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Clinical Urinalysis and
Body Fluids Review, part 1
Austin Community CollegeMedical Laboratory TechnologyClinical II Spring 09
Body Fluids other than urine
What general purposes do the body fluids serve? Nutrition Waste removal Lubrication Cushioning / protection
Body Fluids Types
CSF Serous (transudate versus exudate)
Peritoneal Pleural Pericardial
Synovial Seminal Amniotic Sweat , gastric, feces, etc.
Body Fluids Testing
Gross and hematological Cell counts Differential
Chemistry TP Glucose Enzymes?
Amylase, Lipase and LDH Microbiology – cultures Serology? Cytology ?
Body Fluids
CSF Why evaluate?
Body Fluids
CSF Why evaluate?
Diagnose meningitis Evaluate for intracranial hemorrhage Diagnose malignancies, leukemia Investigate central nervous system disorders
Body Fluids
CSF What normal term(s) are used to describe
the color and clarity of CSF specimens? Identify terms used for ‘abnormal’ colors
and clarity. What is that ‘special’ color term unique to
CSF? How do you differentiate between traumatic
tap and cerebral hemorrhage?
Body Fluids
CSF Reference ranges / normal or expected
values
Body Fluids
What is the term used when there is increased numbers of cells in CSF?
Pleocytosis Can be prefixed as
Neutrophilic pleocytosis Lymphocytic pleocytosis, etc.
Body Fluids
Why evaluate serous and synovial? To determine the reason for increased
production
What’s the term that is used to indicate increased production of these fluids?
Body Fluids
What’s the term ?
Effusion – an increase in the serous fluid due to some disruption in production and/ re-absorption processes.
Seminal fluid
In what tissue are sperm produced?
Four reasons for analyzing seminal fluids
12
Seminal fluid
In what tissue is sperm produced? Spermatozoa - produced in the testes, mature in
the epididymis. Four reasons for analyzing seminal fluids
Infertility issues Post- vasectomy Forensic analysis Sperm donors
13
Body Fluids other than Urine
What are the collection requirements?
Normal appearance?
Expected lab values? Cell count Motility Morphology
14
Body Fluids other than Urine
What is the formula for calculating body fluid cells counted in a hemacytometer?
15
Body Fluids other than Urine
What is the basic formula?
What additional calculation is needed for sperm counts and why?
16
ave . # ce l ls counted x d ilution# squares counted x vo lume of each square
Body Fluids other than Urine
What additional calculation is needed and why? the standard calculation provides results as per
microliter (uL) And sperm normal value is per milliliter (mL) So you have to take the results and multiply X
1000.
17
Body Fluids other than Urine
What seminal fluid substances can be used for forensic and rape evaluations?
18
Body Fluids other than Urine
What seminal fluid substances can be used for forensic and rape evaluations? Acid phosphatase enzyme DNA UV light ABO /HLA
19
Body Fluids other than Urine
Amniotic Fluid Of what is it composed? What is the name of the collection
procedure? What purpose does it serve? Why is it sometimes analyzed?
Body Fluids other than Urine
Amniotic Fluid Indications for analysis
Chromosomal abnormalities, such as Down’s syndrome
Metabolic disorders, such as Tay Sachs Neural tube defects – such as spinal bifida or
an encephalic Determination of extent of HDN Others - gestational age, fetal maturity, etc.
Body Fluids other than Urine
Why do we sometimes analyze sweat? What is the name of that procedure? What are normal values?
Body Fluids other than Urine
Why do we analyze gastric fluids? How are the specimens collected? What lab procedures are performed?
Body Fluids other than Urine Indications for testing
Drug analysis Peptic ulcer evaluation
Specimen collection Nasal or oral intubation Fasting and avoid swallowing saliva
Laboratory procedures Gastric acidy (acid <7.0)
Peptic ulcers, diagnosis and treatment Zollinger-Ellison Syndrome – tumor of pancreas
causing gastric over-secretion Decreased gastric secretion Anacidity – inability to produce acid
Drug screening
Body Fluids other than Urine
Feces What is it and why do we care? What is the significance of different stool
colors?
Body Fluids other than Urine
What test is performed as a screen for colorectal cancer?
Body Fluids other than Urine
What patient preparation is needed for this test to be most useful?
Body Fluids other than Urine
What other tests are done on fecal samples?
Cells of the Body Fluids
What cells can be found in body fluids? Cells seen in the peripheral blood, but they
sure don’t look so good in the BFs.
Cells of the Body Fluids (other than
Urine) More often they look like these:
Lymphocytes and monocytes Cerebrospinal Fluid (CSF)
Cells of the Body Fluids (other than
Urine)
Lymphocytes and eosinophils – CSF Patient had shunt
Cells of the Body Fluids
Lymphocytes, macrophages and basophil
32
Cells of the Body
Other cells Ependymal cells - on left Mesothelial cells - on right
33
Cells of the Body Fluids Then there are the inclusions, and the ‘new’ names
Cells of the Body Fluids
And the ‘other’ cells, ‘unclassified’ – those referred to the cytologist / pathologist.
35
Cells of the Body Fluids
Intracellular inclusions: The yeast
36
Cells of the Body Fluids
The yeast - Cryptococcus in CSF
37
Cells of the Body Fluids
Bacteria
38
Cells of the Body Fluids
For synovial fluid Crystals
Calcium pyrophosphate Monosodium urate
39
Serous and Synovial Fluids
LE cells –
40
Clinical Urinalysis and
Body Fluids Review, part 2
Austin Community CollegeMedical Laboratory TechnologyClinical II Spring 09
Chemical Exam of Urine
Chemical Exam of Urine
Chemical Exam of Urine
Reagent strip manufactures Bayer Corporation- Diagnostics Division
(formerly Ames) produces Multistix
Boehringer-Mannheim Corporation which produces Chemstrip
Behring Diagnostics which produces Rapignost
Chemical Exam of Urine
Recall normal dipstick procedure
What are sources of error?
Chemical Exam of Urine
Sources of error (and preventions) Testing cold specimens
would result in a slowing down of reactions; test specimens when fresh or bring them to RT before testing
Inadequate mixing of specimen could result in false reduced or negative
reactions to blood and leukocyte tests mix specimens well before dipping
Over-dipping of reagent strip will result in leaching of reagents out of pads;
briefly, but completely dip the reagent strip into the urine
Chemical Exam of Urine
Inadequate blotting and Failure to keep strip horizontal will result in over-run or mixing of reagents
between the different reaction pads; blot excess urine off the strip and keep strip horizontal. If dipping from the tube, can run the side of the strip along the rim to remove excess urine.
Improper timing of tests over development of reagent pad colors leading to
falsely increased results; follow manufacturer’s recommendations
Chemical Exam of Urine
Inadequate light misinterpretation of results; use good lighting
Mis-using color chart misinterpretation of results; hold strip just
over color chart and match colors as close as possible, consider use of back-up tests, if needed, especially if urine’s color masks reaction colors.
Chemical Exam of Urine
Handling and Storage Keep strips in original container, stored at
RT Protect from moisture and volatile fumes Use before expiration date Do not touch reagent pad areas
Chemical Exam of Urine
Quality Control - use appropriate, commercially prepared positive and negative controls. Use commercially prepared pos and neg
controls, at least once per 24 hours, and anytime a new bottle is opened, or question of validity of results.
Readings should agree with published results ± one color block.
Urine Glucose Testing
Normal : no glucose detected Clinical significance of abnormal results
(Glucosuria) Sensitivity
Approximately 50-100 mg (compared to Clinitest’s 250) SO- Can have a positive dipstick but a neg Clinitest
Specificity - is specific for glucose only. not affected by other sugars or reducing
substances.
Urine Glucose Testing
Interfering substances
High specific gravity and high pH may depress color.
Ascorbic acid-false neg Bleach or peroxide may give false positive
Urine Bilirubin Testing
Normal : no bilirubin detected
Clinical significance of abnormal results (Bilirubinuria) Jaundice types
Urine Bilirubin Testing
Testing method Urine dipsticks for bilirubin – a diazo
reaction Impregnated with stabilized diazotized 2,4
dichloraniline Color goes from buff to brown also shades of
pink – violet
If urine is strongly colored, look for change in pad color after dipping.
Use Ictotest for backup.
Urine Bilirubin Testing
Interfering substances
Medication metabolites, pigments and indican may obscure readings
False negatives due to aged specimens, especially those exposed to light and oxidation.
Urine Ketone Testing
Ketone Bodies Origin - not normally present
Products of fat catabolism - breakdown of fat into CO2 and H2O
Urine Ketone Testing
Ketone Bodies What are the 3 ketone bodies?
What effect do they have on the body?
What is the testing methodology?
Urine Ketone Testing
Acetone 2%. -Acetone is volatile and excreted primarily through
the lungs
Diacetic Acid (Acetoacetic) the first formed, 20 % of the total the form detected by most ketone test procedures
Beta hydroxybutyric Acid majority formed, but not detected by routine tests. Only Hart’s test, an old ‘wet chemical’ test will detect
this one.
Urine Ketone Testing
Clinical effects Metabolic acidosis
Lowering of blood and urine pH Brain toxicity
Urine Ketone Testing
Testing Most use nitroprusside
Detects diacetic acid and a small amount of acetone, but does not detect β-hydroxybutyric acid.
Produces purple color. Can be used on urine or blood.
Urine Specific Gravity Testing
The specific gravity is a measure of the weight of urine compared to an equal amount of water. Water has an assigned value: 1.000
Specific gravity is related / proportional to urine osmolality; both are measures of concentration.
Urine Specific Gravity Testing
Specific gravity between 1.002 and 1.035 on a random sample is normal if kidney function is normal.
Urine Specific Gravity Testing
Dilute urine will have values less than 1.010. Fixed specific gravity = 1.010; isothenuria Diabetes insipidus End-stage renal disease
And concentrated urine will have values usually over 1.020. Usually due to dehydration and can be seen
in well population as well as sick.
Urine Specific Gravity Testing Increased urine specific gravity may be seen in:
Dehydration Diarrhea Excessive sweating Glucosuria Heart failure (related to decreased blood flow
to the kidneys) Renal arterial stenosis Syndrome of inappropriate antidiuretic
hormone secretion (SIADH) Vomiting Water restriction
Urine Specific Gravity Testing
Decreased urine specific gravity may indicate / be seen in: Excessive fluid intake Diabetes insipidus – central or
nephrogenic Renal failure (that is, loss of ability to
reabsorb water) Pyelonephritis
Urine Specific Gravity Testing
Specific gravity > 1.035 (refractometer) Could have very high glucose levels Could contain radiographic dye
Urine Specific Gravity Testing
Testing Polyelectrolytes , pH indicator (bromthymol
blue measures the pH change) and alkaline buffer
Urine Specific Gravity Testing
Interfering substances False elevation of results may be seen in
samples with increased protein concentration.
Some reports of reduced specific gravity results on alkaline specimens.
Lipids may also effect results
Urine Blood Testing
Normally not found in urine Hemoglobinuria – free hemoglobin in urine
Circulating free hemoglobin normally picked up by haptoglobin preventing loss in urine
When serum levels of hemoglobin > 100 mg/dL threshold is exceeded
Hematuria – RBCs in the urine Trauma / irritation of renal organs
Urine Blood Testing
Urine Blood Testing
Testing dipstick reaction
HGB H2O2peroxidase OxygenHGB H2O2peroxidase Oxygen
Oxygen + Gum guaiac, benzidine or orthotolidine green or blue
oxidation products
Urine Blood Testing
‘Blood’ test detects Free Hemoglobin RBCs – get lysed on the pad and their
hemoglobin reacts Myoglobin – muscle hemoglobin
Principle based on the peroxidase-like activity of the heme portion of the molecule
Urine Blood Testing
Sensitivity – can detect at levels of 5-10 cells/uL
Interfering substances Ascorbic acid Nitrates Oxidizing agents (ie bleach) Contaminate blood (menstrual)
Urine pH Testing
Normal: kidneys capable of 4.5 – 8.0 Factors effecting pH
Diet – general and specific foods Time of day Metabolic disorders Drugs / medications
Dipstick capable: 4.5 – 9.0
Urine pH Testing
Test method Dipstick indicators – methyl red and
bromthymol blue Range 4.5-9.0
Caution – other chemicals on dipstick can effect pH reading
Urine Protein Testing
Normally not found in measurable amounts on dipstick (<150 mg/dL /day) Permeability of glomerulus
Damage to glomerular capillaries Changes in glom blood flow
Albumin excretions may be increased temporarily due to exercise, UTI, and acute illness with fever.
Dipstick results of > 1+ (30mg/dL) would equal to approximately 500 mg/dL (clinical proteinuria)
Urine Protein Testing
Only albumin detectable by dipstick Sensitivity (approximately15-30 ml/dL)
Urine Protein Testing
New testing for microalbumin and creatinine Results:
Protein 20-200 mg/dL (30-300 mg/dL /24 hr) Creatinine 10-300 mg/dL
Albumin/Creatinine ratio Normally albumin in the urine is less than 30 mg/
gram creatinine
Urine Protein Testing
Principle - Protein error of indicators at fixed pH, certain indicators show one color in
the presence of protein and another in absence of protein - the “error” of the indicator.
Indicator – tetrabromphenol blue - can be hard to read at the trace end
Citrate Buffer – maintains pH 3 -quite acid
Urine Protein Testing
Sources of error Sensitive only to albumin Urine with strong / unusual color makes
reading difficult Highly alkaline or buffered urine will
neutralize acid buffer and lead to increased erroneous results.
Urine container contamination would interfere
Urine Protein Testing
Urine back up test 3% sulfosalicylic acid
Added to the supernatant to detect any kind of protein. Urine will turn cloudy if protein is present.
Urine Urobilinogen Testing
Normally found in small amounts, especially in early afternoon
Increased amounts may indicate liver disease or be seen as result of hemolytic disorders
Decreased amounts: If intestinal bacteria destroyed Liver doesn’t conjugate bilirubin Biliary obstruction – failure of bilirubin to
reach small intestine
Urine Urobilinogen Testing
Test principle based on Ehrilich’s reaction
Para-dimethylaminobenzaldehyde = Ehrlich's reagent.
Must protect specimen from light and test immediately
Urine Nitrate Testing Nitrate
Detects presence of certain types of bacteria screening for presence of UTI. Certain species of bacteria convert nitrate
(normal constituent of urine) to nitrite Escherichia - most common cause of UTI Klebsiella Proteus Pseudomonas Enterobacter Citrobacter
Urine Nitrate Testing
Aromatic amine in reagent strip reacts with nitrite; producing a diazonium salt
The diazonium salt reacts with sulfanilic acid and acetic acid to produce a pink azo dye
Urine Nitrate Testing
Limitations reported as positive or negative Not all UTI causing bacteria convert nitrate to
nitrite Haemophilus Staphylococcus Streptococcus
Urine Nitrate Testing
Fresh first morning specimen is preferred - besides being the most concentrated specimen, the urine has been in the bladder longer, allowing bacteria time and opportunity to convert the nitrates to nitrites.
Urine Leukocyte Testing
Leukocyte esterase testing is another test used as a means of screening for urinary tract infection.
Does not measure concentration of leukocytes
Will detect presence of lysed leukocytes as well as intact WBCs
Urine Leukocyte Testing
test principle: Leukocyte esterase, an enzyme present in
granulocytes, hydrolyzes indoxylcarbonic acid esterase to produce indoxyl, which reacts with a diazonium salt to create a purple color usually in 2 min.
Urine Leukocyte Testing
Reaction interference False positives - oxidizing detergents False negatives - greatly increased glucose,
protein, or specific gravity- increased sp gr could cause WBC to crenate preventing their releasing their esterase, So it is possible for the dipstick to be negative when there are WBCs present.
Microscopic Sediment
A number of slides with microscopic elements
RBC, WBC, yeast
Microscopic Sediment – Epithelial Cells Squamous epithelial cells (stained with
Sternheimer-Malbin)
Microscopic Sediment – Epithelial Cells
Transitional epithelial cells Spherical, polyhedral and caudate are terms
describing shapes. All have distinct centrally located nuclei. Sometimes called bladder cells, may be more often
found in elderly. Can be found as fragments or as reactive.
Microscopic Sediment – Epithelial Cells RTEs; 250x magnification Also WBC and RBCs
Microscopic Sediment – Casts
Microscopic Sediment – Casts
RBC cast
Microscopic Sediment
A number of slides with microscopic elements CRYSTALS, Uric acid
Microscopic Sediment – Crystals
Calcium oxalate – envelope; may be dumbbell shaped. Usually appear as a square with a retractile cross
Microscopic Sediment
A number of slides with microscopic elements Alkaline
Microscopic Sediment
A number of slides with microscopic elements
The rarely ever seen, abnormal crystals Cystine Tyrosine Leucine Bilirubin (occasionally seen in premies) Cholesterol
Microscopic Sediment A number of slides with microscopic
elements Mucous threads Bacteria, yeast, Trichomonas sperm Lots of artifacts
Microscopic
What are oval fat bodies?
How can you (quickly, cheaply) provide tentative proof they contain fat?
Microscopic Sediment – Miscellaneous
Oval Fat Bodies This frame shows an oval fat body ("B") next to several
transitional epithelial cells ("A"). Note the drops of lipids that appear to be contained within the cell.” – U of IA