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Denielle Genesis B. Camato
V. URINALYSIS ANALYSIS OF URINALYSIS AND BODY FLUIDS | REVIEWER
1
URINALYSIS
[ Probably the oldest clinical laboratory practice [ Usually involves gross observation and assessment of general appearance,
dipstick analysis, and microscopic assessment [ One of the most commonly performed laboratory test
URINE
[ pale yellow fluid produced by the kidneys, composed of dissolved wastes and excess water or chemical substances from the body
[ produced when blood is filtered through the kidneys
CHANGES IN URINE AT ROOM TEMPERATURE
r Bacteria multiply and may cause turbidity and a positive protein reaction
r Bacteria convert urea to ammonia, which increases pH. r Bacteria metabolize glucose. r RBCs lyse in dilute or alkaline urine. r Casts lyse in alkaline urine. r WBCs disintegrate. r Bilirubin/urobilinogen are lost through exposure to light and/or oxidation. r Ketones are lost through evaporation.
URINE VOLUME
Normal daily volume 1200-1500 mL
Normal day-night ratio 2:1 – 3:1 Diuresis Increased urine production Polyuria >2000 mL/day
r diabetes mellitus r diabetes insipidus
Oliguria <500 mL/day r dehydration r renal disease r obstruction of urinary
tract Anuria No urine production
URINE COLOR AND CLARITY
Urochrome Normal yellow color
Dilute urine Colorless Concentrated urine Dark yellow, amber Bilirubin Yellow-brown or olive green
Yellow foam on shaking Homogentistic acid Normal on voiding
Brown or black on standing Beginning at surface
Melanin Brown or black on standing Methemoglobin Brown or black due to oxidation of
hemoglobin in acid urine Myoglobin “Cola” on standing Blood/hemoglobin Pink or red when fresh
“Cola” or “Smoky” on standing Cloudy with RBCs Clear with hemoglobin
Porphyrin Port-wine Drugs, medications, food Green, blue, orange Pseudomonas infection Green, blue-green Urobilinogen Colorless when excreted
Oxidized to orange-brown urobilin Crystals, WBCs, RBCs, epithelial cells, bacteria
CHEMICAL URINALYSIS BY REAGENT STRIP
Denielle Genesis B. Camato
V. URINALYSIS ANALYSIS OF URINALYSIS AND BODY FLUIDS | REVIEWER
2
Test Substance(s) Detected Principle Sources of Error Comments Sulfosalicylic acid Protein Acid precipitation False-positive:
Radiographic dyes, tolbutamide, some antibiotics, turbid urine. False-negative: highly buffered alkaline urine
Detects all proteins, including Bence Jones proteins.
Clinitest Reducing substances Copper reduction False-positive: High levels of ascorbic acid. False-negative: Glycolysis, pass through. (Color goes through orange and returns to blue or blue-green. Repeat using two-drop method and two-drop color chart.)
Non-specific. Reacts with glucose, galactose, fructose, maltose, lactose. (Sucrose is not reducing sugar.) Test all infants to diagnose galactosemia. Not as sensitive for glucose as reagent strip. Self-heating method. Perform in rack to avoid burning.
Acetest Ketones Sodium nitroprusside reaction
False-negative: Improperly stored specimen
Most sensitive to acetoacetic acid
Ictotest Bilirubin Diazo reaction Drecreased: exposure to light, improperly stored specimen, high levels of ascorbic acid, nitrites. False-positive: Urine pigments.
More sensitive than reagent strip. Less affected by interfering substances
Watson-Shwartz Test Urobilinogen, porphobilinogen
Ehrlich’s aldehyde reaction
Decreased: exposure to light, more than 1 hour at room temperature. False-positive: Warm aldehyde reaction. (Urine should be at room temperature.)
Collect specimen from 2-4pm. Store in dark. Urobilinogen is soluble in chloroform and butanol. Porphobilinogen is not soluble in either.
Hoesch Test Porphobilinogen Ehrlich’s aldehyde reaction
Similar to Watson-Schwartz
Urobilinogen doesn’t react unless very high.
!
[ Sources of error may vary with brand of reagent strip. Refer to manufacturer’s package insert.
CONFIRMATORY/ SUPPLEMENT URINE CHEMISTRY TESTS
EFFECT OF HIGH LEVELS OF ASCORBIC ACID ON URINALYSIS TESTS
*May vary with brand of reagent strip. Refer to manufacturer’s package insert.
False-positive False-Negative or Decrease* Clinitest Glucose Blood Bilirubin Nitrite Leukocyte esterase !
Denielle Genesis B. Camato
V. URINALYSIS ANALYSIS OF URINALYSIS AND BODY FLUIDS | REVIEWER
3
TYPE DESCRIPTION SIGNIFANCE COMMENTS Hyaline Homogenous with
parallel sides and rounded ends
0-2/low power field (LPF) are normal. Increased with stress. Fever, trauma exercise, renal disease
Most common type. Least significant. Contain Tamm-Horsfall protein only. Maybe overlooked if light is too bright
Granular Same as Hyaline but contain granule
0-1/LPF is normal increased with stress, exercise Glomerulonephritis Pyelonephritis
May originate from disintegration of cellular casts.
RBC RBCs in cast matrix Yellowish to orange
color
Acute Glomerulonephritis Strenuous exercise
Pinpoints source of bleeding in kidney. Most fragile of casts. Often in fragments.
Blood Contain hemoglobin. Yellowish to orange
color
Same as RBC cast From disintegration of RBC casts
WBC Leukocytes incorporated into cast matrix.
Irregular in shape
Pyelonephritis Pinpoints kidney as the site of infection
Epithelial cell Renal tubular epithelial cells incorporated into cast matrix
Renal tubular damage Transitional and squamous epithelial cell cast do not exist These cells are found distal to renal tubules and collecting ducts where casts are formed.
Waxy Homogenous Opaque Notched edges Broken ends
Urinary stasis From degeneration of cellular and granular casts Unfavorable sign
Fatty Cast containing lipid droplets
Nephrotic syndrome Maltese crosses with polarized light. Stain with Sudan and oil red O
Broad Wide Maybe cellular, granular
or waxy
Advanced renal disease Formed in dilated distal tubules and collecting ducts. “Renal failure casts.”
!
STRUCTURE DESCRIPTION SIGNIFICANCE COMMENTS Bacteria Rods
Cocci Urinary tract infection or contaminant
Usually accompanied by WBCs when clinically significant,unless patient is neutropenic
Yeast 5-7um ovoid colorless smooth refractile May be budding
Usually due to vaginal or fecal contamination. May be due to kidney infection. May be seen in urine of diabetic patients.
Differentiate from RBCs by adding 2% acetic acid. RBCs are lysed Yeast are not. Presence of pseudohyphae indicates kidney function
Sperm 4-6um head with 40-60um tail
Usually not significant in an adult. Maybe a sign of sexual abuse in a child.
Trichomonas Resembles WBC Rapid Jerky Nondirectional motility
Contaminant from genital tract infection
Should not be reported unless motile
Mucus Transparent Long Thin Ribbon-like structure
with tapering ends
Large amount seen with chronic inflammation of urethra or bladder
Maybe mistaken for hyaline casts
!
Crystal Description Significance Comments Amorphous urates Irregular granules None From pink precipitate in
bottom of tube. May obscure significant sediment. Dissolved by warming to 60°C
Uric acid Very pleomorphic, Four-sided, six-sided, star-shaped, rosettes, spears, plates. Colorless, red brown, or yellow.
Usually normal Birefringent. Polarized light.
Calcium oxalate Octahedral (eight-sided) envelope form is most common. Also dumbbell and ovoid forms.
Normal Occasionally found in slightly urine. Monohydrate form maybe mistaken for RBCs. Most common constituent of renal calculi.
Leucine Yellow, oily-looking spheres with radial and concentric striations
Severe liver disease Often accompanied by leucine
Cystine Hexagonal (six-sided) Cystinuria Must be differentiated from uric acid. Does not polarize light.
Cholesterol Flate plate with notched out corner. “Star-step”
Nephrotic syndrome Birefringent
Bilirubin Yellowish-brown needles, plates and granules
Liver disease Reagent strip or Ictotest should be positive for bilirubin.
!
Crystal Description Significance Comments Amorphous phosphates Irregular granules None Form white precipitate in
bottom of tube. Dissolve with 2 acetic acid.
Triple phosphate “coffin-lid” crystal None Ammonium biurate Yellow-brown
“thorn apples” spheres
None Seen in old specimens
Calcium phosphate Needles Rosettes “pointing finger”
None Only needle form seen in alkaline urine
Calcium carbonate Colorless dumbbells None !
CELL DESCRIPTION ORIGIN CLINICAL SIGNIFANCE
COMMENTS
Squamous epithelial cell
40-50 um. Flat Prominent round nucleus
Lower urethra, Vagina
Usually none. Improperly collected clean-catch specimen
May form syncytia
Transitional epithelial cell
40-50 um. Spherical, pear shaped, or polyhedral. Round central nucleus.
Renal pelvis, ureters, bladder, upper urethra
Seldom significant May form syncytia
Renal tubular epithelial cell
Slightly larger than WBC. Round. Eccentric round nucleus
Renal tubules Same as renal tubular epithelial cells
Maltese crosses with polarized light.
White blood cell (WBC)
Usually polymorphonuclear. Approximately 12um. Granular appearance
Kidney, bladder, or urethra
Cystitis, pyelonephritis, tumors, renal calculi
0-5/high power field (HPF) are normal. Clumps of WBCs are associated with acute infection.
Glitter cell WBC Brownian movement of granules. Stain faintly or not at all.
Same as WBC Same as WBC Seen in hypotonic urine
Red blood cell (RBC) Biconcave disk, approximately 7um. Smooth. Non-nucleated.
Kidney, bladder, urethra
Infection, trauma, tumors, renal calculi. Dysmorphic RBCs indicate glomerular bleeding.
Crenated in hypertonic urine. Lyse in hypotonic urine and with 2% acetic acid.
!
CELLS IN THE URINE SEDIMENT
CRYSTAL FOUND IN ACID OR NEUTRAL URINE
CRYSTALS FOUND IN ALKALINE URINE
CASTS
MISCELLANEOUS URINE SEDIMENT
Denielle Genesis B. Camato
V. URINALYSIS ANALYSIS OF URINALYSIS AND BODY FLUIDS | REVIEWER
4
XXX PICTURES XXX
1. TRIPLE PHOSPHATE
2. CALCIUM OXALATE
3. CYSTINE
4. URIC ACID
5. LEUCINE
6. CALCIUM PHOSPHATE
7. AMMONIUM BIURATE
8. AMORPHOUS POSHPHATES
9. TYROSINE
10. CHOLESTEROL CRYSTAL
11. STAR-SHAPED URATE
12. FINE GRANULAR CAST
13. FATTY CAST
Denielle Genesis B. Camato
V. URINALYSIS ANALYSIS OF URINALYSIS AND BODY FLUIDS | REVIEWER
5
14. RBC CAST
15. WBC CAST
16. GRANULAR CAST
17. WAXY CAST
18. HYALINE CAST
19. BROAD CAST
20. BACTERIA
21. SQUAMOUS EPITHELIAL CELLS
22. COTTON FIBERS ‘
23. YEAST
24. SPERMATOZOA (2-HEADED)
25. SCHISTOSOMA HAEMATOBIUM
26. TRICHOMONAS VAGINALIS
27. RENAL TUBULAR CAST
28. OVAL FAT BODY