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Course: IDPT 5005Course: IDPT 5005School of Medicine, School of Medicine, UCDHSCUCDHSC
Francisco G. La Rosa, MDFrancisco G. La Rosa, MD
[email protected] Assistant Professor, Department of PathologyAssistant Professor, Department of Pathology
University of Colorado at Denver Health Science Center, Denver, University of Colorado at Denver Health Science Center, Denver, ColoradoColorado
UrinalysiUrinalysiss
Specimen Specimen CollectionCollection
– First morning voiding First morning voiding (most (most concentrated)concentrated)
– Record collection timeRecord collection time– Type of specimen (e.g. “clean Type of specimen (e.g. “clean
catch”) catch”) – Analyzed within 2 hours of collectionAnalyzed within 2 hours of collection– Free of debris or vaginal secretionsFree of debris or vaginal secretions
Clean CatchClean Catch
Specimen Specimen CollectionCollection
Supra-pubic Needle AspirationSupra-pubic Needle Aspiration
− Macroscopic ExaminationMacroscopic Examination− Chemical Analysis (Urine Chemical Analysis (Urine
Dipstick)Dipstick)− Microscopic ExaminationMicroscopic Examination− Culture Culture (not covered in this lecture)(not covered in this lecture)
− Cytological ExaminationCytological Examination
Types of AnalysisTypes of Analysis
Macroscopic Macroscopic ExaminationExaminationOdor:Odor:− Ammonia-like:Ammonia-like: (Urea-splitting bacteria)(Urea-splitting bacteria)− Foul, offensive:Foul, offensive: Old specimen, pus or Old specimen, pus or
inflammationinflammation− Sweet: Sweet: GlucoseGlucose− Fruity: Fruity: KetonesKetones− Maple syrup-like: Maple syrup-like: Maple Syrup Urine DiseaseMaple Syrup Urine DiseaseColor:Color:− Colorless Colorless Diluted urineDiluted urine− Deep YellowDeep Yellow Concentrated Urine, RiboflavinConcentrated Urine, Riboflavin− Yellow-GreenYellow-Green Bilirubin / BiliverdinBilirubin / Biliverdin− RedRed Blood / HemoglobinBlood / Hemoglobin− Brownish-redBrownish-red Acidified Blood (Actute GN)Acidified Blood (Actute GN)− Brownish-blackBrownish-black Homogentisic acid (Melanin)Homogentisic acid (Melanin)
Turbidity:Turbidity:− Typically cells or crystals.Typically cells or crystals.− Cellular elements and bacteria will clear by Cellular elements and bacteria will clear by
centrifugation.centrifugation.− Crystals dissolved by a variety of methods (acid or Crystals dissolved by a variety of methods (acid or
base).base).− Microscopic examination will determine which is Microscopic examination will determine which is
present.present.
Macroscopic Macroscopic ExaminationExamination
Chemical AnalysisChemical Analysis
Chemical AnalysisChemical AnalysisUrine Urine
DipstickDipstickGlucoseGlucose
BilirubinBilirubin
KetonesKetones
Specific GravitySpecific Gravity
BloodBlood
pHpH
ProteinProtein
UrobilinogenUrobilinogen
NitriteNitrite
Leukocyte EsteraseLeukocyte Esterase
NegativeNegativeNegativeNegative
Trace (100 mg/dL)Trace (100 mg/dL)Trace (100 mg/dL)Trace (100 mg/dL)
+ (250 mg/dL)+ (250 mg/dL)+ (250 mg/dL)+ (250 mg/dL)
++ (500 mg/dL)++ (500 mg/dL)++ (500 mg/dL)++ (500 mg/dL)
+++ (1000 mg/dL)+++ (1000 mg/dL)+++ (1000 mg/dL)+++ (1000 mg/dL)
++++ (2000+ mg/dL)++++ (2000+ mg/dL)++++ (2000+ mg/dL)++++ (2000+ mg/dL)
The Urine The Urine Dipstick:Dipstick: GlucosGlucos
ee
Glucose + 2 HGlucose + 2 H22OO + O+ O22 --->--->Gluconic Acid + 2 HGluconic Acid + 2 H22OO22
Glucose OxidaseGlucose Oxidase
3 H3 H22OO22 + KI + KI --->---> KIO KIO3 3 + 3 H+ 3 H22OO
Horseradish PeroxidaseHorseradish Peroxidase
Chemical PrincipleChemical Principle
Read at 30 secondsRead at 30 secondsRR: NegativeRR: Negative
SignificanceSignificance– Diabetes mellitus.Diabetes mellitus.– Renal glycosuria.Renal glycosuria.
LimitationsLimitations– Interference: reducing agents, ketones.Interference: reducing agents, ketones.– Only measures glucose and not other sugars.Only measures glucose and not other sugars.– Renal threshold must be passed in order for glucose to spill Renal threshold must be passed in order for glucose to spill
into the urine.into the urine.
Other TestsOther Tests– CuSOCuSO44 test for reducing sugars. test for reducing sugars.
Uses and Limitations of Urine Glucose Uses and Limitations of Urine Glucose DetectionDetection
SugarSugar DiseaseDisease(s)(s)
- Galactose- Galactose GalactosemiasGalactosemias- Fructose- Fructose Fructosuria, Fructose Intolerance, etc.Fructosuria, Fructose Intolerance, etc.- Lactose- Lactose Lactase DeficiencyLactase Deficiency- Pentoses- Pentoses Essential PentosuriaEssential Pentosuria- Maltose- Maltose Non-pathogenicNon-pathogenic
* NOT Sucrose because it is not a reducing sugar* NOT Sucrose because it is not a reducing sugar
Detection of Reducing Sugars* Detection of Reducing Sugars* by by CuSOCuSO44
++++
++
tracetrace
400400 600600 800800 10001000200200
Uri
naly
sis
Glu
cose R
esu
ltU
rin
aly
sis
Glu
cose R
esu
ltU
rin
aly
sis
Glu
cose R
esu
ltU
rin
aly
sis
Glu
cose R
esu
lt
Blood Glucose (mg/dL)Blood Glucose (mg/dL)Blood Glucose (mg/dL)Blood Glucose (mg/dL)
Urine versus Blood GlucoseUrine versus Blood Glucose
NegativeNegative
NegativeNegativeNegativeNegative
+ (weak)+ (weak)+ (weak)+ (weak)
++ (moderate)++ (moderate)++ (moderate)++ (moderate)
+++ (strong)+++ (strong)+++ (strong)+++ (strong)
The Urine The Urine Dipstick:Dipstick: BilirrubiBilirrubi
nn
Bilirubin + Diazo salt Bilirubin + Diazo salt --------->---------> Azobilirubin AzobilirubinAcidicAcidic
Chemical PrincipleChemical Principle
Read at 30 secondsRead at 30 secondsRR: NegativeRR: Negative
SignificanceSignificance- Increased direct bilirubin (correlates with urobilinogen and serum bilirubin)
LimitationsLimitations- Interference: prolonged exposure of sample to light- Only measures direct bilirubin--will not pick up indirect bilirubin
Other TestsOther Tests- Ictotest (more sensitive tablet version of same assay)- Serum test for total and direct bilirubin is more informative
Uses and Limitations of Urine Bilirrubin Uses and Limitations of Urine Bilirrubin DetectionDetection
NegativeNegativeNegativeNegative
Trace (5 mg/dL)Trace (5 mg/dL)Trace (5 mg/dL)Trace (5 mg/dL)
+ (15 mg/dL)+ (15 mg/dL)+ (15 mg/dL)+ (15 mg/dL)
++ (40 mg/dL)++ (40 mg/dL)++ (40 mg/dL)++ (40 mg/dL)
+++ (80 mg/dL)+++ (80 mg/dL)+++ (80 mg/dL)+++ (80 mg/dL)
++++ (160+ mg/dL)++++ (160+ mg/dL)++++ (160+ mg/dL)++++ (160+ mg/dL)
The Urine The Urine Dipstick:Dipstick: KetonesKetones
Acetoacetic Acid + NitroprussideAcetoacetic Acid + Nitroprusside------> ------> Colored ComplexColored Complex
Chemical PrincipleChemical Principle
Read at 40 secondsRead at 40 secondsRR: NegativeRR: Negative
SignificanceSignificance- Diabetic ketoacidosis- Diabetic ketoacidosis- Prolonged fasting- Prolonged fasting
LimitationsLimitations- Interference: expired reagents (degradation with exposure to - Interference: expired reagents (degradation with exposure to moisture in air)moisture in air)- Only measures acetoacetate not other ketone bodies (such as in - Only measures acetoacetate not other ketone bodies (such as in rebound ketosis).rebound ketosis).
Other TestsOther Tests- Ketostix (more sensitive tablet version of same assay)- Ketostix (more sensitive tablet version of same assay)- Serum glucose measurement to confirm DKA- Serum glucose measurement to confirm DKA
Uses and Limitations of Urine Ketone Uses and Limitations of Urine Ketone DetectionDetection
1.0001.0001.0001.000
1.0051.0051.0051.005
1.0101.0101.0101.010
1.0151.0151.0151.015
1.0201.0201.0201.020
1.0251.0251.0251.025
1.0301.0301.0301.030
XX++ + Polymethyl vinyl ether / maleic anhydride + Polymethyl vinyl ether / maleic anhydride---------------> --------------->
XX++-Polymethyl vinyl ether / maleic anhydride + H-Polymethyl vinyl ether / maleic anhydride + H++
HH++ interacts with a Bromthymol Blue indicator to interacts with a Bromthymol Blue indicator toform a colored complex.form a colored complex.
Chemical PrincipleChemical Principle
Read up to 2 minutesRead up to 2 minutesRR: 1.003-1.035RR: 1.003-1.035
The Urine The Urine Dipstick:Dipstick: Specific Specific
GravityGravity
SignificanceSignificance- Diabetes insipidus
LimitationsLimitations- Interference: alkaline urine
- Does not measure non-ionized solutes (e.g. glucose)
Other TestsOther Tests- Refractometry
- Hydrometer
- Osmolality measurement (typically used with water deprivation test)
Uses and Limitations of Urine Specific Uses and Limitations of Urine Specific GravityGravity
NegativeNegativeNegativeNegative
TraceTrace (non-hemolyzed) (non-hemolyzed)TraceTrace (non-hemolyzed) (non-hemolyzed)
ModerateModerate (non-hemolyzed) (non-hemolyzed)ModerateModerate (non-hemolyzed) (non-hemolyzed)
TraceTrace (hemolyzed) (hemolyzed)TraceTrace (hemolyzed) (hemolyzed)
+ (weak)+ (weak)+ (weak)+ (weak)
++ (moderate)++ (moderate)++ (moderate)++ (moderate)
+++ (strong)+++ (strong)+++ (strong)+++ (strong)
The Urine The Urine Dipstick:Dipstick: BloodBlood
Diisopropylbenzene dihydroperoxide +Diisopropylbenzene dihydroperoxide +Tetramethylbenzidine Tetramethylbenzidine
------------>------------> Colored Complex Colored ComplexHemeHeme
Chemical PrincipleChemical Principle
Lysing agent to lyse red blood cellsLysing agent to lyse red blood cells
Read at 60 secondsRead at 60 secondsRR: NegativeRR: Negative
Analytic Sensitivity: 10 RBCsAnalytic Sensitivity: 10 RBCs
SignificanceSignificance- Hematuria (nephritis, trauma, etc)- Hematuria (nephritis, trauma, etc)- Hemoglobinuria (hemolysis, etc)- Hemoglobinuria (hemolysis, etc)- Myoglobinuria (rhabdomyolysis, etc)- Myoglobinuria (rhabdomyolysis, etc)
LimitationsLimitations- Interference: reducing agents, microbial peroxidases- Interference: reducing agents, microbial peroxidases- Cannot distinguish between the above disease processes- Cannot distinguish between the above disease processes
Other TestsOther Tests- Urine microscopic examination- Urine microscopic examination- Urine cytology- Urine cytology
Uses and Limitations of Urine Blood Uses and Limitations of Urine Blood DetectionDetection
5.05.05.05.0
6.06.06.06.0
6.56.56.56.5
7.07.07.07.0
7.57.57.57.5
8.08.08.08.0
8.58.58.58.5
The Urine The Urine Dipstick:Dipstick: pHpH
HH++ interacts with: interacts with:Methyl Red (at high concentration; low pH) andMethyl Red (at high concentration; low pH) andBromthymol Blue (at low concentration; high Bromthymol Blue (at low concentration; high
pH), to form a colored complexespH), to form a colored complexes(dual indicator system)(dual indicator system)
Chemical PrincipleChemical Principle
Read up to 2 minutesRead up to 2 minutesR.R.: 4.5-8.0R.R.: 4.5-8.0
SignificanceSignificance- Acidic (less than 4.5): metabolic acidosis, high-protein diet- Acidic (less than 4.5): metabolic acidosis, high-protein diet
- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)
LimitationsLimitations- Interference: bacterial overgrowth (alkaline or acidic),- Interference: bacterial overgrowth (alkaline or acidic),
“ “run over effect” effect of protein pad on pH indicator padrun over effect” effect of protein pad on pH indicator pad
Other TestsOther Tests- Titrable acidity- Titrable acidity
- Blood gases to determine acid-base status- Blood gases to determine acid-base status
Uses and Limitations of Urine pH Uses and Limitations of Urine pH DetectionDetection
GlucoseGlucoseGlucoseGlucose
BilirubinBilirubinBilirubinBilirubin
KetonesKetonesKetonesKetones
Specific GravitySpecific GravitySpecific GravitySpecific Gravity
BloodBloodBloodBlood
pHpHpHpH
ProteinProteinProteinProtein
UrobilinogenUrobilinogenUrobilinogenUrobilinogen
NitriteNitriteNitriteNitrite
Leukocyte EsteraseLeukocyte EsteraseLeukocyte EsteraseLeukocyte Esterase
Buffers from the protein area of Buffers from the protein area of the strip (pH 3.0) spill over to the the strip (pH 3.0) spill over to the pH area of the strip and make the pH area of the strip and make the pH of the sample appear more pH of the sample appear more acidic than it really is.acidic than it really is.
Buffers from the protein area of Buffers from the protein area of the strip (pH 3.0) spill over to the the strip (pH 3.0) spill over to the pH area of the strip and make the pH area of the strip and make the pH of the sample appear more pH of the sample appear more acidic than it really is.acidic than it really is.
pH Run Over EffectpH Run Over Effect
NegativeNegativeNegativeNegative
TraceTraceTraceTrace
+ (30 mg/dL)+ (30 mg/dL)+ (30 mg/dL)+ (30 mg/dL)
++ (100 mg/dL)++ (100 mg/dL)++ (100 mg/dL)++ (100 mg/dL)
+++ (300 mg/dL)+++ (300 mg/dL)+++ (300 mg/dL)+++ (300 mg/dL)
++++ (2000 mg/dL)++++ (2000 mg/dL)++++ (2000 mg/dL)++++ (2000 mg/dL)
The Urine The Urine Dipstick:Dipstick: ProteinProtein
Chemical PrincipleChemical Principle
HHHH
HH
HH
HHHH
PrPrPrPr
PrPr
PrPr
PrPrPrPr
““Protein Error of Indicators Method”Protein Error of Indicators Method”
PrPr PrPr
PrPr
PrPrPrPr
PrPr
Tetrabromphenol BlueTetrabromphenol Blue(buffered to pH 3.0)(buffered to pH 3.0)
HH++
HH++
HH++HH++
HH++ HH++
Read at 60 secondsRead at 60 secondsRR: NegativeRR: Negative
FunctionalFunctional RenalRenal- Severe muscular exertion- Severe muscular exertion - Glomerulonephritis- Glomerulonephritis
- Pregnancy- Pregnancy - Nephrotic syndrome- Nephrotic syndrome
- Orthostatic proteinuria- Orthostatic proteinuria - Renal tumor or infection- Renal tumor or infection
Pre-RenalPre-Renal Post-RenalPost-Renal- Fever- Fever - Cystitis- Cystitis
- Renal hypoxia- Renal hypoxia - Urethritis or prostatitis- Urethritis or prostatitis
- Hypertension- Hypertension - Contamination with - Contamination with vaginal vaginal secretions secretions
Causes of Causes of ProteinuriaProteinuria
PrimaryPrimary- Lipoid nephrosis (severe)- Lipoid nephrosis (severe)
- Membranous glomerulonephritis- Membranous glomerulonephritis
- Membranoproliferative glomerulonephritis- Membranoproliferative glomerulonephritis
SecondarySecondary- Diabetes mellitus (Kimmelsteil-Wilson lesions)- Diabetes mellitus (Kimmelsteil-Wilson lesions)
- Systemic lupus erythematosus- Systemic lupus erythematosus
- Amyloidosis and other infiltrative diseases- Amyloidosis and other infiltrative diseases
- Renal vein thrombosis- Renal vein thrombosis
Nephrotic Syndrome (> 3.5 g/dL in Nephrotic Syndrome (> 3.5 g/dL in 24 h)24 h)
SignificanceSignificance- Proteinuria and the nephrotic syndrome.- Proteinuria and the nephrotic syndrome.
LimitationsLimitations- Interference: highly alkaline urine.- Interference: highly alkaline urine.- Much more sensitive to albumin than other proteins- Much more sensitive to albumin than other proteins
(e.g., immunoglobulin light chains).(e.g., immunoglobulin light chains).
Other TestsOther Tests- Sulfosalicylic acid (SSA) turbidity test.- Sulfosalicylic acid (SSA) turbidity test.- Urine protein electrophoresis (UPEP)- Urine protein electrophoresis (UPEP)- Bence Jones protein- Bence Jones protein
Uses and Limitations of Urine Protein Uses and Limitations of Urine Protein DetectionDetection
ProteinProtein % of Total% of Total Daily MaximumDaily Maximum
AlbuminAlbumin 40%40% 60 mg60 mg
Tamm-HorsfallTamm-Horsfall 40%40% 60 mg60 mg
ImmunoglobulinsImmunoglobulins 12%12% 24 mg24 mg
Secretory IgASecretory IgA 3%3% 6 mg6 mg
OtherOther 5%5% 10 mg10 mg
TOTALTOTAL 100%100% 150 mg150 mg
Proteins in “Normal” UrineProteins in “Normal” Urine
0.2 mg/dL0.2 mg/dL0.2 mg/dL0.2 mg/dL
1 mg/dL1 mg/dL1 mg/dL1 mg/dL
2 mg/dL2 mg/dL2 mg/dL2 mg/dL
4 mg/dL4 mg/dL4 mg/dL4 mg/dL
8 mg/dL8 mg/dL8 mg/dL8 mg/dL
The Urine The Urine Dipstick:Dipstick: UrobilinogenUrobilinogen
Urobilinogen + DiethylaminobenzaldehydeUrobilinogen + Diethylaminobenzaldehyde
------->-------> Colored Complex Colored Complex(Ehrlich’s Reagent)(Ehrlich’s Reagent)
Chemical PrincipleChemical Principle
Read at 60 secondsRead at 60 secondsRR: 0.02-1.0 mg/dLRR: 0.02-1.0 mg/dL
SignificanceSignificance- High: increased hepatic processing of bilirubin- High: increased hepatic processing of bilirubin- Low: bile obstruction- Low: bile obstruction
LimitationsLimitations- Interference: prolonged exposure of specimen to oxygen - Interference: prolonged exposure of specimen to oxygen (urobilinogen (urobilinogen --->---> urobilin) urobilin)- Cannot detect low levels of urobilinogen- Cannot detect low levels of urobilinogen
Other TestsOther Tests- Serum total and direct bilirubin- Serum total and direct bilirubin
Uses and Limitations of Urobilinogen Uses and Limitations of Urobilinogen DetectionDetection
NegativeNegativeNegativeNegative
PositivePositivePositivePositive
The Urine The Urine Dipstick:Dipstick: NitriteNitrite
Diazo compound + TetrahydrobenzoquinolinolDiazo compound + Tetrahydrobenzoquinolinol---------->----------> Colored Complex Colored Complex
Nitrite + p-arsenilic acid Nitrite + p-arsenilic acid ------->-------> Diazo compound Diazo compoundAcidicAcidic
Chemical PrincipleChemical Principle
Read at 60 secondsRead at 60 secondsRR: NegativeRR: Negative
SignificanceSignificance- Gram negative bacteriuria- Gram negative bacteriuria
LimitationsLimitations- Interference: bacterial overgrowth- Interference: bacterial overgrowth
- Only able to detect bacteria that reduce nitrate to nitrite- Only able to detect bacteria that reduce nitrate to nitrite
Other TestsOther Tests- Correlate with leukocyte esterase and- Correlate with leukocyte esterase and
- Urine microscopic examination (bacteria)- Urine microscopic examination (bacteria)
- Urine culture- Urine culture
Uses and Limitations of Nitrite DetectionUses and Limitations of Nitrite Detection
NegativeNegative
TraceTrace
+ (weak)+ (weak)
++ (moderate)++ (moderate)
+++ (strong)+++ (strong)
The Urine The Urine Dipstick:Dipstick: Leukocyte Leukocyte
EsteraseEsterase
Derivatized pyrrole amino acid ester
------------> 3-hydroxy-5-phenyl pyrroleEsterases
3-hydroxy-5-phenyl pyrrole + diazo salt-------------> Colored Complex
Read at 2 minutesRR: Negative
Analytic Sensitivity: 3-5 WBCs
Chemical Principle
SignificanceSignificance- Pyuria- Pyuria- Acute inflammation- Acute inflammation- Renal calculus- Renal calculus
LimitationsLimitations- Interference: oxidizing agents, menstrual contamination- Interference: oxidizing agents, menstrual contamination
Other TestsOther Tests- Urine microscopic examination (WBCs and bacteria)- Urine microscopic examination (WBCs and bacteria)- Urine culture- Urine culture
Uses and Limitations of Leukocyte Esterase Uses and Limitations of Leukocyte Esterase DetectionDetection
PreservationPreservation- Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp.- Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp.- Refrigeration for up to 48 hours (little loss of cells).- Refrigeration for up to 48 hours (little loss of cells).
Specimen concentrationSpecimen concentration- Ten to twenty-fold concentration by centrifugation.- Ten to twenty-fold concentration by centrifugation.
Types of microscopyTypes of microscopy- Phase contrast microscopy- Phase contrast microscopy- Polarized microscopy- Polarized microscopy- Bright field microscopy with special staining- Bright field microscopy with special staining (e.g., Sternheimer-Malbin stain)(e.g., Sternheimer-Malbin stain)
Microscopic Microscopic ExaminationExamination General AspectsGeneral Aspects
Microscopic Microscopic ExaminationExamination
Per High Power Field (HPF) (400x)Per High Power Field (HPF) (400x)– > 3 erythrocytes> 3 erythrocytes
– > 5 leukocytes> 5 leukocytes
– > 2 renal tubular cells> 2 renal tubular cells
– > 10 bacteria> 10 bacteria
Per Low Power Field (LPF) (200x)Per Low Power Field (LPF) (200x)– > 3 hyaline casts or > 1 granular cast> 3 hyaline casts or > 1 granular cast
– > 10 squamous cells (indicative of contaminated specimen)> 10 squamous cells (indicative of contaminated specimen)
– Any other cast (RBCs, WBCs)Any other cast (RBCs, WBCs)
Presence of:Presence of:– Fungal hyphae or yeast, parasite, viral inclusionsFungal hyphae or yeast, parasite, viral inclusions
– Pathological crystals (cystine, leucine, tyrosine)Pathological crystals (cystine, leucine, tyrosine)
– Large number of uric acid or calcium oxalate crystalsLarge number of uric acid or calcium oxalate crystals
Abnormal Abnormal FindingsFindings
ErythrocytesErythrocytes- “Dysmorphic” vs. “normal”- “Dysmorphic” vs. “normal” (> 10 per HPF)(> 10 per HPF)
LeukocytesLeukocytes- Neutrophils (glitter cells)- Neutrophils (glitter cells) More than 1 per 3 HPFMore than 1 per 3 HPF- Eosinophils- Eosinophils Hansel test (special stain)Hansel test (special stain)
Epithelial CellsEpithelial Cells- Squamous cells- Squamous cells Indicate level of contaminationIndicate level of contamination- Renal tubular epithelial cells- Renal tubular epithelial cells Few are normalFew are normal- Transitional epithelial cells- Transitional epithelial cells Few are normalFew are normal
- Oval fat bodies- Oval fat bodies Abnormal, indicate NephrosisAbnormal, indicate Nephrosis
Microscopic Microscopic ExaminationExamination CellsCells
Microscopic Microscopic ExaminationExamination RBCsRBCs
Microscopic Microscopic ExaminationExamination RBCsRBCs
Microscopic Microscopic ExaminationExamination WBCsWBCs
Microscopic Microscopic ExaminationExamination Squamous CellsSquamous Cells
Microscopic Microscopic ExaminationExamination Tubular Epithelial Tubular Epithelial
CellsCells
Microscopic Microscopic ExaminationExamination Transitional CellsTransitional Cells
Microscopic Microscopic ExaminationExamination Transitional CellsTransitional Cells
Microscopic Microscopic ExaminationExamination Oval Fat BodyOval Fat Body
Microscopic Microscopic ExaminationExamination LE CellLE Cell
BacteriaBacteria-- BacteriuriaBacteriuria More than 10 per HPFMore than 10 per HPF
YeastsYeasts- Candidiasis- Candidiasis Most likely a Most likely a contaminantcontaminantbut should correlate withbut should correlate withclinical picture.clinical picture.
VirusesViruses-- CMV inclusionsCMV inclusions Probable viral cystitis.Probable viral cystitis.
Microscopic Microscopic ExaminationExamination Bacteria & YeastsBacteria & Yeasts
Microscopic Microscopic ExaminationExamination BacteriaBacteria
Microscopic Microscopic ExaminationExamination YeastsYeasts
Microscopic Microscopic ExaminationExamination YeastsYeasts
Microscopic Microscopic ExaminationExamination CytomegalovirusCytomegalovirus
Erythrocyte Casts:Erythrocyte Casts: Glomerular diseasesGlomerular diseases
Leukocyte Casts:Leukocyte Casts: Pyuria, glomerular diseasePyuria, glomerular disease
Degenerating Casts:Degenerating Casts:- Granular casts- Granular casts Nonspecific (Tamm-Horsfall Nonspecific (Tamm-Horsfall protein)protein)- Hyaline casts- Hyaline casts Nonspecific (Tamm-Horsfall Nonspecific (Tamm-Horsfall protein)protein)- Waxy casts- Waxy casts NonspecificNonspecific- Fatty casts- Fatty casts Nephrotic syndromeNephrotic syndrome (oval fat body casts)(oval fat body casts)
Microscopic Microscopic ExaminationExamination CastsCasts
Microscopic Microscopic ExaminationExamination CastsCasts
Microscopic Microscopic ExaminationExamination RBCs Cast - RBCs Cast -
HistologyHistology
Microscopic Microscopic ExaminationExamination RBCs CastRBCs Cast
Microscopic Microscopic ExaminationExamination RBCs Cast - RBCs Cast -
HistologyHistology
Microscopic Microscopic ExaminationExamination WBCs CastWBCs Cast
Microscopic Microscopic ExaminationExamination Tubular Epith. CastTubular Epith. Cast
Microscopic Microscopic ExaminationExamination Tubular Epith. CastTubular Epith. Cast
Microscopic Microscopic ExaminationExamination Granular CastGranular Cast
Microscopic Microscopic ExaminationExamination Hyaline CastHyaline Cast
Microscopic Microscopic ExaminationExamination Waxy CastWaxy Cast
Microscopic Microscopic ExaminationExamination Fatty CastFatty Cast
Bacterial CastsBacterial CastsBacterial CastsBacterial Casts
Single LeukocytesSingle LeukocytesSingle LeukocytesSingle Leukocytes
Leukocyte CastsLeukocyte CastsLeukocyte CastsLeukocyte Casts
Verrier-Jones & Asscher, 1991.Verrier-Jones & Asscher, 1991.
Single ErythrocytesSingle ErythrocytesSingle ErythrocytesSingle Erythrocytes
Erythrocyte CastsErythrocyte CastsErythrocyte CastsErythrocyte Casts
Single BacteriaSingle BacteriaSingle BacteriaSingle Bacteria
Significance of Cellular Significance of Cellular CastsCasts
- Urate- UrateAmmonium biurateAmmonium biurateUric acidUric acid
- Triple Phosphate- Triple Phosphate- Calcium Oxalate- Calcium Oxalate- - Amino AcidsAmino Acids
CystineCystineLeucineLeucineTyrosineTyrosine
- Sulfonamide- Sulfonamide
Microscopic Microscopic ExaminationExamination CrystalsCrystals
Microscopic Microscopic ExaminationExaminationCalcium Oxalate CrystalsCalcium Oxalate Crystals
Microscopic Microscopic ExaminationExaminationCalcium Oxalate CrystalsCalcium Oxalate Crystals
Dumbbell Dumbbell Shape Shape
Microscopic Microscopic ExaminationExaminationTriple Phosphate CrystalsTriple Phosphate Crystals
Microscopic Microscopic ExaminationExamination Urate CrystalsUrate Crystals
Microscopic Microscopic ExaminationExamination Leucine CrystalsLeucine Crystals
Microscopic Microscopic ExaminationExamination Cystine CrystalsCystine Crystals
Microscopic Microscopic ExaminationExamination Ammonium Biurate Ammonium Biurate
CrystalsCrystals
Microscopic Microscopic ExaminationExamination Cholesterol CrystalsCholesterol Crystals
Cytological ExaminationCytological Examination
Staining:Staining:
– PapanicolauPapanicolau– Wright’sWright’s– ImmunoperoxidaseImmunoperoxidase– ImmunofluorescenceImmunofluorescence
Cytology: NormalCytology: Normal
Cytology: NormalCytology: Normal
Cytology: ReactiveCytology: Reactive
Cytology: ReactiveCytology: Reactive
Cytology: PolyomaCytology: Polyoma (Decoy (Decoy Cell)Cell)
Cytology: PolyomaCytology: Polyoma (Decoy (Decoy Cell)Cell)Immunoperoxidase to SV40 agImmunoperoxidase to SV40 ag
Cytology: TCC Low Cytology: TCC Low GradeGrade
Cytology: TCC Low Cytology: TCC Low GradeGrade
Cytology: TCC High Cytology: TCC High GradeGrade
Cytology: TCC High Cytology: TCC High GradeGrade
Cytology: Squamous Cell Cytology: Squamous Cell Ca.Ca.
Cytology: Renal Cell Ca.Cytology: Renal Cell Ca.
Cytology: Prostatic Cytology: Prostatic CarcinomaCarcinoma
Disease DiagnosisDisease Diagnosis
UrinalysiUrinalysiss
A 35-year old man undergoing routine pre A 35-year old man undergoing routine pre employment drug screening.employment drug screening.
Physical characteristics: Clear.Physical characteristics: Clear.Microscopic: Microscopic: Not performed.Not performed.Drugs Identified: Drugs Identified: None.None.
Questions:Questions:
- What is your differential diagnosis?- What is your differential diagnosis?- What would you do next to confirm your - What would you do next to confirm your suspicion?suspicion?- Would you order a microscopic analysis - Would you order a microscopic analysis on this sample?on this sample?
A 35-year old man undergoing routine pre A 35-year old man undergoing routine pre employment drug screening.employment drug screening.
Physical characteristics: Clear.Physical characteristics: Clear.Microscopic: Microscopic: Not performed.Not performed.Drugs Identified: Drugs Identified: None.None.
Questions:Questions:
- What is your differential diagnosis?- What is your differential diagnosis?- What would you do next to confirm your - What would you do next to confirm your suspicion?suspicion?- Would you order a microscopic analysis - Would you order a microscopic analysis on this sample?on this sample?
NegativeNegative
NegativeNegative
NegativeNegative
1.0011.001
NegativeNegative
5.55.5
NegativeNegative
0.2 mg/dL0.2 mg/dL
NegativeNegative
NegativeNegative
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
UrobilinogenUrobilinogen
NitriteNitrite
L.E.L.E.
Diluted urine, request a voided urine in the morningDiluted urine, request a voided urine in the morningIf persisting low SG, possible diabetes insipidaIf persisting low SG, possible diabetes insipida
A microscopic may give negative resultsA microscopic may give negative results
Case Case 11
A 42-year old woman presents with “dark urine”A 42-year old woman presents with “dark urine”
Physical characteristics: Red-brown.Physical characteristics: Red-brown.Microscopic: Not performed.Microscopic: Not performed.
Questions:Questions:
- What is your differential diagnosis?- What is your differential diagnosis?- Could this be a case of hemolytic anemia?- Could this be a case of hemolytic anemia?- How would you rule it out?- How would you rule it out?- What tests would you order next? Why?- What tests would you order next? Why?- Would you order a microscopic analysis?- Would you order a microscopic analysis?
A 42-year old woman presents with “dark urine”A 42-year old woman presents with “dark urine”
Physical characteristics: Red-brown.Physical characteristics: Red-brown.Microscopic: Not performed.Microscopic: Not performed.
Questions:Questions:
- What is your differential diagnosis?- What is your differential diagnosis?- Could this be a case of hemolytic anemia?- Could this be a case of hemolytic anemia?- How would you rule it out?- How would you rule it out?- What tests would you order next? Why?- What tests would you order next? Why?- Would you order a microscopic analysis?- Would you order a microscopic analysis?
NegativeNegative
++++++
NegativeNegative
1.0201.020
NegativeNegative
5.55.5
NegativeNegative
0.2 mg/dL0.2 mg/dL
NegativeNegative
NegativeNegative
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
UrobilinogenUrobilinogen
NitriteNitrite
L.E.L.E.
Possible gallbladder or hepatic disease.Possible gallbladder or hepatic disease.No hemolytic anemia. Perform bilirubins in serumNo hemolytic anemia. Perform bilirubins in serum
Microscopic unlikely to provide additional infoMicroscopic unlikely to provide additional info
Case Case 22
A 42-year old man presents painful urinationA 42-year old man presents painful urination
Physical characteristics: dark red, turbidPhysical characteristics: dark red, turbidMicroscopic: leukocytes = 30 per HPFMicroscopic: leukocytes = 30 per HPFRBCs = >100 per HPFRBCs = >100 per HPFBacteria = >100 per HPFBacteria = >100 per HPF
Questions:Questions:- What is your suspected diagnosis?- What is your suspected diagnosis?- What would you do next?- What would you do next?- What do you make of the nitrite test?- What do you make of the nitrite test?- How would the microscopic exam differ if - How would the microscopic exam differ if
the S.G. were 1.003?the S.G. were 1.003?- Is this a common diagnosis for this type of - Is this a common diagnosis for this type of
patient?patient?
A 42-year old man presents painful urinationA 42-year old man presents painful urination
Physical characteristics: dark red, turbidPhysical characteristics: dark red, turbidMicroscopic: leukocytes = 30 per HPFMicroscopic: leukocytes = 30 per HPFRBCs = >100 per HPFRBCs = >100 per HPFBacteria = >100 per HPFBacteria = >100 per HPF
Questions:Questions:- What is your suspected diagnosis?- What is your suspected diagnosis?- What would you do next?- What would you do next?- What do you make of the nitrite test?- What do you make of the nitrite test?- How would the microscopic exam differ if - How would the microscopic exam differ if
the S.G. were 1.003?the S.G. were 1.003?- Is this a common diagnosis for this type of - Is this a common diagnosis for this type of
patient?patient?
NegativeNegative
NegativeNegative
NegativeNegative
1.0301.030
++++++
6.56.5
TraceTrace
1.0 mg/dL1.0 mg/dL
NegativeNegative
++++++
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
UrobilinogenUrobilinogen
NitriteNitrite
L.E.L.E.
Possible UTI, request culture and antibiotic sensitivityPossible UTI, request culture and antibiotic sensitivityNegative Nitrite test: Gram positive bacteriaNegative Nitrite test: Gram positive bacteria
Lower SG may show less number of cells and bacteriaLower SG may show less number of cells and bacteriaUn-common diagnosis in this type of patientUn-common diagnosis in this type of patient
Case Case 33
A 27-year old woman presents with severe A 27-year old woman presents with severe abdominal pain.abdominal pain.
Physical characteristics: clear-yellow.Physical characteristics: clear-yellow.Microscopic: Not performed.Microscopic: Not performed.
Questions:Questions:- What is the most likely diagnosis?- What is the most likely diagnosis?- What do you make of the ketone result?- What do you make of the ketone result?- What do you expect to happen to the ketone - What do you expect to happen to the ketone
measurement when treatment begins?measurement when treatment begins?
A 27-year old woman presents with severe A 27-year old woman presents with severe abdominal pain.abdominal pain.
Physical characteristics: clear-yellow.Physical characteristics: clear-yellow.Microscopic: Not performed.Microscopic: Not performed.
Questions:Questions:- What is the most likely diagnosis?- What is the most likely diagnosis?- What do you make of the ketone result?- What do you make of the ketone result?- What do you expect to happen to the ketone - What do you expect to happen to the ketone
measurement when treatment begins?measurement when treatment begins?
++++++++
NegativeNegativeNegativeNegative
TraceTraceTraceTrace
1.0151.0151.0151.015
NegativeNegativeNegativeNegative
6.06.06.06.0
NegativeNegativeNegativeNegative
1.0 mg/dL1.0 mg/dL1.0 mg/dL1.0 mg/dL
NegativeNegativeNegativeNegative
NegativeNegativeNegativeNegative
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
DiabetesDiabetesMay be decompensated and with ketoacidosisMay be decompensated and with ketoacidosis
Ketones should become negative after treatmentKetones should become negative after treatment
Case Case 44
NegativeNegative
NegativeNegative
NegativeNegative
1.0151.015
++++++
6.56.5
++
1.0 mg/dL1.0 mg/dL
NegativeNegative
NegativeNegative
8-year old boy presents with discolored urine8-year old boy presents with discolored urine
Physical characteristics: Red, turbid.Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF Microscopic: erythrocytes = >100 per HPF
(almost all dysmorphic)(almost all dysmorphic)Red cell casts present.Red cell casts present.
Questions:Questions:- What is the most likely diagnosis in this - What is the most likely diagnosis in this
case?case?- Does the presence of red cell casts help you - Does the presence of red cell casts help you
in any way?in any way?- If the erythrocytes were not dysmorphic - If the erythrocytes were not dysmorphic
would that change your diagnosis?would that change your diagnosis?
8-year old boy presents with discolored urine8-year old boy presents with discolored urine
Physical characteristics: Red, turbid.Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF Microscopic: erythrocytes = >100 per HPF
(almost all dysmorphic)(almost all dysmorphic)Red cell casts present.Red cell casts present.
Questions:Questions:- What is the most likely diagnosis in this - What is the most likely diagnosis in this
case?case?- Does the presence of red cell casts help you - Does the presence of red cell casts help you
in any way?in any way?- If the erythrocytes were not dysmorphic - If the erythrocytes were not dysmorphic
would that change your diagnosis?would that change your diagnosis?
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Case Case 55
GlomerulonephritisGlomerulonephritisRBC casts reveals renal cortex involvementRBC casts reveals renal cortex involvement
RBC cast are not always present in GNRBC cast are not always present in GN
NegativeNegative
NegativeNegative
NegativeNegative
1.0101.010
NegativeNegative
5.05.0
++
0.2 mg/dL0.2 mg/dL
NegativeNegative
NegativeNegative
22-year old man presenting for a routine 22-year old man presenting for a routine physical required for admission to medical physical required for admission to medical schoolschool
Physical characteristics: YellowPhysical characteristics: YellowMicroscopic: Not performedMicroscopic: Not performed
Questions:Questions:- What is your differential diagnosis?- What is your differential diagnosis?- Would you order a microscopic analysis on - Would you order a microscopic analysis on this sample?this sample?
- What would you do next to confirm the - What would you do next to confirm the diagnosis?diagnosis?
22-year old man presenting for a routine 22-year old man presenting for a routine physical required for admission to medical physical required for admission to medical schoolschool
Physical characteristics: YellowPhysical characteristics: YellowMicroscopic: Not performedMicroscopic: Not performed
Questions:Questions:- What is your differential diagnosis?- What is your differential diagnosis?- Would you order a microscopic analysis on - Would you order a microscopic analysis on this sample?this sample?
- What would you do next to confirm the - What would you do next to confirm the diagnosis?diagnosis?
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Case Case 66
““Functional” proteinuria?Functional” proteinuria?Microscopic may reveal a few leukocytesMicroscopic may reveal a few leukocytes
Request protein concentration in 24 h urineRequest protein concentration in 24 h urine
Common Findings in:Common Findings in:Acute Tubular Acute Tubular NecrosisNecrosis
DecreasedDecreased
+ / -+ / -
+ / -+ / -
Microscopic:Microscopic:
• Renal tubular epithelial cellsRenal tubular epithelial cells• Pathological castsPathological casts
Microscopic:Microscopic:
• Renal tubular epithelial cellsRenal tubular epithelial cells• Pathological castsPathological casts
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
IncreasedIncreased
IncreasedIncreased
Microscopic:Microscopic:
• Erythrocytes (dysmorphic)Erythrocytes (dysmorphic)• Erythrocyte castsErythrocyte casts• Mixed cellular castsMixed cellular casts
Microscopic:Microscopic:
• Erythrocytes (dysmorphic)Erythrocytes (dysmorphic)• Erythrocyte castsErythrocyte casts• Mixed cellular castsMixed cellular casts
Common Findings in:Common Findings in:Acute Acute GlomerulonephritisGlomerulonephritis
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
DecreasedDecreased
IncreasedIncreased
IncreasedIncreased
Common Findings in:Common Findings in:Chronic Chronic GlomerulonephritisGlomerulonephritis
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Microscopic:Microscopic:
• Pathological castsPathological casts(broad waxy casts, RBCs)(broad waxy casts, RBCs)
Microscopic:Microscopic:
• Pathological castsPathological casts(broad waxy casts, RBCs)(broad waxy casts, RBCs)
TraceTrace
PositivePositive
PositivePositive
Microscopic:Microscopic:
• BacteriaBacteria• LeukocytesLeukocytes• Leukocyte, granular, andLeukocyte, granular, and
waxy castswaxy casts• Renal tubular epithelialRenal tubular epithelial
cell castscell casts
Microscopic:Microscopic:
• BacteriaBacteria• LeukocytesLeukocytes• Leukocyte, granular, andLeukocyte, granular, and
waxy castswaxy casts• Renal tubular epithelialRenal tubular epithelial
cell castscell casts
Common Findings in:Common Findings in:Acute PyelonephritisAcute Pyelonephritis
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
++++++++
Microscopic:Microscopic:
• Oval fat bodiesOval fat bodies• Fatty castsFatty casts• Waxy castsWaxy casts
Microscopic:Microscopic:
• Oval fat bodiesOval fat bodies• Fatty castsFatty casts• Waxy castsWaxy casts
Common Findings in:Common Findings in:Nephrotic SyndromeNephrotic Syndrome
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
++
Common Findings in:Common Findings in:Eosinophilic CystitisEosinophilic Cystitis
Microscopic:Microscopic:
• Numerous eosinophilsNumerous eosinophils(Hansel’s stain)(Hansel’s stain)
• NO significant casts.NO significant casts.
Microscopic:Microscopic:
• Numerous eosinophilsNumerous eosinophils(Hansel’s stain)(Hansel’s stain)
• NO significant casts.NO significant casts.
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Common Findings in:Common Findings in:Urothelial CarcinomaUrothelial Carcinoma
Microscopic:Microscopic:
• Malignant cells on Malignant cells on urine cytology urine cytology (urine (urine sample should be submitted sample should be submitted separately to cytology, void separately to cytology, void or 24 hrs.)or 24 hrs.)
Microscopic:Microscopic:
• Malignant cells on Malignant cells on urine cytology urine cytology (urine (urine sample should be submitted sample should be submitted separately to cytology, void separately to cytology, void or 24 hrs.)or 24 hrs.)
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
++
Acknowledgment:Acknowledgment:
Dr. Brad BrimhallDr. Brad Brimhall
Questions ?Questions ?