urinalysssisbilirubin determinations. 3. second-voided specimen first sample after the first void of...

S SURINALYSIS

AR.Merrikhi MD.

Pediatric Nephrologist

Isfahan University of Medical Sciences y

Purposep

General evaluation of health Diagnosis of disease or disorders of the kidneys or

urinary tract Diagnosis of other systemic disease that affect

kidney function Monitoring of patients with diabetes Screening for drug abuse (eg. Sulfonamide or

i l id )aminoglycosides)

The urinary tract

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Most people have two kidneys but it is possible to live with only oneit is possible to live with only one

Each kidney weighs about 160 grams and is 10-15 cm long

Their main job is to cleanse the blood of toxins and transform the waste into urine for excretion

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How is urine formed (1)?6

Renal arteries channel blood to the Renal arteries channel blood to the kidneys

The kidneys filter out waste products from The kidneys filter out waste products from the blood and excrete them in a solution -urine

Renal veins carry filtered blood to the major vein of the lower trunk (inferior

)vena cava).

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How is urine formed (2)?7

Each kidney is composed of about one million y p“filtering packets” called glomeruli

The glomeruli remove waste products from the bl dblood

Each glomerulus connects to a long tube, the tubuletubule

Urine made by the glomerulus moves down the tubule

The glomerulus and the tubule form a unit called a nephron

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Each nephron connects to progressively larger tubular branches on to the ureter abranches, on to the ureter, a large tube connecting the kidney to the bladder

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The bladder serves as a reservoir that holds urine until itThe bladder serves as a reservoir that holds urine until it contracts and expels the urine out of the body via the urethra

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The kidneys:10

Filter the blood and rid the body of toxic waste products e.g. urea & creatinine

Keep the electrolytes (e.g.sodium & potassium) and water content of the body constant

Return vital substances to the blood e.g. vitamins, amino acids, glucose

Secrete some essential hormones

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Hormones secreted by the kidney11

RENIN: keeps blood pressure normal. In kidney RENIN: keeps blood pressure normal. In kidney disease too much renin can lead to hypertension

ERYTHROPOEITIN acts on the bone marrow to ERYTHROPOEITIN acts on the bone marrow to increase red blood cell production. Too little will lead to anaemia

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Contents of:

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Collection of urine specimensp

The first voided morning urine (the most common) The first voided morning urine (the most common) Random urine (for emergency) Clean catch midstream urine (for urine culture) Clean-catch, midstream urine (for urine culture)Attention

N d b i d i hi 1 h Need to be examined within 1 hour

Midstream DeviceMidstream Device

Specimen CollectionSpecimen CollectionSuprapubicSuprapubic Needle AspirationNeedle Aspiration

Specimen Type, Collection, and Use

Specimen Type Collection Use1. Random clean catch or mid-stream collection

Cleanse external genitalia and discard the first part of the void. Routine urinalysis

Routine urinalysis: it is the most2. First morning specimen When the patient first arises in the

morning.

Routine urinalysis: it is the most concentrated and best for protein and bilirubin determinations.

3. Second-voided specimen First sample after the first void of the day.

It may contain cells that are destroyed during stasis in the bladder while the patient sleeps and therefore not seen in the firstsleeps and therefore not seen in the first morning specimen.

4. Post prandial collection At a timed interval (for example, two hours) after the patient has eaten.

This is the best sample for confirming the presence of elevated urobilinogen. May also be used to detect glucose.

5. Day specimen Usually collected from 9:00 a.m. to 8:00 p.m.

Used for quantitative determinations of analytes that may undergo a diurnal variation or be diet dependent.

6. Night specimen Usually collected from 8:00 p.m. to 8:00 Used for quantitative determinations of analytes that may undergo a diurnal6. Night specimen a.m. analytes that may undergo a diurnal variation or be diet independent.

7. Twenty-four hour collection

Day 1: discard first morning void, mark time, and collect all urine voided until Day 2: void at time marked from Day 1 and include that sample

Used when quantitative tests need to be performed.

include that sample.

8. Catheterized collection Spot sample collected via catheter inserted into the bladder.

Occasionally used for bacteriological study, especially in females. May also be done to obtain urine from infants or small children.

color First, thoroughly mix the urine in the collection container

b i i (b h lid i i h !)by inversion (be sure the lid is on tight!)

The COLOR resultS of normal metabolic end products such pas urochrome, urobilin and uroerythrin in the urine .

normal colors of urine range from straw a very pale normal colors of urine range from straw, a very pale yellow, to amber(shade of yellow)

Cloudy urine causes U i ith hi h h h t l t li id U i WBC Urine with high phosphate, oxalate, lipids, Urine WBCs

High purine food intake (increased Uric Acid)

Examples of Urine Colorp

Brown urine causes Bile pigment Myoglobinuria Myoglobinuria Fava beans Medications (Levodopa, Flagyl, Nitrofurantoin)

Black urine causes Melanin Alkaptonuria Methemoglobinuria Cascara or senna Cascara or senna Methyldopa

Blue or green urine Blue or green urine Urinary Tract Infection due to Pseudomonas Bilverdin Medications Medications

Amitriptyline, Triamterene Intravenous mendications (Cimetidine, Phenergan)

Dyes Methylene blue Indigo carmine or indigo blue

Orange to yellow urine Increased urine concentration Bile pigments Phenothiazines Pyridium Carrots Tetracycline Rhubarb (red in alkaline urine) Senna (red in alkaline urine)

Red Urine Microscopic HematuriaMicroscopic Hematuria

Urinary tract source Urethra or bladder Prostate Ureter or kidney

Non-Urinary tract source Vagina

A t Anus or rectum clofazimine

TURBIDITY

mixed the sample well , note if it is clear or turbid

Turbidity may be reported as slight Turbidity may be reported as slight, moderate or excessive

T d i h f h bidi To determine the cause of the turbidity, centrifuge a portion of the urine .

If the cloud settles to the bottom leaving a clear supernatant, the turbidity is caused by cells or crystals .

If the urine remains cloudy after centrifugation, bacteria are present.

Examples of Urine Clarityp y

Causes of Turbid Urines

Amorphous

Phosphates

A normal constituent in alkaline or neutral urines; dissolve upon addition of a dilute acid (e.g. acetic). If combined

with carbonates, gas will be evolved upon the addition of the acid.Phosphates with carbonates, gas will be evolved upon the addition of the acid. AmorphousUrates

A normal constituent in acid urine; often appear as yellow crystals or may be pink ("brick dust" deposit) due to

increased uroerythrin. They dissolve upon warming to 40 degrees C.

iUsually seen as a uniform cloud when an excess of bacteria is present; cannot be removed by ordinary filtration or

Bacteriay p ; y y

centrifugation; seen in microscopic examination.

Blood (red blood cells):

May give a reddish or brown, smoky appearance to the urine; recognized by seeing red cells upon

microscopic examinationor chemical tests for hemoglobinmicroscopic examinationor chemical tests for hemoglobin

Colloidal Particles

Cannot be cleared from urine by filtration or centribugation; are not visible in microscopic

examinationand not removed by ether. Their cause is unknown

Will usually give a milky appearance to urine; may be opalescent; are seen in microscopicFat Globules

Will usually give a milky appearance to urine; may be opalescent; are seen in microscopic

examiniation and removed by ether.

Mucus and Epithelial Cells

Upon cooling and standing, a faint cloud ("nubecula") of mucus, leukocytes and epithelial cells may settle to the bottom. In urine of igh specific gravity (sp gr) it may float near the middle. The nubecula of normal urine is probably due to nucleoprotein (phosphoprotein) and

not a mucin or mucoid (glycoprotein

Pus (white cells)

May resemble amorphous phosphates tot he naked eye. Microscopic examination will reveal that the cloud is due

to leukocytes.

URINE ODOR

Food and medication causes:Medical Causes of abnormal urine odor :

Sweet or fruity odor Diabetic Ketoacidosis Maple syrup urine disease (infants,

of abnormal urine odor : Asparagus Vitamin B6 Supplementation

p y p ( ,rare)

Ammonia odor Bladder retention Urine at room temperature for

l d i d

Inborn Error Of Metabolisim:causing urine odor Phenylketonuriaprolonged period

Fecal odor Bladder-Intestinal fistula

Pungent odor U i T I f i

Phenylketonuria Maple syrup urine disease

(infants, rare) Glutaric acidemia Isovaleric acidemia Urinary Tract Infection

Strong odor Concentrated urine

Musty odor

Isovaleric acidemia Hawkinsinuria Hypermethioninemia Multiple carboxylase deficiency

Phenylketonuria Sulfur odor

Cystine decomposition

Oasthouse urine disease Trimethylaminuria Tyrosinemia

Urine Odors and Their CausesUrine Odors and Their CausesAmmoniacal Occurs especially during decompositoin or urine on standing ("alkaline fermentaion") or retention

within urinary bladder; may be related to some bacterial infectionsy ; y

Effects of drugs and

diet

Many ingested substances will give the urine a distinct odor as ingested asparagus giving

urine its characteristicdiet

Fecal Due to contamination with feces or E. coli; often related to bladder-GI tract fistula

Fetid or Putrid May be caused by suppurative diseases of the GU tract. Decomposition of urine

containing cystine or pus will have the odor of rotten eggs (H2S).

Fruity or Sweetish Usually due to acetone in diabetic acidosis, starvation or dieting.

Urinoid or Faintly

Aromatic; NormalAttributed to volatile organic acids most marked in "concentrated" urine specimens

Urine Blood TestingUrine Blood Testing

GlucoseGlucose

Presence of glucose (glycosuria) indicates that the blood glucose level has exceeded the renal threshold.

f l f di b Useful to screen for diabetes.

Urine Glucose Testingg

Normal : no glucose detected Normal : no glucose detected

Cli i l i ifi f b l lt (Gl i ) Clinical significance of abnormal results (Glucosuria) Plasma glucose level exceeds renal threshold (160-189

mg/dL)mg/dL) Diabetes mellitus

Renal tubular dysfunctione a ubu a dys u c o Filtered glucose not being reabsorbed in tubules

Urine Glucose Testingg

Dipstick Testing Method Dipstick Testing Method Glucose initiates reaction Coupled reactionp

Glucose oxidase – oxidizes glucose to gluconic acid and concurrently reduces oxygen to hydrogen peroxide.

Hydrogen peroxide in presence of the enzyme peroxidase willHydrogen peroxide in presence of the enzyme peroxidase will oxidize an indicator, giving a colored reaction.

Chromogens Potassi m iodide Potassium iodide Tetramethylbenzindine

Urine Glucose Testingg Sensitivity y

@ 50-100 mg (compared to Clinitest’s 250) SO- Can have a positive dipstick but a neg Clinitest

Specificity - is specific for glucose only. not affected by other sugars or reducing substances.

Urine Glucose Testingg Interfering substancesg

High specific gravity and high pH may depress color.A bi id i f l i Ascorbic acid may give false - negative

Bleach or peroxide may give false positive

BilirubinBilirubin

Bilirubin is a byproduct of the breakdown of hemoglobin. Normally contains no bilirubin. Presence may be an indication of liver disease bile duct Presence may be an indication of liver disease, bile duct

obstruction or hepatitis. Since the bilirubin in samples is sensitive to light, exposure of

the urine samples to light for a long period of time may resultthe urine samples to light for a long period of time may result in a false negative test result.

Urine Bilirubin Testingg

Normal : no bilirubin detectedNormal : no bilirubin detected

Cli i l i ifi f b l lt (Bili bi i ) Clinical significance of abnormal results (Bilirubinuria) Jaundice - Condition when serum bilirubin becomes

greater than the liver can handle and there is angreater than the liver can handle, and there is an abnormal collection of bilirubin in the tissues giving them a yellow color


Prehepatic / Hemolytic jaundice Prehepatic / Hemolytic jaundice Excessive hemolysis of RBC; beyond what the liver

can process Type of bilirubin? Is bilirubin found in the urine? YES/NO? Explain.


Prehepatic / Hemolytic jaundice Prehepatic / Hemolytic jaundice Type of bilirubin? – indirect, insoluble, unconjugated Is bilirubin found in the urine? – No, the bilirubin is not Is bilirubin found in the urine? No, the bilirubin is not

water soluble


Hepatic jaundice Hepatic jaundice Liver’s cells malfunctioning Ie. viral hepatitis, cirrhosis etc.p ,

Both (direct) bilirubin and urobilinogen found in urine.


Post hepatic (regurgative or obstructive) hepatitis Post hepatic (regurgative or obstructive) hepatitis Obstruction to outflow of bile – some type of

blockage Gall stones Tumor Edema

Conjugated bilirubin backed up into blood Conjugated bilirubin backed up into blood (Bilirubinuria) and passes into urine

Urine Bilirubin TestingUrine Bilirubin Testing Testing methodes g e od

Urine dipsticks for bilirubin – a diazo reaction Impregnated with stabilized diazotized 2,4 dichloraniline

Color goes from buff to brown also shades of pink – violet

If urine is strongly colored, look for change in pad color after dipping. Use Ictotest for backup.pp g p


Interfering substances Interfering substances

Medication metabolites, pigments and indican may obscure readings

False negatives due to aged specimens, especially those exposed to light and oxidationexposed to light and oxidation.

KetonesKetones

K d h h b d b li Ketones are excreted when the body metabolizes fats incompletely (ketonuria)

Urine Ketone Testingg

Ketone Bodies Ketone Bodies Origin - not normally present

Products of fat catabolism - breakdown of fat into Products of fat catabolism breakdown of fat into CO2 and H2O

What are the 3 ketone bodies?

Urine Ketone Testingg Acetone Acetone

2%. -Acetone is volatile, & excreted primarily through the lungs

Diacetic Acid (Acetoacetic) the first formed, 20 % of the total the form detected by most ketone test procedures

Beta hydroxybutyric Acid majority formed, but not detected by routine tests.

O l H t’ t t ld ‘ t h i l’ t t ill d t t thi Only Hart’s test, an old ‘wet chemical’ test will detect this one.


Definitions DefinitionsKetonuria - ketones in the urineKetonemia - ketones in the bloodKetosis - disease state, when patient has

increased amount of ketones.Acidosis - state when blood pH is decreased, an p

accumulation of acids; commonly occurs as a result of ketosis


Clinical significance Clinical significance Health – formed in liver and completely metabolized

Disease – excessive formation and accumulation

Disturbance of carbohydrate metabolism when there is a decrease of carbohydrate metabolism, then the body

stores of fat must be metabolized to supply energy. As a result of this increased fat metabolism ketones will be found in

the urine. Ex. low carbohydrate diets, diabetes

Starvation Vomiting and diarrhea in children Van Gierke's Disease – glycogen storage disease

Hi h f di High fat diet


Testing Testing most use nitroprusside detects diacetic acid and a small amount of acetone, but

does not detect β-hydroxybutyric acid. Produces purple color

C b d i bl d Can be used on urine or blood

Specific GravitySpecific Gravity

Specific gravity reflects kidney's ability to concentrate. Want concentrated urine for accurate testing, best is first

imorning sample. Low – specimen not concentrated, kidney disease.

High first morning certain drugs High – first morning, certain drugs

Urine Specific Gravity TestingUrine Specific Gravity Testing

The specific gravity is a measure of the weight of urine The specific gravity is a measure of the weight of urine compared to an equal amount of water.

Specific gravity it proportional to urine osmolality which is Specific gravity it proportional to urine osmolality which is a measure of concentration.

Urine Specific Gravity TestingUrine Specific Gravity Testing

The specific gravity will always be greater than The specific gravity will always be greater than 1.000 and will increase as more materials are dissolved in the urinedissolved in the urine.

The value changes throughout the day fdepending on fluid intake.

Urine Specific Gravity Testingp y g

Specific gravity between 1 002 & 1 035 on a Specific gravity between 1.002 & 1.035 on a random sample is normal if kidney function is normalnormal.Specific gravity in Bowman’s capsule fluid is @ 1.007

A di b l hi i di h d iAny reading below this indicates hydrationAny reading above this indicates some degree of

dehydrationdehydration


Again dilute urine will have values less than 1.010.g Fixed specific gravity = 1.010; isosthenuria Diabetes insipidus End-stage renal disease

ll h l ll And concentrated urine will have values usually over 1.020. Usually due to dehydration and can be seen in well Usually due to dehydration and can be seen in well

population as well as sick.

Urine Specific Gravity Testingp y g Increased urine specific gravity may indicate / be seen in: * Dehydration * Dehydration * Diarrhea * Excessive sweating Excessive sweating * Glucosuria * Heart failure (related to decreased blood flow to the

kidneys) * Renal arterial stenosis * Syndrome of inappropriate antidiuretic hormone secretion * Syndrome of inappropriate antidiuretic hormone secretion

(SIADH) * Vomiting * Water restriction


Decreased urine specific gravity may indicate / be Decreased urine specific gravity may indicate / be seen in:

* Excessive fluid intake Excessive fluid intake

* Diabetes insipidus – central or nephrogenic

* Renal failure (that is loss of ability to Renal failure (that is, loss of ability to reabsorb water)

* Pyelonephritis Pyelonephritis


Specific gravity > 1.035 (refractometer) Specific gravity > 1.035 (refractometer) Could have very high glucose levels Could contain radiographic dye Could contain radiographic dye


Interfering substances Interfering substances False elevation of results may be seen in samples

with increased protein concentration. Some reports of reduced specific gravity results on

alkaline specimens. Lipids may also effect results

BloodBlood

Presence of blood may indicate infection, trauma to the urinary tract or bleeding in the kidneys.

False positive readings most often due to contamination with menstrual blood.

Blood 3% of normal persons have >3 RBCs/HPF or >1000 RBCs/mL Abnormal range is >3 RBCs/HPF. Dipsticks (orthotolidine or peroxidase) detect heme peroxidase

i i i RBC Hb l bi i h d i i i factivity in RBCs, Hb, or myoglobin with reported sensitivity of 91–100% and specificity of 65–99%; may miss 10% of patients with microscopic hematuriapatients with microscopic hematuria

False positiveOxidizing contaminants (e.g., bacterial peroxidases, g ( g , p ,hypochlorite)

False negative Reducing agents (e.g., high doses of ascorbic acid

[vitamin C] & pH <5.1 )

Urine Blood Testingg

Normally not found in urineHemoglobinuria – free hemoglobin in urineCirculating free hemoglobin normally picked up by

haptoglobin preventing loss in urineWhen serum levels of hemoglobin > 100 mg/dL

threshold is exceeded

H t i RBC i th iHematuria – RBCs in the urine Trauma / irritation of renal organs


‘Bl d’ t t d t t ‘Blood’ test detects Free Hemoglobin RBC t l d th d & th i h l bi RBCs – get lysed on the pad & their hemoglobin

reacts Myoglobin – muscle hemoglobin Myoglobin muscle hemoglobin

Principle based on the peroxidase-like activity of Principle based on the peroxidase-like activity of the heme portion of the molecule


Sensitivity – can detect at levels of 5-10 cells/uL Sensitivity can detect at levels of 5 10 cells/uL

Interfering substances Ascorbic acid Ascorbic acid Nitrates Oxidizing agents (ie bleach) Oxidizing agents (ie bleach) Contaminate blood (menstrual)

PHPH

pH measures degree of acidity or alkalinity of urine

Urine pH Testingp g

Normal: kidneys capable of 4.5 – 8.0 Normal: kidneys capable of 4.5 8.0 Factors effecting pH Diet – general & specific foodsg p Time of dayMetabolic disorders Drugs / medications

Di i k bl 5 9 0 Dipstick capable: 4.5 – 9.0

Urine pH Testingp g

Test method Test method Dipstick indicators – methyl red and bromthymol blue Range 4.5-9.0

Caution – other chemicals on dipstick can effect pH direading

ProteinProtein

Presence of protein (proteinuria) is an important indicator of renal disease.F l ti i lk li dil t i h False negatives can occur in alkaline or dilute urine or when primary protein is not albumin.

proteinuriap Upper limit of normal protein excretion in healthy children is

150mg/24hr(4mg/m2/hr)150mg/24hr(4mg/m2/hr) It is reported as negative,trace

1+(closest to 30mg/dL)1+(closest to 30mg/dL)2+(closest to 100 mg/dL)3+(closest to 300mg/dL)3+(closest to 300mg/dL)4+(>2000mg/dL)

False positive test False positive testhighly concentrated urine,gross hematuriacontamination with chlorhexidinecontamination with chlorhexidinePH>8.0,phenazopyridine therapy

Urine Protein Testingg

Normally not found in measurable amounts on Normally not found in measurable amounts on dipstick (<150 mg/dL /day) Permeability of glomerulus Permeability of glomerulus Damage to glom capularies Changes in glom blood flow

Albumin excretions may be increased temporarily due to exercise, uti, and acute illness with fever.

Dipstick results of >@ 1+ (30mg/dL) would equal to @ 500 mg/dL (clinical proteinuria)


Only albumin detectable by dipstick Only albumin detectable by dipstick

Sensitivity (at15-30 mg/dL)


Sources of error Sources of error Sensitive only to albumin Urine with strong / unusual color makes reading Urine with strong / unusual color makes reading

difficult Highly alkaline or buffered urine will neutralize acid

buffer and lead to increased erroneous results. Urine container contamination would interfere

Urine Protein TestinggUrine back up testUrine back up test3% sulfosalicylic acid Added to the supernatant to detect any kind of protein. p y p

Urine will turn cloudy if protein is present.

False-negatives:(1) highly alkaline urine [pH ≥8.0](2) l t d ifi it d t hi h lt t ti(2) elevated specific gravity due to high salt concentrations.

NOTE: FOAMY URINE IS SUSPECTED TO PROTEINURIA.

Urine Urobilinogen Testingg g

Normally found in small amounts, especially in Normally found in small amounts, especially in early afternoon

Increased amounts may indicate liver disease or Increased amounts may indicate liver disease or be seen as result of hemolytic disorders

Decreased amounts: Decreased amounts: If intestinal bacteria destroyed Liver doesn’t conjugate bilirubine oes co juga e b ub Biliary obstruction – failure of bilirubin to reach

small intestine

Urine Urobilinogen Testingg g

Test principle based on Ehrilich’s reaction Test principle based on Ehrilich s reaction

Para-dimethylaminobenzaldehyde = Ehrlich's Para-dimethylaminobenzaldehyde = Ehrlich s reagent.

Must protect specimen from light and test Must protect specimen from light and test immediately

Urine Nitrate Testingg

Aromatic amine in reagent strip reacts withAromatic amine in reagent strip reacts with nitrite; producing a diazonium salt

The diazonium salt reacts with sulfanilic acid and acetic acid to produce a pink azo dyeand acetic acid to produce a pink azo dye

NitriteM th 90% f i th it it More than 90% of common urinary pathogens are nitrite-forming bacteria

Sensitivity of the nitrite test is low in infants Sensitivity of the nitrite test is low in infants Predictive value of a positive test is over 99% in girls False-positive: False-positive:

1-delayed transit before testing2-macroscopic hematuria2-macroscopic hematuria

False negative1-presence of ascorbic acid1 presence of ascorbic acid2-frequent voiding of dilute urine

Urine Nitrate Testingg

Nitrate Nitrate Detects presence of certain types of bacteria screening for presence of UTI. screening for presence of UTI. Certain species of bacteria convert nitrate (normal

constituent of urine) to nitrite Escherichia - most common cause of UTI

Klebsiella

Proteus

Pseudomonas

Enterobacter

Citrobacter Citrobacter

Urine Nitrate Testingg Limitationsa o s

reported as positive or negative

Not all UTI causing bacteria convert nitrate to nitrite

Haemophilus Staphylococcus Streptococcus Streptococcus

Urine Nitrate Testingg Fresh first morning specimen is preferred –g p p

besides being the most concentrated specimen, the urine has been in the bladder longer, allowing bacteria time and

t it t t th it t t it itopportunity to convert the nitrates to nitrites.

Urine Leukocyte Testingy g Leukocyte esterase testing is another test used as a means eu ocy e es e ase es g s a o e es used as a ea s

of screening for urinary tract infection. Does not measure concentration of leukocytes

Will detect presence of lysed leukocytes as well as intact WBCs

Urine Leukocyte Testingy gtest principle: es p c p e: Leukocyte esterase, an enzyme present in granulocytes,

hydrolyzes indoxylcarbonic acid esterase to produce indoxyl, which reacts with a diazonium salt to create a purple color usually in 2 min.

Urine Leukocyte Testingy g

Reaction interference Reaction interference False positives - oxidizing detergents

False negatives - greatly increased glucose, protein, or False negatives greatly increased glucose, protein, or specific gravity- increased sp gr could cause WBC to crenate preventing their releasing their esterase, So it is possible for the di ti k t b ti h th WBC tdipstick to be negative when there are WBCs present.

Urine sediment structure

CellsCellsCastsCrystals

O i d ifOrganisms and artifacts

White blood cells

Presence of white blood cells in the urine sediment may be indicative of i f ti i fl ti Th t t f WBC i thinfection or inflammation.The most common type of WBCs seen is the neutrophil.

Correct identification and enumeration are essential.WBCs are reported as number per high power(400x) field

Quantify of WBCs seen may be reported as +1,+2,+3,+4(packed) or as the actual numberthe actual number

WBCs: +1 Example

+1 (6t 20 hi h fi ld)+1 (6to20 per high power field)

or

5 to 11 per high power field5 to 11 per high power field

WBC +2 E lWBCs : +2 Example

+2(21 to 50 per high power field)

WBCs: +3 ExampleWBCs: +3 Example

+3 ( greater than 50)

WBCs: +4 Example

+4 (packed field)

Red Blood Cells RBCs may be present in the urine due to injury or disease of any portion of the urinary

tract. In females ,they may also be present due to menstrual contamination. RBCs may appear in three forms depending on the concentration of the urine.In a

normal urine the cells will appear as oval,round,or biconcave disks.In a concentrated urine (hyper tonic),the cells lose water and become crenated.In a dilute urine(hypo tonic) the RBCs swell and lose their hemoglobin to become ghost cell or may lysetonic) the RBCs swell and lose their hemoglobin to become ghost cell or may lyse completely.

RBCs are reported per high power (400x) field,greater than 2 to 3 per high power field is considered abnormal.Quantify of RBCs may be reported as 1+,2+,3+,packed or as y y p , , ,pactual number seen

Red Blood Cells Presence of red blood cells should be accompanied by a positive biochemical test for

blood. Presence of large number of RBCs may cause the urine to appear red or brown or Presence of large number of RBCs may cause the urine to appear red or brown or

cloudy. RBCs are seen in disease of the glomerulus( GN,nephrotic syndrome) or in the cases of

injury to any portion of the urinary tract.injury to any portion of the urinary tract.Normal RBC Normal RBC

Crenated RBC Ghost RBC

Example 1+Example 1+

1+( 5 to 7 per high power field)

Example 2+

2+ ( 9 to 30 per high power field)

Example 3Example 3

3+( greater than 30 but not packed)

Example 4+Example 4+

4+(packed)

Epithelial cellsEpithelial cells

squamous transitional renalsquamous transitional renal Epithelial cells may be seen in small numbers in normal urine The presence of increased numbers of transitional or renal epithelial

cells may indicate disease. Large numbers of squamous epithelial cells may indicate improper

spacemen collection.p The cells may be visually differentiated by size, shape, appearance

and nuclear to cytoplasmic ratio.

Epithelial CellsEpithelial CellsSquamous transitional renal epithelialSquamous, transitional, renal epithelial

cellsSquamous epithelial cellsLarge flat 30 to 50 micrometers inLarge flat, 30 to 50 micrometers in

diameterNucleus to cytoplasm size ratio is 1:6Contamination from distal genitalContamination from distal genital

tract

Transitional Epithelial CellsTransitional Epithelial Cells

Stratified epithelial lining renal pelvis to bladder Stratified epithelial lining, renal pelvis to bladder and proximal urethra20 30 i i i d l 20 to 30 micrometers in size, pear or tadpole shaped, central nucleus, nucleus to cytoplasmic

i i 1 3ratio is 1:3 Transiently increased with infection,

catheterization, bladder irrigation Large numbers especially with irregular nuclei g p y g

may suggest malignancy

Renal Tubular Epithelial CellsRenal Tubular Epithelial Cells

Li l t b l d ll tiLine renal tubules and collecting ducts

>15/10 hpf (400X) suggests tubular inj rinjury

Slightly larger than leukocytesg y g yLarge eccentric round nucleusNucleus to cytoplasmic ratio is 1:1

Oval Fat BodiesOval Fat Bodies

R l ith li l ll fill d ithRenal epithelial cells filled with lipidsp

Cholesterol containing cells, classic Maltese Cross nder polari ed lightMaltese Cross under polarized light

Oil Red stains triglycerides but not g ycholesterolS d III t i h l t lSudan III stains cholesterol

Urinary CastsUrinary CastsP t i i l f kid t b lProteins in lumen of kidney tubules

Have a protein matrix +/- cells, fat, ave a p ote at / ce s, at,bacteriaT H f ll i /Tamm-Horsfall mucoprotein +/-plasma proteinsp p

Best visualized with phase contrast imicroscope

Cast formationCast formationHyalineHyaline

Hyaline casts are composed primarily of simple Tamm-Horsfall protein with no inclusionHorsfall protein with no inclusion

Hyaline CastsHyaline CastsT H f ll P i lTamm-Horsfall Protein only

Best seen with phase-contrast microscopep pMore likely in concentrated, acidic urine

N t i t d ith t i iNot associated with proteinuriaNonspecific - seen with strenuous p

exercise, dehydration, severe renal diseasedisease

Microscopic ExaminationMicroscopic ExaminationMicroscopic ExaminationMicroscopic ExaminationHyaline CastHyaline Cast

Granular CastsGranular CastsG l i T H f ll iGranules in Tamm-Horsfall protein matrix

Breakdown products of cells within cast, or aggregates of plasma proteinsor aggregates of plasma proteins

Granules become smaller with aging of hthe cast

In glomerular or tubular diseasesg

Cast formationCast formationGranularGranular

Granular casts are formed by aggregation of granules into the Tamm-Horsfall protein matrixthe Tamm Horsfall protein matrix

Granular casts may also be formed from degeneration of cellular casts

Microscopic ExaminationMicroscopic ExaminationMicroscopic ExaminationMicroscopic ExaminationGranular CastGranular Cast

Waxy castWaxy cast Waxy casts are formed when decreased renal flow allows Waxy casts are formed when decreased renal flow allows

cellular or granular casts to remain in the tubule long enough for the cells or granules to degenerate into a smooth matrix cellular cast

Coarse granular cast fine granular cast waxy cast

Waxy CastsWaxy CastsD ti f h li lDegeneration of hyaline, granular, cellular casts

Easy to see, very refractile unlike hyalinehyaline

Smooth blunt ends with sharp bordersA i d i h i iAccompanied with proteinuria

Chronic renal disease, rarely with ARF, yDistinguish from artifacts/fibers

Microscopic ExaminationMicroscopic ExaminationMicroscopic ExaminationMicroscopic ExaminationWaxy CastWaxy Cast

Fatty CastsFatty CastsNephrotic syndrome

M th l l lMercury or ethylene glycol poisoningpoisoningContain droplets of fat, very p y

refractile, easily seenDistinguish from RBC casts

FATTY CAST

SPECIFIC DISORDERS :

-Lipiduria

-Nephroric syndrom

-Hypotyroidisim

RBC CastRBC CastMost fragile of all castsMost fragile of all casts

Fresh urine is necessaryFresh urine is necessaryGlomerular or tubulointerstitial

(conversion of fibrinogen to fibrin in tubules RBCs trappedfibrin in tubules, RBCs trapped in fibrin)

Degrades into pigmented cast

RBC tRBCs casts RBCs can enter the nephron as a result of injury to the RBCs can enter the nephron as a result of injury to the

glomerulus and/or the tubules

RBCs cast: RBCs may be incorporated into the cast matrix RBCs cast: RBCs may be incorporated into the cast matrix

White Cell CastsWhite Cell CastsR l i t titi lRenal interstitial inflammationPyelonephritisAllergic interstitial nephritisnephritis

Distinguish from clump ofDistinguish from clump of WBCs (pseudocast)

WBCs castWBCs castWBCs can enter the tubule via the glomerulus or by amboid g y

action anywhere along the tubule

WBC cast: WBCs may be incorporated into the cast matrixy p

WBCs castWBCs cast WBCs can enter the tubule via the glomerulus or by amboid g y

action anywhere along the tubule

WBC cast: WBCs may be incorporated into the cast matrixy p

Renal cell castsRenal cell castsRenal cells

Renal cells enter from anywhere along the proximal,distal or collecting tubules

Renal cells may be incorporated into the cast matrix

Tubular Epithelial Cell CastTubular Epithelial Cell Cast

Tubular damage, desquamation of cells

Cells are varied in shape and h h dl d d tihaphazardly arranged - desquamation from different segments of tubuleg

Degrades to granular and finally waxy tcast

PseudocastsPseudocasts

P l i d li ht di ti i hPolarized light distinguishes urates, fibers, amorphousurates, fibers, amorphous materials from protein of a

hi h d l icast which does not polarizeUsually not accompanied byUsually not accompanied by

cells or proteinuria

CrystalsCrystalsLeast clinically importantLeast clinically importantStones exist with/without presence of p

crystalsCrystals exist with/without presenceCrystals exist with/without presence

of stonesCooling urine will have some crystal

precipitateprecipitateMore in concentrated urine

Calcium oxalate is the most common form of calcium crystals.

O l t i b d t f t b li It i l f d i b f Oxalate is a byproduct of metabolism. It is also found in a number of foods.

crystals are usually found in acid urine.

They commonly appear octahedral.

Ovoid , Envelop & Dumb-Bell Shaped,Bipyramidal(Octahedral)-Shaped(Calcium Oxalate Dihydrate Crystals)

Calcium oxalate monohydrate crystals

Calcium phosphate calculi often occur as a result of metabolic or hormonal disorders.

They appear most often in alkaline urine.

crystals assume various forms including the rosette and pointed finger forms

They are soluble in dilute acetic acic & insoluble in alkali They are soluble in dilute acetic acic & insoluble in alkali.

pointed finger formsWedge-Shaped Prism

Ca-Phosphate (Rosette- Shaped)Plaques and Prisms of Calcium Phosphate

Calcium carbonate :

It is typical of alkaline and fermented urine It is typical of alkaline and fermented urine

It is soluble in acetic acid, forming small bubbles of CO2.

It can take the form of spheres, which are sometimes dumb-bell-shaped, or appear as

amorphous granules or needle-like clustersamorphous granules or needle-like clusters.

They are soluble in acetic acid & hydrochloric acid & insoluble in alkali.

Spheres formDumb-bell-shaped

dumb-bell-shaped

Calcium sulfates

Calcium sulfates : Calcium sulfates :

C l i lf lli- Calcium sulfate crystallizes

as thin plates with sharp ends.

-The plate can be isolated or

forming a rosette.

-These crystals are of little

clinical meaning

urates Amorphous urates :

-appear as fine pink or brownish-tan or yellow-red granules

-They are salts of uric acid and are normally found in acid or neutral urine.

-Amorphous urates can be dissolved in dilute sodium hydroxide.

- red or pink precipitate is observed on centrifugation.

Ammonium biurates : -The ammonium biurates, also called acid ammonium urates, crystallize as a sphere with strias that reminds a dried applepp

-Several crystals will show characteristic “ox-horn” or” thorn applle” projections

-Ammonium biurates are rarely seen in a fresh specimen. The former are found in old

specimens that turned alkaline

-They are insoluble in acetic acid and sodium hydroxide and they usually formed due to inappropriate storage.

They are the only urate crystals that appear in alkaline urine

Uric acid :U i id i d d h l i id (th b ildi bl k f DNA) l d-Uric acid is produced when nucleic acids (the building blocks of DNA) are recycled.

-High levels of uric acid may result from a diet high in nucleic acids such as meat, fish, and poultry, or in cancer patients treated with chemotherapy who have a high turnover of cellscells.

-Uric acid calculi are more common in men than in women, and account for roughly ten

percent of cases.crystals exhibit extreme pleomorphism in size and in shape.

-Soluble in heat and alkali and insoluble in aceton and hydrochloric acid.

-They appear readily in acid urine allowed to stand at room temperature

A is one of the rhombic plate (diamond-shaped) and is very common. B is the uric acid crystal in the shape of a barrel shape.

uric acid crystal(Spear-shaped uric acid crystals)

Phosphatesp

Amorphous phosphates appear in neutral to alkaline urine as fine, colorless or slightly brown granules.

White precipitate is observed on centrifugation.

Amorphous phosphates will dissolve in dilute acetic acid.

Hippuric acidpp

It usually found in acid urine,soluble in alkali and insoluble in acetic acid y , Sixed-sided prism or rhombic plate and colorless It may be mistaken with Triple Phosphate

Abnormal Crystaly

CystineCystine Tyrosine Leucine Bilirubin BilirubinHematoidinCholesterol

Tyrosiney

Tyrosine crystals are not normally found in urine.

They are products of protein metabolism and appear in urine of people with tissue degeneration or necrosis (acute liver diseasepeople with tissue degeneration or necrosis (acute liver disease, severe leukemia, typhoid fever, and smallpox).

They are present only when urine is acid. They are colorless to yellowish brown, needle shaped crystals and

have a fine silky appearance.

The needles may be single or arranged in sheaves or rosettes. Tyrosine crystals usually appear in urinary sediment together

with leucine crystals Dissolve in HCL and NaOH & Insoluble in Alcohole and acetic acid

needle shapedsilky appearance

rosettes shapedsingle

Leucine Crystaly

Soluble in hot water and NaOH and insoluble in HCL Oily form or Concentric seriation

Concentric Seriation Oily

Leucine(bright field)

Leucine(polarize light)Leucine(polarize light)

Cystiney

Only one to two percent of calculi are formed from cystine, an amino acid that is found in protein.M t t f ti i Most cases stem from cystinuria.

Cystinuria is a rare congenital disorder that produces unusually high levels of cystine. Stones formed due to cystinuria occur throughout life and are difficult to treat. these crystals are found in acid urine and are seen as thin, colorless, hexagonal plates.y , , g p Cystine crystal also can be seen in poisining cases. Hexagonald,colorless and wrinkled when disolved. Souble in NaOH,HCL,NH4OH and insoluble in acetic acid.

colorless plates and have a characteristic hexagonal shape

The pathologic crystals of metabolic diseases and poisoningsCystin Crystal Uric Acid Crystal

Cholesterol crystalsy

Cholesterol crystals are found in acid or neutral urine. They appear as regular or irregular transparent plates.

They may occur singly or in large numbers They may occur singly or in large numbers. Usually one or more corners are cut off or notched, justifying their

descriptionas "stair step crystals".

They are not commonly seen and are always considered pathological. They can be found in various renal diseases.They can be found in various renal diseases. Usually prescence of cholestrol is accompained with proteinuria,increasing

blood cholestrol and decreasing of blood albumin.S l bl i th d hl f d i l bl i dil t id d lk li Soluble in ether and chloroform and insoluble in dilute acids and alkali.

Hemosidrine crystaly

Hemosidine is confirmed by roux Reaction (Prussian Blue Stain )in form of free granules A hor Amorphous mass

They are in Macrophage,tubular cells,or casts It is found in some pathological Dx like:

Paroxysmal Nocturnal Hemoglobinemia

Chronic Hemolytic Anemia

Hemochromatosis

Hemosiderin Granules- UnstainedHemosiderin Granules- Stained

Cast with Hemosidrine Inclusion GranuleCast with Hemosidrine Inclusion GranuleIdentical to the Free Granules

Cast with Hemosidrine Inclusion Granules Prussian Blue Staining

yeasty

In women (and rarely in men), yeast can also be present in urine.

They are most often present in women who have a vaginal yeast infection, because the urine has been contaminated with vaginal secretions during collection.

Fungi. The different Sizesof the Cells

Monomorphic Fungi Chain Formation

Fungi Budinig Formation

Trichomonads

Trichomonads are parasites that may be found in the urine of women or men (rarely). As with yeast, the trichomonads are actually infecting the vaginal canal and their

presencein urine is due to contamination during urine collection.

As it can be mistaken with WBCs,seeing the flagella is necessary

Diluted urine, request a voided urine in the morningIf persisting low SG, possible diabetes insipidaCaseCase 11 If persisting low SG, possible diabetes insipida

A microscopic may give negative resultsCase Case 11

A 3-year old boy undergoing routine pre employment drug screening.A 3-year old boy undergoing routine pre employment drug screening.

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

Physical characteristics: Clear.Microscopic: Not performed.

Drugs Identified: None.

Physical characteristics: Clear.Microscopic: Not performed.

Drugs Identified: None.

NegativeNegative

1.0011.001

KetonesKetones

S.G.S.G.g

Questions:

What is your differential diagnosis?

g

Questions:

What is your differential diagnosis?

NegativeNegative

5.55.5

N iN i

BloodBlood

pHpH

P iP i - What is your differential diagnosis?- What would you do next to confirm your suspicion?- Would you order a microscopic analysis

- What is your differential diagnosis?- What would you do next to confirm your suspicion?- Would you order a microscopic analysis

NegativeNegative

0.2 mg/dL0.2 mg/dL

N tiN ti

ProteinProtein

UrobilinogenUrobilinogen

Nit itNit it on this sample?on this sample?NegativeNegative

NegativeNegative

NitriteNitrite

L.E.L.E.

Possible gallbladder or hepatic disease.No hemolytic anemia Perform bilirubins in serumCaseCase 22 No hemolytic anemia. Perform bilirubins in serum

Microscopic unlikely to provide additional infoCase Case 22

A 12-year old girl presents with “dark urine”A 12-year old girl presents with “dark urine”

NegativeNegative

++++++

GlucoseGlucose

BilirubinBilirubiny g p

Physical characteristics: Red-brown.Microscopic: Not performed.

y g p

Physical characteristics: Red-brown.Microscopic: Not performed.

NegativeNegative

1.0201.020

KetonesKetones

S.G.S.G.

Questions:

- What is your differential diagnosis?

Questions:

- What is your differential diagnosis?

NegativeNegative

5.55.5

BloodBlood

pHpH

P iP i - Could this be a case of hemolytic anemia?- How would you rule it out?- What tests would you order next? Why?- Would you order a microscopic analysis?

- Could this be a case of hemolytic anemia?- How would you rule it out?- What tests would you order next? Why?- Would you order a microscopic analysis?

NegativeNegative

0.2 mg/dL0.2 mg/dL

ProteinProtein


Nit itNit it Would you order a microscopic analysis?Would you order a microscopic analysis?NegativeNegative

NegativeNegative

NitriteNitrite

L.E.L.E.

Possible UTI, request culture and antibiotic sensitivityNegative Nitrite test: Gram positive bacteriaCaseCase 33 Lower SG may show less number of cells and bacteriaUn-common diagnosis in this type of patient

Case Case 33

A 12-year old girl presents painful urination

Physical characteristics: dark red turbid

A 12-year old girl presents painful urination

Physical characteristics: dark red turbid

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

Physical characteristics: dark red, turbidMicroscopic: leukocytes = 30 per HPFRBCs = >100 per HPFBacteria = >100 per HPF

Physical characteristics: dark red, turbidMicroscopic: leukocytes = 30 per HPFRBCs = >100 per HPFBacteria = >100 per HPF

NegativeNegative

1.0301.030

KetonesKetones

S.G.S.G.

Questions:- What is your suspected diagnosis?- What would you do next?

Questions:- What is your suspected diagnosis?- What would you do next?

++++++

6.56.5

BloodBlood

pHpH

P iP i What would you do next?- What do you make of the nitrite test?- How would the microscopic exam differ if the S.G. were 1.003?

I thi di i f thi t f

What would you do next?- What do you make of the nitrite test?- How would the microscopic exam differ if the S.G. were 1.003?

I thi di i f thi t f

TraceTrace

1.0 mg/dL1.0 mg/dL

ProteinProtein


Nit itNit it - Is this a common diagnosis for this type of patient?- Is this a common diagnosis for this type of patient?

NegativeNegative

++++++

NitriteNitrite

L.E.L.E.

DiabetesMay be decompensated and with ketoacidosisCaseCase 44 May be decompensated and with ketoacidosis

Ketones should become negative after treatmentCase Case 44

A 15 year old woman presents with severeA 15 year old woman presents with severe

++++++++

NegativeNegativeNegativeNegative

GlucoseGlucose

BilirubinBilirubin

A 15-year old woman presents with severe abdominal pain.

Physical characteristics: clear-yellow.

A 15-year old woman presents with severe abdominal pain.

Physical characteristics: clear-yellow.

TraceTraceTraceTrace

11..01501511..015015

KetonesKetones

S.G.S.G.

Microscopic: Not performed.

Questions:- What is the most likely diagnosis?

Microscopic: Not performed.

Questions:- What is the most likely diagnosis?


66..0066..00

BloodBlood

pHpH

P iP i - What is the most likely diagnosis?- What do you make of the ketone result?- What do you expect to happen to the ketonemeasurement when treatment begins?

- What is the most likely diagnosis?- What do you make of the ketone result?- What do you expect to happen to the ketonemeasurement when treatment begins?


11..0 0 mg/dLmg/dL11..0 0 mg/dLmg/dL

N tiN tiN tiN ti

ProteinProtein

Nit itNit it




NitriteNitrite

L.E.L.E.

CaseCase 55Glomerulonephritis

RBC casts reveals renal cortex involvementCase Case 55 RBC casts reveals renal cortex involvementRBC cast are not always present in GN

NegativeNegative

NegativeNegative8-year old boy presents with discolored urine

Physical characteristics: Red turbid

8-year old boy presents with discolored urine

Physical characteristics: Red turbid

GlucoseGlucose

BilirubinBilirubin

NegativeNegative

1.0151.015

Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF (almost all dysmorphic)Red cell casts present.

Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF (almost all dysmorphic)Red cell casts present.

KetonesKetones

S.G.S.G.

++++++

6.56.5

p

Questions:- What is the most likely diagnosis in this case?

p

Questions:- What is the most likely diagnosis in this case?

BloodBlood

pHpH

P iP i ++

1.0 mg/dL1.0 mg/dL

case?- Does the presence of red cell casts help you in any way?- If the erythrocytes were not dysmorphic

case?- Does the presence of red cell casts help you in any way?- If the erythrocytes were not dysmorphic

ProteinProtein

Nit itNit it


NegativeNegative

NegativeNegative

would that change your diagnosis?would that change your diagnosis?NitriteNitrite

L.E.L.E.

CaseCase 66“Functional” proteinuria?

Microscopic may reveal a few leukocytesCase Case 66 Microscopic may reveal a few leukocytesRequest protein concentration in 24 h urine

NegativeNegative

NegativeNegative16-year old adolesnce presenting for a routine physical required for admission to medical school

16-year old adolesnce presenting for a routine physical required for admission to medical school

GlucoseGlucose

BilirubinBilirubin

NegativeNegative

1.0101.010

school

Physical characteristics: YellowMicroscopic: Not performed

school

Physical characteristics: YellowMicroscopic: Not performed

KetonesKetones

S.G.S.G.

NegativeNegative

5.05.0Questions:- What is your differential diagnosis?- Would you order a microscopic analysis on

Questions:- What is your differential diagnosis?- Would you order a microscopic analysis on

BloodBlood

pHpH

P iP i ++

0.2 mg/dL0.2 mg/dL

N tiN ti

- Would you order a microscopic analysis on this sample?- What would you do next to confirm the diagnosis?

- Would you order a microscopic analysis on this sample?- What would you do next to confirm the diagnosis?

ProteinProtein

Nit itNit it


NegativeNegative

NegativeNegative

NitriteNitrite

L.E.L.E.

Common Findings in:Acute Tubular Necrosis

GlucoseGlucose

BilirubinBilirubin

DecreasedDecreased Microscopic:Microscopic:KetonesKetones

S.G.S.G.

+ / -+ / -

//

• Renal tubular epithelial cells• Pathological casts• Renal tubular epithelial cells• Pathological casts

BloodBlood

pHpH

P iP i + / -+ / -ProteinProtein

Nit itNit it


NitriteNitrite

L.E.L.E.

Common Findings in:gAcute Glomerulonephritis

GlucoseGlucose

BilirubinBilirubin

Microscopic:Microscopic:KetonesKetones

S.G.S.G.

IncreasedIncreased

I dI d

• Erythrocytes (dysmorphic)• Erythrocyte casts• Mixed cellular casts

• Erythrocytes (dysmorphic)• Erythrocyte casts• Mixed cellular casts

BloodBlood

pHpH

P iP i IncreasedIncreaseded ce u a castsed ce u a casts

ProteinProtein

Nit itNit it


NitriteNitrite

L.E.L.E.

Common Findings in:gChronic Glomerulonephritis

GlucoseGlucose

BilirubinBilirubin

DecreasedDecreased

I dI d

KetonesKetones

S.G.S.G.Microscopic:Microscopic:

IncreasedIncreased

I dI d

BloodBlood

pHpH

P iP i

• Pathological casts(broad waxy casts, RBCs)

• Pathological casts(broad waxy casts, RBCs)

IncreasedIncreasedProteinProtein

Nit itNit it


NitriteNitrite

L.E.L.E.

Common Findings in:gAcute Pyelonephritis

Mi iMi i

GlucoseGlucose

BilirubinBilirubin

Microscopic:

• Bacteria

Microscopic:

• Bacteria

KetonesKetones

S.G.S.G.

• Leukocytes• Leukocyte, granular, and

waxy casts

• Leukocytes• Leukocyte, granular, and

waxy casts

BloodBlood

pHpH

P iP i TraceTrace

PositivePositive

waxy casts• Renal tubular epithelial

cell casts

waxy casts• Renal tubular epithelial

cell casts

ProteinProtein

Nit itNit it


PositivePositive

PositivePositive

NitriteNitrite

L.E.L.E.

Common Findings in:gNephrotic Syndrome

GlucoseGlucose

BilirubinBilirubin


S.G.S.G.

++++++++

• Oval fat bodies• Fatty casts

W t

• Oval fat bodies• Fatty casts

W t

BloodBlood

pHpH

P iP i ++++++++ • Waxy casts• Waxy castsProteinProtein

Nit itNit it


NitriteNitrite

L.E.L.E.

Common Findings in:gEosinophilic Cystitis

GlucoseGlucose

BilirubinBilirubin


S.G.S.G.

++• Numerous eosinophils

(Hansel’s stain)NO i ifi t t

• Numerous eosinophils(Hansel’s stain)NO i ifi t t

BloodBlood

pHpH

P iP i • NO significant casts.• NO significant casts.ProteinProtein

Nit itNit it


NitriteNitrite

L.E.L.E.

Common Findings in:gUrothelial Carcinoma

GlucoseGlucose

BilirubinBilirubin


S.G.S.G.

• Malignant cells on urine cytology (urine

l h ld b b itt d

• Malignant cells on urine cytology (urine

l h ld b b itt d

BloodBlood

pHpH

P iP i

++

sample should be submitted separately to cytology, void or 24 hrs.)

sample should be submitted separately to cytology, void or 24 hrs.)

ProteinProtein

Nit itNit it


NitriteNitrite

L.E.L.E.

urinalysssisbilirubin determinations. 3. second-voided specimen first sample after the first void of...

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