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Approach to abnormal RENAL FUNCTION TEST.pptx
- 1. Approach to abnormal RENALFUNCTION TEST PRESENTER: RANJIT TIWARI (JR -2) MODERATOR: DR. RANJIT DAS
- 2. CONTENTS: Physiology ofkidney Methods of estimating kidney function urinalysis: dipstick, microscopy, urinary electrolytes, 24 h urine citrate, oxalate GFR BUN, Cr Imaging Radionuclide studies Renal biopsy Approach to Hematuria, pyuria, elevated BUN and creatinine case scenario 1
- 3. Excretory organ Maintain electrolyte concentration, ECF volume, osmolality synthesize calcitriol, erythropoietin, renin 2 Davidson principle of Medicine 21st edition
- 4. Tests for analyzingRenal function Urine output Assessment of tubular function: urine concentration and dilution test Urinalysis Serum: Urea, creatinine, sodium, potassium Adjunctive tests in serum: uric acid, phosphorus, calcium, bicarbonate, Hemoglobin Imaging Nuclear scan Renal biopsy 3 Harrison principle of internal medicine 21st edition
- 5. URINE OUTPUT Oliguria:<400ml/d Anuria: <100ml/d Polyuria: >3L/day 4 Harrison principle of internal medicine 21st edition
- 6. urinalysis Spot urineanalysis 24hour urine analysis 5 Harrison principle of internal medicine 21st edition SPOT URINE ANALYSIS -urine dipstick -urine Microscopy -UACR, UPCR -urinary sodium, potassium, calcium -eAER/ ePER 24hour urine analysis -protein creatinine -sodium, potassium, calcium, oxalate
- 7. Urine dipstick sp gravity pH blood/ heme pigments protein Glucose ketones Leukocyte esterase Nitrites Bilirubin and urobilinogen 6 Davidson principle of Medicine 21st edition
- 8. 7 Urine Specific gravity:1.008-1.012 <1.008: hyposthenuria >1.012: hypersthenuria
- 9. Urine dipstick sp gravity pH blood/ heme pigments protein Glucose ketones Leukocyte esterase Nitrites Bilirubin and urobilinogen 8 Davidson principle of Medicine 21st edition
- 10. 9 Urine pH: Normal: 4.5-8.0 High urine pH -urease producing bacteria -vegetarian diet -RTA Low urine PH -High protein dietred meat diet -volume depletion leading to aldosterone stimulation -metabolic acidosis
- 11. Urine dipstick sp gravity pH blood/ heme pigments protein Glucose ketones Leukocyte esterase Nitrites Bilirubin and urobilinogen 10 Davidson principle of Medicine 21st edition
- 12. Urine microscopy RBC WBC Eosinophils Epithelial cells casts crystals 11 Davidson principle of Medicine 21st edition
- 13. Intact RBC dueto bleeding from lower in urinary tract Dysmorphic RBC 12 Davidson principle of Medicine 21st edition
- 14. Urine microscopy RBC WBC Eosinophils Epithelial cells casts crystals 13
- 15. urinary epithelialcells Renal tubular epithelial cells Transitional epithelial cells Squamous epithelial cells 14 Davidson principle of Medicine 21st edition
- 16. Urine microscopy RBC WBC Eosinophils Epithelial cells casts crystals 15
- 17. urinary casts Hyalinecast Granular cast RBC cast Leukocyte cast 16 th
- 18. Muddy brown casts 17 Davidsonprinciple of Medicine 21st edition
- 19. Urine microscopy RBC WBC: sterile pyuria Eosinophils Epithelial cells casts crystals 18
- 20. urinary crystals calciumoxalate calcium phosphate uric acid struvite cysteine 19 comprehensive clinical nephrology , 6th edition
- 21. UACR andUPCR urine electrolyte 24h urine assessment 20
- 22. Measurement ofAlbumin and protein excretion urinary ACR Urinary PCR eAER / ePER 24-hour urine protein 21 comprehensive clinical nephrology , 6th edition
- 23. collection method Normalclinical proteinuria 24 hour excretion <150mg/24h ≥150mg/24h spot Urine PCR <50mg/g ≥150mg/g urine protein collection method Normal Moderately increased Albuminuria Severely increased albuminuria 24 h urine excretion <30mg/24h 30-300mg/24h >300mg/24h conventional spot urine dipstick negative negative positive Albumin specific spot urine dipstick <3mg/dl negative ≥3mg/dl positive positive spot UACR <30mg/g 30-300mg/g >300mg/g Urine albumin 22 comprehensive clinical nephrology , 6th edition
- 24. urine proteinelectrophoresis urine free light chain assay 23 comprehensive clinical nephrology , 6th edition
- 25. what tests wecan do from serum? Serum Creatinine, BUN sodium, potassium, calcium, phosphorus, magnesium, uric acid serum protein, albumin 24
- 26. Immunological tests ANA ENA panel anti-ds DNA Anti-PLA2R antibodies 25 comprehensive clinical nephrology, 6th edition
- 27. Serum creatinine Limitationof eGFR Only an estimate Underestimate true GFR at normal or near normal function Affected by muscle mass, drugs, creatine supplement Not valid in assessing AKI Not valid under 18s or during pregnancy Davidson principle of Medicine, 24th edition 26
- 28. Relationship ofserum cr to GFR 27 Davidson principle of internal medicine, 22nd edition
- 29. Blood Urea Nitrogen(BUN) Use BUN along with creatinine 29 comprehensive clinical nephrology, 6th edition High BUN/SCr ratio ≥20:1 with minimal change in GFR -High protein intake, TPN -Enhanced tissue breakdown mild intravascular volume depletion -moderately severe heart failure High BUN/SCr ratio ≥20:1 with reduced GFR -markedly reduced CO -Shock: septic, hypovolemic -Urinary tract obstruction
- 30. 30 BUN/SCr ratio between10:1 and 20:1 Look for hypovolemia Hypovolemia present -very low dietary protein intake or advanced liver disease -increased creatinine production (e.g. rhabdomyolysis) NO hypovolemia -ATN -Interstitial nephritis -GN Low BUN/SCr ratio -decreased urea production (low protein diet, advanced liver disease) -increased creatinine production (e.g. high intake of cooked meat, creatine supplements, extremely large muscle mass, rhabodomyolysis
- 31. Dynamic tests oftubular function water deprivation test water load test 31 comprehensive clinical nephrology, 6th edition
- 32. Imaging studies USG Renal vessel doppler CT CT UROGRAPHY (contrast enhanced kidney specific CT) MRI with contrast MR angiography Radionuclide imaging 32 comprehensive clinical nephrology, 6th edition
- 33. Usg of kidney,ureter, bladder Davidson principle of internal medicine, 24th edition
- 34. Radionuclide imaging 34 Davidson principleof internal medicine, 24thed
- 35. Renal biopsy: whento do? Glomerular hematuria Severely increased albuminuria Acute or chronic kidney disease of unclear cause When to do biopsy in Diabetic kidney disease Kidney transplant dysfunction and monitoring 35 comprehensive clinical nephrology, 6th edition
- 36. Approach to someurinary abnormalities
- 37. Approach to hematuria Contaminated sample? Any RBC casts or dysmorphic RBC in urine? Associated urinary abnormalities like proteinuria, WBC ? Cystoscopy required ? 36
- 38. Approach to pyuria D/D: Infection: UTI, genitourinary TB, Intersitial nephritis Glomerulonephritis Obstruction in renal tract 37 comprehensive clinical nephrology, 6th ed
- 39. Approach to isolatedproteinuria Is it transient or persistent proteinuria? source of proteinuria: glomerular, tubular, overflow, postrenal Glomerular cause: RBC casts, dysmorphic RBC, lipiduria Major proteins : Albumin vs non-albumin Heterogeneous low molecular weight protein: Evaluate for Tubulo interstial disease 1
- 40. Case 1: 62year old female with chronic liver disease (Ethanol related) Decompensated with ascites without SBP. She had no urinary symptoms and no fever. Call given for persistent AKI. No prior hospitalization. 24hour urine output 1.5 L/day 38
- 41. usg abd/pelvis (Jan 23): Only significant for moderate ascites serology for HIV, HCV, HBV: neg Total protein/ albumin: 6.8/2.2 AST/ALT: X 1.5/ 24 total/ conj. bilirubin: 2.6/1.8 ALP/GGT: 116/109 PT INR: 1.7 stool for occult blood: neg 1
- 42. 9/21 9/22 9/239/24 9/25 9/26 9/28 9/30 urea 43 114 135 131 135 123 114 cr 1.3 0.8 2.0 2.3 3.6 3.8 3.2 urinalyisis RBC - Plenty 50-55 plenty WBC 1-3 10-15 6-8 1-2 Protein 2+ 2+ 2+ + glucose - bacteria seen Seen yeast seen crystals amorphous phosphate urine ph 6 6 TLC 11610 DLC N93L02 1 ceftriaxone 1g bd piperacillin-tazo and levofloxacin Meropenem urine c/s sterile
- 43. Is itRPGN ? Points not favoring RPGN: Bacteria and yeast present no comment on RBC casts Points not favoring UTI No renal angle tenderness, no constituitional s/s rapidly progressive renal failure 40
- 44. 41 serum creatinine: 1.48 eGFR:40ml/min/1.73m2 urea: within reference range sodium, potassium: within reference range case 2 urine R/E M/E Protein2+ RBC- WBC- sugar-
- 45. TAKE HOMEMESSAGE For clinical practice, use CKD-EPI equation for GFR estimation CKD-EPI 2021 incorporating cystatin c and creatinine is more accurate. Absence of protein in dipstick does not mean no proteinuria Absence of dysmorphic RBC does not mean no glomerulonephritis Good correlation between UACR/ UPCR and 24h urine protein 42
- 46. References: Harrisonprinciple of Internal Medicine, 21st edition Davidson principle of Medicine, 22nd edition Nephrology, American college of Physician Comprehensive clinical nephrology 6th edition, John Feehally Brenner Textbook of The kidney, 7th edition 43