Basic examination of urine Formation Ultrafiltrate of blood Average daily output o 1200 to 1500 ml/day 600cc/day still considered

red normal o 170,000 filtered plasma/day o 18L glomerular filtrate reduced to 1-2L o 20 25 % of total blood volume Parts of nephron Glomerulus 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 urine Organic: Urea (50%), creatinine, uric acid Inorganic: Chloride, sodium, potassium o Traces: calcium, phosphate

Polyuria: increase in daily urine volume o 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 output o DM o More than 500cc at night

o o

Types of urine specimens Random: routine screening (most frequent) o ease of collection o anytime o prob: menstruation, hormonal evaluation First morning: o Ideal screening specimen o Concentrated specimen o 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

Water:99% Amino acids, peptides Formed elements:sediments o Cells: RBC, epithelial, WBC o Casts (UNIQUE TO URINE) o Crystals o Mucus, bacteria Mucus threads Yeast, sperm cell

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-prandial o Monitoring insulin therapy in DM o Or in conjunction with OGTT o 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) specimen o Accurate chemical quantitative tests For accurate renal function (not routinely done) o Discard 1st urine o Include last urine after a 24 hour period Detect creatinine Quantify creatinine, total protein, albumin For creatine clearance; protein content Catheterized specimen
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URINE VOLUME Normal: 600-2000 ml/day

Night: >400ml Factors that influence volume: o State of hydration o ADH secretion: caffeine: inhibit ADH o Excretion of dissolved solids Glucose, salts Anuria: complete cessation of urine flow o Decreased renal blood flow o Severe renal failure Oliguria: decreased normal daily urine output (< 30 ml/hr) o Vomiting, diarrhea, perspiration, severe burns, hydronephorsis o Refer o Renal: vascular d/o, AGN, ATN, CGN, CRF, glomerulus, tubules or both are affected
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Bacterial culture Renal functions For difficulty of voiding Sterile specimen and no contamination

o
Odor pH

Excretion proportional to metabolic rate Increased: feer, thyrotoxicosis, starvation Uroerythrin (red) Urobilin (orange-red)

Midstream clean catch: incorporated in a random and 1st morning urine o Bacterial culture o Safer, less traumatic method Suprapubic aspiration o Most sterile o Bacterial culture o Cytologic examination (ideal) o For tumors of UB: has a low yield specimen o Biopsy still superior Three-glass collection o Prostatic infection: evaluation for prostatitis Compare 1st and 3rd specimen (10x the amount of bacteria compared to 1st) 1st urine, midstream, massage prostate, remaining urine Interpretation

ABNORMAL URINE COLOR Dark orange: o Bilirubin, pyridium, nitrofurantoin Fat soluble: unconjugated Excreted: conjugated o Carrots, vitamin A

Yellow-green, yellow-brown o Biliverdin (from bilirubin oxidation) Not common Green, blue-green o Pseudomonas infection, amitriptyline Chek for fruity smell o Methocarbamol, Indican (a potassium salt), phenol Pink, Red o RBCs, Hgb, porphyrins o Beets (jams), menstrual, phenindione Brown, blacks o Methemglobin, homogentisic acid (alkaptonuria: inherited d/o of metabolism), melanin (melanoma) o Argyrols, methyl/levodopa, metronidazole

o
o

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 specimen o Pediatric Urine Collector (PUC): routine Has an adhesive attached to 1 end Px: ensure that fecal contamination is avoided: recheck o Sterile: catheter, suprapubic

Aspiration Note: Plastic cups are used: wide mouth disposable Bottle :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
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NORMAL CLARITY APPEARANCE Normal: clear Non-pathologic causes of turbid urine: o Squamous epithelial cells Vaginal contamination (common in women) o Mucus threads o Amorphous phosphates, carbonates o Sperms cells in females o Fecal contamination: esp in Peds o Radiographic contrast medium o Talcum, vaginal creams Pathologic causes of turbid urine: o Red blood cells: not from menstrual blood o White blood cells o Bacteria, yeast o Abnormal crystals: tyrosine and eosine? o Lymph fluid:Pyuria o Lipids: Lipiduria o 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
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Evaluation of renal concentrating ability Isosthenuria: 1.010 o Same with initial filtrate Hyposthenuric: < 1.010: DI, PN, GN o Pyelo and glomerulonephritis o Diluted urine Hypersthenuric: > 1.010: CHN, DHN o Concentrated urine Urinometer Refractometer

Acidic urine COPD DM Starvation Dehydration Bacteria (E. coli) High protein diet Cranberry juice medications

Alkaline urine Hyperventilation Vomiting Renal tubular acidosis Urease production bacteria (proteus) Vegetables, fruit diet Old specimen

NORMAL ODOR Normal: faint odor (volatile acids) Aromatic Odorless: severe kidney dysfunction ABNORMAL ODOR 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 +crystals o 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

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 Pregnancy o <0.5/DAY o Orthostatic proteinuria o Postural proteinuria when standing for several hours disappears upon lying down o Mild o Renal passive congestion o Renal progressive

Organic proteinuria:systemic disease or renal pathology

CHEMICAL SCREENING Urine pH: concentration of H+ions o Determine the acidity and alkalinity Chemical examination o Reagent strips o Manual (spectrophotometer) Colorimetric Enzymatic o Automated pH Normal: 4.5 8 Minor importance (nneeded only to correlate with other results) Measure of kidneys 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 UTI o 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)
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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 flow o Hypertension o Myxedema o Bence jones protein (MM and lymphomabut not pathogpneumonic) Renal proteinuria: primarily kidney disease o Glumerulonephritis o Nephrotic syndrome Edema Heavy proteinuria Hyperlipidemia hypoalbuminemia o Destructive parenchymal disease (tumor, infection, infarct)

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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 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)

Glucosuria with hyperglycemia o DM o Alimentary glucosuria (transient) secondary to dehydration o Increased ICP o Cushings syndrome, Pheochromocytoma Cortisol Cathecolamines Direct antagonist to insulin o Hyperthyroidism o After MI o Gestational DM

URINE KETONES Normal: none to minute Forms:

o o o

Beta-hydroxybutyric acid (78%) Acetoacetic acid (20%) Acetone (2%)

Detectable levels in urine: ketonuria o Dka (Diabetic coma if untreated) o insulin Clinical Significance: o DKA o Insulin dosage monitoring o Starvation, malabsorption o Pancreatic disorders o Strenuous exercise, vomiting o 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, PN o Trauma, tumors, toxic chemicals o Anticoagulants, strenuous exercise Hemoglobinuria (Intravascular hemolysis) o Transfusion reactions, hemolytic anemia o Severe burns, infections o Strenuous exercise Myoglobinuria o Muscle trauma, prolonged coma o Convulsions, muscle wasting disease o Drug Overdose, alcohol abuse, exertion Myoglobinuria Brown Urine: Cloudy Hemoglobinuria Reddish Clear

URINE GLCUOSE Normal: minute amounts o Almost all is reabsorbed in the PCT o Renal threshold: 180 mg/dL

Glucosuria without hyperglycemia o Glucosuria of pregnancy o Renal glucosuria o Fanconis syndrome o Nephrotoxic: Pb, CO, mercuric Cl
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Centrifuge: Pink Plasma: Clear

Red Red

BILIRUBIN Normal: B2 = < 0.5 mg/dL (0.02) Hepatic jaundice o Hepatitis o Cirrhosis Post-hepatic/ obstructive jaundice o Stones o Malignancy UROBILINOGEN Normal: < 1 mg/dL Significance: o Early detection of liver disease o Hepatitis, cirrhosis, malignancies o Hemolytic disorders Usually absent bilirubin

Damage to glomerular membrane Vascular injury within the GUT Stones, GN, tumor BPH, bladder/ urethral infections

Blood dyscrasias, renal infarct WBC 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 significant o polygonal with abundant cytoplasm and small nucleus o contaminaton of urine o F>M

Type of jaundice Urine bilirubin Urobilinogen

Transitional epithelial cells (Polarizing microscope) o Pelvis, bladder, upper urethra o Seldom pathologic Renal tubular cells: most significant o Tubular necrosis: cellular cast? o PN, GN, toxic reactions Oval fat bodies: signify nephritic syndrome o Cellular cast o With polarized: maltice cross Greenish: from collecting duct tubule/cell

Pre-hepatic (hemolytic disease) Hepatic + or (liver damage) Post hepatic (bile duct obstruction) Normal to decreased ++ CASTS _ +++

+++

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 therapy o Screening of patients at high risk for UTI o Screening of urine culture specimens

Only elements in sediment unique to the kidney Formed in DCT and collecting duct Tamm-horsfall protein o Secreted by tubular cells o Immunologic protection from infection o 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 RBC WBC Bacterial Epithelial cell Granular Waxy Broad casts Fatty

GN, PN, CHF, CRD GN, strenuous exercise PN, Acute interstitial nephritis Pyelonephritis (PN) Renal Tubular damage GN, PN, stress Urine flow stasis Extreme stasis of flow Nephritic syndrome

LEUKOCYTE ESTERASE Normal: 0 5 WBC/hpf Clinical significance o UTI (bacterial or non-bacterial) o Inflammation of the UT without bacteriuria o Screening of urine culture specimens MICROSCOPIC EXAMINATION URINARY SEDIMENT Cells: WBC, RBC, epithelial cells, bacteria, sperm cells Casts Crystals Others- mucus threads, fat cells, YEAST RBC: erythrocytes, biconcave discs, hypertonic, hypotonic
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*must be correlated with the other results CRYSTALS Seldom clinically significant
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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 pH Acid Acid Acid/neutral Alkaline/ neutral Alkaline/neutral Alkaline Alkaline Alkaline Abnormal crystals Crystal pH Acid Acid Acid/neutral Acid/neutral Acid Acid/neutral Acid Acid/neutral

crystal Uric acid Ammonium urates Calcium oxalates Ammonium phosphates Ca PO4 Triple PO4 NH4 biurate Ca CO3

Cystine cholesterol Leucine Tyrosine Bilirubin Sulfonamides Dye 9radio) Ampicillin

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Yeasts

Oval Fat bodies

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