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Nursing Field Notes / Labs & Values · Renal page · Med-Surg + NCLEX
🧪 LABS & VALUES SET NG-194 Highest priority NG-042 BMP & electrolytes NG-121 CBC NG-153 WBC & coagulation NG-048 Renal labs 🧪 By condition 🩺 Bedside tests

Renal Labs 🫘

BUN · creatinine · GFR · urinalysis — and the bedside number that beats all four

NG-048 LABS & VALUES · RENAL ADHD-friendly visual edition

The kidney filters HUC — Hydrogen ions, Urea and Creatinine — and everything on this page is a way of asking how well is it still doing that? Learn the two blood markers and what makes each of them lie, learn what GFR staging actually predicts, and learn to read a urinalysis line by line. Then remember the number that changes before any of them: the hourly urine output.

📄 Simple Nursing original — opens in Drive →

🫘 2 labs, 2 kidneysBUN 10–20 mg/dL · creatinine 0.6–1.2 mg/dL. Over 1.3 = a bad kidney.
🚨 Under 30 mL/hrUrine output below 30 mL/hour is kidney distress — report it. Check the catheter first.
💧 SG 1.005–1.030High = concentrated = DRY. Low = dilute. Color is the same information without a number.
📉 GFR>90 normal · 15–29 severe · <15 = failure, dialysis territory.
⚠️ Read this before you memorize a single number. Every value on this page is a typical adult reference range — ranges vary by laboratory, so always use the range printed on your patient’s result. Critical-value cut-offs vary even more: every facility publishes its own critical list and its own call-back policy. Learn the direction and the meaning; verify the exact digits locally.
🫘

PART 1 · THE TWO BLOOD MARKERS

HUC

Two labs for two kidneys — but only one of them is honest.

FIGURE 1 · ONE NEPHRON — where each renal lab value is madeLEFT: a kidney in coronal section, showing where a nephron sits · RIGHT: that nephron magnified ×250 · follow the filtrate DOWNthe kidney filters HUC:Hydrogen · Urea · CreatinineWHERE IT SITS · CORONAL SECTIONabout a million nephrons per kidneythe filter sits in the CORTEX,the loop dips into the MEDULLAFILTERED OUT OF THE BLOODH⁺acid — retained in failureUREAprotein waste → BUNCREATmuscle waste → creatinineafferent arteriole — blood INefferent arteriole — blood OUTGLOMERULUSBOWMAN’S CAPSULECOLLECTING DUCT → pelvis → ureter → urinePROXIMAL TUBULEreabsorbs most water, sodium,glucose and UREALOOP OF HENLEconcentrates the urine(specific gravity)DISTAL TUBULEALDOSTERONE acts here:keeps Na⁺, dumps K⁺COLLECTING DUCTADH acts here:holds water backWHAT EVERY COLOR IN THIS FIGURE MEANSblood entering / the filterblood leavingtubule — where things are reabsorbedcollecting duct and pelvis — urine🧠 “The kidneys filter out HUC” — Hydrogen · Urea · Creatinine.Creatinine is the honest one — filtered and barely reabsorbed, so it tracks filtration. Urea is reabsorbed with water, which is why dehydration raises the BUN.

Figure 1 — every value on this page is produced somewhere in this drawing. Learn where, and the rest of the page explains itself.

🧠 HUC — what the kidney is filtering out

The kidneys filter out H · U · C — hydrogen, urea and creatinine.

  • H⁺ — hydrogen ions. Acid. When the kidney fails they back up and the client goes into metabolic acidosis — pH below 7.35 with a low CO₂/bicarbonate on the BMP.
  • U — urea (BUN). Protein waste. The liver turns ammonia into urea and the kidney excretes it.
  • C — creatinine. Muscle waste from ordinary wear and tear.
🧠 Think of the kidney as a pirate’s HOOK that hauls Hydrogen, Urea and Creatinine out of the blood.
FIGURE 2 · THE TWO BLOOD MARKERS — one axis eachTWO TRAFFIC-LIGHT SCALES · low LEFT, high RIGHT · the cause is written under the end that produces it“2 labs for 2 kidneys”creatinine over 1.3 = a bad kidneyLOWNORMAL 10–20HIGHVERY HIGH102040mg/dLBUN — blood urea nitrogentypical adult reference range · protein waste, easily fooled⬅ over-hydration · liver failurevery low protein intake · pregnancyDEHYDRATION first ➡then kidney disease · GI bleedhigh-protein diet · steroids · burnsNORMALLOWNORMAL 0.6–1.2HIGHCRITICAL0.61.34.0mg/dLCREATININE — the kidney’s own handwritingtypical adult reference range · muscle waste, produced at a steady rate⬅ low muscle massolder adults · amputees · long bed restOVER 1.3 = a hurt kidney ➡RISING day on day = an acute injuryhappening right nowNORMAL🧠 TWO LABS FOR TWO KIDNEYS — but only one of them is honestBUN is reabsorbed with water, so it climbs whenever the client is dry, bleeding into the gut, eating a lot of protein, or on steroids.Creatinine is barely reabsorbed, so it moves almost only when filtration falls. When the two disagree, believe the creatinine.

Figure 2 — BUN and creatinine on their own axes. Notice how many things raise the BUN that have nothing to do with the kidney.

🫘 BUN — the number that is easily fooled

Typical adult 10–20 mg/dL. Urea is a protein waste product — think of a protein bar wrapper the body throws away.

RAISED by things that are not kidney disease: dehydration, a high-protein diet, GI bleeding (blood is protein), steroids, burns, heart failure.

LOWERED by: over-hydration, liver failure (no urea is made), very low protein intake, pregnancy.

🧠 A high BUN in an otherwise well client usually means “this person is dry.” Offer fluids and look at the intake/output chart before you panic.

🧪 CREATININE — the kidney’s own handwriting

Creatinine over 1.3 mg/dL means a damaged kidney. Typical adult 0.6–1.2 mg/dL. Produced at a steady rate, freely filtered and barely reabsorbed — so it tracks filtration almost purely.

  • Over 1.3 = a hurt kidney.
  • Rising day on day = an acute injury happening right now.
  • Low muscle mass (older adults, amputees, long bed rest) can hide kidney damage behind a normal-looking creatinine.

Even a small rise matters: doubling the creatinine roughly halves the filtration rate.

🧠 When BUN and creatinine disagree, believe the creatinine.

🧩 The BUN : creatinine ratio — three places the problem can be

> 20 : 1PRE-RENAL
The client is DRY. BUN climbs, creatinine barely moves. Dehydration, hemorrhage, shock, heart failure, vomiting and diarrhea. Fix the volume and the numbers come back.
10–15 : 1INTRA-RENAL
The kidney tissue is injured. Both climb together. Acute tubular necrosis, nephrotoxic drugs, contrast dye, glomerulonephritis, prolonged ischemia.
CHECKPOST-RENAL
Something is blocking the exit. Stone, enlarged prostate, tumor, or a kinked/clamped catheter. Bladder scan and check the hourly output.
🧠 Dry · Damaged · Dammed. Before the kidney, in it, or after it.

💊 The drugs that hurt kidneys — nephrotoxic watch list

  • NSAIDs — reduce renal blood flow; a very common cause of a creeping creatinine.
  • Aminoglycoside antibiotics (e.g. gentamicin) and vancomycin — levels and renal function are monitored for this reason.
  • IV contrast dye — hydration before and after per order; hold metformin around the study per policy.
  • ACE inhibitors / ARBs — protective long term, but can drop filtration acutely, especially in a dry client.
  • Diuretics — mostly by making the client volume-depleted.

Never give a nephrotoxic drug without checking the most recent creatinine and urine output.

🧠 Any client with a rising creatinine deserves a drug review before anything else. The answer is often on the medication list.
📉

PART 2 · GFR AND STAGING

HOW MUCH IS LEFT

One number that predicts what will go wrong next.

FIGURE 3 · GFR — the staircase down to dialysisFIVE STEPS, read LEFT → RIGHT · the kidney above each step is shaded to show how much function is left · GFR is in mL/min/1.73 m²GFR falls, creatinine risesthey move in opposite directionsG1 · GFR 90 and overNORMAL functionkidney damage present butfiltration normalG2 · GFR 60 – 89MILD lossusually silent — found onroutine labs18% shaded = function lostG3 · GFR 30 – 59MODERATE lossanemia, bone changes andhigh phosphate begin38% shaded = function lostG4 · GFR 15 – 29SEVERE lossprepare for renalreplacement · build thefistula NOW57% shaded = function lostG5 · GFR under 15KIDNEY FAILUREdialysis or transplant78% shaded = function lostWORSENING →DIALYSIS TERRITORY🧠 GFR is an ESTIMATE calculated from creatinine, age, sex and body size — so anything that changes muscle mass changes it.

Figure 3 — the staircase. Notice that G4 is where the fistula gets built: access is planned long before dialysis is needed.

📉 GFR — what it is and what changes it

Glomerular filtration rate: how many milliliters the kidneys filter per minute. Normal is over 90 mL/min/1.73 m².

It is estimated from the creatinine together with age, sex and body size — so anything that changes muscle mass changes the estimate. A frail older adult can have significant kidney disease with an unremarkable creatinine.

GFR and creatinine move in opposite directions: as filtration falls, creatinine rises.

🧠 GFR down, creatinine up. They are two views of the same failing filter.

📊 The stages, and what each one changes about your care

StageGFRWhat it means for you
G190+Damage present, filtration normal — control blood pressure and glucose
G260–89Mild loss — usually silent, found on routine labs
G330–59Moderate — anemia, high phosphate, low calcium and bone changes begin; drug doses need adjusting
G415–29Prepare for renal replacement — this is when an AV fistula is created, because it needs months to mature
G5under 15Kidney failure — dialysis or transplant
🧠 “Build the fistula at stage 4.” Waiting until stage 5 means dialysing through a temporary catheter, with all its infection risk.
FIGURE 7 · THE KIDNEY’S OTHER FOUR JOBS — and the lab that shows each one failingONE KIDNEY in the center · four arrows to four targets · read CLOCKWISE from the top leftthe kidney is not just a filterit is a gland and a buffer tooTHE KIDNEYERYTHROPOIETINtells the marrow to build red cellsFAILS → ANEMIAnormocytic anemia · low Hgb and Hct · fatigue andpallorACTIVATES VITAMIN Dso calcium can be absorbed from the gutFAILS → LOW CALCIUMlow Ca²⁺ · high phosphate · bone disease · tetanysignsRENIN (RAAS)controls blood pressure and fluid volumeFAILS → HYPERTENSIONrenin rises · fluid is retained · BP climbsEXCRETES ACID (H⁺)and makes bicarbonateFAILS → METABOLIC ACIDOSISpH under 7.35 · low CO₂/bicarbonate on the BMP🧠 THE RENAL-FAILURE PANEL YOU CAN PREDICT WITHOUT SEEING IT⬆ UP: potassium (the lethal one) · BUN · creatinine · phosphate · magnesium⬇ DOWN: calcium · hemoglobin and hematocrit · CO₂ / bicarbonate · pH“Kidneys quit → K, Phos and Mag climb; Calcium, H&H and bicarb fall.”

Figure 7 — the kidney is a filter, a gland and a buffer. When it fails, all four of these jobs fail with it, and each one shows up as a different laboratory value.

🚨 The renal-failure panel you can predict

  • ⬆ Potassium — cannot excrete it. This is the lethal one.
  • ⬆ BUN and creatinine — cannot clear the waste
  • ⬆ Phosphate and ⬆ magnesium — cannot excrete them either
  • ⬇ Calcium — pushed down by the high phosphate, and the failing kidney cannot activate vitamin D
  • ⬇ Hemoglobin and hematocrit — no erythropoietin, so no signal to build red cells
  • ⬇ CO₂ / bicarbonate and pH — acid builds up → metabolic acidosis

Never give a potassium-containing IV or a potassium-sparing diuretic in renal failure without a deliberate order and a current level.

🧠 “Kidneys quit → K, Phos and Mag climb; Calcium, H&H and bicarb fall.” One sentence predicts most of the panel.
🔬

PART 3 · THE URINALYSIS

PHYSICAL · CHEMICAL · MICROSCOPIC

Three layers to a UA, and the collection technique that decides whether any of it is true.

FIGURE 5 · URINE COLOR AND CONCENTRATIONSEVEN SPECIMEN POTS drawn LEFT → RIGHT, palest to darkest · underneath, the specific gravity scale that measures the same thing with a numberlemonade = well waterediced tea = dry as a bonealmost clearover-hydrated ·diuretics · diabetesinsipiduspale strawwell hydrated ✅straw / yellowNORMAL ✅dark yellowgetting dry — offerfluidsamber / honeyDEHYDRATED ·concentratediced-tea / colasevere dehydration ·rhabdomyolysis · liverdiseasered / pinkHEMATURIA — stones,infection, tumor,traumaDILUTENORMAL 1.005–1.030CONCENTRATED1.0051.030SPECIFIC GRAVITY — how thick the urine isthe number version of the color chart⬅ LOW: over-hydration · diureticsdiabetes insipidus · renal failureHIGH: DEHYDRATION ➡SIADH · heart failure · contrast dye⚠️ COLOR IS A CLUE, NOT A CONCLUSION• Pale urine does NOT prove good hydration in a client on diuretics, with diabetes insipidus, or with renal failure — those clients cannot concentrate urine.• Drugs color urine too: phenazopyridine turns it bright orange (harmless, stains clothing), rifampin red-orange, and some laxatives pink.• Cola-colored urine after a crush injury, extreme exertion or a statin → suspect RHABDOMYOLYSIS, and check the creatinine.

Figure 5 — color and specific gravity are the same information told two ways. Both answer: is this urine concentrated?

💧 The physical part — color, clarity, odor, specific gravity

  • Normal: straw-colored, clear, with a mild odor.
  • Dark: concentrated (dehydration), blood, or bilirubin from liver disease.
  • Cloudy: bacteria, pus, protein or blood.
  • Foul odor: infection.
  • Specific gravity 1.005–1.030: HIGH = concentrated = dehydrated; LOW = dilute.
🧠 “Lemonade urine = well watered. Iced-tea urine = dry as a bone.”

⚠️ Color is a clue, not a conclusion

  • Pale urine does not prove good hydration in a client on diuretics, with diabetes insipidus, or in renal failure — those kidneys cannot concentrate urine.
  • Phenazopyridine turns urine bright orange — harmless, and it stains clothing and contact lenses. Tell the client in advance.
  • Rifampin turns secretions red-orange; some laxatives turn urine pink.
  • Cola-colored urine after a crush injury, extreme exertion or a statin → suspect rhabdomyolysis, and check the creatinine.
🧠 Before you chart “concentrated urine, encourage fluids”, check the medication list.
FIGURE 4 · THE URINE DIPSTICK — every pad, and what a positive one meansTHE STRIP read TOP → BOTTOM · each pad is matched to its meaning on the rightphysical → chemicalthen the microscopeDIPSTICKpHnormal: 4.5 – 8.0ACID urine in a client with renal failure or infection; alkaline urine canmean a UTI with certain bacteriaSpecific gravitynormal: 1.005 – 1.030HIGH = concentrated = DEHYDRATED · LOW = dilute = over-hydrated, diureticsor diabetes insipidusProteinnormal: negativePOSITIVE = glomerular damage. Heavy protein loss = NEPHROTIC syndromeGlucosenormal: negativePOSITIVE = the blood glucose has passed the renal threshold — thinkdiabetes. Sugar in urine feeds bacteriaKetonesnormal: negativePOSITIVE = fat is being burned for fuel — DKA, starvation, verylow-carbohydrate dietsBloodnormal: negativePOSITIVE = hematuria — stones, infection, tumor, trauma, or after aTURP/biopsyLeukocyte esterasenormal: negativePOSITIVE = white cells in the urine = INFECTIONNitritesnormal: negativePOSITIVE = bacteria are converting nitrate to nitrite = a bacterial UTIBilirubin / urobilinogennormal: negative / smallPOSITIVE bilirubin points at the LIVER or biliary tract, not the kidney🚨 THE COMBINATION THAT MEANS UTI: leukocyte esterase POSITIVE + nitrites POSITIVE.Add cloudy, foul-smelling urine and it is a UTI until the culture says otherwise. A positive nitrite is quite specific for bacteria.Send the specimen to the lab within about an hour, or refrigerate it — urine left standing grows bacteria and stops being true.

Figure 4 — the dipstick pad by pad. The two that matter most sit next to each other: leukocyte esterase and nitrites.

🧪 The chemical part — reading the dipstick

PadNormalA positive means
pH4.5–8.0Acid urine in renal failure; alkaline urine with some UTI organisms
Specific gravity1.005–1.030High = dehydrated · low = dilute
ProteinnegativeGlomerular damage; heavy loss = nephrotic syndrome
GlucosenegativeBlood glucose past the renal threshold — and sugar in urine feeds bacteria
KetonesnegativeFat being burned — DKA, starvation, very low-carb diets
BloodnegativeHematuria — stones, infection, tumor, trauma, post-TURP
Leukocyte esterasenegativeWhite cells in the urine = infection
NitritesnegativeBacteria converting nitrate to nitrite
🧠 Leukocytes POSITIVE + nitrites POSITIVE = UTI until the culture says otherwise.
FIGURE 6 · UNDER THE MICROSCOPE — what the sediment showsFOUR FIELDS at ×400, read LEFT → RIGHT · this is the part of the urinalysis the dipstick cannot dothe dipstick screensthe microscope confirms1RBCs in urinenormal: 0–2 per hpfHEMATURIAstones · infection · tumortrauma · after TURP or biopsystrain the urine if stonesare suspected2WBCs in urinenormal: 0–4 per hpfPYURIA — INFECTIONUTI, or pyelonephritis ifthere is flank pain and feverexpect a culture & sensitivity3CASTSnormal: few or noneMolds of the tubules —they come from INSIDE thekidney, so they point at thekidney itself, not the bladder4BACTERIAnormal: noneWith WBCs and nitrites,this is a UTI.Alone it may be contamination —was it a clean-catch?🧠 HOW TO COLLECT A SPECIMEN THAT IS WORTH READING• Clean-catch midstream: clean front to back, start the stream, then catch the middle of it.• Sterile specimens come from the sampling PORT of a catheter after clamping — NEVER from the drainage bag; that urine is old, warm and not sterile.• 24-hour collection: DISCARD the first void and note the time, then keep every void including the one at the end. Keep it cold.

Figure 6 — the sediment. Casts are the finding that pins the problem to the kidney rather than the bladder.

🔬 The microscopic part — what the sediment tells you

  • RBCs (normal 0–2/hpf) — hematuria: stones, infection, tumor, trauma, after a TURP or biopsy.
  • WBCs (normal 0–4/hpf) — infection. Add flank pain and fever and think pyeloNephritis.
  • Casts — molds of the kidney tubules, so they come from inside the kidney. They point at the kidney, not the bladder.
  • Bacteria — with white cells and nitrites this is a UTI; alone it may just be a poorly collected specimen.
🧠 Casts are cast in the tubule. If you find them, the problem is upstream of the bladder.

✅ Collecting a specimen that is worth reading

  • Clean-catch midstream: clean front to back, start the stream, then catch the middle of it.
  • Never take a specimen from the urinary drainage bag — that urine is old, warm and not sterile. Use the sampling port after clamping, per policy.
  • Send within about an hour or refrigerate — urine standing at room temperature grows bacteria and the result stops being true.
  • 24-hour collection: discard the first void and write down the time, then keep every void including the one at the end. Keep it cold.
🧠 For a 24-hour collection: “throw away the first, keep the last.” The urine you discard was made before the clock started.
✅

PART 4 · READ IT TOGETHER

WHAT YOU DO

The values only matter when you put them beside the client and the chart.

FIGURE 8 · URINE OUTPUT — the bedside number that beats any labA CALIBRATED UROMETER drawn beside the thresholds · read the volume, then read the hour · this is the earliest sign of kidney distressunder 30 mL/hris a reportable finding0 mL100 mL200 mLfrom the catheterUROMETER · hourly volumethis hour’s urineover 30 mL/hrADEQUATEthe kidneys are being perfusedunder 30 mL/hrOLIGURIA — REPORT ITkidney distress · check for hypovolemia, hypotension, or anobstructionunder 100 mL/24 hrANURIAsevere injury or a complete obstructionno urine at allCHECK THE CATHETER FIRSTkinked, clamped, blocked or lying on it — before you assumerenal failure🧠 OUTPUT CHANGES BEFORE THE BLOODWORK DOESA falling hourly output is often the FIRST sign of an acute kidney injury — before the creatinine has had time to rise. Pair it with daily weights: 1 kg ≈ 1 L of fluid.And always check the catheter before you report anuria. A kinked tube has ended more shifts than renal failure has.

Figure 8 — the urometer. This number moves before the creatinine does, which makes it the earliest sign you have.

🚨 Urine output — the earliest sign of kidney distress

>30 mL/hrADEQUATE
The kidneys are being perfused.
<30 mL/hrOLIGURIA
Report it. Check for hypovolemia, hypotension, or an obstruction.
<100 mL/24hANURIA
Severe injury or a complete obstruction.

Never report anuria before you have checked the catheter — kinked, clamped, blocked, or the client lying on the tubing.

🧠 Output changes before the bloodwork does. Pair it with daily weights: 1 kg ≈ 1 L of fluid.

🧩 Reading four renal values together — a worked example

BUN 19 · glucose 155 · creatinine 1.9 · WBC 14,500

  • BUN 19 — still inside 10–20. Do not get baited by a number just because it sits near the edge.
  • Glucose 155 — high, and expected in a known diabetic.
  • Creatinine 1.9 — this is the one. Over 1.3 means a damaged kidney, and it is the value that changes the plan.
  • WBC 14,500 — infection.

The answer to “which value do you act on?” is the creatinine.

🧠 In a mixed panel, ask which value changes what happens next. That is almost always the intended answer.

🧪 The other renal blood findings worth knowing

  • Metabolic acidosis — from a falling GFR: pH under 7.35, low CO₂/bicarbonate.
  • Anemia — from reduced erythropoietin: low Hgb and Hct, normocytic.
  • Elevated renin — the kidney is driving the blood pressure up. “R for Renin, R for Retains fluid.”
  • Antibody / streptococcal titres — after a streptococcal infection, in post-streptococcal glomerulonephritis.
  • Albumin / protein in urine — glomerular damage; heavy loss = nephrotic syndrome.
🧠 R–R: Renin Retains. High renin means retained fluid and a rising blood pressure.

✅ What you actually do with renal labs on shift

1Check the hourly urine output and the daily weight before you read anything else.
2Compare creatinine with yesterday — a trend beats a snapshot.
3Review the drug list for nephrotoxins and for doses that need renal adjustment.
4Check the potassium — it is the value that kills first in renal failure.
5Strict intake and output, and report a falling output before it becomes anuria.
🧠 Output, trend, drugs, potassium. Four checks, every shift, on every renal client.

🎯 Cover & check — 8 rapid-fire questions

Q1. What does HUC stand for?
Show answerHydrogen ions, Urea and Creatinine — the three things the kidney filters out.
Q2. Creatinine 1.9. What does that tell you?
Show answerOver 1.3 = a damaged kidney. Check the trend, the urine output and the drug list.
Q3. BUN 48 with a creatinine of 1.0. Pre-renal, intra-renal or post-renal?
Show answerPre-renal — the ratio is well over 20:1 with a normal creatinine. The client is dry.
Q4. Urine output has been 22 mL/hr for three hours. What do you do?
Show answerCheck the catheter for kinks or blockage, assess volume status and blood pressure, then report it — under 30 mL/hr is kidney distress.
Q5. Specific gravity 1.032. What does that mean?
Show answerConcentrated urine — the client is dehydrated (or has SIADH or heart failure). Correlate with color, intake/output and weight.
Q6. The UA shows positive leukocyte esterase and positive nitrites. What is it?
Show answerA bacterial urinary tract infection until the culture says otherwise. Expect a culture and sensitivity and antibiotics.
Q7. A client at GFR 22 asks why they need surgery when they “feel fine”. What is being planned?
Show answerAn AV fistula for future hemodialysis. Stage G4 is when access is created, because a fistula takes months to mature.
Q8. Predict the electrolytes in established renal failure.
Show answerUP: potassium, phosphate, magnesium, BUN, creatinine. DOWN: calcium, hemoglobin and hematocrit, bicarbonate and pH.
🫘 HUCHydrogen · Urea · Creatinine. BUN 10–20 · creatinine 0.6–1.2. Over 1.3 = a bad kidney.
🧩 The ratioOver 20:1 = DRY (pre-renal). 10–15:1 with both up = the kidney is hurt. Then rule out an obstruction.
🚨 30 mL/hrLess than 30 mL in an hour = kidney distress = report it. Check the catheter first.
🔬 UASG 1.005–1.030 · protein = glomerulus · leukocytes + nitrites = UTI · casts = the problem is IN the kidney.