Case Summary: Judy, a 40-year-old woman with a past history of kidney infections, was seen by

her physician because she had been feeling lethargic for a few weeks. She also complained of
decreased frequency of urination and a bloated feeling. The physician noted periorbital swelling
and general edema, including a swollen abdomen.
Urinalysis
Macroscopic
Color
Appearance
Specific Gravity
pH
Protein
Glucose
Ketones
Bilirubin
Blood
Urobilinogen
Nitrite
Leukocyte Esterase
Microscopic
WBCs
RBCs
Epithelial Cells
Protein
Albumin
Casts
Cholesterol
BUN
Creatinine
Other

Yellow
Cloudy or frothy
1.022
7.0
3+ (500mg/dL) (SSA: 4+)
Neg
Neg
Neg
Neg
Normal
Neg
Neg

0-3/HPF
0-1/HPF
Reference Range
Rare squamous/HPF
g/dLtubular epithelial/HPF 6.0-8.4 g/dL
Rare5.0
renal
g/dL
3.5-5.0 g/dL
0-3 2.4
Hyaline/LPF
370
mg/dL
1.1Renal Tubular epithelial/HPF <200 mg/dL
33 mg/dL
7-24 mg/dL
1.1Granular/LPF
2.1
mg/dL
0.5-1.2 mg/dL
1.1Waxy/LPF
0-1 Fatty/LPF
Occasional oval fat bodies

Chemistry

Questions:

1. Circle
or highlight the abnormal value(s) or discrepant result(s) in the urinalysis.

The abnormal macroscopic urinalysis results are as follows:

Appearance: Cloudy/Hazy
Protein: 3+
The abnormal microscopic results are as follow.
Casts:
o 0-1 Renal Tubular epithelial/HPF
o 0-1 Granular/LPF
o 0-1 Waxy/LPF
o 0-1 Fatty/LPF
o Occasional oval fat bodies
Discrepant results: None
The abnormal chemistry results are decreased total protein and albumin, and increased
cholesterol, BUN, and creatinine.
2. What type of disease or condition would be characterized by the urinalysis and
chemistry results?
The urinalysis is consistent with nephrotic syndrome.

3. What urinalysis result(s) led to your probable diagnosis?

Marked proteinuria and lipiduria (oval fat bodies and fatty casts) are hallmarks of nephrotic
syndrome.
4. Are the abnormal chemistry tests consistent with the probable diagnosis? Why
or why not?
Nephrotic syndrome is characterized by hypoalbuminemia and hyperlipidemia (elevated
cholesterol). Hyperlipidemia is inversely proportional to the albumin concentration. The lower the
albumin levels fall, the higher the lipid values. Liver synthesis of all proteins increases to
compensate for the increased loss of protein in the urine, and large proteins ( 2 macroglobulin)
that are retained are increased in the blood. Hypoalbuminemia stimulates the liver to synthesize
LDLs and VLDLs. The minimally increased BUN and creatinine are indicative of slightly decreased
renal function.
5. Discuss the physiological cause of edema.
The edema is caused by hypoalbuminemia, which leads to reduced plasma osmotic pressure.
This reduced osmotic pressure allows fluids to leak from blood vessels to the intestinal spaces,
resulting in edema.
6. What is Judys albumin:globulin (A:G) ratio? Is it within the reference range? Is it
consistent with the probable diagnosis?
Judys A:G ratio is 0.92, which is below the reference range. Normal albumin levels are 60% of
the total protein. A low A:G ratio is consistent with a diagnosis of nephrotic syndrome.
7. Describe what you would expect to see in this patients protein electrophoresis.
The patients protein electrophoresis would be characterized by a marked increase in 2 and
globulins and a marked decrease in albumin and -globulins, especially IgG.
8. Which specific proteins would be decreased? Which specific proteins would be
increased?
In nephrotic syndrome, the smaller molecular weight proteins such as albumin and -globulins
will be decreased in the serum but increased in the urine. Larger proteins, including 2
macroglobulin, would be retained.

Source: Sunheimer (2010). Clinical Laboratory Chemistry (1 st edition). Pearson