Last updated: 11/24/2009

Many conditions can affect the ability of the kidneys to carry out their vital functions. Some conditions can lead to a rapid (acute) decline in kidney function; others lead to a gradual (chronic) decline in function. Both can result in a build-up...

of toxic waste substances in the blood. A number of clinical laboratory tests that measure the levels of substances normally regulated by the kidneys can help to determine the cause and extent of kidney dysfunction. Urine and blood samples are used for these tests.

The nephrologist uses these results in a number of ways. Once a diagnosis is made that kidney disease is present and what kind of kidney disease is causing the problem, the nephrologist may recommend a specific treatment. Although there is no specific drug therapy that will prevent the progression of kidney disease, the doctor will make recommendations for treatment to slow the disease as much as possible. For instance, the doctor might prescribe blood pressure medications, or treatments for patients with diabetes. If kidney disease is getting worse, the nephrologist may discuss hemodialysis (blood cleansing by removal of excess fluid, minerals, and wastes) or kidney transplantation (surgical procedure to implant a healthy kidney into a patient with kidney disease or kidney failure) with the patient.

Laboratory tests

There are a number of urine tests that can be used to assess kidney function. A simple, inexpensive screening test—a routine urinalysis—is often the first test conducted 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 presence of cellular elements (red blood cells [RBCs], white blood cells [WBCs], and epithelial cells), bacteria, crystals, and casts (structures formed by the deposit of protein, cells, and other substances in the kidneys's tubules). If results indicate a possibility of disease or impaired kidney function, one or more of the following additional tests is usually performed to pinpoint the cause and the level of decline in kidney function.

• Creatinine clearance test. This test evaluates how efficiently the kidneys clear a substance called creatinine from the blood. Creatinine, a waste product of muscle energy metabolism, is produced at a constant rate that is proportional to the individual's muscle mass. Because the body does not recycle it, all 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 24-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 in urine. It is a more precise measurement than specific gravity for evaluating the 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 kidneys excrete less water and the urine becomes more concentrated. The test may be done on a urine sample collected first thing in the morning, on multiple timed samples, or on a cumulative sample collected over a 24-hour period. The patient will typically be prescribed a high-protein diet for several days before the test and be 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 of protein, 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 sample that 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 byproduct of protein metabolism. Formed in the liver, this waste product is 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 BUN is also affected by protein intake and liver function, the test is usually done together with a 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, similar to urea, is filtered from the blood by the kidneys and excreted into the urine. Production of creatinine depends on an person'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 level is a more sensitive indicator 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.