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RFT creatinine clearance test

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Title: RFT creatinine clearance test


1
CLEARANCE TESTS AND SIGNIFICANCE
  • M.PRASAD NAIDU
  • Msc Medical Biochemistry,
  • Ph.D Research scholar.


2
FUNCTIONS OF KIDNEY
  • REMOVES WASTE PRODUCTS
  • REMOVES FOREIGN AND NON ENDOGENOUS
    SUBSTANCES
  • MAINTAINS ELECTROLYTES AND WATER
  • MAINTAINS ACIDBASE BALANCE
  • HORMONAL FUNCTIONS

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FORMATION OF URINE
  • NEPHRON----FUNCTIONAL UNIT OF KIDNEY
  • NEPHRON CONTAINS
  • a)GLOMERULUS
  • b)TUBULES
  • 1000 to 2000 ml of urine is excreted/day

7



1)STEPS IN
URINE FORMATION Glomerular
filtration tubular reabsorption tubular
secretion
8
GLOMERULAR FILTRATION
  • 700ml of plasma passes through kidneys per
    minute.
  • From this 120 to125 ml is filtered per/minute by
    kidneys.
  • THIS IS GFR.

9
GFR DECREASES
  • GFR DECREASES IN
  • OCCLUSION OF AFFERENT ARTERIOLES
  • DECREASED PERMEABILITY OF THE MEMBRANE.
  • INCREASED INTRA CAPSULAR PRESSURE

10
GFR INCREASES IN
  1. INCRESED BP
  2. DECREASED BLOOD PROTEIN OSMATIC PRESSURE
  3. INCRESED GLOMERULAR PERMEABILITY

11
Effective filtration pressure
  • Is the result of
  • A)The glomerular pressure
    in glomerular capillaries
  • B)The opposing osmotic
    pressure of plasma proteinsHydrostatic
    pressure of Bowmens capsule fluid
  • Capillary pressure75 mmHg
  • Osmatic pressure of plasmproteins30mmHg

12
Net effective filtration pressure
  • PefPg-(PppPbc) 75-(3020)
  • Pef25mmHg
  • Pghydrostatic pressure in the glomerular
    capillaries
  • Ppposmotic pressure of plasma proteins
  • Pbchydrostatic pressure of the bowmans capsule
    fluid

13
RATE OF FILTRATION IS INFLUENCED BY
  • Variation in BP in glomerular cappilary
  • Concentration of plasma proteins
  • Factors altering intratubular pressure viz.
  • a) rise with ureteral obstruction
  • b) during osmotic diuresis
  • c) state of blood vessels

14
THE VOLUME OF GLOMERULAR FILTRATE FORMED DEPENDS
ON
  • The number of glomeruli functioning at a time,
  • The volume of blood passing through the glomeruli
    per minute and
  • The effective glomerular filtration pressure
  • In normal circumastances 700ml of plasma flow
    through the kidneys per minute 120 to125ml of
    fluid is filtered in to bowmans capsule

15
Volume of filtrate reduced in extra renal
conditions
  • 1.Dehydartion
  • 2.Oligemic shock
  • 3.Cardiac failure
  • 4.lower the glomerular filtration pressure

16
  • TUBULAR REABSORPTION
    Formation of primary urine is 120 to 125 ml/mt.
  • Only 1 to 2ml/mt reaches the bldder,
  • 170 litres of water filtered through the
    glomeruli only 1.5 litre is excreted in the
    urine. So,99 glomerular filtrate is reabsorbed
    in the tubules
  • TUBULAR SECRETION
  • Examples of substances secreted by the tubular
    epithelium are creatininepotassium

17
RENAL FUNCTION TESTS
  • 1.TEST BASED ON GLOMERULAR FILTRATION
  • Urea clearance test
  • Endogenous creatinine clearance test
  • Inulin clearance test
  • Cr51-EDTA clearance test

18
2.TESTS TO MEASURE RENAL PLASM FLOW
  • Para-amino hippurate test(PAH)
  • Filtration fraction
  • 3.TESTS BASED ON TUBULAR FUNCTION
  • --Concentration and Dilution tests
  • --15 minute-PSP excretion test
  • --Measurement of tubular secretory mass
  • MISCELANEOUS TESTS Can determine size, shape,
    any
  • Tumour, obstuction, Infarct etc.

19
CLEARANCE TESTS
  • CLEARANCEDEFINED AS A VOLUME OF BLOOD OR PLASMA
    WHICH CONTAINS THEAMOUNT OF THE SUBSTANCE WHICH
    IS EXCRETED IN THE URINE OR
  • THE CLEARANCE OF SUBSTANCE MAY BE DEFINED AS THE
    VOLUME OF BLOOD OR PLASMA CLEARED OF THE
    SUBSTANCE FOUND IN ONE MINUTE EXCRETION OF URINE

20
SALIENT FEATURES OF SUBSTANCE USED FOR CLEARANCE
TESTS
  1. It must be non toxic
  2. It should be small enough to pass through the
    glomerular membrane
  3. It should neither be secreted nor be absorbed by
    renal tubules
  4. It should not be metabolised in the body

21
CREATININE CLEARANCE
  • CREATININE CLEARANCE Useful in the diagnosis and
    prognosis of the kidney disease.
  • CREATININE CLEARANCE
  • Urine creatinine in mg/dl x Total volume of urine
  • ___________________________________
  • Serum creatinine in mg/dl x 1440
  • REF.RANGE Male125ml/mt
  • Female115ml/mt
  • A decresed creatinine clearance is very sensitive
    indicator of a reduced glomerular filtration
    rate, due to acute or chronic damage.

22
CREATININE
  • The kidney reserve is such that only when about
    50 kidney function must be lost before
    creatinine level in blood is raised.
  • But serum creatinine minor change in
    concentration may be of significance, and the
    serum level usually parallel to the severity of
    the disease.

23
CREATININE
  • CREATININEREF.RANGE800---2000mg/day.
  • Creatinine is a waste product formed from
  • Creatinine phosphate which is stored form of
    the energy in muscle. this conversion is
    spontaneous, non enzymatic process and is
    dependant on total muscle mass and this mass is
    not affected by diet,age,sex or exercise.
  • Since the production is continuous and it is not
    affected by other factors thats why Creatinine
    is an ideal substance for clearance test. This
    test is mainly to assess the glomerular
    filtration. GFR provides the most useful index
    for the assessment of the severity of renal
    disease.

24
24 hour urine collection
  • A 24 hour urine collection is a simple diagnostic
    procedure that measures the components of urine.
    The test is cheap, sensitive and is used to
    assess kidney function, hormones other
    substances can also be estimated

25
RISKS OF THE PROCEDURE
  • 24 hour urine collection is a safe, noninvasive
    procedure that is usually done without direct
    assistance.
  • Certain factors or conditions may interfere with
    the accuracy of a 24 hour urine collection,
    include the following
  • Forgetting to collect some of urine
  • Going beyond 24 hour collection period and
    collecting excess urine
  • Losing urine from specimen container through
    spilling
  • Not keeping urine cold during collection period
  • Acute stress
  • Vigorous exercise

26
PATIENT EDUCATION
  • The accuracy of the test results depends on the
    accuracy of the specimen collection
  • Collect in a clean environment
  • It is important that dust from clothing not
    contribute to the specimen content
  • Do not collect urine in metal glass containers
  • Females Do not collect urine while menstruating

27
PATIENT INSTRUCTIONS
  • CAUTION The collection bottle may contain a
    preservative in the form of tablets or strong
    acid solution which may burn your skin.
  • Do not remove preservative from the bottle
  • Keep the bottle upright so it does not spill
  • Do not urinate directly in to the bottle
  • Keep out of reach of children
  • If liquid in the bottle is spilled or splashed,
    wash immediately.

28
PATIENT INSTRUCTIONS
  • Record the time and date on the collection
    container label as the START TIME AND DATE. Also
    record the time and date in the FINISH
    TIME/DATE--------space provided on the laboratory
    requisition
  • Deliver the container and lab requisition to the
    laboratory immediately the collection is finished.

29
PRESERVATIVES
  • Preservatives to be added to 24 hour urine
    collection for various biochemical estimation
  • Amylase, sodium, potassium and chloride-----------
    --- no preservative
  • C peptide, cortisol, lead and zinc----------------
    --------- no preservative
  • Protein and citrate------- no preservative
  • Uric acid--------- no preservative

30
PRESERVATIVES
  • Calcium,phosphorous---10ml 6N HCL
  • VMA,OXALATE-----------10ml 6N HCL
  • CREATININE,UREA------10ml 6N HCL
  • PROTEIEN AND CREATININE-----------
  • ---10ml 6N HCL

31
CREATININE CLEARANCE
  • This is covenient method sensitive indicator for
    GFR
  • ADVANTAGE OF CREATININE CLEARANCE
  • A)It is a normal metabolite of the body
  • B)It does not require I.V. administration
  • C)Estimation of creatinine is simple
  • D)In early stages it has got advantage over
    S.Creatinine
  • CR.CLEARANCEUV/P
  • In the calculation surface area is important
  • Body surface area is calculated from
  • LogA0.425 LogW0.725 LogH -2.144

32
CREATININE CLEARANCE
  • This is covenient method sensitive indicator for
    GFR
  • ADVANTAGE OF CREATININE CLEARANCE
  • A)It is a normal metabolite of the body
  • B)It does not require I.V. administration
  • C)Estimation of creatinine is simple
  • D)In early stages it has got advantage over
    S.Creatinine
  • CR.CLEARANCEUV/P
  • In the calculation surface area is important
  • Body surface area is calculated from

33

LogA0.425 Log SW0.725 log H-2.144
ABody surface area in meter squareWWeight in
Kg
HHeight in cm
  • Standard body surface area is 1.73 m²
  • Creatinine clearance corrected for body surface
    area
  • Calculated as
  • UxV x 1.73/PxA
  • Male normal value125 ml/mt
  • Female normal value115 ml/mt

34
A rough estimate of Creatinine clearancein
Males(140-Age) x Wt in Kg/72 xPcr
  • C cr in Females0.85 xCcr
  • CREATININE COEFFICIENTURINARY CREATININE
  • EXPRESSED IN mg/kg body weight
  • Normal range in Males 20 to 28mg/kg
  • Females 15 to 21mg/kg
  • Factor for converting mg/kg/ to nmol/kg/0.00884
  • Value increses in Muscular Dystrophy

35
P/C RATIO
  • Creatinine estimation is also useful in the
    muscular dystrophy and in Nephrotic syndrome.
  • P/C RATIOprotein concentration in mg/dl
  • ___________________________________
  • creatinine concentration in mg/dl
  • p/c ratio ref.rangelt 1
  • P/C ratio increases in NEPHROTIC SYNDROME

36
M/C RATIO
  • MC RATIOmg of micro albumin/gms of creatinine
  • AS PER AMERICAN DIABETIC ASSOCIATION
  • NORMAL VALUE IS LESS THAN 30 mg of uma/gm
    creatinine
  • Abnormal 30 to 299 Microalbuminemia
  • More than 300 Maacroalbuminemia

37
INULIN CLEARANCE
  • 10 gm of Inulin is dissolved in 100ml of saline
    is injected I.V at a rate of 1 ml/mt over 2 hours
    I.CUV/P ml/mt
  • Uconcentration of inulin in urine in mg/dl
  • Vvolume(ml) of urine passed /mt
  • Pconcentration of inulin in plasma in mg/dl
  • I.C125ml i.e GFR125ml
  • Similar clearance value is seen with
    MANNITOL,SORBITOLDULCITOL

38
INULIN CLEARENCE DECRESES IN
  • Decrease in renal flow
  • Obliteration or decrese in number of functioning
    glomeruli
  • Defect in the effective glomerular filtration
    pressure
  • Used to know the substance reabsorbed
  • Urea reabsorbed in tubulesI.C-UREA CLEARANCE

  • -----------------------------

  • I.C
  • 125-75
  • -------0.4 SO,40 OF UREA REABSORBED
  • 125

39
UREA CLEARANCE
  • Maximum clearance If the urine volume exceeds
    2 ml/mt.
  • Volume of blood cleared of urea/mtUV/P 1000 X
    2.1/2875
  • Standered clearancewhen the urinary volume is
    less than 2ml/mt
  • CsUx square root of vV/P54 ml
  • Only 60 of glomelular filtrate urea excreted
  • Urea clearance is 60 of Inulin clearance
    UC/0.6I.C

40
Determination of CR51 EDTA CLEARANCE
  • SINGLE INJECTION IS USED FOR GFR ESTIMATION
  • USED FOR CHILDREN ADULTS
  • CONVENIENT FOR CHILDREN WHERE IT IS NOT EASY TO
    COLLECT 24 HOUR URINE.

41
THANK YOU
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