Basic examination of urineFormation

Ultrafiltrate of blood Average daily output

o 1200 to 1500 ml/day 600cc/day still considered normal

o 170,000 filtered plasma/dayo 18L glomerular filtrate reduced to 1-2Lo 20 – 25 % of total blood volume

Parts of nephrono Glomeruluso 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 urineOrganic:

Urea (50%), creatinine, uric acid

Inorganic: Chloride, sodium, potassium

o Traces: calcium, phosphate Water:99% Amino acids, peptides Formed elements:sediments

o Cells: RBC, epithelial, WBCo Casts (UNIQUE TO URINE)o Crystalso Mucus, bacteria

Mucus threads Yeast, sperm cell

URINE VOLUME Normal: 600-2000 ml/day Night: >400ml Factors that influence volume:

o State of hydrationo ADH secretion: caffeine: inhibit ADHo Excretion of dissolved solids

Glucose, salts Anuria: complete cessation of urine flow

o Decreased renal blood flowo Severe renal failure

Oliguria: decreased normal daily urine output (< 30 ml/hr)

o Vomiting, diarrhea, perspiration, severe burns, hydronephorsis

o Refero Renal: vascular d/o, AGN, ATN, CGN, CRF,

glomerulus, tubules or both are affected

Polyuria: increase in daily urine volumeo 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 outputo DMo More than 500cc at night

Types of urine specimens Random: routine screening (most frequent)

o ease of collectiono anytimeo prob: menstruation, hormonal evaluation

First morning:o Ideal screening specimeno Concentrated specimeno 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

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-prandialo Monitoring insulin therapy in DMo Or in conjunction with OGTTo 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) specimeno Accurate chemical quantitative tests

For accurate renal function (not routinely done)

o Discard 1st urineo Include last urine after a 24 hour period

Detect creatinine Quantify creatinine, total protein,

albumin For creatine clearance; protein content

Catheterized specimeno Bacterial cultureo Renal functions

For difficulty of voiding Sterile specimen and no contamination

Midstream clean catch: incorporated in a random and 1st morning urine

o Bacterial cultureo Safer, less traumatic method

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Suprapubic aspirationo Most sterileo Bacterial cultureo Cytologic examination (ideal)o For tumors of UB: has a low yield specimeno Biopsy still superior

Three-glass collectiono Prostatic infection: evaluation for prostatitis

Compare 1st and 3rd specimen (10x the amount of bacteria compared to 1st)

o 1st urine, midstream, massage prostate, remaining urine

o Interpretation 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 specimeno Pediatric Urine Collector (PUC): routine

Has an adhesive attached to 1 end Px: ensure that fecal contamination is

avoided: rechecko Sterile: catheter, suprapubic

AspirationNote:Plastic cups are used: wide mouth disposableBottle :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

Excretion proportional to metabolic rate Increased: feer, thyrotoxicosis, starvation

o Uroerythrin (red)o Urobilin (orange-red)

Odor pH

ABNORMAL URINE COLOR Dark orange:

o Bilirubin, pyridium, nitrofurantoin Fat soluble: unconjugated Excreted: conjugated

o Carrots, vitamin A

Yellow-green, yellow-browno Biliverdin (from bilirubin oxidation)

Not common

Green, blue-greeno Pseudomonas infection, amitriptyline

Chek for fruity smello Methocarbamol, Indican (a potassium salt), phenol

Pink, Redo RBCs, Hgb, porphyrinso Beets (jams), menstrual, phenindione

Brown, blackso Methemglobin, homogentisic acid (alkaptonuria:

inherited d/o of metabolism), melanin (melanoma)o Argyrols, methyl/levodopa, metronidazole

NORMAL CLARITYAPPEARANCE Normal: clear Non-pathologic causes of turbid urine:

o Squamous epithelial cells Vaginal contamination (common in

women)o Mucus threadso Amorphous phosphates, carbonateso Sperms cells in femaleso Fecal contamination: esp in Pedso Radiographic contrast mediumo Talcum, vaginal creams

Pathologic causes of turbid urine:o Red blood cells: not from menstrual bloodo White blood cellso Bacteria, yeasto Abnormal crystals: tyrosine and eosine?o Lymph fluid:Pyuriao Lipids: Lipiduriao 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

Evaluation of renal concentrating ability Isosthenuria: 1.010

o Same with initial filtrate Hyposthenuric: < 1.010: DI, PN, GN

o Pyelo and glomerulonephritiso Diluted urine

Hypersthenuric: > 1.010: CHN, DHNo Concentrated urine

Urinometer Refractometer

NORMAL ODOR Normal: faint odor (volatile acids) Aromatic Odorless: severe kidney dysfunction

ABNORMAL ODOR

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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 +crystalso 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

CHEMICAL SCREENING Urine pH: concentration of H+ions

o Determine the acidity and alkalinity Chemical examination

o Reagent stripso Manual (spectrophotometer)

Colorimetric Enzymatic

o AutomatedpH

Normal: 4.5 – 8 Minor importance (nneeded only to correlate with other

results) Measure of kidney’s 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 UTIo 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)

Acidic urine Alkaline urine

COPD Hyperventilation

DM Vomiting

Starvation Renal tubular acidosis

Dehydration Urease production

bacteria (proteus)

Bacteria (E. coli) Vegetables, fruit diet

High protein diet Old specimen

Cranberry juice medications

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 Pregnancyo <0.5/DAYo Orthostatic proteinuriao Postural proteinuria when standing for several

hours disappears upon lying downo Mildo Renal passive congestiono Renal progressive

Organic proteinuria:systemic disease or renal pathology 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 flowo Hypertensiono Myxedemao Bence jones protein (MM and lymphoma- but

not pathogpneumonic)

Renal proteinuria: primarily kidney diseaseo Glumerulonephritiso Nephrotic syndrome

Edema Heavy proteinuria Hyperlipidemia hypoalbuminemia

o Destructive parenchymal disease (tumor, infection, infarct)

o 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

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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)

URINE GLCUOSE Normal: minute amounts

o Almost all is reabsorbed in the PCTo Renal threshold: 180 mg/dL

Glucosuria without hyperglycemiao Glucosuria of pregnancyo Renal glucosuriao Fanconi’s syndromeo Nephrotoxic: Pb, CO, mercuric Cl

Glucosuria with hyperglycemiao DMo Alimentary glucosuria (transient) secondary to

dehydrationo Increased ICPo Cushing’s syndrome, Pheochromocytoma

Cortisol Cathecolamines Direct antagonist to insulin

o Hyperthyroidismo After MIo Gestational DM

URINE KETONES Normal: none to minute

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

Detectable levels in urine: ketonuriao Dka (Diabetic coma if untreated)o insulin

Clinical Significance:

o DKAo Insulin dosage monitoringo Starvation, malabsorptiono Pancreatic disorderso Strenuous exercise, vomitingo 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, PNo Trauma, tumors, toxic chemicalso Anticoagulants, strenuous exercise

Hemoglobinuria (Intravascular hemolysis)o Transfusion reactions, hemolytic anemiao Severe burns, infectionso Strenuous exercise

Myoglobinuriao Muscle trauma, prolonged comao Convulsions, muscle wasting diseaseo Drug Overdose, alcohol abuse, exertion

Myoglobinuria Hemoglobinuria

Brown Reddish

Urine: Cloudy Clear

Centrifuge: Pink Red

Plasma: Clear Red

BILIRUBIN Normal: B2 = < 0.5 mg/dL (0.02) Hepatic jaundice

o Hepatitiso Cirrhosis

Post-hepatic/ obstructive jaundiceo Stoneso Malignancy

UROBILINOGEN Normal: < 1 mg/dL Significance:

o Early detection of liver diseaseo Hepatitis, cirrhosis, malignancieso Hemolytic disorders

Usually absent bilirubin

Type of jaundice Urine bilirubin Urobilinogen

Pre-hepatic(hemolytic disease) _ +++

Hepatic + or - ++

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‘ (liver damage)

Post hepatic (bile duct obstruction) +++

Normal to decreased

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 therapyo Screening of patients at high risk for UTIo Screening of urine culture specimens

LEUKOCYTE ESTERASE Normal: 0 – 5 WBC/hpf Clinical significance

o UTI (bacterial or non-bacterial)o Inflammation of the UT without bacteriuriao Screening of urine culture specimens

MICROSCOPIC EXAMINATION

URINARY SEDIMENT Cells: WBC, RBC, epithelial cells, bacteria, sperm cells Casts Crystals Others- mucus threads, fat cells, YEASTRBC: erythrocytes, biconcave discs, hypertonic, hypotonic Damage to glomerular membrane Vascular injury within the GUT Stones, GN, tumor BPH, bladder/ urethral infections Blood dyscrasias, renal infarctWBC 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 significanto polygonal with abundant cytoplasm and small

nucleuso contaminaton of urineo F>M

Transitional epithelial cells (Polarizing microscope)o Pelvis, bladder, upper urethrao Seldom pathologic

Renal tubular cells: most significanto Tubular necrosis: cellular cast?o PN, GN, toxic reactions

Oval fat bodies: signify nephritic syndromeo Cellular casto With polarized: maltice cross

Greenish: from collecting duct tubule/cell

CASTS Only elements in sediment unique to the kidney Formed in DCT and collecting duct

Tamm-horsfall proteino Secreted by tubular cellso Immunologic protection from infectiono 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 GN, PN, CHF, CRD

RBC GN, strenuous exercise

WBC PN, Acute interstitial nephritis

Bacterial Pyelonephritis (PN)

Epithelial cell Renal Tubular damage

Granular GN, PN, stress

Waxy Urine flow stasis

Broad casts Extreme stasis of flow

Fatty Nephritic syndrome

*must be correlated with the other results

CRYSTALS Seldom clinically significant 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

crystal pH

Uric acid Acid

Ammonium urates Acid

Calcium oxalates Acid/neutral

Ammonium phosphates Alkaline/ neutral

Ca PO4 Alkaline/neutral

Triple PO4 Alkaline

NH4 biurate Alkaline

Ca CO3 Alkaline

Abnormal crystals

Crystal pH

Cystine Acid

cholesterol Acid

Leucine Acid/neutral

Tyrosine Acid/neutral

Bilirubin Acid

Sulfonamides Acid/neutral

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Dye 9radio) Acid

Ampicillin Acid/neutral

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Yeasts

Oval Fat bodies

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