The Kidney and Tests 0

of Renal Function

OUTLINE
I. STRUCTURE OF THE KIDNEY 6. Bilirul,in, urobilinoi,:cn, nilritc, .ind
leukocyte esterase
II. FORMATION OF URINE
C. Microscopic examination of the urine
A. Regu la1ion of ADH output sediment
B. Rc.ibsorp1ion and excretion proc<.-sscs I . Normal findings
C. Regulalion of aldo~terone output 2. Abnormal formed element.s
D. Excretion of adds D. Te~ts of cre,llinlnc, urc.i, ~ncl uric acid
Ill. LABORATORY TESTS OF RENAL 1. Crc.tti nlne
FUNCTION a. Serum crea1inine
(1) Principle
IV. URINALYSIS (2) Reagcnls
A. Macroscopic and physica l examlna1ion (3) Procedure
I . Volume (4 ) Rdurcncc v,1lucs
2. Color (5 ) Increased concen1ra1ion
3. Odor (6) Decreased concentration
4. Specific grav lty b. Urine creal inine
a. Measurement by urinmnctur ( I) Calcul.itlon
(hydrometer) (2) Reference values
(I ) Procedure c. Crcatlnine clearance
b. Mc,1~uremcnt l,y rcfrac1ometry ( 1) Procedure
( I ) Procedure (2) Reference values
c. Measurement by d ipslfck (JI Increased creatinine
5. O smolality cleard nce values
a. Procedure (4) Decreased crealinlnc
b. Reference values clearance values
13. Qualitative or semiqu,rntltative tests d. lo1halama1e clea rance
1. pH (1 ) Principle
2. Protein 2. Urc.i nitrogen
a. 0i~lick a. Serum urea-nitrogen
b. Sulfosallcylic acid ( I ) Detcrmiriation by urca~c/
3. C luco~ glulamate dehydrogenase
4. Kc1one bodies (a) Principle
5. Blood (b) Reference values
IV. URINi\LYSIS 1con1111u• ~JJ t,11 l'r111c ,plt-
Ir) lnnt-,IM'll cc>nlPntr,1t1on thl Rc:ll 'fl'111 c , dlu<.~
hll Dl.•uc•,t't.11 l or1u•ntrJllun td lnuc,,,(,cJ 1 11n(l•n11.1111111
3. Uoc ,K id (di OPC 11•,1,!'ri r 0111 Pnlr.•111 ,,.
,1 . ~ rum unc ,Kid
h. U1 i,w un<. ,t<. icl
t 1) Determ,natton hy urrcJ~ 1UV
~l)';()rh,., nc<• L U11ne ton< t•111rJl tcu111...,1
l,1 ) Pnnuµlt• I 1•11K'Pc.lu rc
(2) Oc·t1·1111m,111uc, by urrl .iwl Urn,.ir~• lr.u I c.ik ult (\lclfl•" )
H ;<>,•<.uuµl c'<l re,tc lion, I . Prine ,pie

OBJE C TI V E S
M!LY ~ l1
1. tlr ~ - 11f11 lllntf na,• i a ~ t !t9lill!oi
- "
I i l:n-.,ul,
1 inr:JJ I t

l ,n.1 tf oJ ', fft 111( ~ l' tr 'I -:-t!U

o ,c, .
1. 1 l• '-l'l'•"•'dte U.« utU4l t:Jt1

◄, t ttn :11 nr,lu•t1'~ · I I

~ N •1 r l
k•
.._ l • 11 w,1 11, 11

1•.-c1 urctw I h ~ l ti O !: C h:-.Jtto;;JC li,f

•
"',u 11'• 1l:,;r;,u•

la. iJ (t~K4t . .l Ufl Jltl&i. 1r1t lt.:l'TW .II Ith&

,,QII 111M tllrl Ill" l....111':111111 lANi r,,c,11 :V-~ I .

1l11 ~ •I• •• •,) ,r,• , 11 •1 u uu rv•;•ir;,Jhl, I c ..: ! • l lr1t. •q lc 1 ,. H. 1u .! u .Jr

•,~,u,·. u 1.tc{! ,., , l1mln1111~ ••illl~l c· ...,..,.h... , ,... 111. I• ~,· l t tt i,.r-:1" " " r
1
l , !IIH -~ ., 1 " ' .,1 tJ .... J ll~• "'' " II I H ' ·- ~- • . , .. , .... ,1 •, ~.,\, .... , ,. '""'" " 1!111:.
Jl• 111! n 111I J•~ • ! n u I i,! I• 1np:--<1 11,1 f11 1 " 1l11 11111~ · 111 , tal \' 1: ,11,,,_., v. · •
l :, lra, :, ... .. .,. , •. l•JI , ., ~• 1-..!.-•1.' .. • · q,•: 11:1: t11r l1o•. r,1 'ii. •I , .,11111•• ,!,.-··o'llrr.
lht l . l r· 11l rr. •111' • t111 r . , tll •t •i • . 111 ,• ,j,. . 1. •11 , , n c• .. II ' • .111,, °' ' '
l',1ll111 I< 'ii•·,-:,,,., ·: olhl•, , :> 111,J .1 11 Il l ,,,,. ,!,, , ..,,., 1 . , ... 1 t,, I l . \•1t lo 11\ , •• • • • 11.
 The Kidney and Tl'1ols of Ren.ii f unction 155
11i.scss Ole efficacy of 1helr artificial kidney. The kidneys perform suveral
endocrine functions, such as the S)'nthesis of erythropoiel in (a hormone thul
stimulates rud l,looJ cell production) and 1.25-dihydroxy-vitamin 0 3 (the
biologicnlly active form of vitamin 0). This c:hnrtrr deals only with the renal
rncdianisms of urine formation ancl how tho clinical r.homistry luhumtury
monitors runal function and renal disease states.

STRUCTURE OF THE KIDNEY

There are two kidneys, 0 110 on each side of the ubdomen. The central region of
the lidney is reforred to as the medulla, and the outer layer is the cortox. Tho
kidneys rocei ve u1,proxlmately one fift h of the blood pumped uut with each
heartbtmt fro m the nmal arte ries, and they ruturn op1, roxhnutoly 99% of lhnt
volume to the ronal veins. The small fraction of flu id thnt ultimnlr,ly forms
urine flows from the collecting ducts into the renal pelvis and through the
ureter (one per kidney) to the bladder.
The working unit or tho ~idney is lho nt•phron, shown schorm1ti<:,1II>• in
fo'iguro 6 . t. A ncphron is composed of a glomorulus (the filter), o proxinliJI
con\folutod tubule (primary site of rr.absorpt inn). a long looJ> of llenle
(thin-walled descending loop nnd lhlc:k-wallnd osccncling loop). a dista l
convoluted tubulo (scconclary siln of rcabsorpticm). and o coUeclinK lubule and
collocting ducts (sites of water ruabsorption and urine com:untration). Most
regions of each nl'phron oro closol)' ossodaled wilh tin, bluo1lstrcam. Wholo
blood within the afferent arteriole is fihered at a tuft of capillaries wilhin tho
glomerulus. The ,,a)uable components of the fillrole, such as salts. gl\lc:Oso,
amino acids, and waler. are reabsorbed in lhe proximal or distal r.on\'olutod
luhules and rnturned lo the capillaries of tho efferent artcriol«!S. The unab-
sorb1?d filtrate flows Into the ureters and bladder for subsuqu1mt excretion as
urine.

FORMATION OF URINE
The llltration of plasma by lhe glomcrulnr c;apilluries Is the first step in the
formation of urim:. The red and white blood cells, plntelels, and moleculos of
molecular woighl > 50,000 daltons (mos t proteins and constituents tightly
bound to proteins) are retained in the caplllrLries. About 20% of tho plasma is
filtered through the c;upillary membrane at tho glomr.rulus and enters tho
11•1,'u·.o Thi" ,li .."T1 1 ltl' ri \he lunt:n n{ \&-., h ,•ffrrQ\',\ ~ \v1\·\-., ~\ :nh°"'\~1.-. \<1
,,:.rull,'.t tlun I h : L1m t ll •1 I 0 1 h ,tfu.,.:;1 ln1 h t iri,CI ..:hr ,Jlt , tla, t ,u ur~ • r i.lOlt
ir, I,~ o j 1,,, .. ,11,,•In tb 11 d1 u 11r ..!.c 1.•11r-.,;1, , ,--i,l 11. Ln~ 11 ... hllr.Y.l-11 i"•~,.. ,.
f ur fillr 11101:i lu t.,h • (11>1 ~- ,1,.. ,r:~thu Olll ull - 11 i n:>.-J l d 11111,~ '''- nJ 11,,
c,,1. ,1,u:.•n. .,, ct:, •A~._ tr aln 111.,, tl1t &•ll•••ltt-111 h pfurr.:a (•mttl-1 (•lfn,~ ~.
<L,1,1.11.1.1~,1 ·.C111;_11.• ll v N 1,,m ,•i.• tululr, U!~ll~.u~ ti"' 111t t lln .',Hr- fi llrc.'.; 11
1••nsw" 1C11l l1111,l,u .:rnui:ulu 11rr 1llrn
l hr filt, ..:.;o i•: L-..•.!~> Is ; ., ,Ml\tl ... a l>..41111 'f\'l'Juut t ·.ll~ O u..;., ~11hl1J111 Ttlr
~,,,1ll~r) u1 ll1 ,,1 t u • ,111n.i tLLLI • . It >I" t hin u d tu ll 11'-11r.,"! , ,. 11, ,11 i,. n1.x:.11
15 6 Clinical Chemi.'> try
Glomerulus Distal tubule
& peritubular
capillaries

i
111

X
~ Plasma filtrate _ ____,;;:=
a: pH7.4
0
(.) specific gravity
1.010

l--------- Proximal
tubule - ~

1
Loop of Henle
Descending limb Ascending limb

TO URETER
pH 5-6.5
URINE: { specific gravity
1.015-1 .030
FIG. 6.1. Repres(.'f)tJtion of ,1 r,ephron ,1nd ,ts blood supply.

as a filler; water and small molecules pass easily lltrough the pores to fom1 an
ultrafillrate of plasma. The ultrafiltmte is largo in volume (about 180 L.lday for
the average adultl, and its constituents are of the same concentrallon as those
in plasma. Ninety-nine percent or the ultrafiltrate water and a la rge percentage
of its constituents must be reabsorbed before the urine leaves tho collecting
tubules on its way to the !.,ladder.
The second step in the formatio n of urine is lhe passage or the ultrafHtrate
down the proximal convoluted tubule. whore tho \•arious seleclivo processes of
absorpllon begin. The flllrato starts out with the same specific gra\•ily as a
protein-free filtrate o( plasma, 1.010. and tho same pl I. 7 .4. About 70% of waler.
Na· . and c1-. and all but negligiblo amounts of glucose. amino acids. and K •,
are reabsorbed In the proximal tubules. Some substances, such us urea,
phosphate, and ea 2 •• are incompletely reabsorl.,ed. H+ is oxchanged for Na ·
throughout the tubule. whereas K+ is exchanged for Na+ only lo the distal
tubule. where the K •-No· exchange is regulated by the hormone aldoslcronc.
 The l(jdney and Tests of Renal Function 15 7
Waler in the filtrate is always reabsorbed passive ly wll(:n the osmotic prnssure
outside a semipermeable tubulor meml,rane Is higher than 11101 inside; water
fo llows the osmotic gradient toward restoration of equilibrium. The osmotic
gnidionl is usually produced by active Na ' transport (the sudium pump), on
energy-requiring process. The glomerular filtrate is red uced to about one third
of its original \!olumc in the proximal tubule, but because water and salts are
absorbed together, no chani;e occurs In the osmotic pressure of tbe filtrate.
Several components of the Ouid leaving the proximal tubule aro selec tively
runbsorbcd depending ou the needs of the body. Por example, during the hours
of slceµ, the physio logic need is to conserve waler and to eliminate excess salts
and 11 • by producing a h}iperosmolar urine Lhat is much moro oc:id ic than
plasma . This need is met by iln interplay of anatomic featums. physic.:al forces,
and finely regulated hormonal control.
The unalomic features that promote the independent reahsorption or walor
and Na 1 from the distal and collccllng tul,ulcs are (1) a thickened wall ill tho
ascemllng limb of the loop of Henle that is impermeable to waler but oot to
ions; (2) the extension of the loop of HenJe and large sections of the dislal aud
collecting tubules from the kidney cortex into the medulla: (3) tJ1e passage of
the blood capillaries lnlo the interslilial !issue, surrou nd ing in counterc urrcnt
fashion the loop of Henle, tbe ,Jjstal tubules. and collecting ducts; and (-l ) tho
imperm eability to water of the walls of the distal and collecting tuh\llcs unlflss
acted upon by the antidiuretic ho rmone.
The interstitial fluid In the kidney increases in osmotic pressure from the
cortex to the medulla. This osmotic gradienl is an important rnnal feature that
is crco,ted and malnlained by llllphrons ond allows them to function . The
osmoHc gradient is caused by dH iucroai.ing concentration of Na ' and c1- as lhe
Na+ is pumped out of the ascending loop of Honie by an acti ve process. The
osmotic gradient in the interstitial fluid surro und ing the descending loop of
Henle is the physical force that greatly acc:clerates the reabsorption of water
fmm the lumen of the descending loop. As the filtrate moves up the ascending
loop, the reabsorplion of water slops because the lumen wall Is lmpormoable to
water. The reabsorption or No· from the ascending loop is consideroble
because of pump action; c1- moves passively wilh it The water nod ions thot
pass into the inttirstilial fluid are redaimeJ by absorption into lhe blood
capill1uies surroundi ng the loops ol Henle and tho tubules. Tho net result is the
producrtion or u hyposmolor urine (greater loss of No+ and c1 - than waler) by
tho time the distal tubule is reached. The intornction of water leaving the
clcsr.encling loop and Na- and c1 - leaving lho ascending loop is responsible for
maintaining a hiKh osmolality wilhln tho kidney medu.Lla while reducing the
osmolality of the urine lo,n•ing thn loop of Honie. This inleraction is known as
a cournlercurrenl mulliplicalion process.
The walls of rho dislnl and collecting tubules are impermeable to water
unless ac:tcd upon by the onlidiuretic hormone (ADIi). \Vben an excess of
water exists within tho body, ADH is not secreted. and IJ1e dilute fluid In the
distal and collecti ng tubules is passed as uri ne. When the body needs to
retain water, a fmal reabsorption of waler takes place under the infl uence of
ADH, !hereby resulting in the produ ction or hyperosmolar, coacentraled
urine. The hyperosmolar interstitial lluid surrounding lhe collecting tubules
158 ClinicaJ Chembtry

RFSPONSE 1A 1 SllMlHU'.,,A, RI Sl'U~hl i,\,

tBloocl YOIUme -
1'
+H,O 1eabsofpllon
1'
+Plasma OIITIOlahfy
1' Na· +--~~+Na•
+Plasma RHblorpllon -l-~+Aldo1lerone '-M~

+Plasma H,O ++-,.-+- +ADH1'------,

P0S I .::hiOR
Pm:ITAAY

+Plasma Osrnolallty - -> t Plasma Osmolalitf

STll~UI US 1B,
➔ I HYPO.WJ.AMU8 J

flC. 6.2. ADI I and aldc,,tt.,One control ol the reNI 11:,1~p11on or wJIC'I and Na • . In
1c5ponse to a fall in blood ,olumle o, blood pm,surc \Stimulus A), wnin i~ ~'(rt•tl'd by the
l.idncy, thcrd,y lcJd lng to .>n ani;lotcn~in ll-r,wd1i1tt'<I clcv;ition ol bk)()(! pres~ure :md an
3ldo:.tcro11('-n~•d1Jt1..-d incrNse '"' Na• reJbsorp1ioo. In re~pon-;(' lo ,in inc lt'J'>C 1n pl,1~a
osmolal!!y \S!imy!y, 61, 1\011 is ~{n;lc,-d l,,y the: po)lcnQr pi\y1t,1ry, !lwr~-by in( re,1sing w,11er
rcab..orphon in the d1s1,1I ,ind collecting tubules.

accelerates the water uptake. ADH scc:rotion ls s timulatm.l IJy a h igh plasma
osmotic pressure ond Is lnhibitnd by a decreased osmotic pressure, so lhat
the net result Is conservation or excretion of body water according to
osmotic need (Fig. 0.2). This process essentially controls the volumu of urino
finally excreted.

Regulation of AOH Output

ADH is n hormone (vasoprossin) producod by the hypothalamus but stornd In

tho posterior pituitnry gland. Rl!ceptor cells in tho hypothalamus aru seni;itlvo
to chnngcs In osmotic prcssuru within tht! blcH>rls trcam and transmit ll(!fVO
impulses to the posterior 11lluitary. Eltwatcd osmotic press ure stimulates tho
pos terior piluitnry glanrl tu secretu ,\DH und thus promotes watur retention by
incrcnsing renal rcabsorplion or walt:r (decreasing urine volwne). An elevation
or osmotic pressure also stimulates lhe feeling of thirst that loads to the
consumption oml absorption of water and a res ultant dt:cruose in os motic
pressure. /\ decrease in osmotic prnssurn within tho IJluo<lstrcurn Inhibits thu
secretion of 1\0M and promotes waler loss by decreasing the ronal mahsorptlon
of water (increasing urinary vulumti).
 The Kidney and Tests of Renal function 159
Reabsorption and Excretion Processes
Many dlHcnml mechanisms are involved in the various absorption processes.
Some are passive and con bo ax plained hy c:n11c:m1traliou grn1ll unts or Ly
osmotic pressure difforences (for exomplu, wntor), whereas otlwrs require
nctive transport mechanisms hwolving tho expnndiluro of energy. Thu active
processes are usually coupled with 1mzymo action lo trnusfer substances
from the lumen into cells a811-i11st a C:llm:ontrotlon srudiont. Water in the
filtrate is ul>sorbed passively in the proximal tubule, l,ut glucose and amino
acids aro 11.lmost comphitely reubsorlied b}• acHvo transport. About 70% of 1h11
sodium Is rnabsorl>ed la tho proximol tubulu by an actlvu process. primarily in
conjunction with chloride. In the distal tubule. hnwev,ir. a specialized ion
uxchange mechanism participates in the conservation of sodium and in tho
excruliua of potassium and hydrogen Ions. 13icorbonato is converted to C01 uml
water by Lhc hydrogen ion In the filtrah! , and the CO 2 diffuses inlo the tul>ular
cells. where it is curl\"erted by the enz~•mo cnrl>onic anhydrase back tu
bicarbo11utt1 ion. The uHeclivo roabsorptiun or 11co; occurs throoghuut the
tmtirc length of the tubuJc. Creallnine. on the other baud. is not absorbed at all
by tho rn1u1I tubule; in fact, ~mall omouuts may be secrtited by the tubulor cells
Into the uri ne. Potassium ion is almo~t co1npletely reabsorbed in the proximal
tubule . but o portion ls exc.hanged for Na + in lho distal tubule, whcro tho
potassium Ion Is secrnted Into the lumen of the tubulo. l'hosphoto ion is
roabsorbed by an active process In the proximal tubule. but tho reahsorplion is
nevur complete. and flno control is achieved by s<icrolion of tho parathyroid
honnone, which lnhil>ils phosphate roahsorptlon. Urea, on thr. other hand ,
diffuses pnsslvely into tho blood as it passes down the tubule. Under ordinary
circumstances, about 60% of the uma in the filtrate i$ t!Xcrntod In the urine, but
th is amount varies with the glomerulnr fi ltration rate and the rate of filtrate flow
in tho tu bules.
Table 6. 1 rov11als that tho klilneys purform a tremendous amount of work in
form ing normal urine. Approximately ·tuo IL {lll0,000 g) of plasma are filtered
In a 24-hr porlod; 178 to 179 L are rcubsorbc,I. Stated another way, about 99.2%
of the 11\0 t nf walt!r in the ultrafiltroto rnt urns to hody fluid s. The amount or
solutes in tho filtrate varif!s from 540 g of sodium and 630 g of chloride to o.uu
g of II mixture of proteins (primarily albumin and glycoproteinsl. Most of the
sodium and chloride Ions and amino acids are reabsorbed. Glucose is
complcloly reabsorbed ln normal circumstances, whereas creatinine is not
reabsorbed at all. The reabsorption capacity for glucose has a threshold or limit ,
however. When its concentration in plasma, and consequently In tho glomor-
ular filtrato, exceeds 180 mg/d L. some of thre glucose escopcs rcnbsorption und
opp1iars in tho urim,. Tho high plasma gluc.o~u le,rcls in unr.ontrollr.il di11holos
mcllitus explain thll customary finding of approciahlo amounts of glucmm In
tho urlnu of di:ibulic patients.
Table 0. 1 nlsu shows in column (3) the amounts of tho difforcnt suhstnr1c;(is
excreted by a person eating an a\"erage diet; In column (<i). tho amounts
roohliorbed or roclaimccJ for use uru 11lvcn. Tho degree of wahsorption or tho
water and salts oppeo.rlng in tho glomerular filtrate is subjoct to lino control
mechanisms responsh•e to body needs.
160 Clinical Chemisl11•
TA!U &.1
AVERAGE FILTRATION, REABSORPTION, AND f>iCIIETION OF CEIITAl"i NORMAL
CONSTITUENTS or Pt.ASMA.

w Ill (41
Il l
Con>1ituen1
11Llff<EOJ24 HK
u;}
EXCR[TI O l ol ltR'
Is.! (RJ
R(.AllSC>RBfDIH IIK
~
...·
\\lalt'f 180,000 1,800 178,200 '}'},0
Chluti{k> 630 5.3 1,25 •J?. 2
Sot.lium 540 ) .) 5.37 99.4
Uicarbonate 300 0 ..3 300 100
Clutu-.(• 140 0 140 100
Am ino acid~ 72 I 71 YIU>
Url'a 5J J2 :?4 39.I>
l'ot.lisium 28 4 24 85.7
Uric a<ld 11.S 0.8 7,7 fl{) I,
l'ho~phJIC 6.5 I S.5 34. 1
Crl'.itmme 1.4 1.4 (1.0 0
Total protrin' I 0.(1', I l

•t.\ulllfit."d ~f1t>1 U.-d,ne,, R.W.• .llnd Gleb,.c-h. G.: &--.1 o1nd T.:i11<w•, l'htw,lc,i,:,c.1111,i-,, ol Mr,!,c-.il P1.1n,r.-. 101h
Ld,unn. B~h,mrne, W,11,lms ~ \\ 11'-rn,, 1'179.
'Twrc,1l 1l()tm,1I , ,1hit->, bul grt·,tlly ,1,1Jl•ric.k•nl or, dk1,1ry ,r1IJI.<'.
MJn1• (l,flc1l"'' p,olc,n, Jl)IIC.•Jr u, the urll'I(.' m II.Kt' .>rnoums. Mo-.t of ll>l'm h.i,e ~ n"1l1'( ul.11 .-c,i;t,1 lov.,., lh,111
1

70,00U d,,h~. wt ii k-w hilve ,1 molt'Cul•r \\Ctgh1 a, hri;h •• 11,0.000 d.ih,'°'

Tbe control mechanism for the regulation of sodium rcabsorption rests with
tlw steroiJ hormone aldostcrone, a mineralocorticoid protJucc!J by !he adrum1I
cortex that responds lo changes in blood volume. Aldusteroutt acculu,dtt!s the
rcabsorption of sodium in tho d istal luhulu hy facilitating its tlxchange for
polassium ions (fig. G.2). FoElowlng tho production and Sl.'Cretion of alJoste•
rono, sodium is retained anti potassiu m is oxcn.:tcd . With a deficiency of thb
hormone, the fC\'crse takes place: sodium exc:rolion Increases as less sodium is
retained b)• the boJy, and potassium excretion is ducreaseJ . The alJoslerone-
mcdiatcd feedback control ul sodium exr.rr tlon makes µossib le a ,·nrialion in
the excretion of Na• from Ztlro lo large amounts, according to tbe needs of tho
body. The necessity for the renal consorYalion of Na 1 mediated by aldostcrono
bc.-comcs acute in areas uf the world whew NaCl is scarca or wben the loss of
NaCl is great because of profu se sweating with inadet1uate Intake to compen-
!:.lto for tho loss. Tho ability to retai n or cxcroto sodium. and water wilh it, is an
ossont lal Ille process.

Regulation of Aldosterone Output

Receptor cells in the kidneys arc sensilivo to changes in renal blood flow and
can stimulate the process of fl uid retcnlion. When tho rcnol blood \'Olumu is
reduced by either a reductio n in total blood volumo or a ruduclion in l,lc,od
pressure, the renal receptor cr.11s rcleasu nwin. a prot.-nso. Runin nets u po n
plasma angiotensinogen (an u 2 -globulin) and splits off 1h11 dl!(:.ipcptide
 The Kidney and Tests of Renal function 161
onglolensin I . Anglotensin I lo::.cs two amino acids from its chai n by the action
or a lung peptidase and becomes ongiolensin LI, a powerful vasoconstrictor.
Angiotensln JI not only produces an immediate rise in blood pressure. but also
stimulates the adrenal cortex to secrete the steroid hormone aldoslerone.
Aldostcrone promotes the retention of Na • in the distal tubule. thereby
increasing water retention by its osmotic effect.
Thus, the regulation or flu id volume and osmotic pressure 1$ coordinated by
the interplay or the two hormones, aldostcrone and ADH, that control the
degrees or reabsorption of Na ' and water, respecti\'cly. in the dis tal and
collecting tubules. The thirst medumism is also an important fa cto r in
regulation , but sick patients may not have reacly occoss to a s upply of fluid s
and, in soute cases, may not be able to retain ingested fluid .
There was no evolutionary pressure to develop a h ighly refinnd mechanism
to conserve potassium by the lidney. Most foodstuffs contai n potassium.
thereby making virtually impossible a K + deficiency in a mammal eating a
natural diet. A K• deficiency in humans hos appearod only in tbe last century,
with the production of highly refined foods devoid of potassium, lbe
introduction of Intravenous saline/glucose therapies, and the use of powerful
diuretic clrug.s for the treatment of high blood pressure. The kidney can excrete
large am ounts of K • when the lntake is high, but ii cannot reduce the K'"
excretion below a ue rtain level, even If the intake faHs to zero. 1\Jdostero ne
media tes o reabsorption of Na • from t!te filtrate in the distal tubule to the
bloodstream by excreting K• in exchange. In this manner, elevated levels of
aJdoshuone promote l,oth the retention of sodium and loss of potassium fro m
the body.
Although bicarbonate ion cannot ba absorbed d irectly [rom the tubuJar
lumen because the wall is impermeable to ii , bicarbo1u1te ion is absorbed
Indirectly. As the glomerular filtrate oc-comes acidic. IIC0 3 is 1>rotonated and
com•erted to carbonic acid (H2C0 3 ). which is in equilibrium wl.th COi and HiO .
The CO2 diffuses Into the tubular cell, where it is recombined with H20 and
reaches an equilibrium with H2 C0 3 , and H- and HCO; . The HC0 3 is absorbed
into the blood capillaries, thereby ach ieving the same result as direct
rm1bsorptlon o( IICOj . The equili bria are summarized in Figure 6 .3.
Under conditions of metabolic alkalosis. however, the urine Is al kaline and
protonalion of bicarbonate does not take place. Appreciable amounts of HC0 3
are then excreted into the urine, a compensatory mer.hnn ism that helps to lower
the plasma concentration of HCOj" as well as tho pH.

Excretion of Acids
Tho principal renal mecha nis ms for excreting excess hyd rogen ions o r protons .
s ummarized in Figure 6 .3, follow:
1. Exchange of lumen Na ~ for cellular H~.
2. Trapping or lumen H ... by the foll ow ing reactions:
a. I IPOi- + Fr - H2 PO;
In tJ1 t1 plJSmd at pH 7.4, 80% or the phosphate Is in tha form of
16 2 Clinical Chemi~try

StO OO
ST H= ~\i
8

8
2Na· + HPO:
Jl ttt tta -c ~ co, + H.O
~ H. _ '..:!!
_:...... ..... H.CO,

Na· +
rN•· ~
+t
W + HCO;
Na"
~ = . _ . . , _ Glut.amine

FIG. 6.3. S<he malk lllustr.tlion of the

mec h;inism of bic arbo nJtc rNb )orp c lon
exchanRe o( N.1 • (or H' and the trap (A), ,llld ol the
ping of H • with amm oni a ,1nd phOl>ph
tuhu ~ d uring .i<.id osl~ 18 ). C.A . .. the l'fll) .itc in the r<'flJI
ltne c-a riiom c anh yd r.i'JC .

HPO ! - . Protons (H •) ore scc:retcd Into the

rena l tub ula r lum en, who re
the prec eding reaction lake s plac e. At pH
fi .O, prac tica lly 100 % of the
phosph ute is In the form of H PO; .
2
l,. l\fl t 3 + H • - NH4 •
In the tub ular cell , glut aml ne is c:on vcr
tcd into glut ami c acid and
amm oni a (NH3 ) by the enz yme glu tam inas
o. The NH J read ily diff use s
Into the lum en, whe re II reac1!1 wit h
H t to form NH : , whi ch Is
exc retu J. An uqulvalent amo unt of Na'
Is retu rne d to the tub ula r cell
in exc hange for the 11· , wit h Lhe net effu
ct of exc reti ng NH: Inst ead
of Na · . Thi s mechan ism becomu s significn
nl for d ispo sing of excess
H + In ch ron ic acid osis , beca use the cap
acit y for pro duc ing NI 1 from
glut ami ne Is greatly incr ease d by S)•n 3
thes ls of tho glut ami nas o
enzyme . whi ch Is stim ulated by the stal
e of acid oi;is.
3. F.xc rcllo n of und issociated acid s. suc
h as keto acicls. in unc ont roll ed
diobctos mol litus or prolonged fast ing.

In su mm ary, urin e is formed by a con

• ultr afih rotl on of plas ma followed by
tinu ous pro cess that star ts wit h tho I
tho rcab sorptlon of the wat or 11ncl oth
con stitu ents to a grea ter or less er oxtc nl.
Rua hso rpli on may take plac:n by man y
er I
mec han ism s: pass.Ive diff usio n , s pt..-cial
trans1>ort mec han ism s, cnc rgy-llnl.:od
I
I
 The Kidney and T~t.s of Rl'JlJI function 163
processes, and ion exchange. The composition and \·olume of the urine arc
influenced by lhe St.'Cretion or w ithholding of essential honnoncs, notably ADI-I
and aldosterone, tlial act upon tubular cells. The final composition of Iha urina
is attained by tbe secretion of somo constituents from the blood plas ma into the
distal tubular lumen. The nonnal urine contains more dissolved substanc;es
than does the plasma ultrafillrale (higher specific gravity) and is much more
acidic. The net effects of this complicated process are the oxc:rction of waste
products of metabolism and tho preservation of the volume. ionic r.onr.cntra-
Lion, balonca, and pH of tho body fluids.

LABORATORY TESTS OF RENAL FUNCTION

Laboratory tests ploy on important role in tho di11gnosis and assessment o f renal
disease bocau~e clinical signs and symptoms may bo vogue or absent. Somo of
the renal function tests reveal primarily disturbances in glomcrulnr filtration.
and others re flect dysfunclion of the tubulr.s, hut damage is seldom confined
solely to a particular portion of the nrphron. Because the anatomic portions of
the nephmn are closely rr.lalllrl and ha\'e a common blood supply, tJumjgo to
one portion gradually irwol\'cs the nephron as a whole. Eventually both
glomerular and tubular portions of the nephron become involved Irrespective
of tho silo of lhe original lesion. AU nephrons are not aHectcd by <llsease at lhe
same limo or lo the same extent, and a reserve capJcity is pruvic.Jed for l iJney
fun ction. As a co.nsequence, the pathologic condition of the l it.lney must be
considerable before the tests of renal function become 11bnom1al.
The formation of a normal urine at a normal rate requires properly
func:tio ning lldneys recei\•ing an aJequale blooJ supply at a surficlcntly high
blood prt!Ss ure, with no obstruction to urine outflow. A malfunction in the
formation and/or elimination of urine may be attributable lo prercnal, renal , or
postrcnal causes. The prcrcnal factors affect blood \•olume, blood now. or blood
press ure, and lncluc.Je such conditions os hemorrhage, shod ., dehydration,
intestinal obslruction , prolonged diarrhea, and cardiac failure. When these
defects are corrected. kidney function usually returns lo nomldl. Tho re na l
factors are within the kidnoys themselves and may affect the Klomerular
filtrati on rate, the various tubular ncUvities, or the renal blood \'esscls. The
postrenal factors thol decrease renal !unction are obstructio ns to lho flow of
urine., such as renal r.alculi (stones); carcinomas or tumors thal may compress
the ureters, uru1hr11, or tho bladder ope11ing; or an enlarged prostate gland that
partially occludes the urethra. Chemistr)' tests alone. howe\•er, arc incapable of
difforonlialing the lhroo prime causes of renal Jysfunc.tion. but u careful history
and phrsk.al exam ination of the µal ien!, in combination with a few other tests,
can elucidate the problem.
Some of the common renal diseases that produce a d iffuse in\'olvement of the
kidneys are glomerulonephritis , the naphrotk s)·ndrome, pyelone phrltis, and
arteriolar nephrosclerosis.
Glomrrulonephrilis. a c.Jiffuso. inflammatory disease, affet.ts the glomeruli
flrst, bul rapilll>• produces degeneration o( the tubule. In its a cute form , the
disease is evident suddenly by the appearance of hcmaturia and protei nuria,
with varying degrees of hypertension (high blooc.J pressure), renaJ insuffic ianc}',
164 Clinical Chemh,try
and edema. The causati\'e agent for the disease is usually a prior infection with
a group A, Jl-hemolytic streptococcus. The deposition of immune complexes on
the renal basement membrane may bo rcsponi;iblc for the glomerulllJ' damage.
Most patients r~cover completely from Uic acute phase. but a fow undergo
progressive loss of renal function and finally die in renal failure.
A chronic form of glomeruloncphritis ,·aries greatly in its dcgroo nf sc,·erity.
In some patients. the Jisease is progressive. with continuing loss of renal
function: in others. remissions anJ relapses may go on for many years.
The nephrolic SJ•ndrome is characterized b)• heavy proteinuria. hypoolbu-
mincmia, edema, and hyperlipidemia. Lesions in the glomerular membrane
allow proteins to escape. Laboratory tests rtivtml no other impufrnwnt uf renal
fun ction. The syndrome Is frequ ently assocfotr.d with S)'ste mic lupus erythe-
matosus, proliferali\'e glomeruloncphrilis, amyloidosis. or syphilis. but fre-
quently. the causative factor is not known. Many patir.nls respond to treatment
with odrenocortical steroids.
PJ1olonephrilis is an inflammatory renal disease caused l,y infectious
organisms that ha,·e ascended tho urinary tract and i11\'adt.-d l.idnoy tissues.
Chronic or repeated infections may load to replacement of renal cells by scar
tissue. witb some loss In renal function .
l\rtcriolor nephrosclcrosis is characteri1.ed by a thickening of the inner lining
of tho renal ar1erioles. resulting in a docrtU1sed lumun and a n increased bluo<l
pressure. As the l,lood \lesscls become ntiCJ"Otic, proi,;russi\'C loss occurs in Loth
glomerular and tubular function. Scar tissue replaces the damaged cells. and
tho kidney becomes contractcJ . Proteinuria is common. In some pctllents. the
high blood pressuro cannot be controlled (malignant hypertension}, and the
impairment in renal function Ut.>cum(.'S µrugressh•e and rupid: the outcome is
fatal. In the benign form, the blood pressure can be reduced to reasonable
,·alucs by appropriate dnigs, so the loss in kidney Junction is relath·cly mild
and slow in its progression.
Renal tubular acidosis (RTt\) is a group of disorders in which the renal
excretion of acid is reduced far more than the g)omerular filtra1ion rate: the
defect is primarily confined to the tubules. The several types of RT A arn
freq uently hereditnry. Tho most common type of RTA a£lects the dlstal tubules,
so that either the H • diffuses back from the lume n Into the tubule or tho distal
tubule is unable lo transport H+ from cells to lumen. The net result Is an
accumulation of H • in the body (acidosis). accompanied by d£.-crcnscd IICO;
and increased c1- concentrat ions In plasma. Tbe plas ma K • concentration is
usually low. The disorder is seen more frequently in childICn than In adults. A
second type of RTA has a dcrcct in the proximal tubules. resulting in ineffective
reabsorption of HCOj'. Acidosis is accompanied by K~ loss and hyperchlor-
emia. The two types or RTA c-.an he difforentlated by giving the patient a11 oral
lo;1d of NH 4 CI and measuring the urine pll: an individ ual with J istal KTA
cannot addlfy the urine below pll S.S. whereas a patient with the proximal
defect can do so. Some gcnatic tubular tfofec:ts producr., in addition tu acidosis,
glucosuria, amino aciduria, and low plasma levels of urate and phosphate
(Fanconi syndromes).
Because the kidney is the primary organ im1olvod in the ext..Teliun of certain
nitrogenous wastes (crcatinine. urea. uric acid), in the regulation of wulr.r and
electrolyte balance, and in the excrntlon of fi xed acids, renal dysfunction is
 The Kidney and Te~ls of Renal function 165
characterized by changes or abnormalities in one or more of these parameters.
Some or these abnormalities (electrolyte or acid-base imbalance) are nonspe-
ci6c, because they may also occur in other disease states. Clinical chemistry
tests for the diagnosis of renal dysfunction are confined, therefore . to the few
that are mo re indic.ili\'e of renal disease: serum creatlnine. serum urea
nitrogen. crcalinlne clearance. and urinalysis. Some other tests are usefuJ for
confirmation or for intelligent management ol the patient and may be ordered
for these purposes. Urinalysi$ is described first because it yields useful
information and is a routine procedure for all palients.

URINAL YSIS 1 - s
Examfoation of tho urine as an aid to diagnosis of many diseases has been
carried o ut for centuries by med ical practitioners. Some of the current methods
of examination are still traditional. such as noting the appearance and odor of
the specimen and making a microscopic examination of the urinary sediment.
The main advances ha\1C been in providing dipsticks or strips for the
semiquantitation of a group of constituents and in measuring urine osmolality
as an indication of total solute concentration. VisuaJ and microscopic
examination may yield useful clinical information and must not be neglected
bt.'Cause it is not "quantitative."
A ro utine urinalysis usually consists of an examination of a morning
specimen (upo n arising) for color. odor. speci6c gravity, or osmolality. Some
qualitath•e or semiquantitative tests are performed for pH, protein. glucose or
reducing sugars, kctoncs. blood and perhaps bilirubin. umbilinogcn. leukocyte
eslerase, and nitritn.
Some hospitals routinely perform a microscopic examination of the urinary
sediment. but others do so only when both the nitrite and the leukoq•te
esterase tests arc posith•e. Tests that are especially useful in evaluating re oaJ
function or renal disease are described in detail; those US(.-d for the diagnosis of
other diseases arc treated more fully in the appropriate chapters .

Macroscopic and Physical Examination

Volume
Knowledge of tho doily urinary output may be of value in tho study of renal
disease. but this test requires a timed specime n and a good collcclion. Tho daily
output of urine depends largely on the fluid intake and many other factors.
such as degree or exertion. temperature. salt (NaCl) intake. and hormonal
control. but the average excretion of a normal adult is approximately 1 mUmin
or about 1400 :: 800 mU24 hr. A decreased urinary output is called oligurio; an
increased output is referred to as pol}1urio. Oliguria may be cnused by prerenol
(low blood pressure , shock, hemorrhage, fluid deprivation), renal (acute
tubuJar necrosis. certain poisons. renal vascular disease. precipitation of
certain compounds in ncphrons). or postrcnol (calculi, tumors compressing
ureters. prustalic hypertrophy) factors. Polyuria may be caused by the excretion
166 dinic.11 Chemi~try
of a large amount of solutes, with obligatory excretion or water (aflcr t?xcessive
salt lntale. in diahetes mellitus with glycosuria). by a deficiency or tlepression
of ADM , or by the excei.si\10 ingestion of fluids or diuretic substances.

Color
Although infrequent, an abno rmally c.olored urinfl is lmpClrtant to note. 1-' resh
blood or hemo~lobin may impart a reddish color. whomas old blood rnaL.es the
urine look srnok}·; both are indications of blut•ding in th<l gunituurinar)' tract.
Bile pigments produce a green, brown, or deep yellow color signifying Liver or
biliary tract disease (see Chap. 11 ). A dark hrown urine may be causC-d by
homogcntisic aLid e.>.cn:tcd in a r.tre ~e11e1lc disease, alL.aptonuria. Some drugs
ur d yes may also contribute color lo the urine.

Odor
Fresh urine has a characteristic odor that may be affodecJ by foods. such as
asparagus. In diabetic acidosis, a fruity odor may be cau~d hy the l ctoacids
and acetone (s~-o Chap. 7). In maple syrup urine disease. a rare scnetic dek'Ct,
tho urine has the odor of c.aramoll:r.cd sugar or maple S)•rur,. When urine
speci mens are old. o r when a Proteus infoction is pri:scnt, a strong odor of
ammonia is usually ap paront. A putrid odor usually maans that the urine has
undergone h,1cterial dl'Composilion tx.-c.ause it has remained loo long without
refrigeration.

Sp(•c.:ific Gr<1vi1y
Tho specific gravity of the urine \'arics directly with the grams of solutes
excreted per liter. II provides information on the abilil)' of the L.idncy to
concentrate tho glomorular filtrato. The ph ysiologic range of spcdfic i;ravity
varies from 1.003 to 1.032. but the usual range fo r a 24-hr s1,ccimen varies from
1.015 lo 1.025. The mosl conc:tmtral♦1d 11pccimcn is obtained o n arising in the
morning. In renal tubular disf'.asc, tho c:onccntraling ability of the kidne)' is one
of the first functions lost.
The specific gra\'ily of urine may be dotcrminml clireclly with a urinomete r o r
indirectly through measurcnwnt of ils rdractivu index.

Measurement By Urinomeler (Hydrometer). Tho urinometer is a hydrometer

designed to fit into and Ooat in a narrow cylinrlor filled with urine. The
urinometer has a slender neck. with n spt.>eific gravity scalo wrap ped around it
that usually covers the range from l .OUO to 1.~0. Thn urinomclcr should be
calibrated by testing it with a solution of L.nown sp,!Cific. gravity.
J>rococJure
l. Fill the qilinder uLout lbrne-fourths full with spuclmen and place on a
level surface.
2. Insert lhe urinomeler into the cylinder and spiu sliKhtly so that it floats
freel y.
3. Read lbe specifi c gravity clin•ctly from thn scale ou the stem a l the lowest
point of the meniscus of the urinn surface.
 l he Kidney .1nd T~LS o f Renal f unction 167
-1 . Temperuture correction: If tho urine is not at the urinomcter calibra tion
te m peratu re, add 0 .001 to the spocific gra\lily fo r C\'ery 3• C that the UTine
is above this tem perature and subt ract 0.001 for every 3° that the urine Is
below this temperature.

Measurement By Refractometry. The refractive index of a solutio n a lso \•a rics

with the amount of d issolved substa nces, and hence Is related to the sp<.-cific
gra\'ity. B,:causc the urine must be clear, this measurement is usually carr ied
out on a centrifuged specimen. Commr.rcial refractometers are a\'ailable wi th a
sr.ale that gi\•cs a di rect rcaciout in spodfic gravity.
Procedu re
t. Pface a small drop of clear urine on the glass su rface or the refractometer
amJ close tlw lid .
2 . Look tltrough the meter di rectly to1vard a light source.
3. Rucord thu specilic gravity at the point w here tho line separating tho light
ar ea from the d ark crosses the specific gravity scale.

Measurement By Dipstick. ,\ d ipstick that estimates specific gravit~• Is

a\·ailaule as part of a multiple test strip (N-Multistix-SG by Ames). The strip
uses a po lyclc.-ctrolyte and an ind icator (bromth}rmol blue) that changes colo.r as
H ' is displaced by Na• o r K+ in the patient's u rine.6 The test is good for
screen ing, but measurement by urinometer or by refractometry is more
accurate.

O sm o l.tl ity
0smolality is a measure of the moles or d issolved particles (und issociated
molecules, as well as ions) contained in a kiloi;;ram or solvent; ii rcOucts the
total concentration of solutes.
When substances are dissolved in a sol\lent. they affect some of the
properties of tho solvent and cause some physical changes that can be
measu red . These changes aru a lowering nf lh1! h1:czing point. a decrease in the
vapor pressure, an d an increase In th·c boiling point or the pure sohrent.
Commercial instruments are available that make use of the freezing point and
\rapor pressure for the measurement of the osmolality of body Ouids. The m ost
commo nly used instru m1.mts use the fmezing poin t depression , whureby one
mole o f each ionic species and each nonioniwd solute per kilogram or water
lowors the freezing point by 1.86° C.
Procedure
1. Follow the manufacturer's directions for the particular instrument
available to you.
2. Calibrate the inslrurnenl with known standards.
3. Centrifuge the specimen well to eliminate suspended matter.
4. Measure the lowering of the freezing point or tbe vapor pressure. as the
case may be.
5 . Record the osmolality.
168 Clinical Chemislry
Reference Values
Serum: 278 to 305 mosm/kg
Urine-random specimen: 40 t,o 1350 mosrn/kg
On normaJ Ouid inlake. 24--hr specimen: 500 to 800 mosm/kg
Owing maximal urine concentration; 850 to 1350 mosmlkg
Note: The osmolality is a more accurate refleclion of the concentration of
dissoh·ed substances than is the specific gravity bec.iuse in various diseases the
urine may contai:n relatively large amounts of glucose or protein. These
substances have a molecular weight much higher than that of the sails
<..-orumonly found in urine, and hence affect the specific gravity much more than
they affect the osmolalily. Tho receptors in the body respond to osmolality or
changes In solute concentration.

Qualitative or Semiquantitative Tests

A routine urinalysis also inch.1des tests for the measurement of pH and for the
detection of protein. glucose or reducing sugars, ketone bodies, and frequently
for bilirubin, blood, and other suLstances. Commercial djpsticks or test strips
incorporate chemical reagents in a paper (solid phase) matrix that react with
specific urine constituents whe n dipped into o urine bottle. Semiquantitation is
achieved by comparing the color produced with that of a c-.olor scale. Some test
strips arc for a single constituent; otbers are designed for two or more tests
simultaneously. Some dipsticks permit the measurement of niine tests at once
(Ames, Boehringer Mannheim). The nine constituents that may be estimated in
this manner arc pH, protein. glucose, ketoncs, blood. bilirubi n. urobilinO).'Un,
nitrite, and leukocyte esterase.

pH
The urine has a physiologic pH ~ange of 4.6 to 8.0, with a mean of
approximately 6.0. Starvation and ketosis increase the acidity of the urine.
Acid,producing salts are someUmes administered for the lreatmenl of urinary
tract infections. The urine is seldom alkaline. but becomes alkaline in alkalosis
after the ingestion of alkali O\'er a period of lime for the treatment of ulcers or
from bacteria in the urine that gener-dte ammonia. Tho pH is usually measured
by means of a paper strip impregnated with an indicator or by using a
commercial dipstick that contains a mat of cellulose or paper impregnated with
two indicators, such as methyl red and bromthymol blue, to co\'er the entire
physiologic range.

Protein
A small amount of protein (50 to 150 mg/24 hr) appears daily in the normaJ
urine. Some of this protein comes from a small amount of albumin that. is
61tered in the glomerulus but not n:absorbcd in the tubules; the rest is the result
of s lycoprotcins from the linings of tho gcoitouri:nary tract. Normally, the
protein concentration in urine is below 10 mg/dL and is not d!etcctable b)' the
usual urinalysis methods.
 The Kidney and Tests of Rl'nal f unc:tion 169
Prolcinurio llbe presence of deteciable amounts or protei n In the urine)
usually Indicates Injury to the glomerular meml,raue, whkh consequently
pemlils the fthration or escape of protein molecules. Proteinuria must be
wflerentiated, however, from a transient proteinurla that muy ta~e place during
lhP. course of a high fever or from a hannlcss condition, orthostolic prulclnuria,
which occurs only when a patient is active and on his feet. Because orthostatic
proteinuria does not occur when the subject is recumbent. the first urine
specimen upon arising in the morning should have no detectable protein.
Protein in urine may he measured by di pstick or sulfosalicyllc acid tests.

llipslic:k. The basis for the protein test is the " protein error" of indicators, a
term applied to the change in ionization and color of the indicator, and hence
Uie apparent pH. when an indicator dye is ad sorbed to protein. The paper s pot
in the d ipstick is impregnated with citratr, buffer (pH 3.0) containing
brompheno l blue indicator, which Is yellow at pH 3.0 and blue at pH -&.2 . Al pli
3.0 , the indicator is mostly un-ionized. If protein is present In the urine Into
which it is dipped, the ionized fraction binds lo the protein, Lherel,y causing
more d re to ionize until equilibrium is reac:hcd; hence. the impregnated strip
bas less yellow a nd more blue color as lhc protein concentration increases.
This reaction is seen visually as a change from yellow to green (a mixture or
yellow dye plus blue dye appears green). The color is compared with that or a
color chart. which provides a crude estimation of the protein content from 30
mg/dL to about 1000 mg/dL.
Note: False-posiU\'e protein indications by the dipstick method may be
obtained wilh a buJfercd , alkaline urine. No false-positi\'eS occur with x-ray
contrast media. sulfonamides, or other d rugs ur medication that may causo
turbidity with other tests for protein (.suUosalicylic acid test or heal precipita-
tion at pl I 5.0).

Sulfosalicylic Acid. To perform a chemical test for urine? protein. transfer

approximately 3 ml of centrifuged urine to a test tube, hold at an angle. and let
J drops of 250 g/t. sulfosa.licylic acid run down the side of the tube. The acid
forms a layer underneath the urine; do not mix.
Examine the urine-add Interface for turhirlity after about 1 min. A barely
perceptible turbidity is reported as a " trace" or :t, and heavier amounts are
graded from 1+ to 4 +. A protein concentration of 5 mgldL usually registers as
o trace, l,ut falsc-positfre sulfosalicy lic acid test results may be encountered
with urine from patients in jected n!CentJy wilb x-ray c:ontrast media or
recei\'iog sulfonamides. tolbutamidc, or other medications.

Glucose
Although 1-tlucose may appear in the urine as a result of renal disease (nmol
glycosuria). this occurrence is not common. The usual rationale for including
a test for glucose in a routine urinalysis is to d etect unsuspected diabetes or to
c:hc!Ck the (1ffir..1C}' or insulin tJ1erapy in diabetic patients. This test is described
in detail in Chapter 7 . Only tJ1e dipstick test is descri bed in this section.
The dipstick papt",r is impregnated wlth glucose oxidase, peroxidase, buffers.
and a r.hromogen that is colorless in tbe reduced state and colored when
170 O inical Chemistry
oxhlized . Glucose ox.idase converts glucose to glucoujc acid a nd produces
I l O2 in the process. In a coupled reactio n. H20 2 is decompost!c.l b)1 pe roxidase.
with the simultaneous production of H2 0 and oxidation of the chrumogen. One
compan y employs potassium iodide as the chromogen that is oxidizud to
iodine (brown): another uses o-toluidine (colorless) as a hydrogen donor that
becomes l,lue when do hyd mgcnated (oxidized ). The color intensity of the
glucose strip is read in 10 sec for tho Ames dipsticks and in 30 SL"C for the
Chem1strips of Boohringcr Mannhoim.

Ketone Bodies
Although kotonurin may accompany situations of carbohydrate deprivation
(fasting or high-fat , high-protein diets). it derives its clinical importance
primaril y from its occurrence in uncontro lled diabetes. Act;0rdingly . ketonurla
is reviewed in greater detaH in Chapter 7.
The dipsticks contain o strip 1mpregnaled with sodium nitroprusside and an
alkaline buffer. ln the presence of aoetoacetate or ac:etone. a la\lender c:olor is
produced and compared with that of a color chart.

Blood
The presence of small amounts of occult blood (l,Jood cells or hemoglobin that
do not ,,isibly color the urine) may be tlelected l,y ap propriate dipsticks. The
reaction is based on tho enzymatic action of hemoglobin in decomposing
peroxides, which in tho presence of a hytlrogen donor, o-toluidine, produces a
blue color. This end reaction ls identical to the color obtained in th•~ glucose
ox.ldase reaction. Hemoglob1n in the u rine iuclJcates hemolysis in the blood -
stream or the lysis of red blood cells in the urinary tract; it is common in
vadous renal disorders or conditions affecting the uri nary tract.
The appropriate dipstick (Ames: Boehringer Mannheim) is Impregnated with
a buHered organJc peroxide and o-toluidine. A l,lue color appears within J O sec
if hemoglobin ls present and may be graded by the intensity of the color.

Bilirubin, Urobilinogcn, Nitrite, and Leukocyte Estcrase

Te.sis for bilirubin. urobilinogen, nitrite, and leukocyte eslerase appear on some
dipsticks, but not all laooratories test for these sul,stances routinely. Tests for
bilirubin and urol,ilinogen have thnir greatei-t app lication in liver disease and
are re,,icwed in Cltaptec 11. Nitrite in the urine suggests the possible presence
in the urinary tract of l,acteria capul,le of reducing nitrate to nitrite. Le ukocyte
eslerase indicates the presem;e of leukocytes in the urinary tract, presumably
atLructod by Invading bacteria. A positive telit for bot11 nitrite and 1isterase is
presumptive B\lidence of urinary tract infoction.

Microscopic Examination of the Urine Sediment

Some hospitals no longer perfo rm a microscopic e.xaminalion of urinary
sed iment on a rouline basis. They reserve this test for cases of suspec:h!d re nal
disease or for patients who exhibit positive tests for both nitrite and leukocyte
esteroso and are thus at risk for urinary tract infof'.tion.
172 Oinical Chemi~try
ulor innammation and 1,lecJing and is assodated with glo morulone-
phritis. systr.mic lupus erythernatosus with liclnt,y involvement, or
other glomerular dis(Jasos.
b. While blood roll C{llSls: These costs conlol n imbeddod le ulocytcs and
signif)• on Infection (pyelonophrilis).
c. ll}•aline costs: Simple hyoline casts contain protein alone and ore cltmr
us glass because they have almost the same refractive lndnx as that of
urine. They may lJtJ present in the urine or normal individuals,
particularly after strenuous exercise, Lui are also found in tho urine in
many disease stales, usuall)• accompanied by protcinuria. Jlyaline casts
may contain some cullular debris or fut .
d. Granular costs: The presence or epithelial ct:llular debris in a cast
mal es ii appear granular.
e. Foll}1 costs: These ('..asts appear like oval fat bodies but are cylindric in
shapo. This abnormal finding Is indicative of renal parenchymal
disease.
r. Waxy costs: These cellular casts have dogonorated and look " waxy" ur
like ground glass. They may be present in any or s,nrcral kidney
disoascs.
g. Brood costs: Those short and wide casts ha\'o formed In tho broad
c:ollcctlng tubules and arc found only in renal failure.
4. Crystals: Crystals fournd In normal urine that have no particular signifi-
cance are calcium phosphate, triple phosphate, calcium oxalate, amor-
phous phosphates, sodium or ammonium urate, and somutimcs calcium
('.arbo nato. Large amounts of urate or uric acid crystals should be noted
bec.iuse they moy lndicoto oxcossivo breakdown or tissue culls (nucloo-
protcins) or he an accompaniment of gout. Unusual crystals, such as
cystine or sulfa drug c:ryslals, must he noted.

Tests for Creatinine, Urea, and Uric Acid

Ln the early days or clinical chemistry, tho nonprotein nitrogen (NPN)
consliluenls of scrum were measured as a single group after precipitation or
serum proh1ins. The principal NPN constituents arc urea, creatinine. uric acid,
and amino acids, all or which are now measured separately in appropriate
clinical situations . The two l'\PN constituents wilh serum conccntrulions that
yield the mosl Information in kidnoy disease are creatinine and urea: their
serum concentration!! are e levated when formation or elimination or urine is
impaired, irrespective or the causr.. The concenlralion or lilood nrnmonla. a
minor NPN constituent. is sometimes rnquestcd when hepatic enc:nphalopalhy
Is suspected (see Chap. 11 ).

Creatin ine4 • 5•7 •6

Creolinine is a wosto product formed In muscle from a high-energy slorage
compound, crealinc pho11photc (phosphocruotine). Adcnnsine trlphosphate
(ATP) is the immcdiato sourco of energy for muscular c:onlrocllon as It is
hydrol)•zed to adenosine diphosphate (ADP). ATP cannot be stored in
 The Kidney and Tesls of lk-n,ll function 173
sullicienl quantity to meet the energy demand or intense muscular acti\•ity;
howe,•er. creatine phosphate can be stored In muscle al approxlmalcly four
times the concentration or ATP and is used for this purpose. When needed for
energy, crcaline phosphate and AUP are converted by enzymatic action lo
cruatine and ATP !Fig. 6.4). A side reaction occurs, howe\'er. and a small
portion or tho crcotino phosphate los1..-s its phosphale as phosphate ion, wit h
closure of the ring lo form creatinine, as illustrated In Figure 6.4. This rnoctlon
is not reversible, and the crealinlne is excreted in tho urine as a waste product.
The omounl of creaLinine excreted daily is a function of the muscle mass and
is not affocted by diet. age, sex. or exen:i.se. II amounts to approximalt:ly 2% of
the body stores or crealine phosphate and ls roughly 1 lo 2 g per day for an
adult. Women excrete less creatine than do men because of lhuir smaller
muscle mass.
A small amount of preformed crealinine is ingested as a constituenl of meat,
but this amount has little effect on the cuncenlratioo of crealinin11 in scrum.
Elevated concunlralions occur only when renal function is impaired.
Crealinlne appears In lhe glomerular fi ltrate and is not rnabsorbed by the
tubule: hence, any t:ond ilion that reduces the glomcrular filtration rate resulls
in a lessened excretion Crom the body, with a consvqutint rise in the
concentration or creatlnine in plasma. Because the excretion rate of crealinlne
is relulively c.:onstant (:!:15% for an individual per da)•) and ils production rate
ls nut influenced by protein calabolism or other e.xlemal faclurs. the concen-
tration of creatinine In the serum is a good measure of renal g.lomerular
function.
The serum creatinine concentration is ele\'ated when u reduclion in the
glomcrular filtration rate Is significant or when urine elimination Is obstructed .

ADP ATP

Creatine - P Creatine
I
B
...,
Creatinine + H2PO; + H'
FIG. ft.4. Schema (o, 1he f01TT1,1hon ol CICJlinine ,n mu~le •~
a side reaction from 1he ~Jl()nt.ineous bfe.ikdown oi creJlmc
pho-,phJle. Reac1ion A 1llu~tralt-s Ilk! rcvl'!s1l,lc , llKage of
hlgh-ener1,,y pho~ph,uc ,1s cre.itine ~ph;ue; reaction B
1ll u,11c11cs 1he side rea~Jion. CK - crcatinc kin.a~; - = a
h1gh-erwrgy bond.
174 Clinic.11Chf'mi'lry
The kidnoy mscn·o is such. howe\•cr. 1ha1 nboul 50'%, of lidney function musl
be losl boforo o rise in lho scrum conctmlrution of crf'atinlne cun he dull.-clcd.
The conc:ontralion of scrum cre.itinlnc is a hctt(•r indicator o( ronal funclion
lhan cilhcr that of urea nitrogen or lhal of uric acid bec-A1uso St>rum creatinine is
nol affcctcJ by d lcl. exercise. or hormones, factors lhat inflll(mtc lhc lcn!ls of
urea nitrogen or uric acid. A small percentage of tho ucatinino appearing in the
urine nu:l)' bo dorlvocl from lul,ulJr socrotion. This amount is ncgligiblo al
normal scrum lc\'els of crcatininc but l,t,-comcs larger as lhc concunlralion in
scrum rises.

Serum Creatinlne
The JaH6 rc.tt.llon was fin,t used for lhe dcicrmination of serum cruatlnintt morn
lhan 80 ye.us ago and is :.till widely U)cd. Although ahemalh·o mclhods bJsec.l
on the enzymalic degradation of crcalinine rt-c..untly ha\·c bc.-cn Increasing in
1>0pularll)', the Comprehensh·u Chemistry 19CJ2 Surrey of lhe College of
American Palhulogis ts (CAP)" rc\ieals thal 77% of U-400 lahorotories m,limJte
scrum crcallnlne conc:cmtralion by some form of lho alLallne picrotc rnactlon
Uaff6 reaction). During the Jaffe reJctlon. crealininc interacts with all.allne
picrato to form a md addition pnxluct; howe\'cr. a few other srrurn conslllu•
onls, such as lutwcids, glucose, \'arious drugs. and ascorhic ac:ld (to a lcssnr
extent), du tho same. The inturforing compounds c.an be romo\•cd by adsorbing
tho crcalinine on aluminum silicates or on a calion•cAchange resin nnd
washing out tho noncreatinine reactants. a timu-consuming wash process. Most
laboratories use somo 1)'1'° of kinetic Ja££6 methoJ In which lhe crealininc
complex formation is monilored shorll>• after mixinH the rnaclants (to to liO sue)
and Is conlinucd for another 20 to 120 sec. This proccduni ovoids tho effect of
fast-reacllng interfering compound s (primarily at.etoacclalc) and slow-reacting
compounds. such as (lrolcins.11 Thu Unctic methoJs require automation.
St!\'ural differenl enzymatic methods of creatinino determination ha\·o bt.'Cn
imµlemented . Crenlinlne iminohrdroloso enz)'malically degrad11s crcatlnino
Into r-.-mclhylhydantoln and rclr asi•s ammonia. Through the production of
ammoniJ, the pll is ohcred in proportion to lho concenlralion of crcJtinlne.
tJ1crcb)• Increasing lhe absorbance of pH-indicatlnR dyes. The appllr.ation of
creolininc omidohrdrolose in enz)•mo-co uplcd reactions has also been used. In
goner.ii, the onZ)'mJlic melhods aru more specifi c lhan the Jaffli reaclion, but
tho)' aru not free Crom lnhtrferences.•
Tho method described In the following lcAI is a fixed -limo JJff6 reaction as.,;uy
that rl'quircs prior remo\·al of proteins b)' pn:,-cipilatlon or dialysis.
Principle. Crcalinino in a protein-frco filtrato reacts with allaline picralo to
form a rc:d nclduct, thu ohsurb1tnce of whlrh Is mc;isureJ at 515 om.
Reagents
1. Picric nc:lcl. 0.036 mol/L. Dissoh·e 9.16 g rcageut-gradc picric acid
(containing 10 to 12% adJeJ waler as n saf1•ty feature•) in warm waler.
Cool and male up lo I L vulumo.
2. Tungstic acid in poly\llnyl alcuhul. Place I g r>0ly\'inyl alcohol (Eh,anol
70- 05. DuPont) In 100 mL water and hral to dissol\'ti. Do nol boil.
• Anh}JrouJ pluic add 111 pow. erful .,_plv~lu:. ricr ic .ouJ c,y~t• I• mu>l ""'er l,y dcsiu.ih•,I o,
hr..itrd.
 The Kidney ,ind Tests of Renal r unction 175
Transfer too 1-L volumolrlc flask containing 11.1 g N11 2 WO. • 211 2 0 in 300
ml. waler. Then add 2.1 mL concentrated HzSO.. in 300 mL wulcr. Mix and
dilute with water to I L \'Olume. This sululion Is stable at room
temperature for 2 ycnrs and does not rnqulru rofrl~crnlion.
3. NaOH, 1.4 mol/L, Dissolve 5 4 K NaOH in waler and dilulc lo 1 L volume.
Store In a polyothylcne l>ollle.
4. <.:rcalini ne stock standard. 0. 111 rng/mL. Dissuh·tJ 111 .0 mg of c:rr,alinino
In I L of 0.1 mol/L HCI.
6. Working standard t\. Diluto stock slundurd I : 50 wilh waler to cnwto 1111
t!<luival,mt tu a serum crcatinino of 2.0 mg/dL il 3.0 mL of working
standard t\ Is treated as a scrum filtrate from 0.5 mL scrum as closcrillf:d in
the following procedure.
fl . Working slaudurd B. Dilute 1tlut.k standard 1 : 20 with wnler, making its
c:cmctmtration tJquivalenl lo 5.0 m)lldL If lrcattld us doscrih•:ll aR follows.
Pmcr.dure
1. Precipitate the scrum proloins by adding 0.5 mL sornm lo 4.0 mL lung,slic
acid solution contained In a 16 x 100 mm lest 1utm. Shake \'lgorously and
centrifuge for 10 min.
2. Set up In ltJSI tulws tho following: blank- 3.0 ml.111 O; sttmdard - 3.11 ml.
stundard : unknown- 3.0 mL proloin-frcu cenlrifuwitu.
3. Add 1.0 ml. picric acid to each and mix well.
4. Add o.5 mL of 1.4 mol/L NaOH to the first tuoo: mix and sot a timer for 15
min. Add NnOH lo the remaining tul,os ul 30 sec inlorvnls.
5. Read absorbanccs of standards 1111d unknowns ngalnst blank al 5 15 nm
cx.nclly l 5 min aft r.r adding the NaOII. Road lubes al :111-scc: intervals.
i\ 0
mg crcnlininc/dL = -, x C
J •

C = conccntrnlion of standard (when trcntotl ns II fillratee) .

i\ and ,, . = obsorbancus of unknown sorurn an1I standtLrd, respectively.
11

1000
For SI units: µm ol/1. ::s mg/dL x 10 x - - = mglclL x 118.4
113

fief ere nee Values

Mon: 0 .7 to 1.2 mg)clL nr 62 to 106 µ1110 1/L
Womon: 0.6 to I. l mg/di. nr 53 lo 97 µm ol/L
Children: Cl.4 lo 1.0 mHldl. or JO lo 88 µm ol/1.

The \'ulues for " lruo·• creatinine arc about 0.1 lo 0.2 mgldL lower than those
Ji Rimi.
lrwmmmd Conccnlrolion. The concontmtion of scrum crualinino ris,1s whm1
formation or oxcrclion of urine is impaired, irruspuctivu of whuthor tho r.ausr.s
aru prorcnal. renal, or poslrcnal in origin.
Voluos thut aro 2 s auovu the upper limit of normol su11gos1 possible mnal
,lnmngo, and tho lost should bo repeated; luvols of 1.5 mi,vdl. and gronlur
indicate lmpairmont of renal fun ction. Minor chani,:cs in co1w(mlrnlion may ho
176 Clinical Chemistry
significant , and ll1e serum level usuaHy parallels ll1e severity of the disease.
Tobie 6.2 shows the relation of the serum crcalinine concentration, the
creatinine clearance value, and the patient's stntl!ls. The prerenal factors
causing an increasoo serum crealinine levol arc congestive heart foilum; shock;
salt a nd water depiction associated wi th vomiting, dia rrhea, o r gastrointestinal
fistu las; uncontrolled diabetes mellitus; excessive use of diuretics; diabetes
insipidus; and oxcossi\10 sweating with deficient sail Jntake. Renal ractors may
involve damage to glomonili, tubules, renal blood vessels, or interstitial tissue.
PostTcnal factors may be prostatic hyp11rtrophy, neoplasms compressing the
ureters, calculi blocking the unllers. or congenital abrmnnaliUes t hat compress
or block the ureters.
The serum creatlnine concentration is monitored closely after a renal
transplant because a rising concen.Lration, even though s mall, may bu an
iudJcation of transpla nt rejection. Some renal transplant units prefer to monitor
a rise in the serum coacent.ration of lh·microglobulin as the earliest indJcator
of renal transplant rejection (see Chap. 9 , Table 9.4).
De.creased Concentration. l.ow scrum creatinine coocenlralions ha\·e no
clinical significance.

Urine Creatinine
Because tho concentration or crealinine in urine (apJlro)(imotoly 1 mg/ml.1 is
much higher t han that in serum, a dilution of u rine is in ordor. For urine of
normal protein content, dilute 1 : 200 with waler ijlld treat the same as a serum
filtrate , that is. take 3.0 ml for analysis. If protclnuria exists, precipitate the
proteins as follows: Add 0.5 mL urine + 0.5 ml wate r to 4 .0 ml tungstic acid
solution; mix and centrifuge. Dilute the filtrate 1 : 20 with water and t.ake 3.0 mL
for .analysis as for serum. Thus, both types of urine, those with and those
without proteinuria. are d iluted 1: 200. De\1elop color in standards A and Bas
for serum. Little noncreatinine cbromogen is in urine.

TABU &.2
mtCAL CORRUATION OF SERUM CREATtNINE CONCENlRl\l lONS WITH THE CR£ATINtNE
CLEARANCE AND PATIENT STATUS

S£RUM CREATININE CRUTININ~ CLEARAr-.a

tmg/100 ml) (mUminl PAll[Nl 'S STATUS
0.6- 1.2 90-140 Normal
Some pa1ients with protcmurla
1.) - 2.4 (i l -
9Q Capable of perfonning usual tyl)tls of awv,ty
2.5- 4.9 24- b0 01flicuhy In performing ~renuous physit.ll u.tivity
5.0 -7.9 12- 23 Unable lo J)(.'lform all daily phy~ical
ac11v111es e>.cepl on IMrt•lime basis
Acidosis, 51,d1um loss, ~rum C.1 l
8.0-12 7- 12 X'\•ere 11mitation u( physical acti\·ily
Scrum K t , Ca l , Na l
> 12 6 or less May be, ~is.ork11MI or in coma

Moc.l,f,~.111,in from /'.Rlt.'f1c.,m I tea" A5~i.1ronn, Counc,I on l(,tlney ,n Cantiova'Cul~r 01sc.-d.e.

 The Kidney and Tests of Renal function 177
Colculolion
. Au 0. 111 100 J\ 11
Fur Standard A: C = - x - x3x- mg/dL = - x 44..4 mg/dL. where
"· 50 3/200 "·
0. 111 3
-
50
x 3 = mg creatinine in 3 mL dilute standard aliquot, -
200
= mL or
undiluted urine in 3 mL aliquot, and x 100 converts mL to dL.
Hcfercncc Values. The urinary excretion of crcalinine depends on the muscle
mass of lhe i·n dividual, but the following arc rough reference values:
Men: 1-1- 28 mg/kg.Id
Women: 1 l - 20 mgllqy'd
Newborn: 7 - 12 mg/kg/d
0.1 - 5 years: 8- 22 mg/kg/d
10- 12 years: 8 - 30 mg/kglt.1
The factor for converting mg/kg/d to mmol/kg/d "" 0.00884.
Creatinine Clearance
The most sensitive chemical melhud of assussing renol function is the
creatinino clearance Inst. This clearnm;e test provides an estimalo of the
amount of pilns ma that musl have flowed through the kidney glomeruli per
minute with complete removal of ils content of crealinine to account for the
creatininc per minute actually appearing in the urine. The test rt.'quims
the complete collection of the urine funned In an accuraloEy recorded time
period (for ,calculation of the rate of urine flow) and quantitalion of the
creatinine concentration 1.n both serum anJ urine. Tho crentinino clearance is
calculated as
u
-x
s v
where IJ is the urine concentration of creatininc, S is the serum c.reatinine
concentration, and V ls the volume of urine excreted per minute. U and S mus t
be measured in tbe same concentration w1its. altbough it does not matter
whether the measurement is in mg!dL or in Sl unl ts. The dimension of the
clearance th,as becomes expressed as mUmin, because the dimensions of UIS
cancel each other out. The crcatinine clearance is practically the same as Lbe
glomerular filtration rate; the tubules excrete a small arnoun1 of creatinine. a
foctor that may become significant when serum creatinlno concentrations are
elevated. The crealiniue clearance value is closer to tho glomerular filtration
rate when ··true"' creatinine is measured because nonc:realinine chromogens
increase the serum creatinlno conw ntration bur not the urine creaUnine
concentration.
The importance of obtaining the total excretion of urine in an accurately
timed period cannot be overstressed because any error oommitted in the
collection and measurement of the volume excreted per minute is carried over
inlo the calculation of tho clearance. The following points should be
emphasiU!d . Those who administer the lest must thoroughly understand the
procedure and communicate in a simple way with the patient so that he or she
understands nnd cooperdtes. The test may bo carrfod out over any occurotely