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Urinalysis

Physiology
Specimen collection
Chemical analysis
Macroscopic
Microscopic
Abnormalities

Functions of the Kidney


Elimination of excess body water
Elimination of waste products of metabolism
(e.g. urea, creatine)
Elimination of foreign substances (e.g. drugs)

Functions of the Kidney


Retention of substances necessary for normal
body function (e.g. proteins, amino acids,
glucose)
Regulation of electrolyte balance and osmotic
pressures of the body fluids

Composition of Urine
I. Water - (1,000 ml to 1,500 ml)/24 h
II. Urine Solute: (60 g/24 h)
A. Urea - most of nitrogen excreted
(10g/day)
Other substances - uric acid,
creatinine, amino acids, ammonia, and
traces of proteins, glycoproteins,
enzymes and purines

Composition of Urine
II. Urine Solute: (60 g/24 h)
B. Sodium Chloride (NaCl) - 5 to 20 g/day
C. Potassium - 70 mEq/day
D. Sulfate - organic or inorganic, 2 g/day
E. Phosphates - 1 g/day

Composition of Urine
Small amounts of:
F. Sugars - pentoses
G. Intermediary metabolites -Oxalic acid, citric
acid, pyruvate.
H. Free fatty acids and trace amounts of
cholesterol
I. Hormones - ketosteroids, estrogens,
aldosterone, pituitary gonadotropins

Composition of Urine
Small amounts of:
J. Biogenic amines - cathecholamines and
serotonin metabolites
K. Vitamins - ascorbic acid
L. Trace amounts of porphyrins
M. Crystals - in concentrated urines; uric acid
and phosphate crystals

Composition of Urine
Small amounts of:
N. Formed elements
1. Red blood cells
2. Leukocytes
3. Renal tubular epithelial cells
4. Transitional epithelial cells
5. Squamous epithelial cells

Specimen Collection
Suprapubic aspiration & straight
catheterization
Clean-catch midstream specimens
Collection bags for specimens from
children
Indwelling catheters
Other methods

Clean-catch midstream
specimens
Clean urethral area with a series of
sponges & soap
Retract skin folds (labia or prepuce)
before voiding
The first-void urine is passed into the
toilet to clear the urethra
Collect the midstream specimen
Continue voiding

Time of Collection
Collected early in the morning
counts increase overnight in bladder

Do not force fluids on patients


may dilute the urine
decrease count to <105 CFU/ml

For asymptomatic patients


collect 3 consecutive early-AM specimens

Specimen Transport
container:

sterile, wide-mouthed, screw-capped


anaerobic transporter for suprapubic aspirate

Pediatric
Urine bag

Specimen Transport
immediately refrigerated (4oC) or
preserved

Transport tubes: has boric acid, glycerol, and


Na formate which preserves bacteria without
refrigeration for 24h when >105 (100,000)
CFU/ml is present in the initial urine specimen.

Specimen Transport
General Considerations
1. Transport urine to the lab as soon as possible
after collection.
2. Culture urine specimens within 2H after
collection, or refrigerate and culture them within
8H whenever possible.
3. Refrigerated urine specimens may be held for
<24hr.

Specimen Transport
1. Request repeat specimen when there is no
evidence of refrigeration and the specimen is
>2H old.
2. Request a repeat specimen when the collection
time and method of collection have not been
provided.
3. If an improperly collected, transported, or
handled specimen cannot be replaced document
in the final report that specimen quality may
have been compromised.

Important Considerations
1. Containers
Container should be washed with
detergent and rinsed well with water
and dried.
For bacteriologic examination, a
sterile container is necessary.

Collection of Urine
2. Deterioration of Specimen
Should be collected in a dry, clean container
Should be examined when freshly voided
Consequences:
- RBC & WBC destroyed by hypotonicity of
urine
- Casts decompose
- Bacterial contamination
- Decreased pH

Collection of Urine
3. Storage

Random specimens should be examined fresh


or refrigerated and examined as soon as
possible.

Preservatives with refrigeration are occasionally


useful for specimens that need to be saved.

Collection of Urine
3. Storage
Preservatives
- One crystal of thymol / 10 to 15 ml of urine

preserve sediments but will interfere with test


for protein
- Formalin, 1 drp / 10 ml urine will preserve
sediments
- Freezing useful bilirubin, urobilinogen or
ketones
- Preservative tablets - for routine screening
preserve glucose and other constituents

Collection of Urine for


Screening Purposes
1. For chemical and microscopic examination, a
voided specimen is usually suitable.
2. For protein and microscopic examination of
sediments - a concentrated specimen is
preferable (morning urine).
3. For glucose examination, it is best to obtain
urine after eating.

Collection of Urine for


Screening Purposes
COLLECTION OF URINE FOR
QUANTITATIVE ANALYSIS - 24 h urine
specimen is collected
FOR BACTERIOLOGIC EXAMINATION voided mid-stream specimen or
catheterized.

Routine Urinalysis
2 Major Components
I. Macroscopic Examination
A. Physical tests
B. Chemical tests
II. Microscopic examination

Routine Urinalysis
1. Number the urine specimens and the
corresponding request.
2. Number the 15 ml centrifuge tube corresponding
to urine sample.
3. Mix each specimen thoroughly and place 12 ml to
corresponding centrifuge test tube.
Note the ff: color
turbidity
reactions

Routine Urinalysis
4. Measure specific gravity.
5. Centrifuge for 5 minutes at 1500 to 25000
rpm

Use supernatant for several tests


- protein
- reducing substances
Use sediments for microscopic exam.

Physical Tests
PHYSICAL
Color
Turbidity
Odor
Volume
Sp Gravity

A. Appearance
1. Color
Normal - yellow color
- due largely to the pigment
urochrome and small amounts of
urobilins
Normal [Walters]: straw to amber

Physical Tests
PHYSICAL
Color
Turbidity
Odor
Volume
Sp Gravity

A. Appearance
2. Character (Clarity)
Normal - essentially clear

Physical Tests
PHYSICAL
Color
Turbidity
Odor
Volume
Sp Gravity

B. Odor
Normal - faint aromatic

Physical Tests
PHYSICAL
Color
Turbidity
Odor
Volume
Sp Gravity

C. Urine Volume
Average daily volume
Adult - 1200 to 1500 ml/24 h
range - 600 to 2000 ml
night urine - 400 ml
Walters
Newborn 20-350
One year 360-600

Ten yrs
Adult

750-1500
750-2000

Physical Tests
PHYSICAL
Color
Turbidity
Odor
Volume
Sp Gravity

D. Osmolality and Specific


Gravity
Hyposthenuria - less than 1.007
Isosthenuria - 1.010
Normal range 1.005 1.030
Most samples 1.010 1.025 Walters

ABNORMAL FINDINGS

Color - Possible Cause


PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

Straw to amber - normal (urochrome)


Orange - concentrated urine
Deep yellow - riboflavin
Bright orange - amidopurine drugs
Orange-brown - urobilin
Greenish orange - bilirubin
Smokey - red blood cells

Color - Possible Cause


PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

Wine red - hemoglobin pigments


Brown to black - melanin
Almost colorless - dilute urine
Reddish orange in alkaline solution rhubarb or serra
Dirty green on standing - excess
indican

Odor
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

A. Lack of odor - acute renal failure


B. Characteristic urine odors in ingestion of
asparagus or thymol
C. Urine odors associated with amino acid
disorders
1. Isovaleric aridemia - sweaty feet and
glutaric acidemia
2. Maple syrup urine disease - maple syrup

Odor
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

C. Urine odors associated with amino acid


disorders
3. Methionine malabsorption - cabbage,
hops
4. Phenylketonuria - mousy
5. Trimethylaminuria - rotting fish
6. Tyrosinemia - rancid

Turbidity
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

Cloudy urine :
phosphates, carbonates
urates, uric acid
leukocytes
red cells (smoky)
bacteria, yeast
spermatozoa

Turbidity
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

Cloudy urine :
prostatic fluid
mucin, mucus threads
calculi
clumps, pus, tissue
radiographic dye

Turbidity
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

Milky urine
many neutrophils (pyuria)
fat: lipiduria - opalsescent
chyluria - milky
emulsified paraffin

Osmolality and Specific


Gravity
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

Osmolality
] give an indication of the
Specific gravity ] urinary total solute
concentration
IN CRITICAL CONDITIONS - Osmolality of
urine and plasma is preferred to
measurement of specific gravity

Osmolality and Specific


Gravity
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

OSMOLALITY:
Normal adult on normal diet
800 mOsm/kg water
range - 800 to 1400 mOsm/kg water

Osmolality and Specific


Gravity
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

SPECIFIC GRAVITY:
Normal adults with normal diet
1.016 - 1.022 / 24 hr.

Urine Volume
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

A. Increase in Urine Volume:


> 2000 ml in 24 h = polyuria
1. Excessive intake of water
2. Increase salt intake and high
protein diet

Urine Volume
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

A. Increase in Urine Volume:


> 2000 ml in 24 h = polyuria
3. Certain drugs with diuretic effect
caffeine
alcohol
thiazides

Urine Volume
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

A. Increase in Urine Volume:


> 2000 ml in 24 h = polyuria
4. Intravenous saline or glucose
5. Pathologic states - diabetes
insipidus and mellitus, chronic renal
failure

Urine Volume
PHYSICAL
Abnormal
Color
Turbidity
Odor
Volume
Sp Gravity

B. Decrease in Urine Volume


1. Dehydration
2. Renal ischemia
3. Renal disease
4. Obstruction

CHEMICAL TESTS

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

2 METHODS:
1. Reagent Strip
Methodology
2. Confirmatory tests

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Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

A. pH in URINE:
a reflection of the ability of the kidney to
maintain normal hydrogen ion
concentration in plasma and extracellular
fluids
Normal pH: 4.6 - 8.0
pH of 5.5 and below - signifies that tubule
mechanisms of acidification are intact.

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

ACID URINE -produced by:


Diet high in meat protein and some
fruits
Drugs - ammonium chloride,
methionine, methenamine mondelate
or acid phosphatase

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

ALKALINE URINE - induced by:


Diet high in certain fruits and
vegetables
Drugs - sodium bicarbonate, potassium
citrate, acetacolamide

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

FAILURE TO ACIDIFY = ALKALINE


URINE
Renal tubular acidosis
Early pyelonephritis
Primary aldosterone secretory
tumor
Hypokalemia

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

B. PROTEIN in URINE
Normal Amount - 150 mg/24 h (1/3 albumin
+ remaining protein[globulin] )
Methods Used:
Reagent strip method - sensitive to albumin
Acid-precipitation test - detects all proteins
and indicates the presence of globulins

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

B. PROTEIN in URINE
Confirmatory tests
- Sulfosalicylic acid method:
*qualitative
*semi-quantitative
- Quantitative methods - more useful
methods for diagnosing kidney
disease

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

Qualitative Test for Proteins


SULFOSALICYLIC ACID TEST
3 ml urine + 3 ml 10% sulfosalicylic acid in 50%
methanol
cloudy precipitate at the junction
of 2 fluids = proteins are present

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

Test for Reducing Substances


BENEDICTS QUALITATIVE TEST
A rough test and at best an approximate guide
to the amount of sugar
0.5 ml urine + Benedicts solution

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

Test for Reducing Substances


BENEDICTS QUALITATIVE TEST
COLOR
RESULTS
Blue
negative
Greenish blue
traces
Green
(+) approx. 0.5%
reducing substance
Greenish brown
(++) approx. 1.0%
Yellow
(+++) approx. 1.5%
Brick red
(++++) approx. 2.0%

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

ROTHERAS TEST
Test for acetone and acetoacetic acid
Principle:
Both acetone and acetoacetic acid
give a purple color with alkaline
sodium nitroprusside

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

SCHLESINGERS TEST
Test for total urobilinogen and urobilin
Principle:
Urobilinogen is oxidized with alcoholic
solutions of zinc acetate green
fluorescent complex

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

FOUCHETS TEST
Test for bilirubin
Principle:
BACl2 + Urine Barium Sulfate (pt),
bilirubin is adsorbed filtered, add
Fouchets ferric chloride Biliberon
(greenish-blue)

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

C. GLUCOSE in URINE
Factors that affect its appearance:

Blood level
Glomerular blood flow
Tubular reabsorption rate
Urine flow

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

C. GLUCOSE in URINE
Methods:

Reagent strip method - based on specific


glucose oxidase and peroxidase method
Confirmatory tests
Copper reduction test (Benedicts test)
Copper reduction tablet tests
Five-drops method
Two-drops method

Chemical Tests
CHEMICAL
pH
Protein
Reducing Subs
Glucose

C. GLUCOSE in URINE
Test for other sugars: by
CHROMATOGRAPHY

Normal Values for Urine


Chemical Tests [Walters]
Substance tested

pH

NV

5.5 8

Protein

neg to trace

Substance tested

Blood
Urobilinogen

NV

negative
0.1-1.0 EU/dL

Glucose negative
Ketone

negative

Bilirubin negative

Bacteria (nitrite) neg


Leukocyte esterase neg

MICROSCOPIC ANALYSIS

Increased RBC in urine


MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Normal : 0-2 / hpf or 3 to 12 / L


Renal disease
glomerulonephritis, lupus nephritis,
calculus, tumors, acute infections, TB,
renal vein thrombosis, trauma,
hydronephrosis, polycystic kidney, acute
tubular necrosis

Increased RBC in urine


MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Normal : 0-2 / hpf or 3 to 12 / L


Lower urinary tract disease
acute and chronic infection, calculus,
tumor, stricture

Extrarenal disease
acute appendicitis, salpingitis, diverculitis,
tumors of the rectum & pelvis

Increased WBC in urine


MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Normal : 0-2 / hpf or 3 to 12 / L


Renal disease
1. Bacterial - acute & chronic pyelonephritis
2. Non-bacterial - acute glomerulonephritis, nephritis

Calculous disease

Increased WBC in urine


MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Normal : 0-2 / hpf or 3 to 12 / L


Bladder tumors
Acute inflammatory disease
Chronic inflammatory disease

Increased WBC in urine


MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Pyuria - increased numbers of


leukocytes, primarily neutrophils:
1. Almost all renal diseases and
diseases of the urinary tract
2. Fevers and following strenous
exercise

Increased WBC in urine


MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Presence of many leukocytes more


than 20/hpf or clumps of leukocytes is
considered ABNORMAL

Crystals
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Not normally present in freshly


voided urine
Generally of no significance,
except:

sulfonamides, cystine, oxalates persons with history of ureteral colic


or stones
urates - gout

Crystals
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

Crystals in acid urine

calcium oxalate, uric acid, urates,


cystine, tyrosine, leucine

Crystals in alkaline urine

phosphates, calcium carbonate,


ammonium urate

Epithelial Cells
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

1. Increase in renal tubular EC

malignant nephrosclerosis
acute glomerulonephritis
acute tubular necrosis
papillitis
acute renal allograft rejection urates gout

Epithelial Cells
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

2. Increase in transitional EC

suggest transitional cell carcinoma of


the renal pelvis or bladder

3. Increase in squamous EC

of little diagnostic significance

Casts
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

1. Hyaline casts

acute glomerulonephritis
malignant hypertension
chronic renal disease
congestive heart failure
diabetic nephropathy

Casts
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

2. Granular casts
almost always indicate significant
renal disease

plyelonephritis
viral disease
chronic lead intoxication

3. RBC casts

pyelonephritis

Casts
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

5. Waxy casts
found in localized nephron obstruction &
oliguria
6. Fatty casts
commonly seen in heavy proteinuria &
are a feature of nephrotic syndrome
7. Crystal casts
found in tubular damage

Casts
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

8. Hemoglobin casts
seen in tubular bleeding
9. Myoglobin casts
seen in muscle damage
10. Bilirubin casts
seen in obstructive jaundice

Casts
MICROSCOPIC
RBC
WBC
Crystals
Epithelial cells
Casts

11. Renal tubular epithelial cast


seen in acute tubular necrosis
viral disease or
exposure to variety of drugs

Abnormal cells & other formed


elements
1. Tumor cells
2. Viral inclusion cells
3. Platelets
4. Bacteria, fungi, parasites

Abnormal cells & other formed


elements
5. Contaminants
6. Artifacts

cotton, hair & other fibers


granules of starch
oil droplets

Glucose in urine
I. Glycosuria with hyperglycemia
1. Endocrine disorders,
pituitary & adrenal disorders eg acromegaly, Cushings
syndrome or hyperadrenocorticism

2. Functioning alpha- or beta cell pancreatic tumors


3. Hyperthyroidism
4. Phaeochromocytoma
5. Pancreatic diseases

Glucose in urine
Glycosuria with hyperglycemia
1. CNS disorders
2. Disturbances in metabolism associated w/ burns,
infection, fractures, myocardial infarction, uremia
3. Liver disease
4. Glycogen storage disease
5. Obesity & feeding after starvation

Glucose in urine
II. Hyperglycemia w/ no significant glycosuria

found in asymptomatic or chemical diabetes

III. Glycosuria w/o hyperglycemia

Renal tubular dysfunction related to inability to


reabsorb glucose
drugs or poison or endogenous toxins
Franconis syndrome
Galactosuria
Amino acid disorders

Protein in urine
I. Heavy proteinuria (>4 g/day)
1. Nephrotic syndrome
2. Acute & chronic glomerulonephritis
3. Lupus nephritis
4. Amyloid disease
5. Severe venous congestion of the kidney

Protein in urine
II. Moderate proteinuria (0.5 to 4 g/day)
all the diseases mentioned above plus:
1. Nephrosclerosis
2. Pyelonephritis w/ hypertension
3. Diabetic nephropathy
4. Pre-eclampsia of pregnancy
5. Toxic nephropathies
6. Radiation nephritis

Protein in urine
III. Moderate proteinuria (0.5 to 4 g/day)
1. Chronic pyelonephritis
2. Inactive phase of glomerular disease
3. Polycystic kidney
4. Renal tubular disease

Casts
Translucent, colorless gels from protein in
the tubules or nephrons.
Normal person - few are seen in the urinary sediments
Increased number of casts indicate that kidney disease is
widespread (many nephrons are involved)
Casts become denser and waxy in chronic renal disease

Casts
Classification of casts :
1. Matrix - hyaline, waxy casts
2. Inclusions - granules, fat globules,
hemosiderin granules, crystals, melanin
granules

Casts
Classification of casts :
3. Pigments - hemoglobin, myoglobin,
bilirubin, drugs
4. Cells - erythrocytes & RBC cell remnants,
leukocytes, renal tubular epithelial cells,
mixed cells, bacterial

Common Urine Preservatives


Formalin
HCl
Sodium chloride
Boric acid
Refrigeration

Common Urine
Preservatives
Formalin

Preserves formed
elements

HCl

Preserves for calcium


& phosphorous tests

Sodium carbonate

Preserves porphyrins,
urobilinogen

Boric acid

Preserves creatinine,
uric acid & glucose

Refrigeration

Barbiturates, drug
abuse screen, protein