Abnormal composition of urineAbnormal composition of urine

mirka.rovenska@lfmotol.cuni.czmirka.rovenska@lfmotol.cuni.cz

Urine examinationUrine examination

PhysicalPhysical – volume, density, colour, odour, turbidity – volume, density, colour, odour, turbidity

ChemicalChemical

Examination of Examination of urine sedimenturine sediment

Chemical examination of urineChemical examination of urine

Routine:Routine:

pHpH proteins proteins ketone bodies ketone bodies glucoseglucose blood in the urineblood in the urine nitritenitritess leukocytes leukocytes

TTargeted:argeted:

bilirubin, urobilinogenbilirubin, urobilinogen amino acidamino acid metabolites metabolites hormones (cortisol, sex hormones (cortisol, sex

hormones, somatotropin)hormones, somatotropin)

pH of urinepH of urine Usual range: Usual range: 5,5 – 7,0 5,5 – 7,0 (maximal range:(maximal range: 4,5 – 7,5 4,5 – 7,5))

Aciduria – Aciduria – pH pH < 5,4< 5,4 Cause: Cause:

diet high in meat products (sulphur and phosphorus are metabolized diet high in meat products (sulphur and phosphorus are metabolized to sulphates and phosphates)to sulphates and phosphates)

compensation of metabolic compensation of metabolic // respiratory acidosis respiratory acidosis alongalong with ketonuria can be predictive of starving/lack of saccha with ketonuria can be predictive of starving/lack of saccha--

rides; if glucosuria is also presentrides; if glucosuria is also present, the combination can indicate , the combination can indicate decompensated DMdecompensated DM

AlkaluriaAlkaluria (alkalinuria) (alkalinuria) – – pH > 6,5pH > 6,5 Cause:Cause:

lacto vegetarian dietlacto vegetarian diet urinary tract infection (bacterial urease)urinary tract infection (bacterial urease) compensation of respiratory compensation of respiratory // metabolic alkalosis at its onset metabolic alkalosis at its onset

Proteins in urineProteins in urine

ProteinuriaProteinuria = excessive excretion of proteins into the urine: = excessive excretion of proteins into the urine: >150 mg/d>150 mg/d Cause:Cause:

physiological: physical effortphysiological: physical effort pathological:pathological:

renal disease renal disease – according to the origin: – according to the origin: glomerular proteinuriaglomerular proteinuria tubular proteinuriatubular proteinuria glomerular and tubular proteinuriaglomerular and tubular proteinuria

post-renal proteinuriapost-renal proteinuria – – either bleeding into the urinary tract, or local either bleeding into the urinary tract, or local secretion of immunoglobulinsecretion of immunoglobulin

pre-renal proteinuriapre-renal proteinuria – due to an increased – due to an increased plasma concentration of plasma concentration of low-molecular proteins (low-molecular proteins ( increased excretion into the urine) increased excretion into the urine)

Ketone bodiesKetone bodies Acetone, acetoacetate, Acetone, acetoacetate, -hydroxybutyrate-hydroxybutyrate Synthesis: from Synthesis: from acetyl-CoAacetyl-CoA, produced by , produced by -oxidation of fatty acids-oxidation of fatty acids Starvation, physical effort, stress Starvation, physical effort, stress lipolysis and lipolysis and -oxidation of FA-oxidation of FA;;

acetyl-CoA is used preferentially for the synthesis of ketone bodies acetyl-CoA is used preferentially for the synthesis of ketone bodies

KetonuriaKetonuria

level of klevel of ketone bodies in the urineetone bodies in the urine (normally – very low) (normally – very low) Causes: Causes:

severe DMsevere DM long-term starvation, marked reduction of saccharides in long-term starvation, marked reduction of saccharides in dietdiet tenacious vomitingtenacious vomiting

Test strips: acetoacetate (not Test strips: acetoacetate (not -HB!) reacts with nitroprusside (in the -HB!) reacts with nitroprusside (in the presence of alkali), producing purple-coloured complexes (Legal presence of alkali), producing purple-coloured complexes (Legal reaction)reaction)

Glucose in urineGlucose in urine

Physiological range: Physiological range: 0,1 – 1,4 mmol/l0,1 – 1,4 mmol/l Test strips: glucose is oxidized by glucose oxidase; HTest strips: glucose is oxidized by glucose oxidase; H22OO22 is formed that is formed that

converts a colourless converts a colourless substratesubstrate to a coloured complex to a coloured complex

Glucosuria (glycosuria) Glucosuria (glycosuria) == increased amount of glucose in the urine; increased amount of glucose in the urine; causes: causes: hyperglycaemia hyperglycaemia > > 10 mmol/l10 mmol/l (DM, acute pancreatitis…) (DM, acute pancreatitis…) renal glycosuria (glucose is abnormally excreted by the kidney)renal glycosuria (glucose is abnormally excreted by the kidney) increased intestinal reabsorptionincreased intestinal reabsorption

Blood in urineBlood in urine

A) A) hematuriahematuria (erythrocyturia) – causes: (erythrocyturia) – causes: renal disease (glomerulonephritis, tumours)renal disease (glomerulonephritis, tumours) other diseases of the urinary tractother diseases of the urinary tract haemorrhagic diathesis (e.g. thrombocytopathy,haemophilia)haemorrhagic diathesis (e.g. thrombocytopathy,haemophilia)

B) B) hemoglobinuriahemoglobinuria – excessive intravascular haemolysis (haemolytic – excessive intravascular haemolysis (haemolytic anaemia, e.g. hereditary or after non-compatible transfusion)anaemia, e.g. hereditary or after non-compatible transfusion)

Test:Test: i)i) test strip detecting test strip detecting hemoglobinhemoglobin:: Hb Hb catalyzes oxidation of the substrate catalyzes oxidation of the substrate

withwith peroxide to a coloured product peroxide to a coloured product ((pseudoperoxidase activitypseudoperoxidase activity)) ii) erythrocytes in the urinary sedimentii) erythrocytes in the urinary sediment

Nitrites in urineNitrites in urine

Nitrates in the urine can by reduced by some pathogenic bacteria to Nitrates in the urine can by reduced by some pathogenic bacteria to nitrites that can thus serve as indicators of the infection nitrites that can thus serve as indicators of the infection inin the urinary the urinary tracttract

These bacterThese bacteriia include: a include: E. Coli, Klebsiella, Salmonella, Proteus, E. Coli, Klebsiella, Salmonella, Proteus, Aerobacter, CitrobacterAerobacter, Citrobacter, some strains of , some strains of Enterococcus, Staphylococcus, Enterococcus, Staphylococcus, PseudomonasPseudomonas

Leukocytes in urineLeukocytes in urine

Increased amount of leukocytes (Increased amount of leukocytes (>> 20/µl) – 20/µl) – pyuriapyuria – is a sign of – is a sign of inflammation in the urinary tractinflammation in the urinary tract

Test: granulocyte esterase activity Test: granulocyte esterase activity

Causes:Causes:

infection infection of the urinary tractof the urinary tract tumourstumours

Urobilinogen and bilirubin in urineUrobilinogen and bilirubin in urine

heme → biliverdin → bilirubin

transport to the liver (albumin)

conjugation with glucuronate bilirubin diglucuronide

secreted into the bile

bacteria in the small intestine release bilirubin from diglucuronide and convert it to colourless urobilinogens

a small fraction is excreted into the urine by the kidney

most of them are oxidi-zed to pigments and excreted in the faeces (urobilin, stercobilin)

a small fraction is reabsorbed and re-excreted through the liver into the bile

Causes of icterusCauses of icterus

Icterus (jaundice): bilirubin in the blood exceedsIcterus (jaundice): bilirubin in the blood exceeds 10 mg/l 10 mg/l (hyperbilirubi (hyperbilirubine-ne-mimiaa) ) bilirubin diffuses into tissues, which become yellow bilirubin diffuses into tissues, which become yellow

Pre-hepaticPre-hepatic: : haemolysis haemolysis overproduction of bilirubin that exceeds the overproduction of bilirubin that exceeds the liver's capacity for handling bilirubin (haemolytic anaemia, neonatal liver's capacity for handling bilirubin (haemolytic anaemia, neonatal jaundice) jaundice) unconjugated bilirubin in blood and urobilinogen in urine unconjugated bilirubin in blood and urobilinogen in urine

HepaticHepatic: liver damage (hepatitis, cirrhosis) : liver damage (hepatitis, cirrhosis) capacity for handling capacity for handling bilirubin (uptake, conjugation, excretion) bilirubin (uptake, conjugation, excretion) conj. as well as unconj. conj. as well as unconj. bilirubin in blood, urobilinogen in urine can bilirubin in blood, urobilinogen in urine can if microobstruction is if microobstruction is present, otherwise it rises present, otherwise it rises (impaired enterohepatic cycle)(impaired enterohepatic cycle)

Post-hepaticPost-hepatic – obstructive– obstructive: obstruction of the biliary tree (concre: obstruction of the biliary tree (concretionstions, , tumotumouurs) rs) conj. birubin regurgitates into the hepatic veins and conj. birubin regurgitates into the hepatic veins and lymphatics lymphatics conj. bilirubin in blood, no urobilinogen in urine conj. bilirubin in blood, no urobilinogen in urine

Urobilinogen in urineUrobilinogen in urine

Abnormal values: Abnormal values: ≥≥ 10 mg/l10 mg/l

Causes:Causes: increased degradation of hemoglobin (heavy bleeding, haemolytic increased degradation of hemoglobin (heavy bleeding, haemolytic

jaundice)jaundice) liver disease interfering with the enterohepatic urobilinogen cycleliver disease interfering with the enterohepatic urobilinogen cycle

(hepatitis, tumours)(hepatitis, tumours)

Causes of the absence of urobilinogen in the urine: Causes of the absence of urobilinogen in the urine: obstruction in the biliary treeobstruction in the biliary tree failure of bile production in the liverfailure of bile production in the liver absence of intestinal floraabsence of intestinal flora

Direct and indirect bilirubinDirect and indirect bilirubin

Conjugated bilirubin = Conjugated bilirubin = directdirect bilirubin x unconjugated = bilirubin x unconjugated = indirectindirect

Normally, Normally, only conjugated bilirubin can appear in the urineonly conjugated bilirubin can appear in the urine the level is the level is increased when increased when the plasma concentration of conjugated bilirubin risesthe plasma concentration of conjugated bilirubin rises

On the other hand,On the other hand, only unconjugated bilirubin can cross BBB only unconjugated bilirubin can cross BBB (neonatal (neonatal jaundice jaundice encephalopathy can occur encephalopathy can occur))

Bilirubin in blood and urineBilirubin in blood and urine

conj.conj. bilirubin in blood bilirubin in blood bilirubin bilirubin is in the urineis in the urine::

liver damageliver damage, microobstruction, microobstruction (hepatitis, cirrhosis) (hepatitis, cirrhosis)

Dubin-Johnson Syndrome: Dubin-Johnson Syndrome: defect in the hepatic secretion defect in the hepatic secretion of conjugated bilirubin into the of conjugated bilirubin into the bilebile

obstructive jaundiceobstructive jaundice

unconj.unconj. bilirubin in blood bilirubin in blood bilirubin is NOT in the urinebilirubin is NOT in the urine::

hemolytic hemolytic anaemiaanaemia

neonatal jaundice: accelerated neonatal jaundice: accelerated haemolysis and immature haemolysis and immature hepatic system for bilirubin hepatic system for bilirubin metabolism (low activity of metabolism (low activity of UDP-glucuronosyltransferase)UDP-glucuronosyltransferase)

Crigler-Najjar Syndrome: Crigler-Najjar Syndrome: decreased activity of bilirubin decreased activity of bilirubin UDP-glucuronosyltransferaseUDP-glucuronosyltransferase

Clinical parameters in 3 different causes Clinical parameters in 3 different causes of jaundiceof jaundice

conditioncondition serum bilirubinserum bilirubin urine urine urobilinogen urobilinogen

urine bilirubinurine bilirubin fecal fecal urobilinogenurobilinogen

normalnormal direct: 0,1-0,4 mg/dldirect: 0,1-0,4 mg/dl

indirect: 0,2-0,7 mg/dlindirect: 0,2-0,7 mg/dl

0-4 mg/24h0-4 mg/24h absentabsent 40-280 mg/24h40-280 mg/24h

haemolytic haemolytic anaemiaanaemia

indirectindirect absentabsent

hepatitishepatitis direct and indirectdirect and indirect if micro-if micro-obstruction is obstruction is presentpresent

present if mic-present if mic-ro-obstruction ro-obstruction occursoccurs

obstructive obstructive jaundicejaundice

directdirect absentabsent presentpresent trace to absenttrace to absent

PhenylketonuriaPhenylketonuria

Defect in phenylalanine hydroxylase Defect in phenylalanine hydroxylase Phe Phe cannot be converted to Tyrcannot be converted to Tyr, accumulates,, accumulates, and is metabolized to phenylacetate, and is metabolized to phenylacetate, phenyllactate, and phenylacetylglutamine. phenyllactate, and phenylacetylglutamine. Urinary level of Urinary level of phenylpyruvatephenylpyruvate is elevatedis elevated..

If If leftleft ununtreated, treated, it it leads to mental retardationleads to mental retardation

Prevention: low-Phe diet Prevention: low-Phe diet

Screening: plasma Phe Screening: plasma Phe → genetic test→ genetic test

UrolithiasisUrolithiasis

Urinary calculi (concreUrinary calculi (concretionstions) are formed in the urinary tract) are formed in the urinary tract 80-90% = renal concre80-90% = renal concretionstions made of made of calciumcalcium salts (oxalate, phosphate) salts (oxalate, phosphate)

Factors that predispose to calculi formation:Factors that predispose to calculi formation: highly concentrated urine (e.g. dehydration)highly concentrated urine (e.g. dehydration) increased urinary excretion of:increased urinary excretion of:

phosphates, calciumphosphates, calcium (e.g. increased breakdown of bones) (e.g. increased breakdown of bones) oxalatesoxalates uric aciduric acid (hyperuricosuria) (hyperuricosuria) cystinecystine (cystinuria – may (cystinuria – may be due to impaired resorption in the be due to impaired resorption in the

kidney)kidney) urine alkalization (in case of excretion of Caurine alkalization (in case of excretion of Ca2+2+, phosphates, oxalates), phosphates, oxalates) urine acidification (pHurine acidification (pH<5,5) in case of excretion of uric acid<5,5) in case of excretion of uric acid

HyperuricosuriaHyperuricosuria

Excretion of Excretion of >700-800 mg>700-800 mg of uric acid into the urine/24h; serum uric acid of uric acid into the urine/24h; serum uric acid rises, too (hyperuricemia)rises, too (hyperuricemia)

Causes:Causes:

goutgout

cancer, especially cancer, especially ifif treat treated withed with cytostatic drugs or radiation therapy cytostatic drugs or radiation therapy (increased cell death and thus also increased NA degradation)(increased cell death and thus also increased NA degradation)

renal diseaserenal disease

high intake of purines high intake of purines in the dietin the diet

dehydrationdehydration

Revision: purineRevision: purinecatabolismcatabolism

GoutGout Enzyme defect Enzyme defect inin PRPP-synthase or HGPRTase PRPP-synthase or HGPRTase overproduction of overproduction of

purinepuriness, and thereby also of uric acid , and thereby also of uric acid crystallization of urates in soft crystallization of urates in soft tissues and joints tissues and joints inflammation (arthritis). inflammation (arthritis).

Therapy: Therapy: allopurinolallopurinol – converted by xanthine oxidase to alloxanthine that – converted by xanthine oxidase to alloxanthine that inhibits the enzyme inhibits the enzyme synthesis of uric acid, more soluble xanthine and synthesis of uric acid, more soluble xanthine and hypoxanthine are excretedhypoxanthine are excreted

PRPPS and HGPRT in purine metabolismPRPPS and HGPRT in purine metabolism

(„salvage pathway“)

(first step)

Urine sedimentUrine sediment

Urine sediment: Urine sediment: substances discharged from organsubstances discharged from organss crystals (oxalates, urates, phosphates)crystals (oxalates, urates, phosphates)

Examination detects the presence of:Examination detects the presence of: bloodblood – erythrocyturia ( – erythrocyturia (>5 ery/µl); causes: impaired permeability of >5 ery/µl); causes: impaired permeability of

glomerular membrane, infection, urolithiasis…glomerular membrane, infection, urolithiasis… leukocytesleukocytes – pyuria (>10 leuko/µl); causes: infection of the urinary tract – pyuria (>10 leuko/µl); causes: infection of the urinary tract casts casts – formed in the kidney (the matrix is made of the protein produced – formed in the kidney (the matrix is made of the protein produced

by tubules, other components: plasma proteins, lipid droplets) by tubules, other components: plasma proteins, lipid droplets) casts casts can indicate a renal disease (different types of can indicate a renal disease (different types of castscasts indicate different indicate different types of damage)types of damage)

epithelial cellsepithelial cells microorganismsmicroorganisms

a…granulocyte; b…bacteria

hyalinecast

macrophage

erythrocytes

a…tubular epithelial cell (inside a cast)b…2 cells of a transitional epithelium

cuboidal epithelialcell

hyaline cast

granularcast

waxy cast (with the cells of tubularepithelium inside)

yeast

granulocyte

fatty cast

yeast