Principles of Renal Measurement 1 Measuring Renal Clearance and Transport

Dr Derek Scott d.scott@abdn.ac.uk

Introduction to Renal Measurement

There are 2 main categories of tests for assessing renal function. Some of these are used clinically, but some can only be used experimentally in the lab. 1. Modern imaging techniques macroscopic views of renal blood flow, filtration and excretory function. 2. Measurements of renal clearance of various substances to evaluate the ability of the kidneys to handle solutes and water.

Clearance Measurements
Clearance compares the rate at which the glomeruli filter a substance (H2O) or solute) with the rate that the kidneys excrete it into the urine. If we measure difference in amount of substance filtered and excreted, we can estimate the net amount reabsorbed or secreted by renal tubules. Gives us information about the 3 basic functions of the kidneys:
Glomerular filtration Tubular reabsorption Tubular secretion

Drawbacks of Clearance Methods

Measuring clearance means you measure OVERALL nephron function i.e. all ~2 million nephrons in both kidneys. This gives the SUM of ALL transport processes occurring along nephrons. So, no information about precise sites and mechanisms of transport. Must therefore use studies on individual nephrons, tubule cells or cell membranes to obtain this data.

Clearance
The clearance of a solute is the virtual volume of blood that would be totally cleared of a solute in a given time. Solutes come from blood perfusing kidneys. Rate at which kidneys excrete solute into urine = rate at which solute disappears from blood plasma. For solute X: Conc. of X in urine

Cx = Ux x V
Clearance

Volume of urine formed in given time Conc. of X in systemic blood plasma

Px

p-aminohippurate (PAH)
There are certain special cases where the kidneys completely clear X from plasma during a SINGLE PASSAGE through them. In this case, renal clearance of X = arterial renal plasma flow. p-aminohippurate (PAH) is such a special solute. Thus, PAH clearance is a good estimate of renal plasma flow. However, for most substances, they are NOT cleared completely on 1st pass some X goes out in venous blood. Thus, the virtual volume cleared of X in given time is less than total renal plasma flow. For most solutes then, clearance describes a virtual volume of blood totally cleared of a solute, whereas in reality, a much larger volume of blood is PARTIALLY CLEARED of the solute.

Renal handling of PAH

PAH is an organic acid that is not usually present in the body, so must give by IV infusion. Note that there is none left in the renal vein - all cleared in first pass. Drawback is that mustnt give too much PAH, otherwise we overwhelm the PAH secretory system and the data can be misleading.

Measurement of GFR
GFR also assessed using principles of clearance. GFR = vol. of fluid filtered into Bowmans capsule per unit time. Same equation, GFR is Cx if X has certain required properties (i.e. Cinulin).
Conc. of X in urine Volume of urine formed in given time Conc. of X in systemic blood plasma

GFR = Ux x V
Glomerular filtration rate

Px

Solutes used to measure GFR

Required properties are:
1. Solute is freely-filtered (conc. in Bowmans space = that in blood plasma). 2. Tubules do not absorb, secrete or metabolize X.

Thus, amount of X in urine per unit time = that which glomerulus filters per unit time. WHAT GOES IN = WHAT COMES OUT! INULIN is such a substance that satisfies all of these criteria and is commonly used to measure GFR.

Drawbacks of Inulin
Most reliable method of measuring GFR, not useful clinically. Inulin must be administered by IV to get relatively constant plasma levels. Chemical analysis of inulin in plasma and urine is technically demanding. Use radiolabelled compounds instead like radioactive Vitamin B or EDTA. However, these may also bind to proteins and distort results slightly. Problems of IV infusion of GFR marker avoided by using an endogenous substance with inulin-like properties CREATININE.

Creatinine
Creatinine itself is secreted by tubules, so might overestimate GFR by 20% in humans. However, colorimetry methods used to measure creatinine overestimate creatinine concentrations. Luckily, these 2 errors cancel each other out, and calculated creatinine clearance inulin clearance. Cheap, easy, reliable, used in clinic. Avoids IV infusion, just requires venous blood and urine samples. Creatinine usually produced by creatinine phosphate metabolism in muscle. Must remember to take into account if person has muscle disease/damage, or has had large quantities of meat to eat. Usually measure over 24 hr period to get reliable results and take samples before breakfast.

CCr = UCr x V PCr

Urinary Excretion of Solutes

Sometimes tricky to calculate. Things like univalent electrolytes, glucose, aas are freely filterable. However, if solute binds to protein, for example, then its not (e.g. Ca2+, PO42-, Mg2+, PAH). For these, you must measure plasma binding and correct for the non-filterable fraction of solute. Solute must also not be synthesized or degraded. Ammonium is synthesised, and glutamate/glutamine is degraded, as are other organic acids. There are also complex combinations of reabsorption and secretion with K+, uric acid and urea. Must be careful, otherwise you will get inaccurate measurements.

Urinary Excretion of Solute

Filtered Load

Reabsorption by Tubules

Secretion by Tubules

Microscopic techniques for measuring single nephron rates of filtration, absorption and secretion
Free-flow micropuncture Stopped-flow microperfusion Continuous microperfusion Isolated perfused tubule

Why use microscopic techniques?

As previously mentioned, whole clearance methods do not reveal much about what areas of the nephron are involved in which transport processes. Impossible to determine which nephrons are responsible for overall urinary excretion. Thus, physiologists have developed a series of invasive techniques that are used to study the function of renal cells in the research laboratory (not used in clinical setting!).

Free-flow micropuncture

What does this tell us?

Apply clearance concept at level of single nephron (gives us identical equation!). Measures [solute] in tubule fluid at site (TFx), volume flow at site (i.e. collection rate) and plasma conc. (Px). Computes amount of fluid that single nephron can filter, as well as amounts of fluid and solutes that a single segment of the nephron handles.
Cx = TFx x Volume collection rate Px

Single nephron glomerular filtration rate (SNGFR)

Uses micropuncture techniques to monitor single nephron. Uses inulin as on large scale to measure GFR. Uses same equation to measure SNGFR.

Stopped-flow microperfusion

Good for looking at how a fluid you introduce may be modified by the tubule, but does not completely reproduce continuously flowing stream of tubular fluid. Does allow us to understand how fluid is changed by various transport processes can alter fluid composition.

Continuous microperfusion

Good technique as it continuously samples the tubular fluid, and the capillary blood, but you have to provide the fluid that comes down the tubule. However, also allows us to make electrophysiological measurements.

Isolated perfused tubule

Allows us to precisely control what goes into the tubule, but is it really representative of a true physiological system?

Summary
There are a range of techniques for measuring renal function, some of which are technically challenging. Some useful clinically, other more suited for lab work with animals or isolated tissue samples. These techniques concentrate more on how the kidneys process fluid, and how efficient they are at modifying it. In the next lecture, we will consider the imaging techniques that are commonly used to identify renal problems, and some commonly-measured parameters that may provide evidence that something has gone wrong with the physiology of these relatively inaccessible organs.