value of urinalysis in clinical medicine copy
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Value Of Urinalys
is In Clinical Medicin
e
Dr./ Sahar
Hamdy
Medical
consultant El-
Mataria Teaching
Hospital, Cairo
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Introduction Urine formed in the kidneys, is a product of ultrafiltration of plasma by the renal glomeruli.
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Formation of Urine The nephron:
•allows for reabsorption of water and electrolytes
•plays a vital role in maintaining normal fluid balance
Three processes of urine formation :
glomerular filtration
tubular reabsorption
tubular secretion
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Physical Composition and Chemical Properties
Urea, uric acid, ammonia, calcium, creatine, sodium, chloride, potassium, sulfates, phosphates, bicarbonates, hydrogen ions, urochrome, urobilinogen
Urine 95% water
5% waste productsOther dissolved chemicals
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Obtaining Specimens General guidelines:
Use the type of specimen container indicated by the lab
Label the specimen container before giving it to patient
Explain the procedure to patient Wash your hands before and after
procedure Complete all necessary paperwork
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Specimens Types It Varies in method used and in time frame in which to :collect specimenTypes of specimens:
RandomFirst morning
Clean catch midstreamTimed24 hour
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Specimens Types (cont.)
Random – most common, taken anytime of day
First morning – has a greater concentration of substances, taken in morning
Clean catch midstream – genitalia is cleaned, urine is tested for microorganisms or presence of infection
Timed – specific time of day, always discard first specimen before timing
24 hour – used for quantitative and qualitative analysis of substances
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UrinalysisEvaluation of urine to obtain information about body health and disease
Four types of testing: Physical Chemical Microscopic Culture and sensitivity( beyond the scope of
lecture)
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Preservation and Storage
Refrigeration – most common method for storing and preserving urine
It prevents bacterial growth for 24 hours.
After 24 hours use chemical preservation
Changes that affect the chemical or microscopic properties of urine occur if urine is kept at room temperature for more than 1 hour
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Normal Values of Urine Normal values of
various elements have been established
A routine vol. of 12 mL urine is analysed
Average adult urine output is 1250 mL/24 hours(>1mL/Kg/hour)
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I- Physical Examination of Urine
Visual examination of physical characteristics
1. Volume 2. Color and
turbidity3. Odor4. Specific gravity/
Osmolality
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Urinary volume
• Normal = 600-1550 mL/d• Polyuria- > 2000mL• Oliguria-< 400 mL• Anuria-complete cessation of urine(<
200 mL)• Nocturia-excretion of urine by a adult
of > 500 ml with a specific gravity of < 1.018 at night (c.c. of chronic GN)
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Common Causes of polyuria
Diabetes mellitus Diabetes insipidus Polycystic kidney Chronic renal failure Diuretics Intravenous saline/glucose
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Common Causes of Oliguria
Acute renal failure: Pre-renal, renal and post-renal
Hypovolemic: Dehydration / vomiting, diarrhea, excessive sweating
Renal ischemia
Acute tubular necrosis
Obstructive Uropathy
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Urinary Color And Its Clinical
Significance Normally urine is amber yellow and clear Colourless: D.I., D.M., diuretics,.. Deep yellow: Conj. Bilirubin, phenacetin, riboflavin,
mepacrine,.. Foamy: proteinuria Milky: Pus, chyluria, spermatozoa, urate crystals(acidic
urine), insoluble phosphates(alkaline urine),.. Orange: Fever, excessive sweating, metronidazole,
aniline dyes(sweets), anthroquinones(laxatives), rifampicin,..
Red: Beeturia(anthrocyaninuria), porphyrins, hematuria, hemoglobinuria, myoglobinuria, phenindione, phenolphthalein,..
Brown: Porphyria, alkaptonuria, L-dopa,.. Green: Pseudomonas, methylene blue, phenol, lysol,..
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Urine Appearance
Turbidity means: Cellular elements, Bacteria(which clear by centrifugation), and Crystals(which clear by addition of acids or
bases)…It’s the microscopic examination which will determine which type…
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Urine Odour
Normal: Urinefrous(aromatic volatile acids)• Sweety: Glucose• Fruity: Ketones• Foul, offensive: old specimen, pus
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Urine Sp. Gr. / Osmolality• Specific Gravity depends on the concentration of
various solutes in the urine.
• N.Sp.Gr. = 1.016 – 1.022• Hyperosthenuria: Dehydr., D.M.,..• Hyposthenuria: Polyuria(except diabetes)• Isosthenuria: Fixed at 1.010 in CRF //////////////////////////////////////////////There is a linear relationship between Sp. Gr. & Osmolality; ; ; Except in Glycosuria, or Excretion of contrast ----- In this case, the Sp. Gr. Will be > Osmolality
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Measurement of Specific
GravityIt’s measured by: -urinometer -refractometer -dipsticks
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UrinometerMethod for use: Take 2/3 of urinometer container with urine Allow the urinometer to float into the urine Read the graduation at the lowest level of
urinary meniscus
*Correction of temperature & albumin is a must.*Urinometer is calibrated at 15 or 200cSo for every 3oc increase/decrease add/subtract 0.001For 1gm/dl of albumin add 0.001
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23
Apply Your Knowledge
What is the specific gravity shown on this refractometer screen?
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24
Apply Your Knowledge -Answer
The specific gravity shown here is 1.030
What is the specific gravity shown on this refractometer screen?
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Urinary Dipsticks
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Dipsticks Use The main
disadvantage :is that
1.Not very accurate (the test is time-sensitive).
2. It is a qualitative and not a quantitative test (no precise information about the severity of the abnormality).
•The main advantage of dipsticks is that they :are
1. convenient ,
2. easy to interpret ,
3. and cost-effective
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II- Chemical Examination of Urine
Usually done with reagent strips or tablets
Used to determine body processes such as CHO metabolism, liver or kidney function or acid-base
balance.
Used to determine presence of drug, toxic environmental substances or infections
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Chemicals In Urine1. pH provides information about metabolic status, diet,
medication or several conditions2. Glucose diabetes3. Ketone bodies DKA, Low CHO diet, or starvation4. Protein Intrinsic renal disease5. Blood Hematuria, hemoglobinuria, myoglobinuria6. Bilirubin / urobilinogen liver disease 7. Nitrite bacterial infection8. Leukocyte esterase Infection9. Phenylketones / aminoacids PKU, aminoaciduria10.Others Urinary Na, K, Ca, Mg, Po4, Creatinine,..N.B: Creatinine Clearance(C Cr.)
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1 -Urinary pH/ reaction Reaction reflects ability of kidney to maintain normal hydrogen ion concentration in plasma & ECFNormal= 4.6-8Tested by :- 1.litmus paper 2. pH paper 3. dipsticks
Other Tests: Titrable acidity Blood gases
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Significance Of Urinary pH
reaction
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Dipstick for pH
• Buffers from the protein area of the strip (pH 3.0) spill over to the pH area of the strip and make the pH of the sample appear more acidic than it really is
Limitations:
• Interference:
Bacterial
overgrowth
• Run-Over Effect:
Protein pad effect
on PH pad
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2 -Urinary Glucose detectionDetection of reducing sugars by:
Benedict’s TestUrinary dipsticks
Semi-quantitative))Benedict:•Principle-Benedict’s reagent contains cuso4.In the
presence of reducing sugars cupric ions are converted to cuprous oxide which is hastened by heating, to give the color.
•Method- take 5ml of benedict’s reagent in a test tube, add 8drops of urine. Boil the mixture.
Blue-green = negative Yellow-green = +(<0.5%)
Greenish yellow = ++(0.5-1%) Yellow = +++(1-2%)
Brick red = ++++(>2%)N.B: Renal threshold must be passed in order for glucose to spill into urine
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Dipsticks for GlucoseHowever, Benedict detects all reducing substances like glucose, fructose, & other reducing sustances such as:
N.B: Sucrose is not a reducing substance
To confirm it is glucose, dipsticks can be used (glucose oxidase)
Disease Sugar
Galactosemia Galactose
Lactase def. or intolerance
Lactose
Fructose intolerance
Fructose
Essential pentosuria
Pentose
Non-pathogenic Maltose
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Causes of glycosuria
Glycosuria without hyperglycaemia -• Renal tubular
dysfunction(ex. Fanconi syndrome; also with: a.a.uria & po4 uria)
• Renal Glycosuria• TTT with SGLT(sodium
glucose transport inhibitors used to treat DM)
Glycosuria with hyperglycaemia- • Diabetes,• Acromegaly, • Cushing’s disease,
Hyperthyroidism, • Drugs like
corticosteroids
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3 -Urinary ketone detection
There are 3 types of ketone bodies: Acetone Acetoacetate Beta-hydroxy-butyrateDetection of ketones by: Rothera’s Test Dipsticks• Rothera’s t. principle:Acetone & acetoacetic acid react
with sodium nitroprusside in the presence of alkali to produce purple colour.
• Method- take 5ml of urine in a test tube & saturate it with ammonium sulphate. Then add one crystal of sodium nitroprusside. Then gently add 0.5ml of liquor ammonia along the sides of the test tube.
• Change in colour indicates a positive result
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Dipsticks For Ketones
Significance:DiabetesStarvationSevere vomiting/diarrheaHigh feverLimitations:
Measure only acetoacetate and not other ketones >>>Cannot detect alcoholic KA(with ↑BHB >AA)
Reagents can undergo degradation with exposure to moist of air
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4 -Urinary protein detection
%of Total
Max. (mg/day)
Protein
40 60 Albumin
40 60 Tamm-Horsefall
12 24 Igs
3 6 Secretory IgA
5 10 Others
--Normally, up to 150 mg total proteins may be found in urine per 24 hours
--More than 300 mg per 24 hours is termed “ Frank Proteinuria “
N.BTest-thermal method:water-
bath))Proteins has an unusual and peculiar property of precipitation at 400 -600c & then dissolving when urine is brought to boiling at 1000c & then reappearing de novo on cooling of sample.
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Tests for proteinsTest – heat & acetic acid testPrinciple-proteins are denatured & coagulated on heating to give white cloud precipitate.Method-take 2/3 of test tube with urine, heat only the upper part keeping lower part as control.Presence of phosphates, carbonates, proteins gives a white cloud formation. Add acetic acid 1-2 drops, if the cloud persists it indicates it is protein(acetic acid dissolves the carbonates/phosphates)Other Tests:
(SSA turbidity test-)Sulphosalicylic acid-Dipsticks
-Esbach-albuminometer- for quantitative estimation of proteinsUrine protein electrophoresis(UPEP)-
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Albumin Excretion:
Alternative Methods for expressing the
normal rangeNormal Value Sample
<30 mg / 24 hrs 24-h urine collection
<20 micro-g / min Timed sample from ambulant pt.
<10 micro-g / min Timed sample for recumbent pt.(or over-night sample)
in male) ) < 2.5 mg / mmol Albumin / creatinine ratio on a random urine sample
<3.5 mg / mmol (in female)
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Dipsticks for proteinsLimitations:
Interference: Highly alkaline urine
-Almost all dipsticks detect proteins if present in an amount more than 300 mg / 24 Hs
-They cannot detect micro-albuminuria (30-150 mg) alb./24-h urinary sample>>>>>
… Esbach –albuminometer can be used
Bences- Jones proteins are light chain globulins present in multiple myeloma, macroglobulinemias and lymphomasThey are detected by: UPEPN.B.: Usually +1 ptn. correlates with 30 mg alb.And +3 ptn. Correlates with > 500 mg alb.
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Importance of micro-albuminuria
It is an early indicator of subclinical nephropathy either due to on intrinsic kidney disease or due to a cardiovascular disease..
It may be an important prognostic marker..? It is considered as a routine check-up in all
cases of diabetes mellitus or in hypertension (every 6 months)..
Serial rise in micro-albuminuria during the first 48 hours after admission to an intensive care unit can predict elevated risk for acute respiratory failure , multiple organ failure , and overall /CV mortality (as a bad prognostic criterion.. )
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Causes Of Proteinuria
Functional
• Pregnancy• Orthostatic(
<1gm/24h)• Severe
Ms.exertion
Prerenal
• Fever• Hypoxia• HTN• Renal vein
thrombosis• Severe
exfoliative skin dis.(eg psoriasis)
Renal
• GN• NS• Diabetes• SLE• Amyloidosis• UTI• Tumours
Postrenal
• Cystitis/Urethritis
• Prostatitis• Obstructive
uropathy• Contaminat
ed vaginal secretions
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5-Urine blood detectionTest- BENZIDINE TEST
Principle-The peroxidase activity of hemoglobin decomposes hydrogen peroxide releasing nascent oxygen which in turn oxidizes benzidine to give blue color.
Method- mix 2ml of benzidine solution with 2ml of hydrogen peroxide in a test tube. Take 2ml of urine & add 2ml of above mixture. A blue color indicates + reaction.
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:Significance -Hematuria: Nephritis, trauma..,
-Hemoglobinuria: Hemolysis (decr.haptoglobin)..,
-Myoglobinuria: Rhabdomyolysis (N.haptoglobin)..,
Limitations -Interference: reducing agents, microbial
peroxidases -Cannot distinguish between the above disease
processes
Other Tests -Urine microscopic examination
-Urine cytology
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Causes of hematuria
Pre renal- bleeding diathesis, hemoglobinopathies, malignant hypertension.
Renal- Trauma, calculi, ac. & chr. glomerulonephritis, pyelonephritis, renal TB, renal tumours, Good-pasture syndrome and Henoch-shonlein purpura
Post renal – severe UTI, calculi, trauma, tumors of urinary tract
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NegativeNegative
Trace (non-hemolyzed)Trace (non-hemolyzed)
Moderate (non-hemolyzed)Moderate (non-hemolyzed)
Trace (hemolyzed)Trace (hemolyzed)
( +weak) ( +weak)
( ++moderate) ( ++moderate)
( +++strong) ( +++strong)
The Urine Dipstick: Blood
Diisopropylbenzene dihydroperoxide+ Tetramethylbenzidine
>------------ Colored ComplexHeme
Chemical Principle
Lysing agent to lyse red blood cells
Read at 60 secondsRR: Negative
Analytic Sensitivity: 10 RBCs
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6 -Urine bilirubin or Urobilinogen
Bilirubin Urobilinogen
Test- fouchet’s test.Causes• Liver diseases, injury, hepatitis• Obstruction to biliary tract
SignificanceIt correlates with D. serum bilirubin
Limitations- Interference: prolonged exposure
of sample to light- Only measures direct bilirubin--
will not pick up indirect bilirubin
Other Tests- Ictotest (more sensitive tablet
version of same assay)
Test- Ehrlich test
Causes- hemolytic anemia's and hepatocellular jaundice
Significance- High: increased hepatic processing of
bilirubin- Low: bile obstruction
Limitations- Interference: prolonged exposure of specimen to oxygen (urobilinogen ---> urobilin)- Cannot detect low levels of urobilinogen
Other Tests- Serum total and direct bilirubin
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Dipsticks for bilirubin and
urobilinogenBilirubin Urobilinogen
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7 -Urinary detection of nitrites
Significance:- Gram negative bacteriuria:Limitations
- Interference: bacterial overgrowth- Only able to detect bacteria that reduce nitrate to nitrite
:Other Tests- Correlate with leukocyte esterase and urine microscopic examination (bacteria)- Urine culture
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NegativeNegative
PositivePositive
The Urine Dipstick for nitrite:
Diazo compound + Tetrahydrobenzoquinolinol>---------- Colored Complex
Nitrite + p-arsenilic acid -------> Diazo compoundAcidic
Chemical Principle
Read at 60 secondsRR: Negative
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8 -Urinary detection of leucocyte
esteraseSignificance
-Pyuria -Acute inflammation
-Renal calculus
Limitations -Interference: oxidizing agents, menstrual
contamination
Other Tests -Urine microscopic examination (WBCs and
bacteria) -Urine culture
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NegativeNegative
TraceTrace
( +weak) ( +weak)
( ++moderate) ( ++moderate)
( +++strong) ( +++strong)
The Urine Dipstick: Leukocyte
Esterase
Derivatized pyrrole amino acid ester
>------------ 3-hydroxy-5-phenyl pyrroleEsterases
3-hydroxy-5-phenyl pyrrole + diazo salt>------------- Colored Complex
Read at 2 minutesRR: Negative
Analytic Sensitivity: 3-5 WBCs
Chemical Principle
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III- Microscopic Examination
of Urine
• Centrifuge the urine sample for a few minutes (10-20 fold conc.)
• Discard the supernatant.• The solid part left in the bottom of the test tube (the
urine sediment) is mixed with the remaining drop of urine in the test tube and one drop is analyzed under a microscope
• FOV(field of view): What is seen through the ocular lens
A normal urine contains few epithelial cells, occasional RBC’s, few crystals.
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Types of microscopy:1. Phase contrast2. Polarized3. Bight field with special stainingN.B:Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp( refrigeration for up to 48 hours is a must to limit cell loss).
Presence of the following is considered “abnormal:”o Fungal hyphae or yeast, parasite, viral inclusionso Mononuclear cells(transplant rejection), eosinophils (all.
Interstitial nephritis, vasculitis, prostatitis & atheroembolic dis.)
o Sperms(post-vasectomy),starch, mucus, fibreso Pathological crystals (cystine, leucine, tyrosine)o Large number of uric acid or calcium oxalate crystals
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Abnormal Microscopical
FindingsPer high power
field(x40)Per low power
field(x10)
> 3 erythrocytes > 5 leukocytes(glitter cells)
Eosinophils: Giemsa or Hansel stain > 2 renal tubular cells > 1 bacteria Mononuclear cells Yeast Trichomonas Crystals
> 3 hyaline casts > 1 granular cast > 10 squamous cells
(contaminated specimen) Any other cast (RBCs,
WBCs)
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RBCS appear dysmorphic(mickey-mouse RBCs) in
glomerular bleeding; whilst derived from LUT, they look
normal
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WBCs(leucocytes) denote UTI, IN, Legionella or
Leptospira, athero-embolic dis, tubulo-interstitial
nephritis, or sarcoidosis
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Squamous cellsTubular Epithelial
cells
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Transitional Cells
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Oval Fat Bodies
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LE Cells
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Bacteria
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Yeasts
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Cytomegalovirus
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Crystals in urineCrystals are not a normal finding in a fresh urinary sampleCrystals in acidic urine Uric acid Calcium oxalate Cystine Leucine Tyrosine Cholesterol BilirubinCrystals in alkaline urine Amorphous phosphates Triple phosphates (NH4 Mg PO4: Struvite) NH4 bi-urate Calcium carbonateOthersDrug-induced (sulfonamide and radiocontrast)
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Bi-pyramidal or bi-concave ovals:Oxalate
Crystals
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Triple Phosphate Crystals
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Flat-square plates:Urate Crystals
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Leucine crystals
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Flat Hexagonal Plates:Cystine
Crystals
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Ammonium bi-urate crystals
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Cholesterol crystals
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Urinary Casts Urinary casts are cylindrical
aggregations of particles that form in the distal nephron, dislodge, and pass into the urine.
In urinalysis they indicate kidney disease.
They form via precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells.
Cast formation is enhanced by:• PH of urine• Solute conc.• Presence of plasma
proteins(albumin, (globulin, hemoglobin, myoglobin,..
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Types of casts
Acellular casts Cellular casts
• Hyaline casts• Granular casts• Waxy casts• Fatty casts• Pigment casts• Crystal casts• Broad casts
• Red cell casts• White cell casts• Epithelial cell cast
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Casts and clinical significance
Clinical Significance Urinary CastGN, tubular bleeding RBCs Cast
• PN, or acute Allergic IN, ATN, sarcoidosis, SLE, Wegner’s
• Ac. GN(post-strept), NS, atheroembolic disease,..
WBCs Cast
• Normal (Tamm-Horsfall glycoprotein)• Fever, exercise, dehydration, emotional
stress,..
Hyaline Cast
• ATN, nephrotoxic injury(aminoglycosides and cisplastin), IN
Tubular Cast
Non-Specific (can result either from breakdown of cellular cast or from aggregation of plasma proteins) indicate CKD
Granular Cast
• NS, DM, ATN, SLE Fatty Cast
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Casts and clinical significance
Clinical Significance Urinary Cast
CRF Broad Cast(Formed in dilated remaining tubules showing compensatory hypertrophy)
Hemolytic anemia, rhabdomyolysis, liver disease
Pigment Cast(Formed by the adhesion of metabolic breakdown products or drug pigments)
ATN, intoxication with mercury, salicylate or diethylene glycol
Epithelial Cast
Heavy crystal load Crystal Cast(Formed by incorporation of crystallised urinary solutes with hyaline casts)
Prolonged stasis (CKD) Waxy Cast
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RBCS Cast
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WBCs Cast
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Hyaline Cast
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Tubular Cast
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Granular Cast
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Fatty Cast
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Waxy Cast
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Cytological Examination
Staining:
o Papanicolaou staino Wright’s staino Hansel’s staino Immunoperoxidase sp. staino Immunofluorescence sp. stain
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CytologyNormal Reactive
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Transitional Cell CarcinomaLow Grade High Grade
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Squamous Cell Carcinoma Prostatic Carcinoma
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Common Microscopically
Urinary Findings in various
DiseasesFINDINGS DISEASE
Dysmorphic RBCs – RBCs and mixed cellular Casts
1- Acute glomerulonephritis
RBCs and broad waxy Casts 2- Chronic glomerulonephritis
Bacteria – Leucocytes – Granular, leucocyte, waxy and renal tubular epithelial Casts
3- Acute pyelonephritis
Oval fat bodies – Fatty casts – Waxy casts
4- Nephrotic syndrome
Renal tubular epithelial cells – Pathological Casts
5- Acute tubular necrosis
No significant casts – Numerous eosinophils
6- Eosinophilic cystitis
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UrinalysisDisease diagnosis
ANDCase study
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A 35-year old man undergoing routine pre employment drug screening.
Physical characteristics: Clear.Microscopic: Not performed .
Drugs Identified: None
Questions :
-What is your differential diagnosis? - What would you do next to confirm
your suspicion? - Would you order a microscopic
analysis on this sample?
A 35-year old man undergoing routinepre employment drug screening.
Physical characteristics: Clear.Microscopic: Not performed .
Drugs Identified: None
Questions :
-What is your differential diagnosis? -What would you do next to confirm
your suspicion? -Would you order a microscopic
analysis on this sample?
NegativeNegative
NegativeNegative
NegativeNegative
1.0011.001
NegativeNegative
5.55.5
NegativeNegative
0.2 mg/dL 0.2 mg/dL
NegativeNegative
NegativeNegative
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
UrobilinogenUrobilinogen
NitriteNitrite
L.E.L.E.
Case 1
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Answer 1Diluted urine with a low Sp. Gr>>>>>.
Request a morning urine sample>>>>>If persisting low Sp.Gr>>>>>.
Possible diagnosis of diabetes insipidus
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A 42-year old woman presents with “dark urine”
Physical characteristics: Red-brown.Microscopic: Not performed.
Questions
-What is your differential diagnosis? - 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?
A 42-year old woman presents with “darkurine”
Physical characteristics: Red-brown.Microscopic: Not performed.
Questions
-What is your differential diagnosis? -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
++++++
NegativeNegative
1.0201.020
NegativeNegative
5.55.5
NegativeNegative
0.2 mg/dL 0.2 mg/dL
NegativeNegative
NegativeNegative
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
UrobilinogenUrobilinogen
NitriteNitrite
L.E.L.E.
Case 2
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Answer 2Possible gallbladder or hepatic disease.No hemolytic anemia .
Perform Serum assessment for total and direct bilirubinMicroscopic exam. is unlikely to provide additional information for diagnosis
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A 27-year old woman presents with severe abdominal pain.
Physical characteristics: clear-yellow.Microscopic: Not performed.
Questions
-What is the most likely diagnosis? -What do you make of the ketone result?
- What do you expect to happen to the ketone measurement when treatment
begins?
A 27-year old woman presents with severeabdominal pain.
Physical characteristics: clear-yellow.Microscopic: Not performed.
Questions
-What is the most likely diagnosis? -What do you make of the ketone result?
-What do you expect to happen to the ketone measurement when treatment begins?
++++
NegativeNegative
TraceTrace
1.0151.015
NegativeNegative
6.06.0
NegativeNegative
1.0 mg/dL 1.0 mg/dL
NegativeNegative
NegativeNegative
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Case 3
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Answer 3 Diabetes
May be associated with ketoacidosisKetones should become negative after treatment
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NegativeNegative
NegativeNegative
NegativeNegative
1.0151.015
++++++
6.56.5
++
1.0 mg/dL 1.0 mg/dL
NegativeNegative
NegativeNegative
8- year old boy presents with discoloredurine
Physical characteristics: Red, turbid. Microscopic: erythrocytes = >100 per HPF(almost all dysmorphic)Red cell casts present.
Questions:
- What is the most likely diagnosis in thiscase?
- Does the presence of red cell casts helpyou in any way?
- If the erythrocytes were not dysmorphicwould that change your diagnosis?
8-year old boy presents with discolored urine
Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF (almost all dysmorphic)Red cell casts present.
Questions:
-What is the most likely diagnosis in this case?
-Does the presence of red cell casts help you in any way?
-If the erythrocytes were not dysmorphic would that change your diagnosis?
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Case 4
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Answer 4GlomerulonephritisRBC casts reveals renal cortex involvement
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NegativeNegative
NegativeNegative
NegativeNegative
1.0101.010
NegativeNegative
5.05.0
++
0.2 mg/dL 0.2 mg/dL
NegativeNegative
NegativeNegative
22-year old man presenting for a routine physical required for admission to medical school
Physical characteristics: YellowMicroscopic: Not performed
Questions:
-?What is your differential diagnosis Would you order a microscopic analysis -
?on this sample What would you do next to confirm the -
?diagnosis
year old man presenting for a routine-22 physical required for admission tomedical school
Physical characteristics: YellowMicroscopic: Not performed
Questions:
- What is your differential diagnosis?- Would you order a microscopic analysis on this sample?
- What would you do next to confirm the diagnosis?
GlucoseGlucose
BilirubinBilirubin
KetonesKetones
S.G.S.G.
BloodBlood
pHpH
ProteinProtein
NitriteNitrite
L.E.L.E.
UrobilinogenUrobilinogen
Case 5
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Answer 5“Functional” proteinuria ?
Microscopic may reveal a few leukocytesRequest protein concentration in 24 h urine
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