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KIDNEY
FUNCTION
TESTS
TEST FOR NPN CONSTITUENTS
CLEARANCE TESTS
URINE CONCENTRATION TEST
KIDNEY STONES
$elin@ SNVPMV
SELINA SRAVANTHI
SNVPMV,
HYDERABAD, TELANGANA
$elin@ SNVPMV
FUNCTIONS OF KIDNEY
₪ Excretion of urea and other waste products, such as creatinine,
uric acid and metabolites of xenobiotics
₪ Maintaining water balance
₪ Excretion of sodium (effect on BP)
₪ Excretion of potassium (effect on heart)
₪ Excretion of hydrogen ions (maintenance of pH)
₪ Activation of vitamin D (effect on bone)
₪ Production of erythropoietin (effect on RBCs)
₪ Filtration: 180 liters/day of water with all sodium, chloride, sugar
and amino acids
₪ Reabsorption: 178.5 liters reabsorbed; all glucose and amino
acids reabsorbed; most of sodium and chloride reabsorbed
$elin@ SNVPMV
CLASSIFICATION OF RENAL FUNCTION TEST
₪ To screen for kidney disease
₪ Complete urine analysis
₪ Plasma urea and creatinine
₪ Plasma electrolytes
₪ To assess renal function:
₪ To assess glomerular function
₪ Glomerular filtration rate
₪ Clearance tests
₪ Glomerular permeability
₪ Proteinuria
₪ To assess tubular function
₪ Reabsorption studies
₪ Secretion tests
₪ Concentration and dilution tests
₪ Renal acidification
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE
₪ NPN constituents stands for NON PROTEIN NITROGENOUS
COMPOUNDS
₪ Nitrogen content other than protein in blood, tissues and waste
material is associated with
₪ Urea
₪ Uric acid
₪ Creatine
₪ Polypeptides
₪ Approximately of the NPN in blood is associated with UREA
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE
₪ Clinically significant NPN constituents in blood plasma are
₪ Urea – 45%
₪ Uric acid – 20%
₪ Amino acids – 20%
₪ Creatinine – 5%
₪ Creatine – 2%
₪ Ammonia – 0.2%
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE - UREA
₪ Present in highest concentration.
₪ Excretory product of protein metabolism.
₪ Measurement of nitrogen in urea is determined as Blood Urea Nitrogen (BUN)/
Urea Nitrogen (Urea N).
₪ Urea is synthesized in the liver, carried by blood to the kidneys and filtered from
the plasma through glomerulus.
₪ Most of the urea in the glomerular filtrate is excreted in the urine, although
some urea is reabsorbed by passive diffusion through the renal tubules.
₪ The amount reabsorbed depends on urine flow rate and extent of hydration.
₪ Small quantities of urea (10% of the total) are excreted through the
gastrointestinal tract and skin.
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE – UREA
WHY MEASURE SERUM UREA
₪ Evaluate renal function,
₪ To assess hydration status,
₪ To determine nitrogen balance,
₪ To aid in the diagnosis of renal disease,
₪ To verify adequacy of dialysis
$elin@ SNVPMV
DETERMINATION OF UREA
METHOD: BERTHELOT METHOD FOR BLOOD UREA
PRINCIPLE
Urea + 2H2O NH4
+ + CO3
2-
NH4
+ + Salicylate + Hypochlorite 2,2-
dicarboxyindophenol
urease
Green
Ammoniu
m ions
Ammoniu
m ions
Carbonate
ions
₪ The intensity of the green colour which is proportional to the concentration of
urea present in the sample is measured at 570 nm
$elin@ SNVPMV
DETERMINATION OF UREA
METHOD: ENZYMATIC ASSAY FOR UREA
PRINCIPLE
Urea + 2H2O NH4
+ + CO3
2-
NH4
+ + 2- oxoglutarate Glutamate + H2O
urease
Glutamate
dehydrogenase
NADH + H+ NAD+
₪ The rate of disappearance of reduced NADH (decrease in absorbance) is
measured at 340 nm
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE –
UREA
CLINICAL SIGNIFICANCE
₪ NORMAL LEVEL
₪ In plasma : 6-20 mg/dL
₪ In urine: 12-20 g/day
₪ INCREASED CONCENTRATION
₪ Prerenal Congestive heart failure
₪ Shock, haemorrhage, Dehydration
₪ Increased protein catabolism
₪ High-protein diet
₪ Renal- Acute and chronic renal failure
₪ Renal disease, including glomerular
nephritis, tubular necrosis
₪ Postrenal - Urinary tract obstruction
₪ DECREASED CONCENTRATION
₪ Low protein intake
₪ Severe vomiting and diarrhoea
₪ Liver disease
₪ Pregnancy
₪ AZOTEMIA
₪ Increase in the blood levels of
urea
₪ UREMIC SYNDROME
₪ High plasma levels of urea
accompanied by renal failure
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE - CREATININE
₪ Creatinine is formed from creatine and creatine phosphate in muscle and is
excreted into the plasma at a constant rate related to muscle mass.
₪ It is removed from the circulation by glomerular filtration and excreted in the
urine.
₪ Small amounts of creatinine are secreted by the proximal tubule and reabsorbed
by the renal tubules
WHY MEASURE SERUM CREATININE
₪ Plasma creatinine is inversely related to glomerular filtration rate (GFR).
₪ it is commonly used to assess renal filtration function - severity of kidney
damage and to monitor the progression of kidney disease.
₪ Plasma creatinine is insensitive marker and may not be measurably increased
$elin@ SNVPMV
DETERMINATION OF CREATININE
METHOD: JAFFE’S METHOD
PRINCIPLE
Creatinine + picric acid orange red colour
(Janovski) complex
Alkaline pH
₪ The intensity of the orange red colour which is proportional to the
concentration of creatinine present in the sample is measured at 510 nm
$elin@ SNVPMV
CLINICAL SIGNIFICANCE
₪ NORMAL LEVEL
₪ In plasma : 0.9-1.3 mg/dL
₪ DECREASED CONCENTRATION
₪ Low muscle mass
₪ Pregnancy,
₪ Starvation, wasting diseases,
₪ Corticosteroid intake
NPN CONSTITUENTS OF URINE – CREATININE
₪ INCREASED CONCENTRATION
₪ Glomerulonephritis – infection or
autoimmune disease
₪ Pyelonephritis (bacterial infection)
₪ Acute tubular necrosis (death of cells in
tubules) by drugs or toxins
₪ Prostrate disease, renal calculi, urinary
tract obstruction
₪ Shock, dehydration, congestive heart
failure, atherosclerosis, complications of
diabetes, Chronic Obstructive Pulmonary
Disorder (COPD)
₪ Muscle injury, vigorous exercise
₪ Drugs- Cimetidine, salicylates reduce
tubular secretion
$elin@ SNVPMV
₪ UREA NITROGEN/ CREATININE RATIO - 10:1 to 20:1
₪ Prerenal conditions tend to elevate plasma urea, whereas plasma creatinine
remains normal, causing a high urea N/creatinine ratio.
₪ A high urea N/creatinine ratio with an elevated creatinine is usually seen in
postrenal conditions.
₪ A low urea N/creatinine ratio is observed in conditions associated with
decreased urea production, such as low protein intake, acute tubular
necrosis, and severe liver disease
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE – URIC ACID
₪ In human, uric acid is the major product of the catabolism of the purine
nucleosides, adenosine and guanosine.
₪ Uric acid is transported in the plasma from the liver to the kidney, where it is
filtered by the glomerulus.
₪ Reabsorption of 98% to 100% of the uric acid from the glomerular filtrate occurs
in the proximal tubules.
₪ Small amounts of uric acid are secreted by the distal tubules into the urine.
₪ Uric acid is relatively insoluble in plasma and, at high concentrations, can be
deposited in the joints and tissue, causing painful inflammation
₪ Renal excretion accounts for about 70% of uric acid elimination; the remainder
passes into the gastrointestinal tract and is degraded by bacterial enzymes
₪ Nearly all of the uric acid in plasma is present as monosodium urate.
$elin@ SNVPMV
NPN CONSTITUENTS OF URINE – URIC ACID
WHY MEASURE SERUM URIC ACID
₪ Assess inherited disorders of purine metabolism,
₪ To confirm diagnosis and monitor treatment of gout,
₪ To assist in the diagnosis of renal calculi,
₪ To prevent uric acid nephropathy during chemotherapeutic treatment,
₪ To detect kidney dysfunction
$elin@ SNVPMV
DETERMINATION OF URIC ACID
METHOD: CARAWAY METHOD
PRINCIPLE
Uric acid + phosphotungstic acid + O2 Allantoin +
tungsten blue + CO2
Alkaline pH
₪ Protein free filtrate of urine sample is used
₪ Uric acid (reducing agent) as it readily converts to allantoin
₪ Method not specific
$elin@ SNVPMV
DETERMINATION OF URIC ACID
METHOD: ENZYMATIC – SIMPLE SPECTROPHOTOMETRIC
METHOD
PRINCIPLE
Uric acid + O2 + 2H2O Allantoin + H2O2 + CO2
Uricase
₪ Differential absorption of uric acid and allantoin at 293 nm.
₪ The difference in absorbance before and after incubation with uricase is
proportional to the uric acid concentration.
$elin@ SNVPMV
DETERMINATION OF URIC ACID
METHOD: COUPLED ENZYMATIC METHOD
PRINCIPLE
Uric acid + O2 + 2H2O Allantoin + H2O2 + CO2
H2O2 + 4-Amino antipyrine + ADPS Quinoneimine
dye + H2O
Uricase
₪ ADPS , highly water soluble aniline derivative, (N-Ethyl-N-(3-sulfopropyl)-3-
methoxyaniline, sodium salt, monohydrate ESPAS)
₪ PHBA (Polyhalogenated benzoic acid ) may also be used instead
₪ The intensity of the pink colour of quinone imine dye which is proportional to
the concentration of uric acid present in the sample is measured at 550 nm
Peroxidase
$elin@ SNVPMV
CLINICAL
SIGNIFICANCE
₪ NORMAL LEVEL
₪ In plasma (Males) :
3.5-7.2 mg/dL
₪ In plasma (females) :
2.6-6.0 mg/dL
₪ In urine : 250-750 mg/
day
₪ DECREASED
CONCENTRATION -
HYPOURICEMIA
₪ Liver disease
₪ Defective tubular
reabsorption (Fanconi
syndrome)
₪ Chemotherapy with
NPN CONSTITUENTS OF URINE – URIC ACID
₪ INCREASED CONCENTRATION -
HYPERURICEMIA
₪ Enzyme deficiencies
₪ Lesch-Nyhan syndrome (hypoxanthine guanine
Phosphoribosyl transferase deficiency)
₪ Phosphoribosylpyrophosphate synthetase deficiency
₪ Glycogen storage disease type I (glucose-6-
phosphatase deficiency)
₪ Fructose intolerance (fructose-1-phosphate aldolase
deficiency)
₪ Gout
₪ Treatment of myeloproliferative disease (tumors) with
cytotoxic drugs
₪ Hemolytic and proliferative processes
₪ Chronic renal disease
₪ Toxemia of pregnancy
₪ Lactic acidosis
₪ Drugs and poisons
$elin@ SNVPMV
₪ Hyperuricemia may lead to Formation of kidney stones
₪ Most of uric acid is removed by the kidneys and disposed of in the urine.
₪ In hyperuricemia Uric acid crystals precipitate in the kidney and may block
filtering tubules leading to renal failure.
Uric acid crystals
in a urine sample
Sodium urate/
kidney stones
$elin@ SNVPMV
Gout: A chronic type of inflammatory arthritis in which uric acid crystals
accumulate in the joints causing severe inflammation. It usually affects the joint
of big toe, other joints including ankles, knees and elbows may be affected
X-ray of gouty uric acid
deposit in the big toe
Uric acid crystals in big toe
joint
$elin@ SNVPMV
The amount of substance excreted in urine is the result of
₪ Glomerular filtration
₪ Tubular reabsorption
₪ Tubular secretion
Urinary excretion rate = filtration rate – reabsorption rate +
secretion rate
$elin@ SNVPMV
₪ CLEARANCE
₪ a theoretical concept defined as the volume of plasma from which a
measured amount of substance can be completely eliminated or cleared,
into the urine per unit time‐ can be used to estimate glomerular function
₪ Glomerular Filtration Rate (GFR)
₪ It’s the volume of fluid filled from the glomerulus into bowman's capsule
per unit time.
₪ Normal level – 120- 125 mL/ min
₪ Affected by
₪ Age
₪ Sex
₪ Body surface area
₪ Protein intake and pregnancy
₪ Reduced GFR
₪ Age
₪ Decrease in functional nephrons (>75%)
₪ BP is below 80 mm Hg
₪ SUBSTANCES USED FOR
CLEARANCE TEST
₪ Endogenous – Creatinine &
Urea
₪ Exogenous – Inulin (gold
standard), 51Cr – labelled
EDTA, 99Tec– labelled EDTA
$elin@ SNVPMV
₪ When GFR decreases to 30% of
normal - moderate renal
insufficiency. Patients remain
asymptomatic with only
biochemical evidence of a decline in
GFR
₪ As the GFR decreases further severe
renal insufficiency characterized by
profound clinical manifestations of
uremia and biochemical
abnormalities, such as acidemia;
volume overload; and neurologic,
Normal -
Dec.Renal reserve
Mild Renal imp
Moderate insuff.
Renal failure
ESRD
100-120ml/min
60-100ml/min
40-60ml/min
25-40ml/min
<25ml/min
<10ml/min
$elin@ SNVPMV
₪ CREATININE CLEARANCE
₪ Measure (rate at which the amount) of creatinine eliminated from the blood
by kidneys
₪ Used to assess renal function
₪ About 98% of creatine pool is in muscle. About1.6% is converted to creatinine
per day, which is rapidly excreted.
₪ Since creatinine excretion is a constant in a particular person, the urine
creatinine is sometimes used to check whether the 24 hours urine sample
does actually contain total urine volume or not.
₪ Normal value : 75-125 mL/min
₪ Males: 105±20 mL/ min
₪ Female: 95±20 mL/ min
$elin@ SNVPMV
CREATININE CLEARANCE
₪ Method
₪ Give 500 mL of water to the patient, to promote good urine flow.
₪ After about 30 minutes, ask to empty the bladder and discard the urine.
₪ Exactly after 60 minutes, again void the bladder and collect the urine, and note
the volume.
₪ Take one blood sample. Creatinine level in blood and urine are tested and
calculated.
₪ Formula
₪ It is useful to correct the clearance value with body surface area.
₪ This is important, especially in children, and persons with short or tall frame.
₪ Creatinine clearance corrected for surface area could be calculated as:
𝐶𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝐶𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 =
𝑈 x 𝑉x 1.73
𝑃 x 𝐴
𝐶𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝐶𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 =
𝐶𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑢𝑟𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑚𝐿(𝑈)
𝐶𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑝𝑙𝑎𝑠𝑚𝑎 𝑖𝑛 𝑚𝑔/𝑚𝐿(𝑃)
x Volume of urine flow(V) (mL/min)
$elin@ SNVPMV
₪ Measurement of plasma creatinine better than measurement of urinary
creatinine because
₪ The accuracy of urine collection is dependent in patient that gives errors.
₪ The values of Plasma creatinine correlates with creatinine clearance in
patient with renal disease.
₪ Plasma creatinine measurement enables progress of renal disease to be
followed with better precision than creatinine clearance.
₪ Measurement of plasma creatinine is effective in detecting early renal
diseases.
$elin@ SNVPMV
₪ LOW CREATININE CLEARANCE
₪ Kidney problems, such as
₪ Damage to the tubule cells
₪ Kidney failure
₪ Too little blood flow to the kidneys
₪ Damage to the filtering units of the
kidneys
₪ Loss of body fluids (dehydration)
₪ Bladder outlet obstruction
₪ Heart failure
₪ HIGH CREATININE
CLEARANCE:
₪ Carbon monoxide poisoning
₪ Hypothyroidism
₪ Pregnancy.
$elin@ SNVPMV
₪ UREA CLEARANCE
₪ The urea clearance is less than GFR, because urea is partially reabsorbed.
₪ Urea clearance is the number of mL of blood, which contains the urea
excreted in a minute by kidneys.
₪ Not as sensitive as creatinine clearance
₪ 40-60 % of the urea is reabsorbed by renal tubule.
₪ Influenced by extra renal factors
₪ Dietary proteins
₪ Fluid intake
₪ Haemorrhage
₪ Infection
$elin@ SNVPMV
₪ Method
₪ Allow the patient to have a normal breakfast.
₪ At 9 AM give a cup of water and the patient is instructed to void the bladder,
and urine is discarded.
₪ At 10 AM bladder is completely emptied and the volume of urine is
measured and the urine urea is estimated.
₪ A blood sample is taken and blood urea is also estimated.
$elin@ SNVPMV
CREATININE CLEARANCE
₪ Formula
₪ Normal value : 75 mL/min
₪ STANDARD UREA CLEARANCE
₪ Clearance value is decreased when V, the volume of urine, is less than 2
mL/min.
₪ Normal value : 54 mL/min
₪ Standard urea clearance =
U x √V
P
₪ Where,
₪ U – mg of urea/ mL of urine
₪ P – mg of urea / mL of plasma
₪ V- volume of urine flow (mL/ min)
𝑈𝑟𝑒𝑎 𝐶𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 =
𝑚𝑔 𝑜𝑓 𝑢𝑟𝑒𝑎 𝑝𝑒𝑟 𝑚𝐿 𝑜𝑓 𝑢𝑟𝑖𝑛𝑒
𝑚𝑔 𝑜𝑓 𝑢𝑟𝑒𝑎 𝑝𝑒𝑟𝑚 𝑜𝑓 𝑝𝑙𝑎𝑠𝑚𝑎
x Volume of urine flow (mL/min)
$elin@ SNVPMV
₪ LOW CREATININE CLEARANCE
₪ Less than 75% of normal
₪ The values fall progressively with failing renal function.
₪ The clearance value may be abnormal even though the plasma urea values
are within normal limits.
₪ The plasma urea values will start to rise only when the clearance value falls
below 50% of the normal.
₪ Urea is normally reabsorbed from renal tubules and therefore, tubular
function also affects urea clearance.
₪ Hence, creatinine clearance test is more preferred.
₪ Urea is freely filtered by the glomerulus and passively reabsorbed in both
PCT and DCT. Urea clearance is less than GFR
$elin@ SNVPMV
₪ INULIN CLEARANCE
₪ Inulin is a polysaccharide of fructose.
₪ It is not metabolized by the body.
₪ It is neither absorbed nor secreted by the tubules.
₪ Inulin clearance is a measure of GFR.
₪ The value of GFR as measured by inulin clearance is 125 mL/min.
₪ METHOD
₪ About 100 mL of sterile 10% solution of inulin is given as slow intravenous drip within 2
hours.
₪ Urine specimen formed during this period is collected totally.
₪ Blood sample is taken at the middle of the test.
₪ Inulin is estimated by resorcinol giving a red color.
₪ The test needs continuous infusion of inulin so as to keep the plasma level adequate.
$elin@ SNVPMV
INULIN CLEARANCE
₪ Inulin clearance (GFR) = 125 mL/min and urea clearance = 75
mL/min.
₪ In other words, 40% of urea present in the glomerular filtrate is
reabsorbed in the tubules.
𝐼𝑛𝑢𝑙𝑖𝑛 𝑐𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 −𝑢𝑟𝑒𝑎 𝑐𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒
𝐺𝑙𝑜𝑚𝑒𝑟𝑢𝑙𝑎𝑟 𝐹𝑖𝑙𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑟𝑎𝑡𝑒
=
125 −75
125
= 0.4
$elin@ SNVPMV
$elin@ SNVPMV
URINE CONCENTRATION TEST
₪ This is used to asses the renal tubular function.
₪ This test includes the measurement of specific gravity which depends on
concentration of solute present in urine.
₪ This test requires a water deprivation for 14 hrs in healthy individuals.
₪ A specific gravity of > 1.02 indicates normal concentrating power.
₪ Specific gravity of 1.008 to 1.010 is isotonic with plasma and indicates no work
done by kidneys.
₪ The test should not be performed on a dehydrated patient.
$elin@ SNVPMV
URINE CONCENTRATION TEST
₪ VASOPRESSIN TEST
₪ This is used to asses the renal tubular function.
₪ More patient friendly than water deprivation test.
₪ The subject has nothing to drink after 6 p.m. At 8 p.m.
₪ Five units of vasopressin tannate is injected subcutaneously.
₪ All urine samples are collected separately until 9 a.m. the next morning.
₪ Satisfactory concentration is shown by at least one sample having a specific
gravity above 1.020, or an osmolality above 800 m osm/kg.
₪ The urine/plasma osmolality ratio should reach 3 and values less than 2 are
abnormal.
$elin@ SNVPMV
URINE CONCENTRATION TEST
₪ URINE DILUTION (WATER LOAD) TEST
₪ After an overnight fast the subject empties their bladder completely and is given 1000
ml of water to drink.
₪ Urine specimens are collected for the next 4 hours, the patient should empty the
bladder completely on each occasion.
₪ Normally the patient will excrete at least 700 ml of urine in the 4 hours, and at least
one specimen will have a specific gravity less than 1.004.
₪ Kidneys which are severely damaged cannot excrete a urine of lower specific gravity
than 1.010 or a volume above 400 ml in this time.
₪ The test should not be done if there is edema or renal failure; water intoxication may
result.
$elin@ SNVPMV
KIDNEY STONES/ RENAL CALCULI/ NEPHROLITH
₪ Formed in the kidneys from minerals in the urine.
₪ Kidney stones typically leave the body by passage in the urine stream, and
many stones are formed and passed without causing symptoms.
₪ If stones grow to sufficient size (usually at least 3 millimeters (0.12 in)) they
can cause blockage of the ureter.
₪ This leads to pain, most commonly beginning in the flank or lower back and
often radiating to the genitals.
₪ This pain is often known as renal colic and typically comes in waves lasting 20
to 60 minutes.
$elin@ SNVPMV
CLASSIFICATION- KIDNEY STONES
Based on location of formation
₪ Kidneys (Nephrolithiasis)
₪ Ureter (Ureterolithiasis)
₪ Bladder (Cystolithiasis)
₪ Slightly More Men Are Affected than women.
Types of Kidney Stones
₪ Not all kidney stones are made up of the same crystals.
₪ The different types of kidney stones include:
₪ Calcium
₪ Uric acid
₪ Struvite
₪ cystine
$elin@ SNVPMV
CLASSIFICATION- KIDNEY STONES
₪ Calcium
₪ Calcium stones are the most common. They can be made of calcium oxalate (most
common), phosphate, or maleate. Vitamin C and spinach contain oxalate.
Calcium-based kidney stones are most commonly seen in young men between the
ages of 20 and 30.
₪ UricAcid
₪ This type of kidney stone is more common in men than in women. They can occur
in people with gout or those going through chemotherapy.
₪ Struvite
₪ This type of stone is found mostly in women with urinary tract infection. These
stones can be quite large and cause urinary obstruction.
₪ Cystine
₪ Cystine stones are rare. They occur in both men and women who have the genetic
disorder cystinuria.
₪ Other
₪ Medications like triamterene and acyclovir also can cause stones.
$elin@ SNVPMV
CAUSES- KIDNEY STONES
₪ Dehydration
₪ Protein(High dietary intake of animal protein )
₪ Sodium
₪ Refined sugars
₪ Fructose
₪ High fructose corn syrup
₪ Oxalate
₪ Grapefruit juice
₪ Apple juice increase the risk of kidney stone formation.
$elin@ SNVPMV
SYMPTOMS - KIDNEY STONES
₪Blood in the urine
₪Vomiting
₪Nausea
₪Discolored or foul-smelling urine
₪Chills
₪Fever
DIAGNOSIS:
₪AbdominalX-rays
₪Ultrasound of the kidney
₪MRI of the abdomen and kidneys
₪AbdominalCT scan
$elin@ SNVPMV
TREATMENT - KIDNEY STONES
₪ Drinking six to eight glasses of water a day increases urine flow.
₪ People who are dehydrated or have severe nausea and vomiting may need
intravenous fluids.
₪ Other treatment options include:
Medication
₪ Pain relief may require narcotic medications.
₪ The presence of infection requires treatment with antibiotics.
₪ Other medications include:
₪ allopurinol for uric acid stones
₪ Diuretics
₪ sodium bicarbonate or sodium citrate
₪ phosphorus solutions
$elin@ SNVPMV
SURGICAL REMOVAL - KIDNEY STONES
₪ Lithotripsy:
₪ Extracorporeal shock wave lithotripsy uses sound waves to break up large stones so they
can more easily pass down the ureters into your bladder.
₪ This procedure can be uncomfortable and may require light anesthesia.
₪ It can cause bruising on the abdomen and back and bleeding around the kidney and
nearby organs.
₪ Tunnel Surgery (Percutaneous Nephrolithotomy)
₪ Stones are removed through a small incision in your back and may be needed
₪ When the stone causes obstruction and infection or is damaging the kidneys
₪ When the stone has grown too large to pass
₪ When pain cannot be controlled
₪ Ureteroscopy
₪ When a stone is stuck in the ureter or bladder,
₪ Instrument called a ureteroscope is used to remove it.
₪ A small wire with a camera attached is inserted into the urethra and passed into the
bladder.
₪ A small cage is used to snag the stone and remove it.
$elin@ SNVPMV

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Kidney function test npn constituents clearance tests_kidney stone_concentration test

  • 1. KIDNEY FUNCTION TESTS TEST FOR NPN CONSTITUENTS CLEARANCE TESTS URINE CONCENTRATION TEST KIDNEY STONES $elin@ SNVPMV SELINA SRAVANTHI SNVPMV, HYDERABAD, TELANGANA
  • 2. $elin@ SNVPMV FUNCTIONS OF KIDNEY ₪ Excretion of urea and other waste products, such as creatinine, uric acid and metabolites of xenobiotics ₪ Maintaining water balance ₪ Excretion of sodium (effect on BP) ₪ Excretion of potassium (effect on heart) ₪ Excretion of hydrogen ions (maintenance of pH) ₪ Activation of vitamin D (effect on bone) ₪ Production of erythropoietin (effect on RBCs) ₪ Filtration: 180 liters/day of water with all sodium, chloride, sugar and amino acids ₪ Reabsorption: 178.5 liters reabsorbed; all glucose and amino acids reabsorbed; most of sodium and chloride reabsorbed
  • 3. $elin@ SNVPMV CLASSIFICATION OF RENAL FUNCTION TEST ₪ To screen for kidney disease ₪ Complete urine analysis ₪ Plasma urea and creatinine ₪ Plasma electrolytes ₪ To assess renal function: ₪ To assess glomerular function ₪ Glomerular filtration rate ₪ Clearance tests ₪ Glomerular permeability ₪ Proteinuria ₪ To assess tubular function ₪ Reabsorption studies ₪ Secretion tests ₪ Concentration and dilution tests ₪ Renal acidification
  • 4. $elin@ SNVPMV NPN CONSTITUENTS OF URINE ₪ NPN constituents stands for NON PROTEIN NITROGENOUS COMPOUNDS ₪ Nitrogen content other than protein in blood, tissues and waste material is associated with ₪ Urea ₪ Uric acid ₪ Creatine ₪ Polypeptides ₪ Approximately of the NPN in blood is associated with UREA
  • 5. $elin@ SNVPMV NPN CONSTITUENTS OF URINE ₪ Clinically significant NPN constituents in blood plasma are ₪ Urea – 45% ₪ Uric acid – 20% ₪ Amino acids – 20% ₪ Creatinine – 5% ₪ Creatine – 2% ₪ Ammonia – 0.2%
  • 6. $elin@ SNVPMV NPN CONSTITUENTS OF URINE - UREA ₪ Present in highest concentration. ₪ Excretory product of protein metabolism. ₪ Measurement of nitrogen in urea is determined as Blood Urea Nitrogen (BUN)/ Urea Nitrogen (Urea N). ₪ Urea is synthesized in the liver, carried by blood to the kidneys and filtered from the plasma through glomerulus. ₪ Most of the urea in the glomerular filtrate is excreted in the urine, although some urea is reabsorbed by passive diffusion through the renal tubules. ₪ The amount reabsorbed depends on urine flow rate and extent of hydration. ₪ Small quantities of urea (10% of the total) are excreted through the gastrointestinal tract and skin.
  • 7. $elin@ SNVPMV NPN CONSTITUENTS OF URINE – UREA WHY MEASURE SERUM UREA ₪ Evaluate renal function, ₪ To assess hydration status, ₪ To determine nitrogen balance, ₪ To aid in the diagnosis of renal disease, ₪ To verify adequacy of dialysis
  • 8. $elin@ SNVPMV DETERMINATION OF UREA METHOD: BERTHELOT METHOD FOR BLOOD UREA PRINCIPLE Urea + 2H2O NH4 + + CO3 2- NH4 + + Salicylate + Hypochlorite 2,2- dicarboxyindophenol urease Green Ammoniu m ions Ammoniu m ions Carbonate ions ₪ The intensity of the green colour which is proportional to the concentration of urea present in the sample is measured at 570 nm
  • 9. $elin@ SNVPMV DETERMINATION OF UREA METHOD: ENZYMATIC ASSAY FOR UREA PRINCIPLE Urea + 2H2O NH4 + + CO3 2- NH4 + + 2- oxoglutarate Glutamate + H2O urease Glutamate dehydrogenase NADH + H+ NAD+ ₪ The rate of disappearance of reduced NADH (decrease in absorbance) is measured at 340 nm
  • 10. $elin@ SNVPMV NPN CONSTITUENTS OF URINE – UREA CLINICAL SIGNIFICANCE ₪ NORMAL LEVEL ₪ In plasma : 6-20 mg/dL ₪ In urine: 12-20 g/day ₪ INCREASED CONCENTRATION ₪ Prerenal Congestive heart failure ₪ Shock, haemorrhage, Dehydration ₪ Increased protein catabolism ₪ High-protein diet ₪ Renal- Acute and chronic renal failure ₪ Renal disease, including glomerular nephritis, tubular necrosis ₪ Postrenal - Urinary tract obstruction ₪ DECREASED CONCENTRATION ₪ Low protein intake ₪ Severe vomiting and diarrhoea ₪ Liver disease ₪ Pregnancy ₪ AZOTEMIA ₪ Increase in the blood levels of urea ₪ UREMIC SYNDROME ₪ High plasma levels of urea accompanied by renal failure
  • 11. $elin@ SNVPMV NPN CONSTITUENTS OF URINE - CREATININE ₪ Creatinine is formed from creatine and creatine phosphate in muscle and is excreted into the plasma at a constant rate related to muscle mass. ₪ It is removed from the circulation by glomerular filtration and excreted in the urine. ₪ Small amounts of creatinine are secreted by the proximal tubule and reabsorbed by the renal tubules WHY MEASURE SERUM CREATININE ₪ Plasma creatinine is inversely related to glomerular filtration rate (GFR). ₪ it is commonly used to assess renal filtration function - severity of kidney damage and to monitor the progression of kidney disease. ₪ Plasma creatinine is insensitive marker and may not be measurably increased
  • 12. $elin@ SNVPMV DETERMINATION OF CREATININE METHOD: JAFFE’S METHOD PRINCIPLE Creatinine + picric acid orange red colour (Janovski) complex Alkaline pH ₪ The intensity of the orange red colour which is proportional to the concentration of creatinine present in the sample is measured at 510 nm
  • 13. $elin@ SNVPMV CLINICAL SIGNIFICANCE ₪ NORMAL LEVEL ₪ In plasma : 0.9-1.3 mg/dL ₪ DECREASED CONCENTRATION ₪ Low muscle mass ₪ Pregnancy, ₪ Starvation, wasting diseases, ₪ Corticosteroid intake NPN CONSTITUENTS OF URINE – CREATININE ₪ INCREASED CONCENTRATION ₪ Glomerulonephritis – infection or autoimmune disease ₪ Pyelonephritis (bacterial infection) ₪ Acute tubular necrosis (death of cells in tubules) by drugs or toxins ₪ Prostrate disease, renal calculi, urinary tract obstruction ₪ Shock, dehydration, congestive heart failure, atherosclerosis, complications of diabetes, Chronic Obstructive Pulmonary Disorder (COPD) ₪ Muscle injury, vigorous exercise ₪ Drugs- Cimetidine, salicylates reduce tubular secretion
  • 14. $elin@ SNVPMV ₪ UREA NITROGEN/ CREATININE RATIO - 10:1 to 20:1 ₪ Prerenal conditions tend to elevate plasma urea, whereas plasma creatinine remains normal, causing a high urea N/creatinine ratio. ₪ A high urea N/creatinine ratio with an elevated creatinine is usually seen in postrenal conditions. ₪ A low urea N/creatinine ratio is observed in conditions associated with decreased urea production, such as low protein intake, acute tubular necrosis, and severe liver disease
  • 15. $elin@ SNVPMV NPN CONSTITUENTS OF URINE – URIC ACID ₪ In human, uric acid is the major product of the catabolism of the purine nucleosides, adenosine and guanosine. ₪ Uric acid is transported in the plasma from the liver to the kidney, where it is filtered by the glomerulus. ₪ Reabsorption of 98% to 100% of the uric acid from the glomerular filtrate occurs in the proximal tubules. ₪ Small amounts of uric acid are secreted by the distal tubules into the urine. ₪ Uric acid is relatively insoluble in plasma and, at high concentrations, can be deposited in the joints and tissue, causing painful inflammation ₪ Renal excretion accounts for about 70% of uric acid elimination; the remainder passes into the gastrointestinal tract and is degraded by bacterial enzymes ₪ Nearly all of the uric acid in plasma is present as monosodium urate.
  • 16. $elin@ SNVPMV NPN CONSTITUENTS OF URINE – URIC ACID WHY MEASURE SERUM URIC ACID ₪ Assess inherited disorders of purine metabolism, ₪ To confirm diagnosis and monitor treatment of gout, ₪ To assist in the diagnosis of renal calculi, ₪ To prevent uric acid nephropathy during chemotherapeutic treatment, ₪ To detect kidney dysfunction
  • 17. $elin@ SNVPMV DETERMINATION OF URIC ACID METHOD: CARAWAY METHOD PRINCIPLE Uric acid + phosphotungstic acid + O2 Allantoin + tungsten blue + CO2 Alkaline pH ₪ Protein free filtrate of urine sample is used ₪ Uric acid (reducing agent) as it readily converts to allantoin ₪ Method not specific
  • 18. $elin@ SNVPMV DETERMINATION OF URIC ACID METHOD: ENZYMATIC – SIMPLE SPECTROPHOTOMETRIC METHOD PRINCIPLE Uric acid + O2 + 2H2O Allantoin + H2O2 + CO2 Uricase ₪ Differential absorption of uric acid and allantoin at 293 nm. ₪ The difference in absorbance before and after incubation with uricase is proportional to the uric acid concentration.
  • 19. $elin@ SNVPMV DETERMINATION OF URIC ACID METHOD: COUPLED ENZYMATIC METHOD PRINCIPLE Uric acid + O2 + 2H2O Allantoin + H2O2 + CO2 H2O2 + 4-Amino antipyrine + ADPS Quinoneimine dye + H2O Uricase ₪ ADPS , highly water soluble aniline derivative, (N-Ethyl-N-(3-sulfopropyl)-3- methoxyaniline, sodium salt, monohydrate ESPAS) ₪ PHBA (Polyhalogenated benzoic acid ) may also be used instead ₪ The intensity of the pink colour of quinone imine dye which is proportional to the concentration of uric acid present in the sample is measured at 550 nm Peroxidase
  • 20. $elin@ SNVPMV CLINICAL SIGNIFICANCE ₪ NORMAL LEVEL ₪ In plasma (Males) : 3.5-7.2 mg/dL ₪ In plasma (females) : 2.6-6.0 mg/dL ₪ In urine : 250-750 mg/ day ₪ DECREASED CONCENTRATION - HYPOURICEMIA ₪ Liver disease ₪ Defective tubular reabsorption (Fanconi syndrome) ₪ Chemotherapy with NPN CONSTITUENTS OF URINE – URIC ACID ₪ INCREASED CONCENTRATION - HYPERURICEMIA ₪ Enzyme deficiencies ₪ Lesch-Nyhan syndrome (hypoxanthine guanine Phosphoribosyl transferase deficiency) ₪ Phosphoribosylpyrophosphate synthetase deficiency ₪ Glycogen storage disease type I (glucose-6- phosphatase deficiency) ₪ Fructose intolerance (fructose-1-phosphate aldolase deficiency) ₪ Gout ₪ Treatment of myeloproliferative disease (tumors) with cytotoxic drugs ₪ Hemolytic and proliferative processes ₪ Chronic renal disease ₪ Toxemia of pregnancy ₪ Lactic acidosis ₪ Drugs and poisons
  • 21. $elin@ SNVPMV ₪ Hyperuricemia may lead to Formation of kidney stones ₪ Most of uric acid is removed by the kidneys and disposed of in the urine. ₪ In hyperuricemia Uric acid crystals precipitate in the kidney and may block filtering tubules leading to renal failure. Uric acid crystals in a urine sample Sodium urate/ kidney stones
  • 22. $elin@ SNVPMV Gout: A chronic type of inflammatory arthritis in which uric acid crystals accumulate in the joints causing severe inflammation. It usually affects the joint of big toe, other joints including ankles, knees and elbows may be affected X-ray of gouty uric acid deposit in the big toe Uric acid crystals in big toe joint
  • 23. $elin@ SNVPMV The amount of substance excreted in urine is the result of ₪ Glomerular filtration ₪ Tubular reabsorption ₪ Tubular secretion Urinary excretion rate = filtration rate – reabsorption rate + secretion rate
  • 24. $elin@ SNVPMV ₪ CLEARANCE ₪ a theoretical concept defined as the volume of plasma from which a measured amount of substance can be completely eliminated or cleared, into the urine per unit time‐ can be used to estimate glomerular function ₪ Glomerular Filtration Rate (GFR) ₪ It’s the volume of fluid filled from the glomerulus into bowman's capsule per unit time. ₪ Normal level – 120- 125 mL/ min ₪ Affected by ₪ Age ₪ Sex ₪ Body surface area ₪ Protein intake and pregnancy ₪ Reduced GFR ₪ Age ₪ Decrease in functional nephrons (>75%) ₪ BP is below 80 mm Hg ₪ SUBSTANCES USED FOR CLEARANCE TEST ₪ Endogenous – Creatinine & Urea ₪ Exogenous – Inulin (gold standard), 51Cr – labelled EDTA, 99Tec– labelled EDTA
  • 25. $elin@ SNVPMV ₪ When GFR decreases to 30% of normal - moderate renal insufficiency. Patients remain asymptomatic with only biochemical evidence of a decline in GFR ₪ As the GFR decreases further severe renal insufficiency characterized by profound clinical manifestations of uremia and biochemical abnormalities, such as acidemia; volume overload; and neurologic, Normal - Dec.Renal reserve Mild Renal imp Moderate insuff. Renal failure ESRD 100-120ml/min 60-100ml/min 40-60ml/min 25-40ml/min <25ml/min <10ml/min
  • 26. $elin@ SNVPMV ₪ CREATININE CLEARANCE ₪ Measure (rate at which the amount) of creatinine eliminated from the blood by kidneys ₪ Used to assess renal function ₪ About 98% of creatine pool is in muscle. About1.6% is converted to creatinine per day, which is rapidly excreted. ₪ Since creatinine excretion is a constant in a particular person, the urine creatinine is sometimes used to check whether the 24 hours urine sample does actually contain total urine volume or not. ₪ Normal value : 75-125 mL/min ₪ Males: 105±20 mL/ min ₪ Female: 95±20 mL/ min
  • 27. $elin@ SNVPMV CREATININE CLEARANCE ₪ Method ₪ Give 500 mL of water to the patient, to promote good urine flow. ₪ After about 30 minutes, ask to empty the bladder and discard the urine. ₪ Exactly after 60 minutes, again void the bladder and collect the urine, and note the volume. ₪ Take one blood sample. Creatinine level in blood and urine are tested and calculated. ₪ Formula ₪ It is useful to correct the clearance value with body surface area. ₪ This is important, especially in children, and persons with short or tall frame. ₪ Creatinine clearance corrected for surface area could be calculated as: 𝐶𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝐶𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 = 𝑈 x 𝑉x 1.73 𝑃 x 𝐴 𝐶𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝐶𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 = 𝐶𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑢𝑟𝑖𝑛𝑒 𝑖𝑛 𝑚𝑔/𝑚𝐿(𝑈) 𝐶𝑜𝑛𝑐𝑒𝑛𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 𝑖𝑛 𝑝𝑙𝑎𝑠𝑚𝑎 𝑖𝑛 𝑚𝑔/𝑚𝐿(𝑃) x Volume of urine flow(V) (mL/min)
  • 28. $elin@ SNVPMV ₪ Measurement of plasma creatinine better than measurement of urinary creatinine because ₪ The accuracy of urine collection is dependent in patient that gives errors. ₪ The values of Plasma creatinine correlates with creatinine clearance in patient with renal disease. ₪ Plasma creatinine measurement enables progress of renal disease to be followed with better precision than creatinine clearance. ₪ Measurement of plasma creatinine is effective in detecting early renal diseases.
  • 29. $elin@ SNVPMV ₪ LOW CREATININE CLEARANCE ₪ Kidney problems, such as ₪ Damage to the tubule cells ₪ Kidney failure ₪ Too little blood flow to the kidneys ₪ Damage to the filtering units of the kidneys ₪ Loss of body fluids (dehydration) ₪ Bladder outlet obstruction ₪ Heart failure ₪ HIGH CREATININE CLEARANCE: ₪ Carbon monoxide poisoning ₪ Hypothyroidism ₪ Pregnancy.
  • 30. $elin@ SNVPMV ₪ UREA CLEARANCE ₪ The urea clearance is less than GFR, because urea is partially reabsorbed. ₪ Urea clearance is the number of mL of blood, which contains the urea excreted in a minute by kidneys. ₪ Not as sensitive as creatinine clearance ₪ 40-60 % of the urea is reabsorbed by renal tubule. ₪ Influenced by extra renal factors ₪ Dietary proteins ₪ Fluid intake ₪ Haemorrhage ₪ Infection
  • 31. $elin@ SNVPMV ₪ Method ₪ Allow the patient to have a normal breakfast. ₪ At 9 AM give a cup of water and the patient is instructed to void the bladder, and urine is discarded. ₪ At 10 AM bladder is completely emptied and the volume of urine is measured and the urine urea is estimated. ₪ A blood sample is taken and blood urea is also estimated.
  • 32. $elin@ SNVPMV CREATININE CLEARANCE ₪ Formula ₪ Normal value : 75 mL/min ₪ STANDARD UREA CLEARANCE ₪ Clearance value is decreased when V, the volume of urine, is less than 2 mL/min. ₪ Normal value : 54 mL/min ₪ Standard urea clearance = U x √V P ₪ Where, ₪ U – mg of urea/ mL of urine ₪ P – mg of urea / mL of plasma ₪ V- volume of urine flow (mL/ min) 𝑈𝑟𝑒𝑎 𝐶𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 = 𝑚𝑔 𝑜𝑓 𝑢𝑟𝑒𝑎 𝑝𝑒𝑟 𝑚𝐿 𝑜𝑓 𝑢𝑟𝑖𝑛𝑒 𝑚𝑔 𝑜𝑓 𝑢𝑟𝑒𝑎 𝑝𝑒𝑟𝑚 𝑜𝑓 𝑝𝑙𝑎𝑠𝑚𝑎 x Volume of urine flow (mL/min)
  • 33. $elin@ SNVPMV ₪ LOW CREATININE CLEARANCE ₪ Less than 75% of normal ₪ The values fall progressively with failing renal function. ₪ The clearance value may be abnormal even though the plasma urea values are within normal limits. ₪ The plasma urea values will start to rise only when the clearance value falls below 50% of the normal. ₪ Urea is normally reabsorbed from renal tubules and therefore, tubular function also affects urea clearance. ₪ Hence, creatinine clearance test is more preferred. ₪ Urea is freely filtered by the glomerulus and passively reabsorbed in both PCT and DCT. Urea clearance is less than GFR
  • 34. $elin@ SNVPMV ₪ INULIN CLEARANCE ₪ Inulin is a polysaccharide of fructose. ₪ It is not metabolized by the body. ₪ It is neither absorbed nor secreted by the tubules. ₪ Inulin clearance is a measure of GFR. ₪ The value of GFR as measured by inulin clearance is 125 mL/min. ₪ METHOD ₪ About 100 mL of sterile 10% solution of inulin is given as slow intravenous drip within 2 hours. ₪ Urine specimen formed during this period is collected totally. ₪ Blood sample is taken at the middle of the test. ₪ Inulin is estimated by resorcinol giving a red color. ₪ The test needs continuous infusion of inulin so as to keep the plasma level adequate.
  • 35. $elin@ SNVPMV INULIN CLEARANCE ₪ Inulin clearance (GFR) = 125 mL/min and urea clearance = 75 mL/min. ₪ In other words, 40% of urea present in the glomerular filtrate is reabsorbed in the tubules. 𝐼𝑛𝑢𝑙𝑖𝑛 𝑐𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 −𝑢𝑟𝑒𝑎 𝑐𝑙𝑒𝑎𝑟𝑎𝑛𝑐𝑒 𝐺𝑙𝑜𝑚𝑒𝑟𝑢𝑙𝑎𝑟 𝐹𝑖𝑙𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝑟𝑎𝑡𝑒 = 125 −75 125 = 0.4
  • 37. $elin@ SNVPMV URINE CONCENTRATION TEST ₪ This is used to asses the renal tubular function. ₪ This test includes the measurement of specific gravity which depends on concentration of solute present in urine. ₪ This test requires a water deprivation for 14 hrs in healthy individuals. ₪ A specific gravity of > 1.02 indicates normal concentrating power. ₪ Specific gravity of 1.008 to 1.010 is isotonic with plasma and indicates no work done by kidneys. ₪ The test should not be performed on a dehydrated patient.
  • 38. $elin@ SNVPMV URINE CONCENTRATION TEST ₪ VASOPRESSIN TEST ₪ This is used to asses the renal tubular function. ₪ More patient friendly than water deprivation test. ₪ The subject has nothing to drink after 6 p.m. At 8 p.m. ₪ Five units of vasopressin tannate is injected subcutaneously. ₪ All urine samples are collected separately until 9 a.m. the next morning. ₪ Satisfactory concentration is shown by at least one sample having a specific gravity above 1.020, or an osmolality above 800 m osm/kg. ₪ The urine/plasma osmolality ratio should reach 3 and values less than 2 are abnormal.
  • 39. $elin@ SNVPMV URINE CONCENTRATION TEST ₪ URINE DILUTION (WATER LOAD) TEST ₪ After an overnight fast the subject empties their bladder completely and is given 1000 ml of water to drink. ₪ Urine specimens are collected for the next 4 hours, the patient should empty the bladder completely on each occasion. ₪ Normally the patient will excrete at least 700 ml of urine in the 4 hours, and at least one specimen will have a specific gravity less than 1.004. ₪ Kidneys which are severely damaged cannot excrete a urine of lower specific gravity than 1.010 or a volume above 400 ml in this time. ₪ The test should not be done if there is edema or renal failure; water intoxication may result.
  • 40. $elin@ SNVPMV KIDNEY STONES/ RENAL CALCULI/ NEPHROLITH ₪ Formed in the kidneys from minerals in the urine. ₪ Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. ₪ If stones grow to sufficient size (usually at least 3 millimeters (0.12 in)) they can cause blockage of the ureter. ₪ This leads to pain, most commonly beginning in the flank or lower back and often radiating to the genitals. ₪ This pain is often known as renal colic and typically comes in waves lasting 20 to 60 minutes.
  • 41. $elin@ SNVPMV CLASSIFICATION- KIDNEY STONES Based on location of formation ₪ Kidneys (Nephrolithiasis) ₪ Ureter (Ureterolithiasis) ₪ Bladder (Cystolithiasis) ₪ Slightly More Men Are Affected than women. Types of Kidney Stones ₪ Not all kidney stones are made up of the same crystals. ₪ The different types of kidney stones include: ₪ Calcium ₪ Uric acid ₪ Struvite ₪ cystine
  • 42. $elin@ SNVPMV CLASSIFICATION- KIDNEY STONES ₪ Calcium ₪ Calcium stones are the most common. They can be made of calcium oxalate (most common), phosphate, or maleate. Vitamin C and spinach contain oxalate. Calcium-based kidney stones are most commonly seen in young men between the ages of 20 and 30. ₪ UricAcid ₪ This type of kidney stone is more common in men than in women. They can occur in people with gout or those going through chemotherapy. ₪ Struvite ₪ This type of stone is found mostly in women with urinary tract infection. These stones can be quite large and cause urinary obstruction. ₪ Cystine ₪ Cystine stones are rare. They occur in both men and women who have the genetic disorder cystinuria. ₪ Other ₪ Medications like triamterene and acyclovir also can cause stones.
  • 43. $elin@ SNVPMV CAUSES- KIDNEY STONES ₪ Dehydration ₪ Protein(High dietary intake of animal protein ) ₪ Sodium ₪ Refined sugars ₪ Fructose ₪ High fructose corn syrup ₪ Oxalate ₪ Grapefruit juice ₪ Apple juice increase the risk of kidney stone formation.
  • 44. $elin@ SNVPMV SYMPTOMS - KIDNEY STONES ₪Blood in the urine ₪Vomiting ₪Nausea ₪Discolored or foul-smelling urine ₪Chills ₪Fever DIAGNOSIS: ₪AbdominalX-rays ₪Ultrasound of the kidney ₪MRI of the abdomen and kidneys ₪AbdominalCT scan
  • 45. $elin@ SNVPMV TREATMENT - KIDNEY STONES ₪ Drinking six to eight glasses of water a day increases urine flow. ₪ People who are dehydrated or have severe nausea and vomiting may need intravenous fluids. ₪ Other treatment options include: Medication ₪ Pain relief may require narcotic medications. ₪ The presence of infection requires treatment with antibiotics. ₪ Other medications include: ₪ allopurinol for uric acid stones ₪ Diuretics ₪ sodium bicarbonate or sodium citrate ₪ phosphorus solutions
  • 46. $elin@ SNVPMV SURGICAL REMOVAL - KIDNEY STONES ₪ Lithotripsy: ₪ Extracorporeal shock wave lithotripsy uses sound waves to break up large stones so they can more easily pass down the ureters into your bladder. ₪ This procedure can be uncomfortable and may require light anesthesia. ₪ It can cause bruising on the abdomen and back and bleeding around the kidney and nearby organs. ₪ Tunnel Surgery (Percutaneous Nephrolithotomy) ₪ Stones are removed through a small incision in your back and may be needed ₪ When the stone causes obstruction and infection or is damaging the kidneys ₪ When the stone has grown too large to pass ₪ When pain cannot be controlled ₪ Ureteroscopy ₪ When a stone is stuck in the ureter or bladder, ₪ Instrument called a ureteroscope is used to remove it. ₪ A small wire with a camera attached is inserted into the urethra and passed into the bladder. ₪ A small cage is used to snag the stone and remove it.