIN, BILE, etc…………………

33. A. PROTEIN:
- NORMAL RANGE : 0- trace
- Urinary proteins include:
i. ALBUMIN
ii. LMW SERUM GLOBULINS
- Healthy individuals excrete 80-100 mg of protein/day
- TERMINOLOGIES :
TERM DEFINITION
PROTEINURIA Renal loss of protein
ALBUMINURIA Abnormal renal excretion of albumin
CLINICAL PROTEINURIA Loss of >500 mg/day of protein through
urine
MICROALBUMINURIA Loss of 30-300 mg/day of albumin

34. TYPE OF
PROTEINURIA
RENAL PROTEIN
EXCRETION(in
g/day)
FOUND IN
MILD <0.5 Lower UTI, Renal
tubular damage
MODERATE 0.5-3 Diabetic nephropathy,
pyelonephritis,
Glomerulonephritis
SIGNIFICANT >3 Lupus nephritis,
Glomerulonephritis,
Diabetic nephropathy

35. B. pH:
- NORMAL RANGE : 4.5-8.0
- Urinary PH can be affected by various ACID-BASE DISORDERS
- Urine PH can turn ACIDIC/ ALKALINE, depending on the following conditions:
URINE PH NATURE CAUSES SUGGESTS
ALKALINE Hyperventilation Respiratory/ metabolic
acidosis
Proteus splits urea to
NH3
UTI
Drugs Thiazides, acetazolamide
ACIDIC Food Fruit juices, plums
DM, high fever Ketoacidosis
Cellular hypoxia Metabolic acidosis
Drugs NH4Cl, Methenamine

36. C. SPECIFIC GRAVITY:
- NORMAL RANGE : 1.010-1.025
- SPECIFIC GRAVITY is defined as “RATIO of WEIGHT of a given FLUID , to the
WEIGHT of an EQUAL VOLUME of DISTILLED WATER”
- SODIUM, UREA, SULFATE & PHOSPHATE are major contributors of URINE
SPECIFIC GRAVITY
LOW VALUES FOUND IN HIGH VALUES FOUND IN
Acute tubular necrosis Dehydration
Diabetes insipidus Fasting
Renal failure Proteinuria
Syndrome of inappropriate ADH
secretion(SIADH)

37. D. UROBILINOGEN:
- NORMAL RANGE: 0-1 Erlich Unit
- UROBILINOGEN is formed by BACTERIAL CONVERSION of CONJUGATED
BILIRUBIN in the INTESTINE
HIGH VALUES ARE
FOUND IN
LOW VALUES ARE FOUND
IN
CIRRHOSIS DRUGS(Neomycin, Tetracycline,
Chloramphenicol)
VIRAL HEPATITIS TOTAL BILIARY
OBSTRUCTION
HEMOLYTIC ANEMIA

38. E. BILIRUBIN:
- NORMAL RANGE: 0
- BILIRUBINURIA is a condition, in which there is presence of BILIRUBIN in
URINE, resulting in DARK YELLOW/ GREENISH-BROWN colored urine
- Observed in:
i. Intrahepatic cholestasis
ii. Bile duct stones, tumors, etc…………………………….

39. F. BLOOD & HEMOGLOBIN:
- NORMAL RANGE: 0- trace
- Presence of blood/ hemoglobin in urine indicates:
i. HAEMATURIA
ii. HEMOGLOBINURIA(In intravascular hemolysis)
iii. MYOGLOBINURIA( In rhabdomyolysis)………………………

40. G. LEUKOCYTE ESTERASE:
- NORMAL RANGE: 0- Trace
- This test gives a SEMI-QUANTITATIVE ESTIMATION of PYURIA(Pus in
urine), that suggests UTI……………………………

41. H. NITRITE:
- NORMAL RANGE: None
- Bacteria(E.Coli, Klebsiella, Proteus, Staphylococcus)  reduce NITRATE to
NITRITE  Suggests UTI……………………….

42. I. GLUCOSE:
- NORMAL RANGE: None
- At glucose concentration >180 mg/dl  capacity of PCT to reabsorb glucose
exceeds  thus, glucose is found in urine  suggests DM, GLYCOSURIA,
etc…………………..

43. J. KETONES:
- NORMAL RANGE: 0
- In patients, with KETONURIA + GLYCOSURIA  Indicates TYPE I DM
- KETONURIA is observed in:
i. Pregnancy
ii. Starvation
iii. Carbohydrate-free diets……………………….

44. K. URINARY ELECTROLYTES:
Include the estimation of SODIUM, POTASSIUM, etc
I. SODIUM:
- NORMAL RANGE: Varies
- Sodium conc. is used to ASSESS VOLUME STATUS of a patient
LOW VALUES FOUND IN HIGH VALUES FOUND IN
Vomitting Diuretics
Diarrhea SIADH
Burns ARF/CRF
Cirrhosis Renal tract obstruction
Nephrotic syndrome Sodium chloride tablets

45. II. POTASSIUM:
- NORMAL RANGE: Varies
- Urine potassium levels are generally helpful , only in patients, with
UNEXPLAINED HYPOKALEMIA
- Urine potassium levels between 0-10 mEq/L  Suggests GI tract as a source for
POTASSIUM LOSS
- Urine potassium levels > 10 mEq/L  Suggests renal potassium loss
LOW LEVELS ARE FOUND IN HIGH LEVELS ARE FOUND IN
Adrenal gland insufficiency Hyperaldosteronism
Hypoaldosteronism Acute tubular necrosis
Drugs (Beta-blockers, Li, NSAIDs) Metabolic acidosis

46. III. FE(Na) TEST:
- Defined as PERCENT of SODIUM(FRACTION), that is FILTERED in the
GLOMERULUS, that is eventually excreted in the urine
- Calculated by the following formula:
a. FE(Na) = [(Urinary sodium) * Serum creatinine)]/ [(Serum sodium) * (Urinary
creatinine)]
- If FE(Na) < 1%  indicates PRE-RENAL AZOTEMIA
- If FE(Na) > 2-3%  indicates ACUTE TUBULAR
NECROSIS…………………………..

47. 1. Thrombetta.P.D; Foote.T.Edward; “Chapter 7:THE
KIDNEYS”; “Basic skills in Interpreting Laboratory Data
by Mary Lee”; 4th edition; American Society of Health-
System Pharmacists Inc. ; 2009; Pg: 161-176.
2. Normal lab values app.

48. THANK YOU
  