Pemeriksaan

Laboratorium
Sistem Urinarius

Indriani Silvia

FK UNSWAGATI
25 Juni 2012
1
Tujuan
Evaluasi kesehatan
Diagnosis penyalit/kelainan ginjal/saluran urin
Diagnosis kelainan sistemik yang mempengaruhi
fungsi ginjal
Monitoring kasus diabetes
Pemeriksaan penyaring penyalahgunaan obat
sulfonamid, aminoglikosida
Pengumpulan Spesimen Urin
Urin yang pertama dikeluarkan pada pagi
hari setelah bangun tidur (urin pagi)
Urin random untuk emergensi
Clean-catch, midstream urine (for urine
culture)
Pengumuman
Harus diperiksa lab dalam 1 jam setelah
dikumpulkan
Specimen Collection
1. Random Specimens
Clean-not sterile
Ordered for
Urinalysis testing
Measurement of specific gravity
pH
Glucose levels
Urine specimen collection
2. Midstream Specimen
Clean voided
C&S
30-60 mls urine
3. Sterile Specimen
Indwelling catheter
Drainage bag

Urine collection
4. Timed urine specimens
2-72 hr intervals (24hr most common)
Begin after urinating
Note start time on container & requisition
Collect all urine in timed period
Post Reminder Signs
Contents
Physical examination
Chemical examination
Microscopic examination
Physical examination
Appearance
Urine volume
Specific gravity (SG)

Appearance
Including color and clarity
Color : normally , pale to dark yellow (urochrome)
Abnormal color :
some drugs cause color changes
1. red urine : causes: hematuria
hemoglobinuria
myoglobinuria
2. yellow-brown or green-brown urine: bilirubin
cause : obstructive jaundice
Red Urine
Microscopic Hematuria
Urinary tract source
Urethra or bladder
Prostate
Ureter or kidney
Non-Urinary tract
source
Vagina
Anus or rectum

Pseudohematuria (non-hematuria
related red urine)
Myoglobinuria
Hemoglobinuria
Phenolphthalein Laxatives
Phenothiazines
Porphyria
Rifampin
Pyridium
Bilirubinuria
Phenytoin
Pyridium
Red diaper syndrome
Foods (Beets, Blackberries,
Rhubarb)

Red Urine
Causes of Asymptomatic Gross Hematuria by Incidence
Acute Cystitis (23%)
Bladder Cancer (17%)
Benign Prostatic Hyperplasia (12%)
Nephrolithiasis (10%)
Benign essential hematuria (10%)
Prostatitis (9%)
Renal cancer (6%)
Pyelonephritis (4%)
Prostate Cancer (3%)
Urethral stricture (2%)

Appearance
Clarity: normally, clear
Abnormal color: cloudy urine
Causes: 1. crystals or nonpathologic salts
phosphate, carbonate in alkaline urine
(dissolve---add acetic acid)
uric acid in acid urine
(dissolve---warming to 60)
2. various cellular elements: leukocytes,
RBCs, epithelial cells
Urine volume
The average adult : 1000 mL 2000ml/24h
Increase
polyuria---more than 2000ml of urine in 24
hours
1. physiological states: water intake, some
drugs, intravenous solutions
2. pathologic states: diabetes mellitus,
diabetes insipidus
Urine volume
Decrease
Oliguria---less than 400ml of urine in 24 hours
Anuria---less than 100ml of urine in 24 hours
1. prerenal: hemorrhage, dehydration,
congestive heart failure
2. postrenal: obstruction of the urinary tract
(may be stones, carcinoma)
3. renal parenchymal disease:
acute tubular necrosis, chronic renal failure

Urological Assessment
Key Signs and Symptoms of
Urological Problems
POLYURIA
More than 2 Liters urine per day
OLIGURIA
Less than 400 mL per day
ANURIA
Less than 50 mL per day
Specific gravity (SG)
Reflect the density of the urine
Range of 1.001 to 1.040
Increase: DehydrationFeverVomiting Diarrhea
Diabetes Mellitus and other causes of Glycosuria
Congestive Heart FailureSyndrome Inappropriate
ADH Secretion (SIADH) Adrenal Insufficiency
failure (urine volume and SG)
Decrease: diabetes insipidus
(urine volume and SG )
Chemical examination
Urine PH
Protein
Glucose
Ketones
Occult blood
Bilirubin
Urobilinogen
Nitrites

Urine PH
Normal PH
The average is about 6
Range from 5~9 (depends on diet)
Higher PH---alkaline urine
1.drugs: sodium bicarbonate
2.classic renal tubular acidosis
3.alkalosis (metabolic or respiratory)
Lower PH---acid urine
1.drugs: ammonium chloride
2. acidosis (metabolic or respiratory)
Protein in urine
Reference value
Qualitative method: negative
Quantitative method: less than 150mg of
protein in 24 hours
Urine proteins come from plasma protein
and Tamm-Horsfall (T-H) glycoprotein
Proteinuria---more than 150mg proteins in
urine in 24 hours or qualitative test is
positive
Proteinuria quantification (depend on the
amount of protein )
heavy proteinuria----4.0g/24 hours
moderate proteinuria----1.0~4.0g/24 hours
minimal proteinuria----1.0g/24 hours
Qualitative categories of proteinuria
Glomerular proteinuria:
1. glomerular diseases damage glomerular
basement membrane but tubular function
is normal
2.selective proteinuria---chiefly albumin
nonselective proteinuria
3.heavy proteinuria
4.disease: acute glomerulonephritis

Tubular proteinuria
1.Renal tubular disease damage tubular
function but glomerular is normal
2.Moderate proteinuria
3. disease: pyelonephritis

Overflow proteinuria
Excess levels of a protein in the circulation,
hemoglobin, myoglobin, etc. The renal
function is normal

Overflow Causes
Hemoglobinuria
Myoglobinuria
Multiple Myeloma
Amyloidosis


Proteinuria Causes
Glomerular Causes (Increased glomerulus
permeability)
Primary Glomerulonephropathy
Minimal Change Disease
IgA Nephropathy
Idiopathic membranous
Glomerulonephritis
Focal segmental Glomerulonephritis
Membranoproliferative Glomerulonephritis
Heavy metals
Tubular Causes (Decreased tubular reabsorption)
Hypertensive nephrosclerosis
Uric Acid nephropathy
Acute hypersensitivity
Interstitial Nephritis
Fanconi Syndrome
Heavy metals
Sickle Cell Anemia
NSAIDs
Antibiotics
Secondary Glomerulonephropathy
Diabetes Mellitus (Diabetic Nephropathy)
Systemic Lupus Erythematosus (Lupus Nephritis)
Amyloidosis
Preeclampsia (Pregnancy Induced Hypertension)
Infection
HIV Infection
Hepatitis B
Hepatitis C
Poststreptococcal Glomerulonephritis
Syphilis
Malaria
Endocarditis
Lung Cancer
Gastrointestinal Cancer
Lymphoma
Renal transplant rejection

Overflow Causes (Increased low molecule
weight protein production)
Hemoglobinuria
Myoglobinuria
Multiple Myeloma
Amyloidosis


Glucose in urine
Reference value
Qualitative method: negative
Glycosuria--- qualitative test is positive
1.hyperglycemia: diabetes mellitus
Cushings syndrom
2.without hyperglycemia: renal tubular
dysfunction, such as pyelonephritis

Ketones in urine
Including three ketone bodies:
acetoacetic acid 20%
acetone 2%
-hydroxybutyric acid 78%
The products of fat metabolism
Reference value:
qualitative method: negative
Ketonuria--- qualitative test is positive
Ketonuria
1. diabetic ketonuria
2. nondiabetic ketonuria:
Hyperemesis of pregnancy
Patients accompanied by vomiting or
diarrhea
30, coklat
Karakteristik Urin
Warna dan Kejernihan
Jernih, kuning pucat gelap urokrom
Urin yang terkonsentrasi kuning gelap
Abnormal merah, coklat kemerahan
pewarna makanan, konsumsi umbi bit, obat,
hemoglobin atau mioglobin
Eritrosit > merah berawan
Turbiditas/kepekatan seluler atau protein >

31
Karakteristik Urin
Berat jenis (BJ) kepekatan urin di dalam
air
1,001 1,035 encerkan
1,001 encer
1,035 pekat
dipengaruhi bahan terlarut/solusio
> 1,035 terkontaminasi atau
mengandung glukosa
pewarnaan radiopaque dan dekstran
BJ
32
Karakteristik Fisik Urin
Bau
bau amoniak
obat dan sayuran (asparagus)
keton bau buah-buahan/menyerupai
aseton
33
Komposisi Kimiawi Urin
95% air dan 5% solusio
sisa metabolisme nitrogen ureum, asam urat
,kreatinin
solusio:
sodium, potasium, ion sulfat
kalsium, magnesium, ion bikarbonat
kadar solusio abnormal patologi
Urinalysis can reveal diseases that have
gone unnoticed because they do not produce
striking signs or symptoms.
The most cost-effective device used to
screen urine is a paper or plastic dipstick.

A sample of well-mixed urine is centrifuged in
a test tube at relatively low speed for 5 minutes
The sediment is resuspended in the remaining
supernate by flicking the bottom of the tube
several times. A drop of resuspended sediment
is poured onto a glass slide and coverslipped.
The supernatant is used for the dipstick
method and decanted.
Methodology

36
Urinalysis
Metode Dipstik:
reaksi kimia methyl red
dan bromthymol blue
perubahan warna
pada 10 kotak strip

1. lekosit
2. nitrit
3. urobilinogen
4. protein
5. pH
6. darah
7. keton
8. bilirubin
9. glukosa

37
Interpretasi Urinalisis Disptik
Lekosit infeksi atau inflamasi
Normal=negatif
Piuria: lekosit dalam urin
Sistitis: infeksi kandung kemih
Pielonefritis: infeksi ginjal

Benedicts Reagent
A blue colored solution used to test for the presence of a
reducing sugar such as glucose, fructose,
glyceraldehyde, lactose etc. (note that sucrose is not a
reducing sugar)
It is prepared from NaHCO3, Na Citrate and CuSO4
(Cupric)
The carbonyl (aldehyde or ketone) group will reduce
and change Cu (II)s electron configuration to Cu (I) as
manifested by the brick red color change
Common, easy access test for gestational diabetes and
other forms of excess circulating blood sugar



Materials and Procedure
Comparison of pathologic and sample urine for
glucose
- 2 Test tubes (one for the sample and the
pathologic) filled with 5 ml of Benedicts
solution, bring to a boil
- Add 8 drops in the test tube (one for each
source) and bring to a boil again for 2 minutes
at least
Results
Sample: (+)- distinct blue green
upper portion
Pathologic: (+++)- murky brown
to orange upper portion
Expected: blue (sugar should not be
excreted by the kidneys; it is 100%
reabsorbed)
41
Interpretasi Urinalisis Disptik
Nitrit infeksi bakteri batang Gram
negatif Escherichia coli
Normal=negatif

42
Interpretasi Urinalisis Disptik
pH rentang lebar 4,58,0
dicatat dan diaporkan
Diet pH
Asam diet protein, ketoasidosis
Alkalin vegetarian diet, infeksi saluran kemih
Fosfat presipitasi dalam suasana urin yang alkali
Asam urat presipitasi dalam suasana urin yang asam
43
Interpretasi Urinalisis Disptik
Protein berat molekul (BM) >
normal tidak via barier glomerulus
abnormal inflamasi glomerulus proteinuria
Normal=negatif
ringan/trace ibu hamil, diet protein
Albuminuria albumin dalam urin
44
Interpretasi Urinalisis Disptik
Glukosa (Benedictss Copper Reduction Test /modifikasi Benedik)
filtrasi glukosa melampaui kapasitas reabsorpsi tubular
maksimal terhadap glukosa

Normal=negatif
Glikosuria glukosa dalam urin

45
Interpretasi Urinalisis Disptik
Keton metabolisme intermediate lemak
Pemeriksaan urin hanya asam aseto asetat, bukan
keton lainnya atau asam beta hidroksibutirat
Normal=negatif atau trace ( ringan)
Ketonuria keton dalam urin
ketonuria + glukosa dalam urin dibates melitus
46
Interpretasi Urinalisis Disptik
Urobilinogen hasil produksi bilirubin via intestin
Normal=dalam jumlah sedikit
Urobilinogen (-): gangguan fungsi ren, obstruksi bilier
Produksi atau retensi bilirubun

hepatitis, sirosis, gangguan sistem biliaris
47
Interpretasi Urinalisis Disptik
Bilirubin gangguan fungsi hati,
obstruksi bilier
Normal=negatif
Bilirubinuria: bilirubin dalam urin
Busa berwarna kuning shake
48
Interpretasi Urinalisis Disptik
Darah BM tidak dapat via GBM
Normal=negatif
Darah dalam urin (hematuria) abnormal
Batu ginjal, infeksi, tumor
Perhatikan eritrosit dapat ditemui
pada menstruasi
49
Analisis Kimiawi
Sulfat zat normal dalam urin
Derivat sulfur mengandung asam amino dan
dipengaruhi oleh asupan protein
Fosfat zat normal dalam urin
Bufer H
+
pada duktus saluran kemih
Klorida zat normal dalam urin
Anion ekstraseluler terbanyak
menyeimbangkan ion t.u counter-ion
garam/sodium

50
Analisis Kimiawi
Urea hasil akhir pemecahan protein

Asam urat metabolit hasil pemecahan purin

Kreatinin metabolisme otot dari fosfat
kreatin
51
Pemeriksaan Mikroskopis Urin
Lekosit dalam urin

Normal:
<2 lekosit/LPB
<5 lekosit/LPB
Piuria lekosit dalam urin
inflamasi sepanjang sal kemih
52
Pemeriksaan Mikroskopis Urin
Hematuria eritrosit dalam urin
Bentuk eritrosit
menggembung urin yang encer
crenated urin pekat

bentuk dismorfik (odd shaped)
eritrosit dalam urin
gangguan fungsi glomerular
glomerulonefritis
Eritrosit dismorfik
53
Pemeriksaan Mikroskopis
sel epitel
Sel skuamos >
kontaminasi
spesimen tidak baik

54
Pemeriksaan Mikroskopis
sel epitel
Sel transisional asli berasal dari pelvis renalis,
ureter, vesika urinaria dan atau uretra
Ukuran sel epitel transisional > normal
karsinoma vesika urinaria
55
Pemeriksaan Mikroskopis

Bakteri
urin yang terkontaminasi
ditelusuri apakah ada infeksi bakteri di traktus urinarius

A = crenated RBC, B = RBC, C = bakteri
56
Struvite Crystal

Urin alkali

ISK bakteri produksi urease
Proteus vulgaris struvite crystal pH dan
amoniak bebas
57
Kristal Asam Urat
Asam urat darah hasil digesti
purin/protein
Gout/artritis

58
Kristal Asam Oksalat
Tampak
di semua pH urin
Penyebab:
diet asparagus dan
intoksikasi glikol
etilen (antifreeze)
59
Pemeriksaan Mikroskopis Urin
Cast
cast fragmen sel padat, terbentuk di
tubulus distal dan duktus proksimal
> patologis
hanya tampak pada pemeriksaan urin
mikroskopis
62
Hyaline Cast
Hyaline cast terbentuk dari
pertama kali dari mukoprotein
(Tamm-Horsfall
protein) disekresikan oleh
sel tubulus



Etiologi: LFG , kadar garam , pH , denaturasi dan
presipitasi dari protein Tamm-Horsfall
Hyaline Casts appear Transparent
63
Red Cell Cast
Red blood cell/eritrosit melekat satu sama lainnya
membentuk red blood cell cast
Glomerulonefritis lolosnya eritrosit via glomeruli
atau kerusakan tubular yang luas

64
White Cell Cast
> pielonefritis/inflamasi ginjal
< nefritis interstisialis (inflamasion tubulus dan
sel-sel antara tubulus dan glomeruli)

Calcium Oxalate
CaOx cont...
Triple Phosphate
Triple
Phosphate
Ammonium
Biurate
Cystine
Abnormal Crystals
of Metabolic Origin
Cystine continued
May confuse with uric acid
both are acid pH crystals
confirmatory for cystine: Nitroprusside Reaction
Tyrosine
Severe liver disease
Rarely seen
Colorless needles, acidic pH
Tyrosine
Abnormal Crystals
of Metabolic Origin
Leucine (Rare)
Liver disease (with tyrosine)
Yellow, oily-looking spheres, acidic pH,
birefringent (pseudo Maltese cross when
polarized)
Cholesterol
Seen as free fat, in renal epis, fatty casts in
cases of nephrotic syndrome
Abnormal Crystals
of Metabolic Origin
Cholesterol
Acidic pH, colorless, large, flat, rectangular
plates with one or more corners notched.
May be mistaken for radiologic dyes
Specific gravity

Cholesterol
Abnormal Crystals of
Iatrogenic Origin
Sulfonamides
Renal damage as these ppt out in nephron
Acidic pH, yellow to brown, needles in sheaves
but have a variety of shapes
Ampicillin
High dose
Acidic pH, thin colorless needles
Abnormal Crystals of
Iatrogenic Origin
Radiologic Contrast Media
renografin, hypaque
Look like cholesterol (variety of shape)


Radiologic
Dye
Sulfonamid
es
Bilirubin Crystals
Bilirubin Crystals Cont
82
The End