Kidney function tests
Kidney function tests is a collective term for a variety of individual testsand procedures that can be done to evaluate how well the kidneys are functioning.
The kidneys, the body's natural filtration system, perform many vital functions, including removing metabolic waste products from the bloodstream, regulating the body's water balance, and maintaining the pH (acidity/alkalinity) ofthe body's fluids. Approximately one and a half quarts of blood per minute are circulated through the kidneys, where waste chemicals are filtered out andeliminated from the body (along with excess water) in the form of urine. Kidney function tests help to determine if the kidneys are performing their tasksadequately.
Many conditions can affect the ability of the kidneys to carry out their vital functions. Some lead to a rapid (acute) decline in kidney function; otherslead to a gradual (chronic) decline in function. Both result in a build-up oftoxic waste substances in the blood. A number of clinical laboratory tests that measure the levels of substances normally regulated by the kidneys can help determine the cause and extent of kidney dysfunction. These tests are doneon urine samples, as well as on blood samples.
There are a variety of urine tests that assess kidney function. A simple, inexpensive screening test, called a routine urinalysis, is often the first testadministered if kidney problems are suspected. A small, randomly collected urine sample is examined physically for things like color, odor, appearance, and concentration (specific gravity); chemically for substances such a protein, glucose, and pH (acidity/ alkalinity); and microscopically for the presenceof cellular elements (red blood cells, white blood cells, and epithelial cells), bacteria, crystals, and casts (structures formed by the deposit of protein, cells, and other substances in the kidneys' tubules). If results indicatea possibility of disease or impaired kidney function, one or more of the following additional tests is usually performed to more specifically diagnose the cause and the level of decline in kidney function.
- Creatinine clearance test. This test evaluates how efficiently the kidneys clear a substancecalled creatinine from the blood. Creatinine, a waste product of muscle energy metabolism, is produced at a constant rate that is proportional to the muscle mass of the individual. Because the body does not recycle it, all of the creatinine filtered by the kidneys in a given amount of time is excreted in the urine, making creatinine clearance a very specific measurement of kidney function.The test is performed on a timed urine specimen--a cumulative sample collected over a two to twenty-four hour period. Determination of the blood creatinine level is also required to calculate the urine clearance.
- Urea clearance test. Urea is a waste product that is created by protein metabolism and excreted in the urine. The urea clearance test requires a blood sample to measure the amount of urea in the bloodstream and two urine specimens, collected one hour apart, to determine the amount of urea that is filtered, or cleared, by the kidneys into the urine.
- Urine osmolality test. Urine osmolality is a measurement of the number of dissolved particles inurine. It is a more precise measurement than specific gravity for evaluatingthe ability of the kidneys to concentrate or dilute the urine. Kidneys that are functioning normally will excrete more water into the urine as fluid intake is increased, diluting the urine. If fluid intake is decreased, the kidneysexcrete less water and the urine becomes more concentrated. The test may bedone on a urine sample collected first thing in the morning, on multiple timed samples, or on a cumulative sample collected over a twenty-four hour period. The patient will typically be prescribed a high-protein diet for several days before the test and asked to drink no fluids the night before the test.
- Urine protein test. Healthy kidneys filter all proteins from the bloodstream and then reabsorb them, allowing no protein, or only slight amounts ofprotein, into the urine. The persistent presence of significant amounts of protein in the urine, then, is an important indicator of kidney disease. A positive screening test for protein (included in a routine urinalysis) on a random urine sample is usually followed-up with a test on a 24-hour urine samplethat more precisely measures the quantity of protein.
There are also several blood tests that can aid in evaluating kidney function. These include:
- Blood urea nitrogen test (BUN). Urea is a by-productof protein metabolism. This waste product is formed in the liver, then filtered from the blood and excreted in the urine by the kidneys. The BUN test measures the amount of nitrogen contained in the urea. High BUN levels can indicate kidney dysfunction, but because blood urea nitrogen is also affected by protein intake and liver function, the test is usually done in conjunction witha blood creatinine, a more specific indicator of kidney function.
- Creatinine test. This test measures blood levels of creatinine, a by-product of muscle energy metabolism that, like urea, is filtered from the blood by thekidneys and excreted into the urine. Production of creatinine depends on anindividual's muscle mass, which usually fluctuates very little. With normal kidney function, then, the amount of creatinine in the blood remains relatively constant and normal. For this reason, and because creatinine is affected very little by liver function, an elevated blood creatinine is a more sensitiveindication of impaired kidney function than the BUN.
- Other blood tests. Measurement of the blood levels of other elements regulated in part by the kidneys can also be useful in evaluating kidney function. These include sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphorus, protein, uric acid, and glucose.
Patients will be given specific instructions for collection of urine samples,depending on the test to be performed. Some timed urine tests require an extended collection period of up to 24 hours, during which time the patient collects all urine voided and transfers it to a specimen container. Refrigerationand/or preservatives are typically required to maintain the integrity of such urine specimens. Certain dietary and/or medication restrictions may be imposed for some of the blood and urine tests. The patient may also be instructedto avoid exercise for a period of time before a test.
Normal values for many tests are determined by the patient's age and sex. Reference values can also vary by laboratory, but are generally within the ranges that follow.
- Creatinine clearance. For a 24-hour urine collection, normal resultsare 90-139 ml/min for adult males less than 40 years old, and 80-125 ml/minfor adult females less than 40 years old. For people over 40, values decreaseby 6.5 ml/min for each decade of life.
- Urea clearance. With maximumclearance, normal is 64-99 ml/min.
- Urine osmolality. With restricted fluid intake (concentration testing), osmolality should be greater than 800mOsm/kg of water. With increased fluid intake (dilution testing), osmolalityshould be less than 100 mOSm/kg in at least one of the specimens collected.
- Urine protein. A 24-hour urine collection should contain no more than 150 mg of protein.
- Blood urea nitrogen (BUN). 8-20 mg/dl.
- Creatinine. 0.8-1.2 mg/dl for males, and 0.6-0.9 mg/dl for females.
Low clearance values for creatinine and urea indicate diminished ability of the kidneys to filter these waste products from the blood and excrete them inthe urine. As clearance levels decrease, blood levels of creatinine and ureanitrogen increase. Since it can be affected by other factors, an elevated BUN, by itself, is suggestive, but not diagnostic, for kidney dysfunction. An abnormally elevated blood creatinine, a more specific and sensitive indicator of kidney disease than the BUN, is diagnostic of impaired kidney function.
Inability of the kidneys to concentrate the urine in response to restricted fluid intake, or to dilute the urine in response to increased fluid intake during osmolality testing may indicate decreased kidney function. Because the kidneys normally excrete almost no protein in the urine, its persistent presence, in amounts that exceed the normal 24-hour urine value, usually indicates some type of kidney disease as well.