JKKJI

Removal of excess NH3 in the body is accompanied

by production of urea which is excreted in the
urine.
NH3 is toxic to the body. It is metabolized by 3
ways:
1. Conversion into Urea
2. Formation of Glutamine
3. Amination of -Keto acid to form -Amino
acid.
Normal blood levels of NH3 is 40-70 g/100ml. Free
Ammonium ion NH4+ conc.. in the plasma is <
20g/100ml

IMPORTANCE OF UREA

Urea as we all know is a marker for renal

disorders
Another important aspect of urea is forming
hypertonic urine (concentrated)
In the distal portion of the kidney urea is
reintroduced to increase osmolarity
(Concentration). There after water flows back
into the body thru aqua porins.
Urea is not only excreted by the kidney in urine
but also in small amounts in sweat along with
sodium chloride.

Apart from commercial and agricultural use it

is used in laboratory as a protein denaturant at
a concentration of 10 M. At this concentration
it disrupts the noncovalent bonds in proteins.
It is used in synthesis of urea nitrate which is
highly explosive similar to ammonium nitrate.
It is also used in dermatology clinics topically
to promote rehydration of skin.
40% urea is used for nonsurgical debridement
of nails
Isotopically labelled urea is used in urea
breadth test in the detection of H.pylori

Urea can be irritating to eyes and skin.

Too high concentration can cause
damage to other organs.
Urea
can
cause
algal
blooms
(proliferation of algae which release
neurotoxins).
Repeated and prolonged use may cause
dermatitis

SYNTHESIS OF UREA (Urea Cycle)

The synthesis by which urea occurs is called

urea cycle. It is also known as krebs
Henseleit cycle after it was deduced by Hans
Adolf Krebs and Kurt Hensleit in 1932

Synthesis occurs in liver

Substances involved
- Carbondioxide
Aspartate
Ammonia
Regulatory enzyme involved is acetyl
glutamate
Ammonia and L-Aspartate donate amino
groups and thereby get converted to urea.
Intermediates formed are L-ornithine, citrulline,
L.Arginosuccinate and L-Argnine

UREA CYCLE

Clinical Features of Urea Cycle Disorders

Hyper Ammonemia
Encephalopathy
Respiratory Alkalosis
Vomiting, irritability, lethargy
Mental Retardation (Infant normal at Birth)
Intermittent Ataxia
Diagnosis
Now a days the defects in the enzymes of
UCD in neonatal blood by
TANDEM MASS SPECTROMETRY

Treatment
Low Protein Diet with sufficient Arginine .
Energy by frequent feeding, minimize
brain damage.
Attempt to eliminate Amino Nitrogen in
other forms. Ex: Hippuric Acid, Phenyl
acetyl glutamate.
Gene Therapy (in experimental stages).
Breast milk avoided in Citrullinemia.
(breast milk contains significant amount
citrulline)

Hepatic Coma (Acquired Hyper Ammonemia)

In the diseases of liver Hepatic failure can
finally leads to COMA, and DEATH.
Hyper Ammonemia is a characteristic
feature of liver failure also called Portal
Systemic Encephelopathy.
Normally NH3 and other toxic compounds
produced in the body transported to the
liver by Portal Circulation & Detoxified in
the Liver.
But when there is Portal Systemic Shunting
of blood, the toxins by-pass the liver & the
conc.. raises in the system circulation.

Signs & Symptoms

Mainly CNS dysfunction -Altered Sensorium,
convulsions or Manifestations of the liver
failure (Ascitis, Jaundice, Hepatomegaly,
Oedema, Hgh, Spidernaevi)
Management (very difficult task)
Low protein diet
Intestinal disinfection (bowel cleaning and
antibiotics)
With hold hepato-toxic drugs
Electrolyte & Acid Base balance
maintenance.

Normal conc.. in blood plasma in adult 20 to 40

mgs%
In INDIANS 15 to 40 mgs% (due to less protein

intake)

Serum Plasma urea nitrogen 5 to 23 mgs%

Urine urea 15 to 30gms/day.
Urea is a few mgs higher in men than women
Serum conc.. increases as the age advances
lower range is seen in young and upper limit in
elderly people. Values of 40mg% in young is
suspicious
while the same in the person of 60 years age is
considered as perfectly normal.
Influenced by the amount of protein in diet.

Increases in blood urea may occur in a

number of diseases
Increase of blood urea above normal is
called uremia or Azotemia

CAUSES
1. Pre-renal
2. Renal
3. Post renal
4. Others (Medication)

1. PRERENAL CAUSES:
seen in conditions in which plasma volume/body fluid
are reduced.
Salt and water depletion
Severe and protracted vomiting as in pyloric and
intestinal obstruction
Severe and prolonged diarrhoea.
Pyloric stenosis with severe vomiting (bl.urea
exceeds 200mg%)
Haematemesis
Haemorrhage and shock due to severe burns
Ulcerative colitis with severe chloride loss
In crisis of Addisons disease.
Increased protein break down in fevers and other
toxic conditions
Cardiac failure ie in coronary thrombosis
(moderate increase from 40 to 110)

Blood urea increases in all forms of

kidney diseases.
Acute glomerulonephritis (normal to over
300mg)
In late stages of Type II nephritis with
renal failure
Malignant nephrosclerosis
Chronic pyelonephritis
Mercurial poisoning
In hydronephrosis and renal tuberculosis.

Obstruction to the urine flow may cause

an increase in blood urea.
This causes retention of urine and so
reduces the effective filtration pressure at
glomeruli.
If prolonged, irreversible kidney damage
results.
Enlargement of Prostate
Stones in urinary tract
Stricture of urethra
Tumors of the bladder affecting urinary
flow.

4. Medications:
a. ACE Inhibitors
b. Acetaminophen
c. Aminoglycodies
d. Amphotericin B
e. Diuretics
f. NSAIDS

Decreased Conditions
1. Very Rare
2. Severe Liver Diseases
3. In conditions of low Protein intake.
Physiologically Decreased in PREGNANCY

In Acute renal failure : Urea Clearance is

lowered usually less than half the normal and
increases again with clinical improvement.
Chronic nephritis : Urea clearance falls
progressively and reaches a volume half or
less of the normal before the bl. Urea conc.
begins to rise.
Terminal ureamia : Maximum clearance falls
to about 5% of normal values.
Nephrotic syndrome : Clearance is usually
normal until the onset of renal insufficiency

sets on and produces the same changes

as in chronic nephritis.
4. Benign Hypertension : Urea clearance
is normal and maintained indefinitely
except in few terminal malignant phase
when it falls rapidly.

Note :
A very low protein diet can lead to low
clearance values even in normal persons
and in patients with mild renal disease.
Urea is normally reabsorbed from renal
tubules and therefore tubular function
also affects urea clearance. Hence
creatinine clearance test is more
preferred.

It is the blood urea levels expressed in

terms of its nitrogen content.

ie 60 mgs of urea contains 28 mg of urea

nitrogen.

so BUN is 7 to 18 mgs / 100 ml

Urea nitrogen value can be converted to

urea by multiplying with 60/28 or 2.14
Clinical significance :

Most widely used screening test for

evaluation of kidney function

Less sensitive than urea clearance

Aid in the differential diagnosis of prerenal,

renal and post renal hyperuremia.

Interpretation :
Variations in blood non-protein nitrogen
mainly reflect alterations in blood urea.
It is raised in those conditions in which
blood urea is raised.
In uremic coma with the blood urea at 500
mg per 100 ml, it forms about 90 percent.
On ordinary diets the urea nitrogen forms
80 to 90 percent of total urea nitrogen.
On low protein diet it may fall to about 60
percent.

Urea is being use in the synthesis of DMP

450.
DMP 450 is water soluble cyclic urea
compound.
It is known to inhibit HIV Replication by
its action on protease enzyme.
Research
is
going
on
the
pharmacokinetics of DMP 450 for its
further use.

CREATININE
Creatine is a nitrogenous organic acid naturally occuring in
vertebrates and helps to supply energy to muscle and nerve cells.

Michel Eugene Chevreul discovered creatine in 1837. (Kreas

means Flesh in Greek Word.)
SYNONYMS:
a)Kreatin
b) Methyl guanido acetic acid
c)N- amidino Sarcosine
Creatinine: It is the anhydride of creatine creatinine is a break down
product of creatine phosphate in muscle.
Creatinine is a waste product formed from Creatine Phosphate.

CREATINE (P)

CREATININE
Non
Enzymatic

Characteristics of Above Reaction:

1. Irreversible
2. Non-Enzymatic
3. Creatinine has RING structure

STRUCTURE OF CREATINE
IUPAC name of Creatine
2 (1-Methylcarbamimidamido) acetic
acid
Molecular formula: C4 H9 N3 O2

STRUCTURE OF CREATININE
IUPAC name of Creatinine
2-amino3-methyl-4H-imidazol-5-one
Molecular formula: C4 H7 N3 O

Creatine is present and functions in all

vertebrates and some invertebrates in
conjunction with the enzyme creatine
kinase. Phospho creatine/creatine kinase
act as an intracellular energy transport
system where ATP is generated.
In invertebrates arginine/ phospho arginine operates via the arginine kinase.
The above two enzyme buffer system that
keeps the ATP/ADP ratio high at subcellular
places constitute the phosphagens.

Creatine in the body occurs in

1.
Free form
2.
Phosphorylated form
(Creatine PO4)
Total amount of creatine in adult human
body is approximately 120gm.
98% of total amount is present in muscle
as phophorylated form
1.3% in Nervous System
0.5 0.7% in Tissues
SOURCES:

Half of stored creatine originates from food

meat and fish.

Creatine is a normal constituent of the

body present in
Urine
Muscle
Liver
Testes
Blood

Creatine concentration is higher in striated

muscle as compared to smooth muscle.
Total 300 500 mg/100 gm.

Biosynthesis of creatine occurs from 3

amino acids
Glycine
Arginine
Methionine
Sites of Synthesis:
Kidney
Liver
Other sites of creatine synthesis include
pancreas
which
can
synthesis
glycocyamine and creatine phosphate.

First Step:

Amidino group of arginine is transferred to

glycine to form guanido acetic acid in the
presence of amido transferase.

It is seen in mitochondria of kidney and

pancreas.
Second Step:
Guanido acetic acid is methylated by s-adenosyl
methionine by methyl transferase to form
creatine. The reaction takes place in the liver.
Third Step:
Creatine is phosphorylated to creatine
phosphate by creatine kinase enzyme present in
the muscle, brain and liver.
Fourth Step:
Creatine phosphate converted to anhydride
creatinine. It is a non enzymatic reaction.

Genetic deficiency in the creatine biosynthetic path way leads to severe

neurological defects.
Creatinine is mainly filtered by kidney
There is little (or) no tubular reabsorption of
creatinine.
If filtering of kidney is impaired blood levels
of creatinine is raised.
As a result ,creatinine blood levels may be
used to calculate creatinine clearance,
which reflects GFR a measurement of renal
function test.

Normal Values:

Creatine -Whole blood Creatine 2 to 7 mg%

In Plasma/Serum
In males 0.2 0.6 mg%
Females 0.35 0.9 mg%
Creatinine -Whole Blood Creatinine 1.0 2.0 mg%
Serum/Plasma Creatinine in
Males:
0.7-1.4mg/dl,
Females: 0.6-1.3mg/dl,
Children:
0.5-1.2mg/dl
Urinary Creatinine in
males 1.5 to 2.0gm. In 24hr. Urine
Females 0.8 to 15gm. In 24 hr. Urine
creatinine clearance is increased in pregnancy
resulting in lower serum creatinine levels.
Vegetarians have low creatinine
Men have more creatine as they have more muscle
mass

Increased serum creatinine levels seen in

Impaired renal function

Chronic nephritis

Urinary tract obstruction

Muscle diseases such as gigantism, acromegaly,

myasthenia gravis.

Congestive heart failure

Shock
In Muscular dystophy both blood creatinine and
urinary creatinine increases.
Enzyme CK(Creatinine Kinase) is elevated in MI.
Decreased serum creatinine levels seen in
Elderly people with small structure
Decreased muscle mass
Muscular Atrophy
Inadequate protein intake

Factors that influence the increase in Serum

Creatinine:
Old Age
Males
Renal Diseases
- Glomerulonephritis
- Pyelonephritis
- Renal Failure
- Urinary Obstructions
C C F
Dehydration
Shock
Medicines (Amphotericin B, Captopril
Cephalosporin and Kenamycin).

Factors that influence the decrease in Serum

Creatinine:
Low muscle mass
Females
Mal nutrition
Medicines (Thiazide, Vancomycin)

Serum creatinine and Blood Urea Nitrogen(BUN) are

often compared to evaluate renal function.While
serum creatinine increases only with nephron
damage ,Blood Urea Nitrogen is affected by
hydration,hepatic protein metabolism and decreased
glomerular filtration rate. Then ratio of serum
creatinine to the Blood Urea Nitrogen is approx.1:10
A patients Blood Urea Nitrogen and serum creatinine
should always be checked before giving nephrotoxic
drugs eg:Aminoglycoside antibiotics.
Since the increased serum creatinine levels is
obsreved only with marked damage to functioning
nephrons, this test is not suitable for detecting early
stage kidney disease.
A better estimation of kidney function is given by
creatinine clearance test.
In U.S.A all radiologists must see the results of Serum
creatinine levels before performing the C.T scan.

Urinary Creatinine

With steady state day to day renal function

each gram of creatinine in 24hrs urine
collection represents 18.5gms of fat free
skeletal muscle.
Since skeletal muscle is the major component
of fat free mass, measurement of creatinine in
24hrs. Urine collection can be used as a
relative measure of this body compartment
during the initial assessment or to assess the
efficacy of nutritional support.
Creatinine excretion in urine is a constant, used
to check the adequacy of 24 hr.urine sample
especially in children, mentally retarded
patients.

Creatinine coefficient: represents the

amount of creatinine excreted per
kilogram of body weight.
In males - 20-26mg/kg Ideal body weight
In females- 14-22mg/kg Ideal body weight
Creatinine-Height Index: represents the
ratio of the measured 24hr urine creatinine
excretion to the value predicted by the
creatinine co-efficient for the patients ideal
body weight according to height.
Unpredictable Creatinine excretion may
occur through faeces or skin in patients
with serum creatinine levels >6mg/dl.

Creatinuria
Excretion of creatine in urine occurs in:
children- lack of ability to convert creatine to
creatinine.
In adult females in pregnancy and maximum after
parturition (2-3 weeks)
In febrile conditions
In thyrotoxicosis,probably due to associated
myopathies.
Lack of carbohydrate in diet and in Diabetes
mellitus
In muscular dystrophies,myositis and Myasthenia
gravis
In wasting diseases eg:Malignancies
In starvation

Therapeutic uses of creatine

In 1992, creatine supplements popularized as sports

performance enhancing supplement.
Creatine as a new therapeutic strategy in depression.
Creatine plays a pivotal role in brain energy homeostasis being a
temporal and spatial buffer for cytosolic and mitochondrial pools
of the cellular energy.
Recent studies have suggested increased brain utilization of
oxygen following oral creatine supplementation(Persky &
Brazena 2001)
Creatine tried in treatment of neurological, neuromuscular and
atherosclerotic diseases.
Creatines influence on physical performance has been well
documented since early 20th century; it recently came into
public view following the 1992 olympics in Barcelona.
In 1998, the launch of the first creatine, carbohydrate-alpha
lipoic acid supplement,cell tech by Muscle Tech Research and
development ,took place.

In 2004,first creatine ethyl ester(CEE) supplements were

launched.
Scientific studies have shown that creatine supplements can
marginally increase athletic performance in high intensity
anaerobic repetitive cycling sprints.
Ingesting creatine can increase the level of phosphocreatine in
muscles upto 20%.
Also research have shown that creatine increases the activity of
satellite cells which make muscle hypertrophy possible.
Creatine use is not considered Doping, In France creatine is
banned.

Side effects of creatine supplementation:

Major side effect is its ability to pull water into the muscle cells
making other tissues of the body compartment hypo hydrated.

Therefore it is very important to drink an optimal amount of

water while supplementing the creatine.(1-2 ounces of water/kg
of body weight)

Creatine Phosphokinase

In human tissues ,CK isoenzymes occur in three distinct molecular

forms.
Each isoezyme is a dimer consisting of two primers M(Muscle) and
B(Brain).

Type5

Ploypeptide
Chain

Tissue
Type

Electrophoreti
c Mobility

Mean % in
Blood

CK-1

BB

Brain

Fast

1%

CK-2

MB

Hybrid

Medium

5%

Ck-3

MM

Muscle

Slow

80%

Atypical iso-enzymes of CK
Macro-CK(CK-Macro)
Mitochondrial type(CK-Mi)
Normal serum levels for CK
In Males- 15 100U/L
In Females 10- 80 U/L
Normally major isoenzyme found in serum is CK-MM
The level of CK in serum is very much elevated in muscular
dystrophies(500-1500IU/L)

CK-BB is found elevated in

- Cerebrovascular accident
- Brain tumors
- Central nervous system shock
- Placental & uterine trauma
Recently it has been reported that CK-BB is significantly
increased in various carcinomas such as
Adenocarcinomas,Prostatic carcinomas.Hence CK-BB useful as
tumor marker.
Cardiac muscle contain significant amount of CK-MB isoenzyme.
Hence estimation of CK-MB is of immense value in diagnosis of
Acute Myocardial Infarction.
Increased levels of CK-MB>6% of total CK is taken as most
specific indicator of Acute Myocardial Infarction.
CK-MB accounts for 4.5- 20% of total CK activity of plasma of
patients with recent Acute myocardial infarction; and CK-MB
isoenzyme may be elevated 20 times above normal.
Not specific as rise is observed in other cardiac and non-cardiac
disorders.

CK-MM: Major isoenzyme found in striated muscle and normal

healthy serum.
CK-MM is elevated in
- Hypothyroidism
- Myocardial Infarction
- Muscular dystrophies
- Polymyositis

Atypical Isoenzymes:

Macro-CK is formed by aggregation of CK-BB with

immunoglobulin usually IgG.
CK-1 IgG complex causes false positive diagnosis of Myocardial
infarction because it has elecrophoretic mobility close to CK-2.
CK-Mi: It is present bound to the exterior surface of inner
mitochondrial membrane of muscle,liver, brain.
Its presence in the serum indicates severe illness when there is
extensive tissue damage causing breakdown of mitochondria &
cell wall.

ARF (Acute Renal Failure) :

Occurs as a result of Ischemic or Nephrotoxic insults.

ARF develops rapidly & its sequelea are Electrolyte, Acid-Base &
Fluid Imbalance .
ARF can be divided
* Pre-Renal
* Intra-Renal
* Post-Renal
Role of clinical lab in assessment and monitoring ARF is limited
to Electrolyte & Fluid-Balance measurements.
Although temporary replacement of renal function thru
hemodialysis has cut the mortality to 50%.
During recovery phase Polyurea occurs.

CRF (Chronic Renal failure):

Progressive loss of functioning nephrones

Main cause
* Diabetes
* Renal Vascular Diseases
* Glomerulonephrites

CKD (Chronic Kidney Disease) :

GFR < 60ml/min/1.73sqm for 3 months are more with/without

kidney damage indicated CKD.
MDRD Equation used to grade CKD
Grade

State

GFR
ml/min/1.73sqm

Minimal damage with normal

GFR

> 90

Mild damage with slightly low

GFR

60 89

Moderately low GFR

30 59

Severely low GFR

15 29

Kidney Failure

< 15

ESRD (End Stage Renal Disease) :

Results from any of a wide variety of Renal Diseases including

ch.glomerulonephrites, ch.pyelonephrites, immunological
diseases with renal involvement (SLE).

HTN, Acute obstruction of lower urinary tract, toxic & ischemic

damage to the kidney.

Uremic Syndrome
Uremia or Azotemia is defined as excess in blood of Urea, Creatinine
and Other Nitrogenous end products of Amino Acids & Protein
Metabolism.

Uremic Syndrome is a terminal clinical expression of Kidney Failure.

Signs & Symptoms: Weakness, Fatigue, Loss of appetite, Nausea,
Vomiting, Muscle Wasting, Tremors, Abnormal Mental functions,
Shallow Resp., Stupor, Coma, & Death.
Investigations:
1. Lab Findings:

Increase conc.. of Nitrogenous Compounds in plasma (Urea,

Creatinine & Uric Acid).

Fluid, Acid-Base & Electrolyte Disturbances.

Abnormal Lipid Metabolism.

Altered Endocrine Functions.

- Decreased Erythropoietin Production Anemia
- Altered Thyroxin Metabolism.
- Gonadal Dysfunction.
- Sec. Hyperparathyrodism.
- Osteomallcia.
- Hyper/Hyporeninemia.
- Hyper/Hypoaldosteronism

2. Imaging
3. Renal Biopsy linked with optical / electron microscopy in assoc. with
immuno histochemistry or more recently in situ Hybridization & PCR
Technique.

Classification:
Renal diseases are classified in 4-stages as defined by percentage of
Renal function remaining, Plasma conc.. of Creatinine & Urea-Nitrogen.
S.No

Stage

Renal function
Remaining
(%)

Serum
creatinine
(mg/dl)

Serum Urea
Nitrogen
(mg/dl)

Decreased Renal Reserve

50 75

1.0 2.5

15 30

Renal Insufficiency

25 50

2.5 6.0

25 60

Renal Failure

10 25

5.5 11.0

55 110

Uremic Syndrome Endstage

0 10

> 8.0

> 80

Treatment:

Treat the cause

Fluid, Electrolyte, Acid-Base Balance Maintenance.
Dialysis
- Peritoneal Dialysis
- HemoDialysis
Kidney Tranplantation