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Basic examination of urineFormation
Ultrafiltrate of blood Average daily output
o 1200 to 1500 ml/day 600cc/day still considered normal
o 170,000 filtered plasma/dayo 18L glomerular filtrate reduced to 1-2Lo 20 – 25 % of total blood volume
Parts of nephrono Glomeruluso Bowman's capsule
Cortical nephron and ? PCT and DCT located in the cortex Glomerulus: only type of capillary that can filter; 2 arterioles
(afferent and efferent)o Compared to normal capillary: 1 venule and 1
arteriole
Composition of urineOrganic:
Urea (50%), creatinine, uric acid
Inorganic: Chloride, sodium, potassium
o Traces: calcium, phosphate Water:99% Amino acids, peptides Formed elements:sediments
o Cells: RBC, epithelial, WBCo Casts (UNIQUE TO URINE)o Crystalso Mucus, bacteria
Mucus threads Yeast, sperm cell
URINE VOLUME Normal: 600-2000 ml/day Night: >400ml Factors that influence volume:
o State of hydrationo ADH secretion: caffeine: inhibit ADHo Excretion of dissolved solids
Glucose, salts Anuria: complete cessation of urine flow
o Decreased renal blood flowo Severe renal failure
Oliguria: decreased normal daily urine output (< 30 ml/hr)
o Vomiting, diarrhea, perspiration, severe burns, hydronephorsis
o Refero Renal: vascular d/o, AGN, ATN, CGN, CRF,
glomerulus, tubules or both are affected
Polyuria: increase in daily urine volumeo More than 2L in 24 hrs
o DM- excess glucose requires water for excretion,( osmolarity: excrete a lot of concentrated urine)
o Diabetes Insipidus-decrease in secretion of ADH, (diluted urine)
o caffeine, alcohol
Nocturia: increase in nocturnal urine outputo DMo More than 500cc at night
Types of urine specimens Random: routine screening (most frequent)
o ease of collectiono anytimeo prob: menstruation, hormonal evaluation
First morning:o Ideal screening specimeno Concentrated specimeno Pregnancy test- false negative results (random
urine is not concentrated)o Orthostatic proteinuria: happends when patient
stands at prolonged standing due to pressure on thee renal vein which increases the GFR
Upon waking up: collect 1st
Let patient walk: collect 2nd
Positive if first is negative and 2nd is positive
Fasting specimen (2nd morning)o Glucose monitoring (ideal specimen)
FOR INSULIN THERAPY for diabetics Why not first: will no tell the efficiency
of insulin therapy due to its high concentration
Because 2nd morning is more accurate
2 – hour post-prandialo Monitoring insulin therapy in DMo Or in conjunction with OGTTo To further correlate amount of glucose in
comparison to the 1st morning specimen
GTT specimens: corresponding blood samples (and urine)o Glucose and ketones
24-hour (timed) specimeno Accurate chemical quantitative tests
For accurate renal function (not routinely done)
o Discard 1st urineo Include last urine after a 24 hour period
Detect creatinine Quantify creatinine, total protein,
albumin For creatine clearance; protein content
Catheterized specimeno Bacterial cultureo Renal functions
For difficulty of voiding Sterile specimen and no contamination
Midstream clean catch: incorporated in a random and 1st morning urine
o Bacterial cultureo Safer, less traumatic method
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Suprapubic aspirationo Most sterileo Bacterial cultureo Cytologic examination (ideal)o For tumors of UB: has a low yield specimeno Biopsy still superior
Three-glass collectiono Prostatic infection: evaluation for prostatitis
Compare 1st and 3rd specimen (10x the amount of bacteria compared to 1st)
o 1st urine, midstream, massage prostate, remaining urine
o Interpretation 1st: if + for WBC 2nd: control 3rd: if + for bacteria = Prostatitis (negative
control and in either 1 & 3 (+) UTI?
IF all are positive: recollect thru 3 glass 4 glass also for prostatitis
Pediatric specimeno Pediatric Urine Collector (PUC): routine
Has an adhesive attached to 1 end Px: ensure that fecal contamination is
avoided: rechecko Sterile: catheter, suprapubic
AspirationNote:Plastic cups are used: wide mouth disposableBottle :contamination if not sterilized properly
Routine urinalysis
Physical examination clarity, color, specific gravity, odor
Chemical examination glucose, protein, pH, ketones, etc
Microscopic study cells, crystals, casts, microbes
Urine sediment examination urine test strips cover some of physical and chemical
parameters
PHYSICAL EXAMINATION Appearance Color
o Normal: straw to amber (pale yellow)o if dilute or concentrated (dark yellow)
Normal urine pigments:o Urochrome (yellow): major pigment
Excretion proportional to metabolic rate Increased: feer, thyrotoxicosis, starvation
o Uroerythrin (red)o Urobilin (orange-red)
Odor pH
ABNORMAL URINE COLOR Dark orange:
o Bilirubin, pyridium, nitrofurantoin Fat soluble: unconjugated Excreted: conjugated
o Carrots, vitamin A
Yellow-green, yellow-browno Biliverdin (from bilirubin oxidation)
Not common
Green, blue-greeno Pseudomonas infection, amitriptyline
Chek for fruity smello Methocarbamol, Indican (a potassium salt), phenol
Pink, Redo RBCs, Hgb, porphyrinso Beets (jams), menstrual, phenindione
Brown, blackso Methemglobin, homogentisic acid (alkaptonuria:
inherited d/o of metabolism), melanin (melanoma)o Argyrols, methyl/levodopa, metronidazole
NORMAL CLARITYAPPEARANCE Normal: clear Non-pathologic causes of turbid urine:
o Squamous epithelial cells Vaginal contamination (common in
women)o Mucus threadso Amorphous phosphates, carbonateso Sperms cells in femaleso Fecal contamination: esp in Pedso Radiographic contrast mediumo Talcum, vaginal creams
Pathologic causes of turbid urine:o Red blood cells: not from menstrual bloodo White blood cellso Bacteria, yeasto Abnormal crystals: tyrosine and eosine?o Lymph fluid:Pyuriao Lipids: Lipiduriao Malignant cells
SPECIFIC GRAVITY Normal: 1.015 to 1.035
o Urea, NaCl, Sulfate, Phosphate (major components of urine)
o Proportion of dissolved solid components to total of specimen
Evaluation of renal concentrating ability Isosthenuria: 1.010
o Same with initial filtrate Hyposthenuric: < 1.010: DI, PN, GN
o Pyelo and glomerulonephritiso Diluted urine
Hypersthenuric: > 1.010: CHN, DHNo Concentrated urine
Urinometer Refractometer
NORMAL ODOR Normal: faint odor (volatile acids) Aromatic Odorless: severe kidney dysfunction
ABNORMAL ODOR
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Foul, ammonia-like: UTI, old specimen (Standing) Fruity, sweet: DKA, starvation, vomiting
o Nilalangam! Maple syrup: Maple Syrup disease Mousy: Phenylketonuria (PKU) Rancid: Tyrosyluria
o +crystalso Sour smells? Panis?
Sweaty foot: Isovaleric acidemia Cabbage/hops: methionine malabsorption Rotting fish: Trimethylaminuria Bleach: Semen contamination Lack of odor: ATN
o Tubules for reabsorption: filtrate that passes thru the kidney is NOT ALTERED from glomerulus then outside
CHEMICAL SCREENING Urine pH: concentration of H+ions
o Determine the acidity and alkalinity Chemical examination
o Reagent stripso Manual (spectrophotometer)
Colorimetric Enzymatic
o AutomatedpH
Normal: 4.5 – 8 Minor importance (nneeded only to correlate with other
results) Measure of kidney’s ability to maintain normal H+ ion
concentration in plasma and in ECF Acid base disorders
o Primary respiratory and metabolic acidosis: acidic vv
Treatment of UTIo Organism thriving in acidic environment we can
make it alkaline Precipitation of crystals Calculi formation Defects in renal tubular secretion and reabsorption of acids
and bases Determination of unsatisfactory urine specimen (pH > 9.0)
Acidic urine Alkaline urine
COPD Hyperventilation
DM Vomiting
Starvation Renal tubular acidosis
Dehydration Urease production
bacteria (proteus)
Bacteria (E. coli) Vegetables, fruit diet
High protein diet Old specimen
Cranberry juice medications
URINE Proteins Normal: < 10 mg/dL or < 100 mg/24 hrs Mainly albumin Not always renal in origin Functional proteinuria Organic proteinuria: systemic disease or renal pathology Functional proteinuria
o Severe muscular exertion
o Pregnancyo <0.5/DAYo Orthostatic proteinuriao Postural proteinuria when standing for several
hours disappears upon lying downo Mildo Renal passive congestiono Renal progressive
Organic proteinuria:systemic disease or renal pathology Prerenal proteinuria: not due to primary renal disease
o Fever or toxic conditions MC cause of organic proteinuria (due to Acute Phase Reactants)
o Venous congestion: MC by CPC due to heart failure; by intraabdominal compression of the renal vein
o Renal hypoxia: severe DHN, shock, severe acidosis, severe anemia
Decreased renal blood flowo Hypertensiono Myxedemao Bence jones protein (MM and lymphoma- but
not pathogpneumonic)
Renal proteinuria: primarily kidney diseaseo Glumerulonephritiso Nephrotic syndrome
Edema Heavy proteinuria Hyperlipidemia hypoalbuminemia
o Destructive parenchymal disease (tumor, infection, infarct)
o Postrenal proteinuria: protein added to urine down the urinary tract from the parenchyma (beyond kidney)
Infection of the renal pelvis/ ureter Cystitis Urethritis, prostatitis Contamination with vaginal secretions
PROTEINURIA QUANTIFICATION Heavy proteinuria
o >4g/day
o Nephrotic syndrome
Minimal change disease
RPGN-Rapidly Progressing, CGN
o Malaria, malignant HPN, amyloidosis, neoplasia, renal transplant rejection, heavy metanls (Au,Hg) poisoning, toxemia of pregnancy
Moderate
o 1-4g
o Nehprosclerosis
o Muliple myeloma
o Calculi
Mild
o <1
o CPN
o Chronic interstitial nepgritis
o Nephrosclerosis
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o Poylcystic disease
o Medualay cysticdisease
o Glomerular or tubular and site of damage
QUALITATIVE CATEGORIES OF PROTEINURIA
Glomerular pattern
o Glomerular disease: loss of albumin (prealbumin, transferrin
Tubular pattern
o Loss of small maount of urinary protein
Overflow proteinuria
o Due to overflow of excess CHON in circulation
o HGb, myoglobin, IG loss into urine
Bence Jones protenuria
o MM, macroglobulinemia, lymphoma
o Tubular cells deteriorate due to high CHON reabsoprtion
Microalbuminuria
o Presnece of albumin in urine above N level but below detectable range
o 4-6 fold increase in microvascular mortality in DM (predictor)
URINE GLCUOSE Normal: minute amounts
o Almost all is reabsorbed in the PCTo Renal threshold: 180 mg/dL
Glucosuria without hyperglycemiao Glucosuria of pregnancyo Renal glucosuriao Fanconi’s syndromeo Nephrotoxic: Pb, CO, mercuric Cl
Glucosuria with hyperglycemiao DMo Alimentary glucosuria (transient) secondary to
dehydrationo Increased ICPo Cushing’s syndrome, Pheochromocytoma
Cortisol Cathecolamines Direct antagonist to insulin
o Hyperthyroidismo After MIo Gestational DM
URINE KETONES Normal: none to minute
Forms:o Beta-hydroxybutyric acid (78%)o Acetoacetic acid (20%)o Acetone (2%)
Detectable levels in urine: ketonuriao Dka (Diabetic coma if untreated)o insulin
Clinical Significance:
o DKAo Insulin dosage monitoringo Starvation, malabsorptiono Pancreatic disorderso Strenuous exercise, vomitingo Inborn errors of AA metabolism
BLOOD Normal: 0 – 5 /uL Forms: intact RBC (hematuria)- red turbid, hemoglobin (hemoglobinuria)- red clear Clinical significance: Hematuria
o Renal calculi, GN, PNo Trauma, tumors, toxic chemicalso Anticoagulants, strenuous exercise
Hemoglobinuria (Intravascular hemolysis)o Transfusion reactions, hemolytic anemiao Severe burns, infectionso Strenuous exercise
Myoglobinuriao Muscle trauma, prolonged comao Convulsions, muscle wasting diseaseo Drug Overdose, alcohol abuse, exertion
Myoglobinuria Hemoglobinuria
Brown Reddish
Urine: Cloudy Clear
Centrifuge: Pink Red
Plasma: Clear Red
BILIRUBIN Normal: B2 = < 0.5 mg/dL (0.02) Hepatic jaundice
o Hepatitiso Cirrhosis
Post-hepatic/ obstructive jaundiceo Stoneso Malignancy
UROBILINOGEN Normal: < 1 mg/dL Significance:
o Early detection of liver diseaseo Hepatitis, cirrhosis, malignancieso Hemolytic disorders
Usually absent bilirubin
Type of jaundice Urine bilirubin Urobilinogen
Pre-hepatic(hemolytic disease) _ +++
Hepatic + or - ++
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‘ (liver damage)
Post hepatic (bile duct obstruction) +++
Normal to decreased
NITRATE Normal: NO2 = < 0.05 mg/dL
o Colony forming units/CC < 100,000/mL Clinical significance
o UTI: cystitis, PN (high value)o Evaluation of antibiotic therapyo Screening of patients at high risk for UTIo Screening of urine culture specimens
LEUKOCYTE ESTERASE Normal: 0 – 5 WBC/hpf Clinical significance
o UTI (bacterial or non-bacterial)o Inflammation of the UT without bacteriuriao Screening of urine culture specimens
MICROSCOPIC EXAMINATION
URINARY SEDIMENT Cells: WBC, RBC, epithelial cells, bacteria, sperm cells Casts Crystals Others- mucus threads, fat cells, YEASTRBC: erythrocytes, biconcave discs, hypertonic, hypotonic Damage to glomerular membrane Vascular injury within the GUT Stones, GN, tumor BPH, bladder/ urethral infections Blood dyscrasias, renal infarctWBC Pyruria
o May be accompanied by bacteriuria Bacterial infections
o PN, prostatitis, cystitis, urethritis Non-bacterial
o GN, lupus, tumors, interstitial nephritis
EPITHELIAL CELLS Squamous cells: most common
o least significanto polygonal with abundant cytoplasm and small
nucleuso contaminaton of urineo F>M
Transitional epithelial cells (Polarizing microscope)o Pelvis, bladder, upper urethrao Seldom pathologic
Renal tubular cells: most significanto Tubular necrosis: cellular cast?o PN, GN, toxic reactions
Oval fat bodies: signify nephritic syndromeo Cellular casto With polarized: maltice cross
Greenish: from collecting duct tubule/cell
CASTS Only elements in sediment unique to the kidney Formed in DCT and collecting duct
Tamm-horsfall proteino Secreted by tubular cellso Immunologic protection from infectiono Gels best: urine flow stasis, Na and Ca
Make proteins aggregate and form a meshwork
It becomes the base of the cast
Type Significance
Hyaline GN, PN, CHF, CRD
RBC GN, strenuous exercise
WBC PN, Acute interstitial nephritis
Bacterial Pyelonephritis (PN)
Epithelial cell Renal Tubular damage
Granular GN, PN, stress
Waxy Urine flow stasis
Broad casts Extreme stasis of flow
Fatty Nephritic syndrome
*must be correlated with the other results
CRYSTALS Seldom clinically significant Formed by precipitation of urine salts
o Changes in pH, temperature, concentrations Either true crystals or amorphous material Important: Abnormal crystals
o Liver disease, Inborn Errors of Metabolism like in cysteinuria, renal damage due to crystallization of drug metabolites (like sulfa and ampicillin)
o They exhibit a unique appearance
Normal crystals
crystal pH
Uric acid Acid
Ammonium urates Acid
Calcium oxalates Acid/neutral
Ammonium phosphates Alkaline/ neutral
Ca PO4 Alkaline/neutral
Triple PO4 Alkaline
NH4 biurate Alkaline
Ca CO3 Alkaline
Abnormal crystals
Crystal pH
Cystine Acid
cholesterol Acid
Leucine Acid/neutral
Tyrosine Acid/neutral
Bilirubin Acid
Sulfonamides Acid/neutral
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Dye 9radio) Acid
Ampicillin Acid/neutral
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Yeasts
Oval Fat bodies
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