Urine Screening for

Metabolic Disorders
Ang. Avena. Blas. Tagarao.
3FMT

Metabolic
Substances in the
Urine
Overflow Type
-

disruption of normal metabolic pathway

increase in plasma concentrations from the

non-metabolized substances.
Renal Type

- abnormal accumulations of substances that

are caused by malfunctions in the mechanism
of tubular reabsorption

Amino Acid Disorders

Phenylalanine-Tryptophan Disorders
Branched Chain Amino Acid Disorders
Cysteine and Homocysteine Disorders
Porphyrin Disorders
Mucopolysaccharide Disorders
Purine Disorders
Carbohydrate Disorders

Phenylalanine-Tryptophan
Disorders

Phenylketonuria
Tyroslyuria
Melanuria
Alkaptonuria

Phenylketonuria (PKU)
Inherited autosomal recessive trait
absence of activity of the enzyme phenylalanine hydroxylase
(PAH)
catalyzes the conversion of phenylalanine to tyrosine
Catabolites: phenylpyruvic acid, phenyllactic acid, phenylacetic
acid, phenylacetylglutamine
Types:
Mild PKU (600-1200 mol/L)
Non-PKU mild hyperphenylalaninenemia (180-600 mol/L; no
phenylketones)

 Can cause:
Mental retardations
Convulsions
Behavior problems
Skin rash
Musty body odor

Urine: Musty Odor

Test: Ferric Chloride Tube Test
Procedure: 5 drops 10% FeCl3 + 1mL urine
sample
FeCl3 reacts w/ phenylpyruvic acid = Permanent
blue-green color.

Tyrosyluria
accumulation of excess tyrosine in the plasma
(tyrosinemia)
either inherited or metabolic defect
Urine: excess tyrosine or , phydroxyphenylpyruvic acid and p-hydroxy
phenyllatic acid.

 Three types of Tyrosinemia:

1) Type I low levels of the enzyme
fumarylacetoacetate hydrolase, the last of
five enzymes needed to break down tyrosine
2) Type II a deficiency of the enzyme tyrosine
aminotransferase, the first in a series of five
enzymes that converts tyrosine to smaller
molecules
3) Type III deficiency of the enzyme 4hydroxyphenylpyruvate dioxygenase,
ncluded in the five enzymes needed to break
down tyrosine

 Test: Nitroso-Napthol Test

Procudure:
1mL of 2.63N nitric acid + 1 drop of 21.5%
sodium nitrite + 0.1mL 1-nitroso-2-napthol + 5
drops of urine
Mix and wait for 5 minutes
Result: Orange-red color which indicates
tyrosine metabolites

Melanuria
Darkening of the urine = increase of melanin in
the body
Melanin - is the pigment responsible for the dark
color of hair, skin and eyes.
Serious finding: if urinary melanin is elevated indicates proliferation of the normal melaninproducing cells (melanocytes)
Urine: Dark urine
5,6-dihydoxyindole - a colorless precursor of
melanin
secreted by Malignant melanoma oxidizes to
melanogen melanin

Alkaptonuria
Inborn metabolic disease transmitted as an autosomal
recessive gene
HDG gene - the lack of the enzyme homogentisate
oxidase (needed in the metabolism of tyrosine and
phenylalanine)
Test: Homogentisic Acid Test
Procedure:
0.5 mL of urine + 4 mL of 3% silver nitrite and mix
Result: Black color after 24 hours
Other tests
Ferric Chloride Test: transient deep blue color
Clinitest: Yellow precipitate

Branched Chain Amino

Acid Disorders

Maple Syrup Urine Disorders

Organic Acidemia
Indicanuria
5-Hydoxyindolacetic Acid

Maple Syrup Urine

Disorders (MSUD)
rare autosomal recessive genetic inherited
disorder
absence or reduced activity of the enzyme
branched-chain--ketoacid decarboxylase
blocking the normal metabolism of the three
essential branched-chain amino acids leucine,
isoleucine and valine.

 1:150,000 births
Urine: Maple syrup or burnt sugar odor

Test: 2,4-Dinitrophenylhydrazine (DNPH) Test

Procedure
10 drops of 0,2% 2,4-DNPH + 2N HCL +1 mL
urine
Wait for 10 minutes
Result: Yellow turbidity and precipitate.

Organic Acidemia
Three most frequently encountered disorders:
Isovaleric
Propionic
Methylmalonic
The presence of these three can be detected
by newborn screening programs using MS/MS.

Isovaleric academia
autosomal recessive metabolic disorder from a
deficiency of the enzyme isovaleryl-CoA
dehydrogenase
preventing normal metabolism of the amino
acid leucine.
1:250,000 births
Urine: Sweaty feet odor urine

Propionic and
Methylmalonic Acidemia
due from the errors in the metabolic pathway
converting isoleucine, valine and threonine and
methionine to succinyl CoA.

Indicanuria
Due to certain intestinal disorders, presence of
abnormal bacteria, malabsorption syndrome
Hartnup disease - increase amounts of
tryptophan are converted to indole
Excess indole is then reabsorbed from the
intestine into the bloodstream and circulated to
the liver, converted to indican and then
excreted in the urine.
Urine: Colorless
Urine exposed to air: oxidized to Indigo Blue.

5-Hydoxyindolacetic
Acid (5-HIAA)
The degradation product of serotonin that is excreted in the
urine normally in small amounts.
Serotonin - produced from the second metabolic pathway
of tryptophan by the argentaffin cells in the intestine.
If there are carcinoid tumors involving the argentaffin cells
develop = increase in the production of serotonin results
in the elevation of urinary 5-HIAA levels.

Cysteine and
Homocysteine Disorders
Cystinuria
Cystinosis
Homocystinuria

Cystinuria
inherited renal tubular disorder.
Two forms:
1. patients cannot reabsorb lysine, ornithine, arginine, or
cysteine
2. only cysteine and lysine cannot be reabsorbed.
more likely to have pathological urinary cysteine
crystals and stones composed of cysteine.
.Cystine forms urinary calculi (insoluble, unless alkalinize)

 Test: Cyanide nitroprusside test

Result: Red Purple Color
Treatment:
More water intake (4L/day)
Penicillinase
Percutaneous nephrolithotripsy

Cystinosis
Inborn Errors of Metabolism (IEM) can range
from from severe and fatal in infancy to a
milder adult form.
defect in the lysosomal membrane
prevents release of cystine into the cellular
cytoplasm for metabolism
Leads to: Deposition of cysteine crystals in
many cells of the body.

 Patients w/Fanconi syndrome deposits of

cysteine in the cells of the proximal convoluted
tubule interfere with reabsorption and of these
crystal deposits in cells can lead to early renal
failure.
Mild Form: No kidney involvement
polyuria and positive urine tests for reducing
substances
Urinalysis tests = lack of ability to vary specific
gravity.
Test: cyanide nitroprusside test
Result: Positive

Homocystinuria
Lack of the enzyme cystathionine -synthase
necessary for the metabolism of the amino
acid methionine
increased plasma and urine levels of
methionine and of the precursor homocysteine.
Result to:
failure to thrive
mental retardation
Cataracts
increased thrombosis risk
Death

 Prevention:
Diet modification with reduction in methionine
sources
high doses of Vitamin B6

Test: Cyanide nitroprusside test

Result: Positive
Other test:
Silver Nitroprusside test needed to differentiate
from the cystine disorders.
Homocystinuria = postive
Cystinuria = negative
Cystinosis = negative

Porphyrin Disorders
Porphyrins complex iron-fee cyclic substances;
intermediates in the biosynthetic pathway of heme.
Porphyrins differ in the side chains present at
the eight available positions on the pyrrole rings.
Major sites for Porphyrin production are:
1. bone marrow - intermediates in the synthesis of
hemoglobin
2. liver and other tissues - produce intermediates for
other heme proteins like myoglobin.

 Porphyrins can be seen elevated in: urine,

feces, and/or blood
Porphobilinogen (PBG) and the
porphyrinogens -colorless, non-fluorescent
substances
Oxidized forms or the Porphyrins have red
pigments under the microscope
Urine: port wine / burgundy color
Common method for separating individual
porphyrin: high performance liquid
chromatography

Delta-aminolevulenic
Acid Dehydrogenase
Deficiency Porphyria
Delta-aminolevulinic acid dehydratase (ALAD),
also known as porphobilinogen synthase, catalyzes
the second step of heme synthesis. Deficiency of
this enzyme produces ALAD deficiency porphyria
(ADP), an extremely rare cause ofacute porphyria.
a rare form of acute porphyria
aminolevulenic acid is increased
PBG is not increased

Acute porphyrias
rapid testing is important.
Porphobilinogen is increased patients with
symptoms of acute porphyrias
PBG testing is both sensitive and specific
Measurement of PBG is often combined with
measurments for delta aminolevulenic acid and
total urine porphyrins.

Cutaneous Porphyria
measuring total plasma Porphyrins is effective
for screening patients with skin
photosensitivity
Plasma Porphyrins are rarely increased in other
medical conditions.

Mucopolysaccharide
Disorders
Mucopolysaccharidoses
Hurler Syndrome
Hunter Syndrome
Sanfilippo Syndrome

Mucopolysaccharides
aka Glycosaminoglycans
group of large compounds located primarily in
connective tissue (CT)
consists of a protein core with numerous
polysaccharide branches
products most frequently found in urine are
dermatan sulfate, keratan sulfate, and heparan
sulfate

Mucopolysaccharidoses
inherited disorders in the metabolism of
mucopolysaccharides
preventing complete breakdown of
polysaccharide portion
accumulation of incompletely metabolized
polysaccharide portion in lysosomes of CT cells
increased excretion in urine

 Types
1. Hurler Syndrome
.abnormal skeletal structure
.severe mental retardation
.mucopolysaccharides accumulate in the cornea of the eye

2. Hunter Syndrome
.abnormal skeletal structure
.severe mental retardation
.sex-linked recessive (rarely seen in females)

3. Sanfilippo Syndrome
.mental retardation

 Diagnosis: Urinary screening test newborn

1. acid-albumin and CTAB turbidity test
2. metachromatic staining spot test

.Result: white turbidity (+)

Purine Disorders
Lesch-Nyhan Disease

Carbohydrate Disorders
Melituria

Lesch-Nyhan Syndrome
inherited, sex-linked recessive
massive excretion of urinary uric acid crystals
severe motor defects
mental retardation
tendency towards self-destruction, gout, and
renal calculi

 Diagnosis

normal development for

the first 6-8 months
First Sign: uric acid crystals
in diaper resembling
orange sand
Increased uric acid crystals
in pediatric urine specimen

Melituria
increased urinary sugar
usually caused by an inherited disorder
Most cause no disturbance in body metabolism
Type:
1. Pentosuria
2. Galactosuria
3. Lactosuria
4. Fructosuria

Pentosuria
presence of pentose sugars in urine
one of Garrods original six IEMs
ingestion of large amounts of fruit

Galactosuria
inability to properly metabolize galactose to
glucose
deficiency in any of the enzymes:
1. galactose-1-phosphate uridyl transferase
(GALT) - causes severe, possible fatal
symptoms
2. galactokinase - result in cataracts in adulthood

3. UDP-galactose-4-epimerase
asymptomatic or produce mild symptoms
results to galactosemia with toxic intermediate
metabolic products
infant failure to thrive
liver disorder, cataracts, severe mental
retardation

Lactosuria
may be seen during pregnancy and lactation

Fructosuria
associated with parenteral feeding

 Diagnosis
Tests:
1. Copper reduction test postive
2. Reagent strip glucose oxidase test negative
3. Newborn screening tests

References

Graffs Textbook of Routine Urinalysis and Body Fluids by Mundt 2 nd ed.

Concise Book of Medical Laboratory Technology: Methods and Interpretations
William Clarkes Contemporary Practice in Clinical Chemistry, 2 nd ed.
Henrys Clinical Diagnosis and Management by Laboratory Methods, 22 nd ed.
by Mcpherson
Uniralysis and Other Body Fluids by Strasinger 6th ed.
Clinical Laboratory Medicine by Richard Ravel
Fundamentals of Urine and Body Fluids Analysis by Brunzel, 3 rd ed.
Clinical Laboratory Science: the Basics and Routine Techniques, 6 th ed. by
Turgeon
Inborn Metabolic Diseases: Diagnosis and Treatment by Saudubray 5 th ed
Medical Biochemistry: Human Metabolism in Health and Disease by Rosenthal
Clinical Chemistry: Principles, Techniques and Correlations by Bishop 7 th ed.