Armed Forces College Of medicine

AFCM

1 (Write the Name of the department) Tuesday, May 21, 2019

 Tutorial renal II

2 (Write the Name of the department) Tuesday, May 21, 2019

Q1:65- year – old man with a family history of urinary
stones presents with flank pain. A creatinine clearance
assessment is performed. Creatinine clearance test equates
with which of the following:
A. Renal blood flow
B. Renal plasma flow
C. Amount of creatinine entering the urinary
bladder/min
D. Amount of creatinine traversing the glomerulus/min
E. Plasma volume completely cleared of
creatinine/min
 Plasma Clearance
(Renal Clearance of a substance)
 It is the volume of plasma in ml cleared of a particular substance
excreted in urine per minute.
 (X) / minute by the kidneys.

The amount of substance The amount of substance

cleared from plasma / min. excreted in urine / min.

Volume of cleared plasma (Cx) / Volume of Urine (V) / min

min x concentration of x concentration of
substance / ml plasma (Px) substance / ml urine (Ux)

Px X Cx = V X Ux
Cx = V X Ux
Px
Clearance rate of a substance (ml/min)

= U x Vx
Px

Urine conc. of the substance x Urine flow rate (ml/min)

Plasma concentration of the substance per ml of plasma

 Importance of the determination of
plasma clearance
Clearance ml /
Substance Tubular Handling
min
Neither reabsorbed or
Inulin 125
secreted
Urea Partially reabsorbed < 125

Glucose Completely reabsorbed 0

PAH Completely secreted 650

Creatinine Partially secreted 125-650

Ammonia Synthesized and secreted >650


 If the clearance of
substance= GFR 125/ml
 Substance is freely filtered
only
 Example; Inulin
 If the clearance of
substance less than GFR
125/ml
 Substance is freely filtered
+ partial reabsorption
 Example; urea=70 ml
 If the clearance of
substance= Zero
 Substance is freely filtered
then completely absorbed
 Example; glucose
 If the clearance of substance
more than GFR, more than
125 ml/min
 Substance is freely filtered
then completely secreted
 Example; PAHA=625
ml/min
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this

Urine inulin conc. of 120 mg/ml individual GFR ?
Plasma PAH conc. of 0.1mg/ml A. 40 ml/min
Urine PAH conc. of 63 mg/ml B. 60 ml/min
Extraction ratio of PAH of 90% C. 100 ml/min
D. 120ml/min
Plasma sodium conc. of 140 mEq/l
E. 400 m/min
Urine sodium conc. of 250 mEq/l
Urine flow rate of 120 ml/ 2 hours
HV of 30%
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this

Urine inulin conc. of 120 mg/ml individual GFR ?
Plasma PAH conc. of 0.1mg/ml
Urine PAH conc. of 63 mg/ml
Extraction ratio of PAH of 90% 1mlx120
1.2
Plasma sodium conc. of 140 mEq/l
Urine sodium conc. of 250 mEq/l
100 ml/min
Urine flow rate of 120 ml/ 2 hours
HV of 30%
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this

Urine inulin conc. of 120 mg/ml individual RPF ?
 500 ml/min
Plasma PAH conc. of 0.1mg/ml
 600 ml/min
Urine PAH conc. of 63 mg/ml
 700 ml/min
Extraction ratio of PAH of 90%
 800 ml/min
Plasma sodium conc. of 140 mEq/l
 1000 ml/min
Urine sodium conc. of 250 mEq/l
Urine flow rate of 120 ml/ 2 hours
HV of 30%
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this individual

Urine inulin conc. of 120 mg/ml RPF ?
Plasma PAH conc. of 0.1mg/ml CPAH = UPAH X V / PPAH
Urine PAH conc. of 63 mg/ml 1mlx63 Effective RPF
630 ml/min
Extraction ratio of PAH of 90% 0.1
Plasma sodium conc. of 140 mEq/l
Actual RPF= ERPF/extraction ratio
Urine sodium conc. of 250 mEq/l
630 90
Urine flow rate of 120 ml/ 2 hours
?
100
HV of 30%
= 700 ml
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this individual

Urine inulin conc. of 120 mg/ml RBF ?
700 ml 100-ht= 70%
Plasma PAH conc. of 0.1mg/ml

Urine PAH conc. of 63 mg/ml ? 100%

= 1000 ml
Extraction ratio of PAH of 90%
A. 1000 ml/min
Plasma sodium conc. of 140 mEq/l
B. 1250 ml/min
Urine sodium conc. of 250 mEq/l
C. 1300 ml/min
Urine flow rate of 120 ml/ 2 hours
D. 1350 ml/min
HV of 30%
E. 1400 ml/min
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this filtration

Urine inulin conc. of 120 mg/ml
fraction ?
GFR/RPF= 100/700
Plasma PAH conc. of 0.1mg/ml
= 14%
Urine PAH conc. of 63 mg/ml

Extraction ratio of PAH of 90%

Plasma sodium conc. of 140 mEq/l A. 14%

Urine sodium conc. of 250 mEq/l B. 20%
Urine flow rate of 120 ml/ 2 hours C. 30%
HV of 30%
D. 40%
E. 50%
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this individual

Urine inulin conc. of 120 mg/ml
rate of PAH secretion ?
Plasma PAH conc. of 0.1mg/ml

Urine PAH conc. of 63 mg/ml

A. 50 mg/min
Extraction ratio of PAH of 90%
B. 53 mg/min
Plasma sodium conc. of 140 mEq/l
C. 60 mg/min
Urine sodium conc. of 250 mEq/l
D. 63 mg/min
Urine flow rate of 120 ml/ 2 hours E. 10 mg/min
HV of 30%
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this individual rate of

Urine inulin conc. of 120 mg/ml
Plasma PAH conc. of 0.1mg/ml
Urine PAH conc. of 63 mg/ml
Extraction ratio of PAH of 90%
Plasma sodium conc. of 140
mEq/l
Urine sodium conc. of 250 mEq/l
PAH secretion ?
Excreted amount= filtered load+
secreted amount
 Excreted amount=63x1=63 mg
 Filtered load=GFR(100)
xconc(0.1)=10 mg

Urine flow rate of 120 ml/ 2 hours

HV of 30%
 63= 10+?
 53 mg
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this individual

Urine inulin conc. of 120 mg/ml
fractional sodium
excretion?
Plasma PAH conc. of 0.1mg/ml

Urine PAH conc. of 63 mg/ml

A. 0.01%
Extraction ratio of PAH of 90%
B. 0.1%
Plasma sodium conc. of 140 mEq/l
C. 1.7%
Urine sodium conc. of 250 mEq/l
D. 5.0%
Urine flow rate of 120 ml/ 2 hours
E. 10.0%
HV of 30%
 Q2:An individual has the following data:
Select the best answer

Plasma inulin conc. of 1.2 mg/ml What is this individual fractional

Urine inulin conc. of 120 mg/ml
Plasma PAH conc. of 0.1mg/ml
Urine PAH conc. of 63 mg/ml
Extraction ratio of PAH of 90%
Plasma sodium conc. of 140
mEq/l
Urine sodium conc. of 250 mEq/l
Urine flow rate of 120 ml/ 2 hours
sodium excretion ?
 Excreted amount/filtered load
 Excreted amount=0.250x1=0.25
mg
 Filtered load=GFR(100)
xconc(0.140)=14 mg
 0.25/14 x100= 1.7%

HV of 30%
Q3:A researcher observed a consistent 60% decrease in
RBF in subjects performing maximal exercise. Which of the
following accounts for the decreased flow?

A. Decrease in mean arterial pressure

B. Decrease in renal arterial pressure
C. Sweat- induced hypovolemia
D. Increased renal sympathetic activity
E. ADH release
Q5:If the urine concentration of a substance is 7.5
mg/ml of urine, its plasma concentration is 0.2 mg/ml
of plasma and the urine flow rate in 2 ml/min.
A. What is the clearance rate of this substance?
B. Is the substance being reabsorbed or secreted by the
kidneys?

-Clearance = U x V / Px
= 7.5 x 2 / 0.2
= 75 ml/min
-This substance is reabsorbed
Q6: Calculate a patient’s rate of urine production, given
his inulin clearance is 125 ml/min and his plasma and
urine concentrations of inulin are 3 mg/l and 300 mg/l
respectively

Amount of inulin filtered / min = Amount of inulin excreted /

min
GFR x P inulin = U inulin x V
125 x 3 = 300 xV

V = 1.25 ml/min
Q7: If the plasma concentration of substance X is 200 mg/dL
and the GFR is 125 ml/min :
 What is the filtered load of the substance X?
Filtered load = 125 x 2mg/ml = 250 mg/min
 If the Tm of substance X is 200 mg/min; how much of
the substance will be reabsorbed at plasma
concentration of 200 mg/dL and a GFR of 125
ml/min.
200mg/min
 How much of the substance X will be excreted in the
above question (b)?
The amount excreted/min = amount filtered/min –
amount reabsorbed/min
250 - 200 = 50 mg/min
Q8: A 36 year old man suffers third degree burn,
which of the following events will occur?

 Renal perfusion pressure increases

 GFR is increased
 Adenosine is released from juxtaglomerular cells
 Renin secretion decreases
 Afferent arteriole will be dilated
Tubulo glomerular feedback

absorption
Q9:Which of the following can increase
both RBF, GFR?
 A- Both afferent and efferent arterioles are
constricted
 B-The afferent arteriole is constricted and the
efferent arteriole is dilated
 C- The afferent arteriole only is dilated
 D- The efferent arteriole only is dilated
 E- The afferent arteriole only is constricted
Q10: A vasodilator drug was prescribed to a
hypertensive patient, which of the following will
decrease?
A. Filtration fraction
B. Glomerular filtration rate
C. Peritubular capillary oncotic pressure
D. Renal plasma flow
E. Renin release from juxtaglomerular apparatus
I have fatigue and lower limb Edema
 Case study
 A 34 year-old woman, who weighed 80 Kg has had diabetes
mellitus 23 years ago. She suffered a number of diabetic
micro-vascular complications including retinopathy, peripheral
neuropathy, and nephropathy. Proteinuria was noted 7 years
ago on routine urine analysis . She now complains of
increasing fatigue , decreased appetite , loss of weight,
infrequent attacks of epistaxis , leg swelling and bone
aches.
 On physical examination, the physician noticed that she was
pale, her blood pressure was 170/95 mmHg. She had
peripheral pitting edema up to the mid calf muscles and
muscle wasting. Also, she has decreased vibration sense and
diminished deep tendon reflexes.
Laboratory data reveal the following:

 Urine analysis: glycosuria, heavy proteinuria.

 Serum creatinine: 7.3 mg/dl
 Serum BUN: 85mg/dl.
 Serum sodium: 135 mEq/l
 Serum potassium: 6 mEq/l
 Serum phosphate: 5.8 mg/dl
 Serum calcium: 9.0 mg/dl
 Arterial PH= 7.1
 Hematocrit value: 27%
Q1:What are the main functions of the kidney?

 Homeostasis
 Maintain ECF volume and composition
 Acid base balance
 Excrete waste products
 Arterial blood regulation
 Endocrine functions
Q2:Explain the role of the kidney in
regulation of the arterial blood pressure.
A-Regulation of ECF volume(sodium and
water)
Q2:Explain the role of the kidney in
regulation of the arterial blood pressure.
Q3:Explain mechanism of hypertension
in this patient.
 Incidence of hypertension in chronic renal failure
patients is 85-90%
 Causes:
 Volume expansion
 Activation of RAS
Q4: Can you explain cause of the
patient pitting oedema?
 Salt and water retention
 Proteinuria: Decrease plasma oncotic pressure
 Increase filtration and decrease absorption
What are the main hormones secreted
from the kidney?
Q6: Explain cause and type of anemia in
this patient.

 The decrease in GFR to 30% of the normal was

associated with fall in HT value (27%)
 Anemia is Normocytic normochromic anemia

1- inadequate renal secretion of EPO (main cause)

2- Reduction of RBCs life span
3- Hyperparathyroidism-induced bone marrow
fibrosis
Q7: What is the cause of epistaxis
observed in this case?
Epistaxis is caused by:
 Uremic toxins leads to platelet dysfunction

(thromboasthenia) and bleeding tendency ,

increased bleeding time.
Q8: What is the cause of hyperphosphatemia and its
effect on calcium homeostasis?

 GFR fall Decrease filtered PO4 load

decrease PO4 excretion Increase blood PO4
 Calcium-phosphorus product constant

 Increase blood PO4, decrease serum Ca+

 Q9: Give reason for bone pains in this
case.

 Increase in PTH
 Lowered calcium
 Lowered calcitriol

 Effects of Excess PTH Bone

demineralization
(Renal osteodystrophy)=
bone pains+ pathological
fractures.
Q10: What is the estimated GFR and relate it to
the serum BUN, and creatinine levels.

 eGFR= (140-age)x BW(Kg)

Pcr x 72

 eGFR= 106x 80
7.3 x 72
 =16.1 ml/min

 Serum BUN and creatinine levels are elevated due to

the decline in GFR because these substances are
excreted mainly by glomerular filtration.