CHAPTER

Urinalysis and Body Fluids

Outline 908
>• Introduction to Urinalysis
>• The Kidney and Urine Formation
>• Renal Pathology and Renal Function Tests
>• Urine Volume and Sample Handling
>• Physical Examination of Urine
V Chemical Examination of Urine
>• Microscopic Examination of Urine
V Special Urine Screening Tests
>• Body Fluids and Fecal Analysis
Review Questions 935
Answers & Rationales 945
References 957

907

CHAPTER 11: URINALYSIS AND BODY FLUIDS

I. INTRODUCTION TO URINALYSIS

A. Introduction
1. Urinalysis is the practice of examining urine for diagnostic purposes; it aids in
following the course or treatment of disease.
B. Importance of Urine
1. Urine contains most of the body's waste products.
2. Urine chemical changes are directly related to pathologic conditions.
3. A complete urinalysis is composed of multiple tests, including physical,
chemical, and microscopic analysis.
4. Urinalysis is used for disease diagnosis, disease monitoring, drug screening,
and initial diagnosis of inborn errors of metabolism.
C. Urine Composition
1. Urine contains mostly water and various amounts of dissolved
organic/inorganic compounds.
2. Composition varies according to diet, physical activity, metabolism, and
disease processes. Composition is directly related to the amount and type of
waste material that is to be excreted.
3. Urine organic substances
a. Urea accounts for roughly 50% of all dissolved solids in the urine.
b. Other organic substances in relatively large amounts include creatinine
and uric acid.
c. Organic substances in small amounts include glucose, protein, hormones,
vitamins, and metabolized medications.
4. Urine inorganic substances (listed in order of highest to lowest average
concentration)
a. Chloride, sodium, and potassium
b. Other inorganic substances in small amounts include sulfate, phosphate,
ammonium, calcium, and magnesium.
5. Nondissolved substances may include bacteria, crystals, casts, mucus, and
various types of cells.

II. THE KIDNEY AND URINE FORMATION

A. Renal Anatomy
1. The kidneys are two bean-shaped organs located under the diaphragm on
either side of the aorta in the posterior, upper abdominal region.
2. The ureter is a muscular tube that connects the pelvis of the kidney to the
bladder.
3. Urine is stored in the bladder until excretion through the urethra.
4. The renal pelvis is a cavity area that is an expansion of the ureter. The pelvis
functions to collect urine from the calyces for transport from the kidney to the
ureter.

THE KIDNEY AND URINE FORMATION

5. The kidneys consist of two regions, the cortex (outer layer) and the medulla
(inner layer). The cortex is comprised of the renal corpuscles and the proximal
and distal convoluted tubules of the nephron. The medulla is comprised of the
loops of Henle and the collecting ducts.
6. The abdominal aorta supplies blood to the renal artery, which in turn
provides blood to the kidney, and the renal vein functions to return blood to
the inferior vena cava.
7. Microscopically, the functional unit of the kidney is the nephron, which is
responsible for urine formation. It is comprised of a renal corpuscle and a
tubular system. These areas are further delineated with the renal corpuscle
consisting of the glomerulus and Bowman's capsule and the tubular system
consisting of the proximal convoluted tubule, loop of Henle, distal convoluted
tubule, and collecting duct. More than a million nephrons may be found in
each kidney.
a. The glomerulus is a tuft of capillaries that lie in a tubular depression
called Bowman's capsule. The afferent arteriole carries blood into the
glomerulus, and the efferent arteriole carries blood away. The
peritubular capillaries, which arise from the efferent arteriole, aid in
the tubular reabsoiption process by surrounding the various segments
of the renal tubule. The main function of the glomerulus is to filter the
blood.
b. The proximal convoluted tubule is located in the cortex.
c. The loop of Henle begins in the cortex, with the descending limb of the
loop extending into the medulla where the bend of the loop is formed that
then becomes the ascending limb, which ends in the cortex.
d. The distal convoluted tubule (DCT) is located in the cortex, and DCTs
from multiple nephrons direct the urine flow into a collecting duct.
e. The collecting duct joins with other collecting ducts, forming a papillary
duct to carry urine into a calyx of the renal pelvis.

B. Renal Physiology
1. In order to form and excrete urine, three processes function together:
glomerular filtration, tubular reabsoiption, and tubular secretion,
a. The glomerulus functions as a semipermeable membrane to make an
ultrafiltrate of plasma that is protein free.
1) Large molecules (proteins, cells) remain in the arterioles, whereas
smaller molecules (glucose, urea, sodium, chloride, potassium,
bicarbonate, calcium, etc.) pass through the glomerular capillary walls
to become part of the filtrate.
2) These smaller molecules and ions flow into the proximal convoluted
tubule.
3) The glomerular filtration rate (GFR) is about 115-125 mL of filtrate
formed per minute by the glomeruli. The renal tubules will reabsorb
all but 1 mL of the filtrate, which will be passed in the urine.

910 • CHAPTER 11: URINALYSIS AND BODY FLUIDS

b. Reabsorption is the process by which filtered water, ions, and molecules
leave the tubules for return to the blood via the peritubular capillaries.
c. Secretion is the process by which a substance from the blood is
transported across the wall of the tubule into the filtrate.
2. Function of the nephron
a. The proximal convoluted tubule
1) Responsible for most of the reabsorption (approximately 65%) and
secretion that occurs in the tubules
2) For some analytes, there is a limitation as to how much solute can be
reabsorbed. This is defined as the "renal threshold."
3) Reabsorbs water, Na+, CF, K+, urea, glucose (up to renal threshold of
160-180 mg/dL), amino acids, etc.
4) Secretes hydrogen ions and medications
b. Loop of Henle
1) Descending limb reabsorbs water.
2) Ascending limb reabsorbs Na+ and CF.
3) Filtrate leaves the loop of Henle and moves into the distal convoluted
tubule.
4) Approximately 85% of tubular reabsorption of water and salt is
completed before the filtrate passes into the distal convoluted tubule.
c. Distal convoluted tubule
1) Reabsorbs Na+
2) Reabsorption of water controlled by antidiuretic hormone (ADH)
3) Secretion of H + and K+
4) Aldosterone controls the reabsoiption of sodium and water and
secretion of potassium and hydrogen into the filtrate.
d. Collecting duct
1) Final site for water reabsorption to make urine more dilute or
concentrated
2) Na+ and CF reabsorption controlled by aldosterone
3) Water reabsorption occurs by osmosis as well as in response to ADH.

C. Endocrine Functions
1. Renin-angiotensin-aldosterone axis
a. Renin is secreted by the juxtaglomerular apparatus of the kidneys and
catalyzes the conversion of angiotensinogen to angiotensin I (a hormone
in the inactive form).
b. Angiotensin I stimulates the production of angiotensin II (a hormone in
the active form).
c. Angiotensin II regulates renal blood by:
1) Constriction of renal arterioles
2) Secretion of aldosterone from the adrenal glands to facilitate retention
of sodium.

RENAL PATHOLOGY AND RENAL FUNCTION TESTS • 911

2. Aldosterone, made in the cortex of the adrenal glands, acts on the kidneys by
promoting the reabsorption of Na+ from the filtrate into the blood and the
secretion of K+ from the blood into the filtrate. Water will be reabsorbed along
with the Na+.
3. Antidiuretic hormone (ADH), secreted by the posterior pituitary gland,
promotes water reabsorption from the filtrate into the blood. ADH primarily
affects the reabsorption of water from the distal convoluted tubule and the
collecting duct.
4. Parathyroid hormone (PTH), made in the parathyroid glands, promotes Ca2+
reabsorption from the filtrate into the blood and excretion of phosphate ions
from the blood into the filtrate.
5. Erythropoietin is an alpha-globulin produced by the peritubular fibroblasts in
the kidneys to stimulate red blood cell production in response to lowered
oxygen levels.

III. RENAL PATHOLOGY AND RENAL FUNCTION TESTS

A. Renal Pathology
1. Acute glomerulonephritis: Inflammation of the glomerulus seen in children
and young adults; can follow a Group A Streptococcus respiratory infection;
characterized by hematuria, proteinuria, WBCs, and casts (RBC, granular
and hyaline)
2. Rapidly progressive glomerulonephritis: A more serious condition than
acute glomerulonephritis that may result in renal failure; urinalysis results
would be similar to acute glomerulonephritis
3. Acute interstitial nephritis: Inflammation of the renal interstitium that may
be caused by an allergic reaction to medication; characterized by hematuria,
proteinuria, WBCs (especially eosinophils), and WBC casts
4. Membranous glomerulonephritis: Thickening of the glomerular capillary
walls and basement membrane; characterized by hematuria and proteinuria
5. Nephrotic syndrome: May be caused by renal blood pressure irregularities;
characterized by proteinuria (>3.5 g/24 hr), hematuria, lipiduria, oval
fat bodies, renal tubular epithelial cells, and epithelial, fatty, and waxy
casts
6. Focal segmental glomerulosclerosis: Affects a specific number of glomeruli,
not the entire glomerulus; often seen in HIV patients; characterized by
hematuria and proteinuria
7. Chronic glomerulonephritis (Berger disease): Results in a long-term
progressive loss of renal function; characterized by hematuria, proteinuria,
glucosuria, presence of casts, including broad casts
8. Acute pyelonephritis: An infection of the renal tubules caused by a urinary
tract infection; characterized by hematuria, proteinuria, WBC's, bacteria,
and WBC and bacterial casts

and urine flow rate. U: urine creatinine mg/dL. a substance that is infused into the patient. diet. Renal tubular reabsorption tests (also known as concentration tests) are used to detect early renal disease. V: urine flow in mL/min. Note: Urea is not normally used in clearance testing because of tubular reabsorption. and WBC. P: plasma Creatinine mg/dL. Chronic pyelonephritis: Chronic infection of the tubules and interstitial tissue that may progress to renal failure. and monitor fluid and electrolyte therapy.73 m2 . 1. waxy.73 m2 C (mL/min) = X SA 3) 24-hour timed urine is the specimen of choice. and broad casts 10. A decreased clearance test indicates compromised kidney function. Creatinine clearance is used to assess glomerular filtration rate. and SA: body surface area. 1) Creatinine levels are not changed by diet (normal) or rate of urine flow. c.912 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 9. bacterial. 2) Creatinine clearance formula: U XV 1. 3.73 m2 is average body surface area.73 m2 Females: 95 ± 20 mL/min/1. values decrease with age. Renal failure: Tubular necrosis caused by nephrotoxic agents and other disease processes. Secretion test a. PAH is completely removed from the blood by functional renal tissue. b. resulting in a failure of the kidneys to filter blood B. b. Males: 105 ± 20 mL/min/1. 4) Reference ranges differ according to age and sex. Osmolality and specific gravity evaluate renal concentrating ability. Specific gravity depends on the solute dissolved in a solution and the density of this solute. granular. WBCs. Creatinine is not reabsorbed by renal tubules. Tubular secretion or renal blood flow test uses/?-aminohippuric acid (PAH). Glomerular tests are used to assess renal waste removal and solute reabsorbing abilities. characterized by hematuria. Examples of these tests include: a. Renal Function Tests 1 . the PAH will not be removed completely. Osmolality measures the amount of solute dissolved in a solution. a. monitor the course of renal disease. proteinuria. If renal problems exist. Osmolar/Free Water Clearance 1) Used in the diagnosis of various types of diabetes mellitus 2) Measures renal clearance of solutes and substance-free water 2. bacteria.

normal range of urine output 600-2000 mL/24 hr. Oliguria: Decrease in urine output because of dehydration (e. If the chemical preservative alters the pH. 1) Correction for gender and race required 2) Results only reported as a number if <60 mL/min/1. Excretion of dissolved solids. c. caffeine. vomiting. and the date and time of urine collection. and alcohol (suppresses secretion of antidiuretic hormone) B. Determined by the body's state of hydration. stones. Urine must be treated as biohazardous material. 3. Chemical preservatives can be bactericidal. Factors that affect urine volume a. perspiration. URINE VOLUME AND SAMPLE HANDLING • 913 b. urine must be brought to room temperature. Analyze within 2 hours or preserve. Nocturia: Increased urine output at night 1) Caused by a reduction in bladder capacity resulting from pregnancy. Estimated glomerular filtration rate (eGFR) uses only a blood creatinine and the MDRD (modification of diet in renal disease) formula. 2. Volume of Urine 1. 5.73 m2 IV. may exceed 2 L/day 1) Usually caused by such diseases as diabetes mellitus and diabetes insipidus 2) May also be caused by ingestion of diuretics (medications that block water reabsorption). dry cups with lids. Use clean. Diuretic and antidiuretic hormone levels c. Fluid intake and fluid loss related to nonrenal functions b. thus warranting that standard precautions be followed. but they will preserve formed elements and will not. Polyuria: Increased daily output. Before testing. with 1200-1500 mL/24 hr being the normal adult output 2. including glucose and salts 3. interfere with chemical testing. Anuria: No urine output because of kidney damage or renal failure c. Refrigeration will decrease bacterial growth but will cause precipitation of amoiphous phosphates/urates. Label container with name. or prostate enlargement 2) Increased fluid intake at night d. Preserve urine a. and burns) b. . it can interfere with the pH test on the strips. diarrhea. Urine volume terminology a.g. identification number. generally. URINE VOLUME AND SAMPLE HANDLING A.. b. Specimen Collection and Handling 1. 4.

PHYSICAL EXAMINATION OF URINE A. formed from the oxidation of urobilinogen as urine stands. disease. and Odor 1. used for bacterial culture and is the preferred collection method for routine urinalysis because it is the most concentrated sample of the day. Appearance. 24-Hour: Collected over a period of 24 hours for creatinine clearance or for quantifying other analytes.914 • CHAPTER 11: URINALYSIS AND BODY FLUIDS d. c. The normal color of urine (yellow) is derived from urochrome. bacteria. Midstream clean-catch: Genital area cleansed with a detergent and urine collected in the middle of urination. used to monitor glucose content e. Urobilin.). and bilirubin 3) Formed element destruction 4) Change in color 6. and turbidity 2) Decreased urobilinogen. Urine specimen types and collection times a. which is a pigmented substance excreted at a constant rate. green. time of collection not a consideration. and physical activity. patient cleans the external urinary meatus. Catheterized: Collected from a tube placed through the urethra into the bladder. the color deepens to orange-brown. adds minimally to the normal yellow color. pregnancy tests. . a. Increased urochrome production can result from thyroid disease or a fasting urine sample. glucose. Color. used for bacterial culture and cytologic testing i. red. diet. Suprapubic aspiration: Needle inserted into the bladder through the abdominal wall. Pediatric collection: Use small. Changes in unpreserved urine include: 1) Increased pH. Urine color varies from colorless to any color shade (black. b. usually the second voided specimen of the morning following a fasting period d. First morning: Concentrated specimen used for routine screening. h. and for detecting orthostatic proteinuria b. Random midstream clean-catch: Used for routine screening and microalbuminuria determination. Changes in color can be due to normal metabolism. ketones. Fasting: Used for glucose monitoring. nitrites. 2-Hour postprandial: Void 2 hours after eating. and then collects the rest of the voided sample. urinates a small volume into the toilet. used for bacterial culture and routine screening g. As urine sits unpreserved. etc. including Na+ and K+ f. clear plastic bags with adhesive to adhere to the genital area V.

cloudy. 3) Concentrated urine will also exhibit high specific gravity. With an increase of bilirubin in the blood. etc. Colorless/pale yellow 1) Random specimen 2) Diabetes insipidus or diabetes mellitus with increased urine excretion b. and phenols 2) Infections caused by Pseudomonas species f. PHYSICAL EXAMINATION OF URINE • 915 c. Abnormal urine color a. milky. or homogentisic acid Note: Many abnormal colors are nonpathogenic in nature and are the result of food. 2. a. indican. Brown/black 1) Denatured hemoglobin. turbid. whereas dark yellow samples are usually concentrated. erythrocytes 3) Myoglobin (muscle trauma) 4) Poiphyrins e. drugs. Pale yellow (straw) samples are generally dilute. bilirubinuria occurs. Hazy/slightly cloudy: May be due to the presence of low numbers of formed elements . when the pigment attaches to precipitated amorphous urates. c. hazy. burns. Clear: Indicates the absence of significant numbers of formed elements b. Dark yellow 1) Concentrated specimen: First morning or following strenuous exercise 2) Caused by dehydration from fever. d. melanin. Uroerythrin adds a slight pink pigment. slightly cloudy. 2) Bilirubin: Bilirubinemia occurs from liver problems. d. etc. and bloody. biliary obstruction. yellow foam forms when urine is shaken due to the presence of conjugated bilirubin. 3. or vitamins. mostly apparent following refrigeration. Green/blue 1) Medications and dyes such as amitriptyline. Intense yellow/amber/orange 1) Pyridium (phenazopyridine): This medication is prescribed for urinary tract infections (UTIs). 2) Hemoglobin. such as hepatitis. Red/pink 1) Blood: Glomerular bleeding can also produce brown/black urine. resulting thick orange urine will mask chemical and microscopic analysis. Appearance of urine (clarity): The visual inspection of urine uses the following terminology: clear.

Cloudy: In acid urine. Aromatic odor: Normal b. b. glomerulonephri- tis. diarrhea. b.G. may be due to amorphous urates showing a slight pink color. falling between 1. calcium oxalate crystals. indicates loss of concentrating and diluting ability) c.) values: Plasma filtrate entering the glomerulus has a S.003 to 1. Reabsorption is the first renal function to become impaired.010 (fixed S. Specific gravity determines the kidney's ability to reabsorb essential chemicals and water from the glomerular filtrate. Specific gravity also detects dehydration and antidiuretic hormone abnormalities. Various odors: Different foods B. It can also be found normally if the person has a large fluid intake.G. may be due to amoiphous phosphates and carbonates d. such as diabetes insipidus. Maple syrup odor: Maple syrup urine disease f. > 1. Specific gravity is the density of a substance compared with the density of a similar volume of deionized water at a similar temperature and is influenced by the number of particles dissolved and by particle size. .010 d. 3. hepatic disease.010.916 • CHAPTER 11: URINALYSIS AND BODY FLUIDS c. and dehydration due to vomiting.G. Conditions associated with specific gravity value a. Specific gravity instrument: Refractometer measures a refractive index. Specific gravity (S. and pyelonephritis. Normal random urine ranges from 1.035. Specific Gravity 1. Hyposthenuric urine: Less than 1. congestive heart failure.035. Sweet or fruity odor: Ketone bodies (diabetic ketosis) e. Strong odor: Bacterial infection d. by comparing the velocity of light in air to the velocity of light in a solution. or strenuous exercise. Urine odor is not generally a part of the routine urinalysis but may provide useful information to the physician. Isosthenuric urine: 1. with the average S. diabetes mellitus. a. Low specific gravity indicates loss of the kidney's ability to concentrate urine or presence of disease.025. T\irbid: May be due to the presence of large numbers of formed elements 4. Ammonia odor: Urea metabolized by bacteria into ammonia c. in alkaline urine. or uric acid crystals.G. low fluid intake. Method uses a small volume of urine and does not require temperature corrections. if the sample is white. 2. a. High specific gravity may result from adrenal insufficiency.010 5. Interference from X-ray contrast media excretion may result in S. of 1. c. 4.015 and 1. Hypersthenuric urine: Greater than 1.G.

vomiting.0): Excreted after meals in response to gastric HC1. . 1) Principle ("protein error of indicators"): The indicator is yellow in the absence of protein and the pad changes from shades of green to blue when abnormal amounts of protein (albumin) are present. The acid-base balance of the body is primarily regulated by the lungs and the kidneys. The kidneys provide regulation through secretion of hydrogen ions via ammonium ions. CHEMICAL EXAMINATION OF URINE A. hydrogen phosphate. the pad will go from orange to yellow to green. The pH of urine ranges from 4. CHEMICAL EXAMINATION OF URINE • 917 VI. and UTIs. 3.0): High-protein diets. as the pH increases. renal tubular acidosis. 4. increased consumption of vegetables. Reagent strips are the method of choice for the chemical analysis of urine. after normal sleep. For pH. Reagent Strips 1. B. The reagent strip uses tetrabromphenol blue to detect protein. 2.0 for the first morning void.0 for random urines and from 5. Note that urine may also be alkaline as a result of delay in testing due to the action of bacteria on urea to form ammonia. The following urine pHs may indicate various diseases and conditions: 1) Acidic pH (<6. protein. Sources of error in reagent strip use include excess time in the urine. and specific gravity.0. not following specific reaction times to read results. nitrite. The kidneys also facilitate the reabsorption of bicarbonate from the convoluted tubules. pH a. run on at least a daily basis. Color intensity is semiquantitative for these substances. ketones. At pH 5.0 to 6. respiratory/metabolic acidosis. bilirubin. Reagent strips should be assessed for accuracy by the use of "normal" and "abnormal" urine controls. The color is characteristic of positive reactions for various substances. uncontrolled diabetes mellitus 2) Alkaline pH (>7. respiratory/metabolic alkalosis. leukocytes. Protein a. and finally to blue at pH 9. blood. and not testing samples at room temperature. and organic weak acids.5 to 8. b. Reagent strips are used for the following tests: pH. 2. creatinine. urobilinogen. Basic use: Reagent strips are chemical-containing absorbent pads that react with urine. the reagent strip uses methyl red and bromthymol blue to detect changes in pH.0 the pad is orange. c. producing a chemical reaction that results in a color change. glucose. runover between chemicals. Chemical Tests and Clinical Significance 1. Confirmatory tests are then performed for some analytes.

3) Reagent strips with the creatinine pad will commonly lack a urobilinogen pad. b. 2) The final concentration from the creatinine pad is matched in a grid with the concentration from the protein pad. g. c. lupus. This complex has pseudoperoxidase activity that catalyzes the oxidation of a chromagen to a colored end product. these other sources of protein will not usually be detectable by the reagent strip method. and glomerular membrane damage caused by toxic agents. The intersection of the two test results will indicate if the protein result is normal or abnormal. such as prostate. Protein can come from nonrenal sources. The protein levels found may be less than that detectable by routine protein reagent strip tests. seminal. Normal urine will contain less than 10 mg/dL of protein or 100 mg/24 hr. c. f. d. and vaginal secretions. Benign proteinuria can occur in cold temperatures and as a result of exercise. proteins other than albumin present b. Performed on random urines. fever. resulting from alkaline medicine and keeping the reagent strip in urine too long b) False negatives: Dilute urine. which will be interpreted as a specimen that is too dilute to use for analysis. and it is reported as an Alb/Cr ratio. 4) Sensitivity of the creatinine method is 10 mg/dL. Creatinine provides an assurance that the water volume of the sample is not influencing the protein concentration. Urine protein is very diagnostic for renal disease and many indicate tubular reabsorption problems. or streptococcal glomerulonephritis. Creatinine a. a) False positives: None b) False negatives: Ascorbic acid . Bence Jones protein is produced due to a proliferative disorder of plasma cells as seen in multiple myeloma. Bence Jones proteins are light chain monoclonal immunoglobulins. Protein types include albumin. However. Creatinine testing in a random urine is performed only for comparison with the protein level to rule out microalbuminuria. Microalbumin evaluation is useful for patients with renal complications of diabetes mellitus. late pregnancy. and orthostatic/postural proteinuria in young adults (going from supine to upright). microalbumin analysis always requires the simultaneous analysis of creatinine. increased low-molecular-weight proteins.918 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 2) Reaction interference a) False positives: Urine pH >9. dehydration. and uromodulin (Tamm-Horsfall). Abnormal values (microalbuminuria) will be 30-299 mg albumin/g creatinine. microglobulins. which is selective for albumin. 3. e. Methodology of creatinine testing 1) Creatinine in the urine sample forms a complex with copper reagent in the reagent strip pad.

3) The enzymatic method uses beta-hydroxybutyrate dehydrogenase to detect the presence of beta-hydroxybutyric acid. Methodology of ketone testing 1) Reagent strips use sodium nitroprusside (nitroferricyanide) to measure acetoacetic acid. b. a) False positives: Antibiotics. a) False positives: Strong oxidizing agents (e. thyroid disorders. starvation. Glucosuria is the presence of urine glucose and is seen in the following conditions: diabetes mellitus. this test is not used for confirming the presence of glucose. and rapid weight loss e. The H2O2 + chromogen are catalyzed by peroxidase to form an oxidized colored chromogen + water. and dehydration due to excessive carbohydrate loss such as vomiting. Clinitest tablet): Method utilizes a reduction reaction. but when fat reserves are needed for energy. Glucose a. insulin dosage monitoring. Ketonuria: The presence of ketones in the urine d. acetoacetic acid. c. Glucose testing is most commonly used to detect and monitor diabetes mellitus.. electrolyte imbalance. and beta-hydroxybutyric acid b. ketones will show up in the urine. in which glucose (or other reducing substances) reduces copper sulfate (blue) to cuprous oxide (various shades of yellow to green). impaired tubular reabsoiption seen in Fanconi syndrome. Include three intermediate products of fatty acid metabolism: acetone. this test is mainly used to detect the presence of galactose in urine for patients with galactosemia. CHEMICAL EXAMINATION OF URINE • 919 4. Currently. Instead. central nervous system (CNS) damage. gives an enhanced color reaction and permits serial dilutions to be done. and pregnancy.g. c. phenylketones b) False negatives: Bacterial breakdown of acetoacetic acid 2) Acetest is a nitroprusside and glycine tablet used to detect ketones. bleach) b) False negatives: Ascorbic acid 2) Copper reduction test (Benedict's. ascorbic acid and other reducing sugars b) False negatives: None 5. The addition of glycine permits the measurement of acetone and acetoacetic acid. Ketones a. dyes. Clinical significance: Uncontrolled diabetes mellitus. . exercise. because it is much less sensitive to glucose than the strip test. a) False positives: Pigmented urine. Methodology of glucose testing 1) Reagent strip: Glucose + oxygen are catalyzed by glucose oxidase to form gluconic acid and H2O2. Normal urine contains no ketones when metabolized fat is broken down completely. Reaction interference parallels the reagent strip method. advanced tubular renal disease.

and exercise 3) Myoglobin (hemoglobin-like protein found in muscle tissue) a) The presence of myoglobin will cause a positive reaction on the reagent strip pad for blood. and protoporphyrin. toxins. coma. Hemoglobin is metabolized into iron. Bilirubin is a pigmented yellow compound. Free hemoglobin or high numbers of red blood cells in the urine will form a uniform color on the pad.920 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 6. H2O2 plus chromogen reacts with hemoglobin peroxidase to form oxidized chromogen and water. convulsions. formalin preservatives. muscle-wasting diseases. Reagent strip test detects hematuria and hemoglobinuria. Reagent strip methodology 1) Detects the pseudoperoxidase activity of hemoglobin or myoglobin. The chromogen is tetramethylbenzidine. d. negative reaction: hemoglobin c. releasing hemoglobin. b. In the liver. The protoporphyrin is converted to bilirubin by reticuloendothelial system cells. pyelonephritis. d. a degradation product of hemoglobin b. and extensive exercise. Types of blood/hemoglobin in the urine 1) Hematuria (intact RBCs in the urine) a) Caused by renal calculi. and pregnancy 2) Hemoglobinuria (hemoglobin in the urine) a) Caused by transfusion reactions. trauma. menstruation. Urobilin gives feces their brown color. glomerulonephritis. tumors. bilirubin is conjugated with glucuronic acid to form bilirubin diglucuronide. use ammonium sulfate to precipitate hemoglobin out of the urine. Myoglobin can be detected in muscle trauma. infections. Blood a. bilirubin binds to albumin for transport to the liver as unconjugated bilirubin. Bilirubin a. Detects bilirubinuria. c. Reaction interferences 1) False positives: Vegetable peroxidase and Escherichia coli peroxidase 2) False negatives: High levels of ascorbic acid and nitrites. Positive reaction: myoglobin. 2) A speckled pattern on the reagent strip pad occurs when low numbers of intact RBCs lyse upon touching the reagent strip pad. exercise. hemolytic anemia. protein. which forms a green-blue color when oxidized. which goes to the intestines and is reduced to urobilinogen via bacterial action and excreted in the feces as urobilin. the urine supernatant is then filtered and tested with a reagent strip. severe burns. A small amount of urobilinogen reaches the kidney via the bloodstream and is excreted in the urine. captopril (hypertension medication) 7. . b) To screen for myoglobin.

which does not react . Note that it is not possible to detect the absence of urobilinogen by the reagent strip. Reaction interferences 1) False positives: Pigmented urine (i. medications. Increased urobilinogen in the urine can indicate early liver disease. biliary obstruction. which then reacts with a dye to produce a pink product. ascorbic acid. excessive exposure to light (bilirubin exposed to light is converted to biliverdin. and early liver disease when conjugated bilirubin enters the circulation. g.e. indican. c. 1) Conjugated bilirubin is water soluble and excreted in urine. which does not react with diazonium salts). and hemolytic diseases. In hemolytic disease. nitrite reacts with an aromatic amine to form a diazonium salt. cirrhosis. CHEMICAL EXAMINATION OF URINE • 921 e. urine urobilinogen is positive and urine bilirubin (unconjugated form increased in plasma) is negative. high levels of nitrite Nitrite a. f. diet low in nitrates. Reaction interferences 1) False positives: Pigmented urine 2) False decrease: Improper storage. Rapid test for UTIs b. produced from the reduction of bilirubin by bacteria in the small intestine b. Formed from hemoglobin metabolism. Bile duct obstruction is positive for urine bilirubin (conjugated form increased in plasma) but normal for urine urobilinogen. antibiotics.. e. Reagent strip uses Ehrlich's reagent (paradimethylaminobenzaldehyde) or a diazo dye to detect urobilinogen. bacteria that do not reduce nitrate. d. hepatitis. Bilirubinuria may result from hepatitis. and heavy concentration of bacteria that reduces nitrate all the way to nitrogen. and Lodine) 2) False negatives: Specimen too old. c. Reagent strip uses diazonium salt reaction (bilirubin —» azobilirubin) methodology. and nitrite Urobilinogen a. Reaction interferences 1) False positives: Old urine samples containing bacteria and pigmented urine 2) False negatives: Ascorbic acid. Used for evaluation of UTI antibiotic therapy d. A positive nitrite can indicate cystitis (bladder infection) and pyelonephritis. Reagent strip detects the ability of certain bacteria to reduce nitrate (found in urine normally) to nitrite (abnormal in urine). inadequate time in bladder for reduction of nitrate to nitrite. The Ictotest® tablet is a diazo confirmatory test for bilirubin that is more sensitive and less subject to interference. 2) Unconjugated bilirubin is not water soluble and cannot be excreted in urine. h. i. In the reagent strip method.

loss of renal tubular concentrating ability. b. Reagent strip method does not quantify the number of WBCs.G. MICROSCOPIC EXAMINATION OF URINE A. This causes a change in pH that is detected as a decrease in pH. Gives an approximate specific gravity value in increments of 0. pad color is yellow in acid solution. Reagent strip reaction: An acid ester reacts with leukocyte esterase to form an aromatic compound that reacts with a diazonium salt. lower urogenital tract. S. high specific gravity (prevents release of leukocyte esterases). 10-12 mL of urine are centrifuged leaving 0. inflammation of urinary tract b. protein. pad color is blue in alkaline solution. c. Standard rules for microscopies a. Reaction interferences 1) False positives: Elevated protein or ketone levels increase the specific gravity. Clinical significance: Monitors hydration and dehydration. Reaction interferences 1) False positives: Pigmented urine. Leukocytes a. . S. epithelial cells. leukocytes. and external contaminants 2. strong oxidizing agents 2) False negatives: Increased glucose. parasites. yellow-pigmented substances. crystals. yeast. The strip method detects lysed leukocytes that would not be found under the microscope. forming a purple color. Specific gravity a. = 1. Microscopic Examination of Urine 1. d. lymphocytes (do not contain leukocyte esterase).5-1. d. thus causing a color change of bromthymol blue. and artifacts 3.005 b. selected antibiotics like gentamicin and tetracycline 1 1 . Indicate possible urinary tract infection. e. Must be done to identify insoluble substances from the blood.000. add 0. Reagent strip reaction: The ionization of a polyelectrolyte in an alkaline solution (due to change in dissociation constant) produces hydrogen ions proportionally to the ions present in the solution. = 1. VII. and ascorbic acid. sperm. Formed elements: Erythrocytes.5. mucus.922 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 10. and diabetes insipidus c. fungal elements.030.0 mL of sediment for viewing. 2) False negatives: If urine pH >6. bacteria. kidney. Note that the pad is sensitive only to ions in the urine. which is an indicator able to measure pH changes.005 to the reading.G. Cells and nonionized solutes like glucose will not cause a reaction. Examine urine while fresh or when properly preserved.

some types of crystals. Pyuria is increased WBCs in the urine and may indicate infection in the urogenital tract. report casts and crystals using low-power magnification (i.e. d. leaving only yeast. e.e. 2) Eosinophils in the urine may indicate a drug-induced nephritis or renal transplant rejection. 1) WBCs swell in dilute alkaline urine (hypotonic). and urethritis 2) Nonbacterial pyuria resulting from glomerulonephritis. which appears as a ghost cell. low-power field [Ipf]). irregular cytoplasm and a central nucleus the size of a RBC. which have a sparkling appearance due to the Brownian movement of the granules. Epithelial cells a. Erythrocytes (7 microns) a. phase contrast. All formed elements must be identified and quantified. menstrual contamination. prostatitis. glomerular membrane damage.. and exercise. and tumors b. d. c. or urogenital tract vascular damage. 0-5 WBCs (hpf). Squamous epithelial cells line the lower urethra and vagina in women and the urethra of males. and mucus. high-power field [hpf]). MICROSCOPIC EXAMINATION OF URINE c. Leukocytes in the urine may indicate the following: 1) Bacterial infections. Microscopic methods include brightfield. cystitis. b. trauma. renal calculi. pyelonephritis. RBCs swell and lyse with release of hemoglobin. C. Note that the reference ranges for these will vary by the method and volume used. Excessive numbers of these cells may suggest the sample has not been collected . Leukocytes (10-15 microns) a. RBCs can be confused with yeast cells or oil droplets (highly refractile). and polarized. toxins. special staining will be needed to visualize these cells. Neutrophils are the predominant WBC appearing in the urine with cytoplasmic granules and multilobed nuclei. lupus. 2. If suspected to be present. Normal Urines: Contain 0-2 RBCs (hpf). They are the largest of the cells found in sediment with abundant. Urine Formed Elements 1.. Number of cells counted is related to extent of renal damage. producing glitter cells. B. RBCs associated with infections. in dilute or alkaline urine. several epithelial cells (hpf). in concentrated urine they shrink and appear crenated. 0-2 hyaline casts (Ipf). RBCs in normal urine appear as colorless disks. circulatory problems. oil droplets. Dilute acetic acid can be used to lyse RBCs. leaving an empty cell. and WBCs. Squamous epithelial (30-50 microns): These cells are very common in the urine and usually not clinically significant. 3. Report RBCs/WBCs using high-power magnification (i. cancer.

c.) contained within them or attached to their surface. 4) Casts may have formed elements (such as bacteria. transitional cells are spherical/polyhedral/caudate and have a central nucleus. with the PCT being coarsely granulated and the CD being very finely granulated. and viral infection.924 • CHAPTER 11: URINALYSIS AND BODY FLUIDS properly by the clean-catch method. These cells are filled with fat and are larger than oval fat bodies. . RBCs. 3) Casts are formed within the lumen of the distal convoluted tubule and collecting duct. larger cells in the proximal convoluted tubule (PCT) to cells slightly larger than a WBC-shaped cuboidal or columnar originating from the collecting duct (CD). Tubular injury is suggested when > 5/hpf are present. and upper urethra in males. There is no associated pathology. including vacuoles and irregular nuclei. renal tubular damage. 4. Can indicate renal cancer. b. Of all the formed elements in the urine. except in large numbers. It has a small eccentric nucleus. Transitional epithelial: These cells line the renal pelvis. WBCs. Their presence is associated with dilation of endoplasmic reticulum before the death of injured cells. Cell size and shape vary from rectangular. toxic and allergic reactions. which may indicate renal carcinoma or viral infection. only casts are unique to the kidney. taking on a shape similar to the tubular lumen. Renal tubular epithelial (RTE): The RTE cell is the most significant epithelial cell in the urine. Types of renal tubular cells include: 1) Bubble cells are RTE cells that contain large. with abnormal morphology. clue cells may appear. d. ureters. Cytoplasm varies. 1) Different casts represent different clinical conditions. 2) Cylindruria is the term for casts in the urine. pyelonephritis. non-lipid-filled vacuoles. 5) Uromodulin (Tamm-Horsfall glycoprotein) is the major constituent of casts and is poorly detected by reagent strip methods. In the presence of a vaginal infection. Casts a. Smaller than squamous epithelial cells. They may indicate nephrotic syndrome. Miscellaneous cells: Histiocytes in the urine may indicate lipid-storage disease. Uromodulin is made by the renal tubular epithelial cells that line the DCT and upper CD. bladder. These cells can be seen in renal tubular necrosis. 2) Oval fat bodies are renal tubular epithelial cells that have absorbed lipids that are highly retractile and stain with Sudan III or oil red O. Increased number of cells may be present after catheterization due to the invasiveness of the procedure. etc. Their formation is favored when there is urinary stasis. clue cells are squamous epithelial cells covered with Gardnerella vaginalis (coccobacillus). Casts also consist of some albumin and immunoglobulins.

g. and allograft rejection 2) Appearance: Contain renal tubular epithelial cells f. can have cracks or fissures on the sides h. Finely granular casts appear gray or pale yellow. 0-5/lpf normal 1) Increased hyaline casts normally follow exercise. Fatty cast: Seen with oval fat bodies in disease states that result in lipiduria . Hyaline cast: Most commonly seen cast. 2) Disease association: Acute glomerulonephritis. formed from degeneration of granular casts 1) Disease association: Chronic renal failure with significant urine stasis 2) Appearance: High refractive index. heat. such as cellular casts or protein aggregates. Bacterial cast: 1) Disease association: Pyelonephritis 2) Appearance: Bacilli contained within the cast and bound to the surface. contains hemoglobin and intact erythrocytes c. seen in heavy metal. viral infections. damage to the glomerulus or renal capillaries as found in post-streptococcal infections 2) Seen following strenuous contact sports 3) Appearance: Orange to red color. with varied morphology b. Coarsely granular casts contain larger granules that may appear black. or drug toxicity. colorless to yellow with a smooth appearance. Waxy cast: Contains surface protein. thus appearing granular with multilobed nuclei d. and emotional stress. WBC cast: A cellular cast containing WBCs 1) Disease association: Infection (pyelonephritis) or inflammation within the nephron (acute interstitial nephritis) 2) Appearance: Primarily contain neutrophils. RBC cast: Cellular casts containing erythrocytes 1) Disease association: Bleeding within the nephron. dehydration. MICROSCOPIC EXAMINATION OF URINE • 925 5. mixed cast containing bacteria and WBCs may occur e. chronic renal disease. Types of casts a. Granular cast: 1) Disease association: The granular appearance may result from glomerular precipitants. pyelonephritis. 2) Seen with hyaline casts following stress and exercise 3) Appearance: Granular casts can be coarsely or finely granular (differentiation holds no clinical significance). granules adhere to the cast matrix. chemical. and congestive heart failure 3) Appearance: Colorless. Epithelial cell cast: 1) Disease association: Advanced renal tubular damage.

and retrograde ejaculation 10. Bacteria can be distinguished from amorphous crystals by their motility (tumbling or directional flagellar movement). toxic tubular necrosis. the ultrafiltrate becomes saturated. which shows a characteristic Maltese cross formation.9Z6 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 1) Disease association: Nephrotic syndrome. Crystal identification: Crystals differ in their solubility. Parasites: The most common parasite in the urine is Trichomonas vaginalis. Crystals will appear more frequently if urine stands at room temperature for prolonged time periods or is refrigerated. 8. Crystals are formed by the precipitation of urine salts. Disease association: Lower and upper UTI b. pH. Yeast: a. . can be confused with hyaline casts 11. and urine concentration. Bacteria: Not present in normal sterile urine a. male infertility. diabetes mellitus 2) Appearance: Highly refractile. contains yellow-brown fat droplets 3) Positive identification of fatty casts is by Sudan III stain or polarized light. leading to the solute precipitating into a characteristic crystal form. i. organic compounds. Crystal formation is enhanced when urine flow through the renal tubules is inhibited. Mucus: Protein substance produced by the RTE cells and the urogenital glands. not considered clinically significant a. and in immunocompromised individuals b. Another parasite sometimes found in the urine is pinworm ova from Enterobius vermicularis. 7. Sperm: Seen in urine following intercourse or nocturnal emissions. diabetes mellitus. If an increased amount of a solute is present. b. look for budding yeast forms. which is usually due to fecal contamination. with the most common being granular and waxy 6. Crystal formation can be altered by temperature. Yeast can be confused with erythrocytes. 9. and medications. view under reduced light. Disease association: UTI. The reduced flow allows time for concentration of the solutes in the ultrafiltrate. Crystals: a. c. vaginal infections. no clinical significance except in forensic cases. Broad cast: Formed in the DCT and CD due to anuria 1) Disease association: Suggests renal failure 2) Appearance: All types of casts can occur in the broad form. Urine pH is important in determining the type of crystal formation. then the solutes in the ultrafilrate are concentrated. All clinically significant crystals are in acidic and neutral urine. Appearance: Threadlike structures with low refractive index. Crystal formation: The glomerular ultrafiltrate passes through the renal tubules.

with chemotherapy for leukemia. e. K+. 2) These crystals are most often seen in liver disease. and oranges. Tyrosine 1) Abnormal crystal: Fine delicate needles. Amorphous urates 1) Formed from the urate salts of Na+. Uric acid 1) Seen in gout. may make other urine elements difficult to see 4) Refrigerated samples will produce more amorphous urates and may appear as pink sediment because of the presence of uroerythrin on the surface of the granules. monohydrate form appears as dumbbell or oval shaped. b. yellow-to-brown granules usually in large amounts. Types of acidic urine crystals: a. rhombic plates. MICROSCOPIC EXAMINATION OF URINE • 927 12. In addition. and they appear as fine needles or granules that are yellow to brown in color. 3) These crystals are associated with renal calculi formation. berries. Calcium oxalate 1) Most urine oxalate is from oxalic acid. dihydrate form appears as octahedral envelope or two pyramids joined at their bases. Bilirubin 1) Abnormal crystal: These crystals are formed when urine bilirubin exceeds its solubility. which is found in such foods as tomatoes. and Ca2+ 2) No clinical significance 3) Small. oxalic acid is a metabolite of ascorbic acid. asparagus. and rosettes c. colorless to yellow found in clumps or rosettes 2) Associated with severe liver disease and in inherited diseases that affect amino acid metabolism 3) May be seen with leucine crystals in urine that tests positive for bilirubin . Monohydrate form is seen in poison centers where children have ingested ethylene glycol (antifreeze). wedges. Casts may contain bilirubin crystals in cases of viral hepatitis when there is renal tubular damage. d. 2) Colorless. and in Lesch-Nyhan syndrome 2) Appear yellow to orange/brown but can be colorless 3) Pleomorphic (many) shapes include four-sided flat plates. 5) Amorphous urates will dissolve at alkaline pH or by heating above 60°C. Mg+. spinach.

hence cystinuria.050) 13. oily-looking spheres with concentric circles and radial striations. may be associated with UTI c. j.to six-sided prism often resembling a coffin lid 2) Not clinically significant. thin prisms or rectangular plates 2) Not clinically significant. hexagonal plates 2) These crystals result from a congenital disorder that inhibits renal tubular reabsorption of cystine. any buildup can result in renal damage. a) Ampicillin crystals appear colorless in the form of needles. three. Amorphous phosphate 1) Identical in appearance to amorphous urates and generally colorless. sheaves of wheat. Calcium phosphate 1) Colorless. Crystals from medications 1) Medications are excreted by the kidneys. Cholesterol 1) Abnormal crystal: Clear. and ornithine will also be present but they are more soluble than cysteine so not visible. or rosettes. Leucine 1) Abnormal crystal: Yellow to brown. Triple phosphate (ammonium magnesium phosphate) 1) Colorless. refrigerated samples appear as a white sediment 2) Amorphous phosphates are soluble in acetic acid (amorphous urates are insoluble in acetic acid) and will not dissolve when heated above 60°C. Alkaline urine crystals: a. more commonly seen following refrigeration. Note that lysine. may be associated with renal calculi formation . 3) Associated with renal calculi formation h. seen with fatty casts and oval fat bodies 2) Associated with nephrotic syndrome and other disorders that produce lipiduria i.• CHAPTER 11: URINALYSIS AND BODY FLUIDS f. Cystine 1) Abnormal crystal: Colorless. Radiographic dyes 1) Resemble cholesterol 2) Correlate with increased specific gravity (> 1. 3) Not clinically significant b. may be found with tyrosine crystals 2) Associated with severe liver disease and in inherited diseases that affect amino acid metabolism g. b) Sulfonamide crystals appear colorless to yellow-brown in the form of needles. rectangular plates with a notch in one or more corners. flat. which may form bundles. fan formations. arginine.

leucylalanine. 5. 1) Microfluorometric assay directly measures phenylalanine in dried blood filter disks. subtilis growth around the disks (positive PKU). As the child grows. The urine gives off a mousy odor associated with phenylpyruvate because of the increased ketones. The presence of phenylalanine in the urine indicates defective metabolic conversion of phenylalanine to tyrosine. Blood is placed on filter paper disks on culture media streaked with Bacillus subtilis. colorless crystals having dumbbell or spherical shapes 2) Not clinically significant VIM. Types of PKU testing (all positive screening tests are confirmed by high- performance liquid chromatography) a. When the PKU test is positive. subtilis. a positive test is blue-green. which is an inhibitor of B. Ammonium biurate 1) Normal crystal commonly seen in old urine samples. and copper tartrate. resulting in B. Urine test for phenylpyruvic acid uses ferric chloride (tube or reagent strip). will be counteracted. Occurs in 1:10. 4) A pretreated (trichloroacetic acid) patient sample extract is reacted in a microtiter plate containing ninhydrin. If phenylalanine is present in the blood sample. 4. . 5) The sample is measured at 360 nm and 530 nm. SPECIAL URINE SCREENING TESTS (USUALLY PERFORMED IN SPECIAL CHEMISTRY) • 929 d. Calcium carbonate 1) Appear as small. will result in severe mental retardation. 3) It is not affected by antibiotics.000 births and. if undetected. the diet is changed to eliminate all phenylalanine from the diet. beta-2-thienylalanine in the media. also can show irregular. converts to uric acid crystals if acetic acid added and dissolves at 60°C 2) Yellow to brown spheres with striation on the surface. thorny projections (thorn apple) e. PKU screening tests are required in all 50 states for newborns (at least 24 hours old). Phenylketonuria (PKU) 1. b. 2) It is a quantitative test (Guthrie is semiquantitative). an alternative phenylalanine pathway develops and dietary restrictions are eased. Guthrie bacterial inhibition test uses blood from a heel stick. 3. 7. 2. 6. SPECIAL URINE SCREENING TESTS (USUALLY PERFORMED IN SPECIAL CHEMISTRY) A. which is caused by a gene failure to produce phenylalanine hydroxylase. succinate.

and cardiac problems. Arise from enterochromaffin cells of the gastrointestinal tract b. which contain significant amounts of serotonin. 4. acidosis. This is a genetic defect resulting in failure to produce homogentisic acid oxidase. Screening tests include: 1) Ferric chloride tube test (blue color) 2) Benedict's test (yellow color) 3) Alkalization of fresh urine (urine darkens) 3. and acquired severe liver disease. Alkaptonuria a. Hereditary defects are usually fatal. which causes accumulation of homogentisic acid in blood and urine. . and valine c. breath. whose major urinary excretion product is 5-hydroxyindoleacetic acid (5-HIAA) c. premature infants with an underdeveloped liver. Tyrosinosis a. 5. Maple syrup urine disease a. If untreated. and hypoglycemia. whereas chromatography is used as a confirmatory test. Screening test uses 2. b. b. convulsions. Produce increased blood serotonin. d. Excess tyrosine (tyrosinuria) or its by-products (p-hydroxyphenylpyruvic acid orp-hydroxyphenyllactic acid) in the urine b. Argentaffinoma a. pineapples.930 • CHAPTER 11: URINALYSIS AND BODY FLUIDS B. c. Increased melanin in urine is produced from tyrosine. presenting with liver and renal diseases. The nitrosonaphthol test is used as a screening test. Death occurs during the first year. b. d. Screening tests include ferric chloride (gray/black precipitate) and sodium nitroprusside (red color). All of these conditions will produce tyrosine and leucine crystals. Indicates malignant melanoma c. isoleucine. the disease causes severe mental retardation. Characteristic of this disorder is maple syrup smell of the urine. Patient must be on diet free of bananas. inhibits metabolism of leucine. liver. Melanuria a. Metabolic disease states include transitory tyrosinemia. and tomatoes.4-dinitrophenylhydrazine (DNPH) to form yellow turbidity or precipitate. This condition produces brown pigment deposits in body tissue that can lead to arthritis. and skin. Miscellaneous Special Urine Screening Tests 1. Detected using l-nitroso-2-naphthol to yield a purple color d. Caused by low levels of branched-chained keto acid decarboxylase. 2. Inherited or metabolic defects c. urine darkens upon standing.

seen in meningitis. c. Cerebrospinal fluid microscopic: Normal CSF contains 0-5 WBC/uL. hemorrhage. bilirubin. If traumatic tap. Total adult volume is 140-170 mL. protein. The order of draw is: a. hematology. If there is hemorrhage. 2. which is performed by a physician between 3-4 or 4-5 lumbar vertebrae. BODY FLUIDS AND FECAL ANALYSIS • 931 IX. 20 mL of CSF is produced each hour. Microbiology testing a. removes wastes. or bacteria. Bloody: This may be due to subarachnoid hemorrhage or traumatic tap. Xanthochromic (yellow): Increased hemoglobin. Tube #2: Microbiology (culture and sensitivity) c. protein. screw-capped tubes. CSF is made by the brain's third choroid plexus as an ultrafiltrate of plasma. and cushions the brain and spinal cord against trauma. increased in viral and fungal meningitis c. possible complication of AIDS b. Tube #1: Chemistry and serology (glucose. lymphocytes and monocytes predominate b. Lymphocytes: Seen in normal fluids. and neonate volume is 10-60 mL. Gram stain and culture: Used to detect bacteria . note that hematology will also receive this tube initially to compare with tube #3 for determining possibility of traumatic tap b. BODY FLUIDS AND FECAL ANALYSIS A. CSF total protein: Assayed using trichloroacetic acid precipitation method or Coomassie brilliant blue 5. numbered. Chemistry testing a. Tube #3: Hematology (red and white blood cell counts) 3. Cloudy: Indicates WBCs. CSF glucose: 60-70% of the patient's plasma glucose b. antibodies). protein. disorders of the blood-brain barrier. there will be less blood in tube #3 than in tube#l. Cerebrospinal Fluid (CSF): (Most CSF analysis is performed in chemistry. Differentiation between the two is made by noting the difference in appearance between tubes #1 and #3. all tubes will appear bloody. Early cell forms: Acute leukemia e. RBCs. Plasma cells: Multiple sclerosis or lymphocytic reactions 6. Specimen collection is by lumbar puncture. India ink: Used to detect Cryptococcus neoformans. Cerebrospinal fluid appearance a. The samples are collected into sterile. It supplies nutrients to nervous tissue. Hematology testing a. and microbiology. immature liver in premature infants 4. PMNs: Bacterial meningitis (cerebral abscess) d. d. etc. Clear and colorless: Normal b.) 1.

Laboratory analysis (nonchemistry) includes color. Semen analysis a. Synovial fluid is a plasma ultrafiltrate and is often called joint fluid. pinhead. Synovial Fluid 1. Specimen collection a. infection.CHAPTER 11: URINALYSIS AND BODY FLUIDS B. Volume: 2-5 mL b. Viscosity: Normal is no clumps or strings. Cells other than sperm present: The presence of red blood cells or white blood cells would be significant. . pH: 7. borderline is 10-20 million/mL. 2.0 is normal (>8. Synovial fluid functions as a lubricant and nutrient transport to articular cartilage. which. bleeding. Morphology: Oval-shaped head with a long. 50-60% or greater with a motility grade of 2 is normal (0—immotile. Seminal Fluid (Semen) 1. Plastic containers will inhibit motility c. and coiled tail. C. Keep at room temperature. g. giant head. and forensic medicine cases 2. Normal color of synovial fluid is clear to straw colored. e. which takes about 30-60 minutes. Appearance: Normal is a translucent. Used to evaluate infertility. 5. 3. including inflammation. flagellar tail is normal. c. d. b.0 could indicate infection).2-8. the presence of hyaluronic acid gives synovial fluid a unique viscosity. can suggest the presence of bacteria secreting hyaluronidase. f. h. Motility: Based on the percentage of movement. gray-white color. Sperm count: Normal is 20-160 million/mL. if absent. No condom collection (may contain spermicidal agents) d. a. Most crystals found in synovial fluid are associated with gout (uric acid) or calcium phosphate deposits. Collect in sterile containers after 3-day period of no sexual activity for infertility studies. and crystal identification with a polarizing microscope. transport to the lab professionals within 1 hour. must have specimen that is completely liquefied. In addition. Different joint disorders change the chemical and structural composition of synovial fluid. 4—motile with strong forward progression). double tail. 3. post-vasectomy. differential count. and crystal- associated disorders. Gram stain with culture. and sterile is less than 10 million/mL. post-vasectomy requires no waiting period b. Abnormal forms include double head. amorphous head. 4.

F. 3. phosphatidyl glycerol) will increase as the fetus's lungs mature. 3. Differentiation of the presence of blood versus bilirubin can be achieved by measuring for increased absorbance at 410 nm (bilirubin) and 450 nm (hemoglobin). volume. needle aspiration termed amniocentesis 2. Peritoneal Fluid 1. and gross color examination. Levels of phospholipids (phosphatidyl choline [lecithin]. Pleural and pericardial fluids are found between the visceral and parietal pleural (around the lungs) and pericardial (around the heart) membranes. BODY FLUIDS AND FECAL ANALYSIS • 933 D. Protective fluid surrounding the fetus. E. Both fluids are clear to pale yellow. Increases in volume in peritoneal. Aspiration of pleural/pericardial fluids is termed thoracentesis and pericardiocentesis. Gastric Fluid: Gastric fluid collection is performed by nasal or oral intubation. H. Analysis involves physical appearance. Aspiration is termed peritoneocentesis. 3. 2. or pericardial fluids are called effusions. or meconium (dark green fetal intestinal secretions) content that in large amounts is associated with meconium aspiration syndrome. 2. respectively. Gram stains. infection. Gram stains. Laboratory analysis includes cell counts. Inflammatory effusions are called exudates and will have higher than 1000 cells^L and more than 3 g/dL protein. gross color examination and specific gravity. Pleural and Pericardia! Fluids 1. fetal bleeding. titratable acidity. G. Amniotic Fluid 1. Laboratory analysis includes cell counts. and pH. . it is called a transudate and will have fewer than 1000 cells^L and less than 3 g/dL protein. pleural. respectively. If the mechanism is noninflammatory. 4. fetal lung maturity. 3. Clear to pale yellow fluid contained between the parietal and visceral membranes in the peritoneum (serous membrane that covers the walls of the abdomen and pelvis). Amniotic fluid is mostly used for genetic studies but may be used to check for bilirubin. Fluid Effusions 1. Most uses of gastric analysis are for toxicology and for the diagnosis of Zollinger- Ellison syndrome. also called ascites fluid 2.

and parasites c. which is associated with colorectal cancer.934 • CHAPTER 11: URINALYSIS AND BODY FLUIDS I. old name. which may indicate pancreatic insufficiency seen in cystic fibrosis. f. e. however. liver and biliary duct disorders. most common c) Immunological: Use of an antihemoglobin to react with the patient's hemoglobin has the advantage of not requiring any special diet before sample collection. Hb —» H2O2 —*• ortho-toluidine —» blue oxidized indicator b) Gum guaiac: Least sensitive. if the gastrointestinal bleed is in the upper intestine. of hemoglobin degradation (and nondetection by antibody). abscesses 2) No neutrophils: Toxin-producing bacteria. . increased fecal fat (>60 droplets/hpf) suggestive of steatorrhea d. Used in the detection of gastrointestinal (GI) bleeding. pale: Bile-duct obstruction/obstructive jaundice b. malabsorption syndromes. There is the possibility. Fecal Analysis 1. Occult blood: Used for early detection of colorectal cancer. iron therapy 2) Red stool: Lower GI bleeding 3) Steatorrhea: Fat malabsorption 4) Diarrhea: Watery fecal material 5) Ribbon-like stools: Bowel obstruction 6) Mucus: Inflammation of the intestinal wall (colitis) 7) Clay-colored. viruses. Types of fecal analysis a. and infections 2. guaiac test 1) Occult blood most frequently performed fecal analysis 2) Several chemicals used that vary in sensitivity a) Ortho-toluidine: Pseudoperoxidase activity of hemoglobin (Hb) reacts with H2O2 to oxidize a colorless reagent to a colored product. DNA test detects K-ras mutation. Qualitative fecal fat: Detects fat malabsorption disorders by staining fecal fats with Sudan III or oil red O. Color and consistency 1) Black (tarry) stool: Upper GI bleeding. Muscle fibers: Look for undigested striated muscle fibers. Fecal leukocytes: Determine cause of diarrhea 1) Neutrophils: Bacterial intestinal wall infections or ulcerative colitis.

Least likely to be contaminated with C. Most concentrated specimen of the A. Carotene microorganisms because the bladder is D. 4. What is the expected pH range of a freshly voided urine specimen? A. • •\w I questions J. Porphyrin 4. Indican abnormalities will be detected C.0 C. 3. what C. 3.0 935 . Urochrome a sterile environment 3. In certain malignant disorders. Urobilinogen day and therefore it is more likely that B. Melanin B.5-8.5 D. Select the best answer or completion statement in each case. What substance is A.0-8. Why is the first-voided morning urine 2. Bilirubin limits of the reagent strips B.M o -L Jtv LJ v_x JL JLVjJNI O Each of the questions or incomplete statements that follows is comprised of four suggested responses.5-8. 4. Melanin D.5-9.0 B. 1. Most dilute specimen of the day and normally found in urine that is principally therefore any chemical compounds responsible for its yellow coloration? present will not exceed the detectability A. The physical characteristic of color specimen the most desirable specimen for is assessed when a routine urinalysis routine urinalysis? is performed. Most likely to contain protein because substance is found in the urine that turns the patient has been in the orthostatic the urine dark brown or black on exposure position during the night of the urine to air? D..

CHAPTER 11: URINALYS1S AND BODY FLUIDS 5.020 D. Beta-globulins 130mg/day. Oliguria C. Hemoglobin than 0. Urine specimens should be analyzed as 9. Albumin B. B. A urine specimen that exhibits yellow D. Protein that exhibit a B. 8. Anuria weekly basis.010 .007 C. Specific gravity greater than 1. If urine precision and accuracy of the reagent test specimens are allowed to stand at room strips used for the chemical analysis of temperature for an excessive amount of urine? time. Positive and negative controls should 6. Positive and negative controls should C. Glucose concentration is greater than D. C. the urine pH will become alkaline A. Hypersthenuria protein is able to detect as little as 5-20 nig of protein per deciliter.5 g/day. Creatinine be run when the test strips' expiration D. Bilirubin D. Polyuria 10. A. Specific gravity of exactly 1. What may cause a 7.0.000 C. C. Vitamin C concentration is greater B. Nitrite B. Positive controls should be run on a 24-hour period? daily basis and negative controls on a A. Urea B. The colorimetric reagent strip test for D. The reagent test strips used for the false-positive urine protein reading? detection of protein in urine are most A. Which term is defined as a urine volume be run on a daily basis. Specific gravity less than 1. Fixed specific gravity of approxi- mately 1. Positive controls should be run on a because of bacterial decomposition of daily basis and negative controls when A.5 g/day. How should controls be run to ensure the soon as possible after collection. foam on being shaken should be suspected 11. Uric acid concentration is greater than reactive to 0. Protein opening a new bottle of test strips. Ketones date is passed. pH is greater than 8. in excess of 2000 mL excreted over a D. Hemoglobin A. "Isosthenuria" is a term applied to a series of having an increased concentration of of urine specimens from the same patient A. Alpha-globulins C. B.

causing a false- acidosis. organic substance found in urine? C. A protein other than albumin must be be explained by which of the following present in the urine. 16. The child is suffering from lactic taken at 2 minutes). The child is suffering from increased A. thus causing reagent test strip is negative for glucose a false-negative reaction. Diacetic acid and beta-hydroxybutyric phosphates that caused the turbidity acid seen with the sulfosalicylic acid test. and the lactic acid has falsely negative reaction to be detected. Tetracycline results are reported out C. Setting collection guidelines for catalyzing the oxidation of a dye with 24-hour urines peroxide to form a colored compound. The child has Type 1 diabetes mellitus. The reagent area for ketones was read D. test was exceeded (the reading being B. Potassium intestinal absorption. Setting a maintenance schedule for This method may yield false-positive microscopes results for the presence of hemoglobin C. Requiring acceptable results for A. REVIEW QUESTIONS • 937 12. Glucose D. The of the reagent strip. Urea after the maximum reading time 14. Reporting units to be used for crystals when the urine specimen contains D. This strip test is sensitive the latter results in a reading of 2+ to the presence of protein. The reagent strip impregnated with sodium former yields a negative protein. statements? D. Each of the following is included in the allowed. but positive for ketones. whereas nitroprusside. Which of the following statements A. Nitrite . A urine specimen is tested by a reagent 15. The urine contained an excessive B. The urine pH was greater than 8. Which one represents a strip test for hemoglobin is based on the preanalytical component of testing? peroxidase activity of hemoglobin in A. Myoglobin D. Acetoacetic acid and beta- best explains this difference? hydroxybutyric acid A. These results may C. C. Ascorbic acid control specimens before any patient B. The principle of the colorimetric reagent laboratory. reacted with the impregnated reagent 13. Which of the following is the major area for ketones. Beta-hydroxybutyric acid and acetone B. Sodium catabolism of fat because of decreased B. quality assurance program for a urinalysis 17. B. A routine urinalysis is performed on a exceeding the buffering capacity young child suffering from diarrhea. Acetoacetic acid and acetone amount of amorphous urates or C. The presence of ketone bodies in urine strip test and the sulfosalicylic acid test to specimens may be detected by use of a determine whether protein is present. The reading time of the reagent strip A. D.

Significant urinalysis results are consistent with show the following: color = yellow. Brightfield microscopy B. A reagent test strip impregnated with 23. "Glitter cell" is a term used to describe 19. Polarized microscopy A. With infections of the urinary system. These B.4-dichloroaniline may be used to by use of polarized microscopy? determine which analyte? A. Moderate bacteria granular casts undergo is represented 20. specific B. Ketone bodies D. 0-1 RBC/hpf. and increased creatinine. Chronic renal failure . Lymphocyte of kidney infection is seen by her physician C. Fluorescent microscopy nitrogen. A 40-year-old female patient with a history B. Coarse blood cell is seen the most frequently in C. Nephrotic syndrome 4+. Neutrophil C. 3+ amorphous phosphates 25. Casts B. Waxy A. 0-1 fatty 22.pH = 7. Ketone C. Bilirubin 24. Neutrophil weeks. A random urine is collected from a patient urination and a bloated feeling. Which of the following will contribute to a a specific type of specimen's specific gravity if it is present A. Fine the urine sediment. Glucose B. 85 mg/dL glucose D. A. Hemoglobin D.022. 10-20 hyaline casts/lpf. by which of the following casts? white blood cells are frequently seen in A. 0-1 granular casts/lpf. Nephrotic syndrome D. 0-3 WBC/hpf. Physical and the results obtained are as follows: examination shows periorbital swelling urine albumin = 1 6 mg/dL and urine and general edema. To detect more easily the presence of casts casts/lpf. Cellular urine sediment? D. Monocyte because she has felt lethargic for a few D. Eosinophil 26. She has decreased frequency of 21. 0-2 D. Glomerulonephritis C. increased urea A. What type of white B.0. Microalbuminuria appearance = cloudy/frothy. Lipids A. The final phase of degeneration that D. including a swollen creatinine = 140 mg/dL. Fatty droplet B. which microscopic serum chemistries show significantly method can be used? decreased albumin. CHAPTER 11: URINALYSIS AND BODY FLUIDS 18. Red blood cells C. Multiple myeloma D. Oval fat body A. occasional oval fat bodies. 50-100 RBC/hpf C. These findings abdomen. Which substance found in urinary a diazonium salt such as diazotized sediment is more easily distinguished 2. Obstructive jaundice renal epithelial cells/hpf. protein = C. Ketone body in a person's urine? B. Macroalbuminuria gravity = 1. Her in urine sediments. Phase-contrast microscopy findings suggest which condition? C.

Serotonin color = yellow. is the expected fasting cerebrospinal fluid appearance = cloudy. 25^0 WBC/hpf. The major formed elements are white A. Which of the following is true 31. Lower urinary tract infection D. 50 0-3 RBC/hpf. Nephrolithiasis . Some clinical conditions are characterized for this patient? by unique urinalysis result patterns. Homogentisic acid C. 25 esterase . Intensive dieting: increased ketones. (CSF) glucose level in mg/dL? nitrite = positive. Alkaptone presence of B. 5-Hydroxytryptophan pH = 6. appearance = cloudy. The type and number of epithelial sulfosalicylic acid cells suggest incorrect sample B. 2-5 squamous epithelial C. moderate bacteria. If a fasting plasma glucose level of 100 urine as part of a lab class. Yeasts student performs a urinalysis on her own 33. A 22-year-old female clinical laboratory D. negative protein with C. White blood cells C. The number of bacteria seen would Which of the following shows such a result in a positive nitrite. REVIEW QUESTIONS • 939 27. increased excretion of urinary clean-catch specimen. B. Upper urinary tract infection C. A 47-year-old female patient with 30. A. a rare hereditary disease. Red blood cells D. These findings suggest A.2+. Metastatic carcinoid tumors arising from controlled type 2 diabetes mellitus the enterochromaffin cells of the gastroin- complains of urinary frequency and testinal tract are characterized by burning.5. leukocyte A. 5-Hydroxyindole acetic acid B. relationship? B. The red blood cells would be sufficient C. Phenylalanine A. 100 chemistries and microscopic results were normal. 65 cells/hpf. Cystitis: positive nitrite and protein characterized by the urinary excretion of 32. is D. Bacteria 29. 5-Hydroxyindole acetic acid Plate 46B. Multiple myeloma: positive protein to give a positive blood result on the by both reagent strip and sulfosalicylic reagent strip. Homogentisic acid high-power field is shown in Color D. a representative microscopic C. acid 28. B. Nephrotic syndrome: positive protein blood cells and yeast. Nitrite in a urine specimen suggests the A. Alkaptonuria. pH = 7. negative glucose D. on reagent strip. Significant mg/dL is obtained on an individual. Results show A. what results include: color = yellow.5. Glomerulonephritis B. All other D. She provides a first-morning. collection.

Phenylalanine and tyrosine kidney damage. D. This test requires a 24-hour urine patient's urine along with which soluble collection. C. The major formed element in the high- severe crush injuries sustained in a car power field shown in Color Plate 48 • accident. Production of an acid urine filtration rate (eGFR) of 42 mL/min/1. Isoleucine and leucine using the Cockgroft-Gault formula. through (0-1/Ipf). protein is 1 + . Casts found final concentrating of urine in the kidney? include hyaline (0-2/lpf) and granular A. which of D. May be found in normal alkaline urine B. Fiber artifact There is. B. biochemicals? B. D. based on these results. 36. The patient does not have chronic A. 38. Vasopressin controls the collecting hemolytic anemia. Water reabsorption is influenced by been positive for this patient. Rhabdomyolysis may be a cause for the discrepant chemical/microscopic 39. A 35-year-old man has just experienced 37. Which of the following is true about this B. He has a broken pelvis and right is most likely a femur and has numerous abrasions and A. A. Associated with renal pathology C. Deterioration of any albumin present Which of the following is true for this patient? 40. Hyaline cast shows a brown color and clear appearance. reabsorbs water. duct reabsorption of water.940 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 34. The bilirubin result should have also D. The distal convoluted tubule. only 0-1 RBC/hpf. A. B. however. Water is reabsorbed under the direct patient? influence of angiotensin II. Associated with lung pathology .73 m2. active transport. Granular cast contusions. temperature for several hours. If a urine specimen is left standing at room blood findings. The formed element shown in Color Plate 49B would usually be found in the A. Similar results would be obtained C. Multiplication of bacteria B. D. Waxy cast pH is 6. The positive blood result is from a C.0. C. Which is true about the formed element shown in Color Plate 47 •? A. Other urine results are normal. Acetoacetic acid and (3-hydroxy- D. Which of the following is true about the along with 0-3 WBC/hpf. An increase in the glucose concentra- 35. Ornithine and arginine C. The bone crushing led to the increased the following changes may occur? protein result. urine filtrate levels of potassium. A random urinalysis specimen B. and blood is 3+. Characteristic of glomerulonephritis D. A 67-year-old male has routine testing tion done and shows an estimated glomerular C. The patient is in Stage 3 chronic butyric acid kidney damage.

Normal sample white blood cells per microliter and 5 g/dL total protein. Phenylpyruvic acid excess appears 48. Noninflammatory B. Excess tyrosine accumulates in the following would be characteristic for this blood. Yellow stool with increased mucus B. Stool with lack of brown color number of the formed element that ("clay-colored") predominates in the high-power field C. A transudate levels of which of the following? B. C. Which of the following will be character- routine physical before the school year. C. Nephrotic syndrome other chemical results were normal. phenylalanine oxidase. Glomerulonephritis D. Glucose D. protein = trace. It may cause brain damage if B. Biliary tract obstruction representative microscopic high-power C.0. Acute glomerulonephritis hazy. D. Chloride C. condition? A. Sphingomyelin A. With the development of fetal lung sediment maturity. From this it can be deter- 44. Phosphatidyl choline enzyme. normal 47. Phenylketonuria may be characterized significantly and consistently increases? by which of the following statements? A. Phosphatidyl inositol B. Protein D. Lactate dehydrogenase glomerulonephritis D. It is caused by the absence of the D. Pyelonephritis 49. Which of the D. Contamination from vaginal discharge field is shown in Color Plate 50B. Hyaline casts and mucus. which of the following phospho- lipid concentrations in amniotic fluid 42. The 46. upper gastrointestinal bleed. pH = 6. REVIEW QUESTIONS • 941 41. Albumin/globulin ratio C. which of the suggest . Magnesium . An exudate A. Hemorrhagic C. Granular casts and red blood cells. Creatinine concentration nephrotic syndrome B. Improperly collected specimen C. Delta absorbance at 410 nm B. Brown stool with streaks of bright red 43. Mucus and fibers. Phosphatidyl ethanolamine untreated. To determine amniotic fluid contamination major formed elements are and with maternal urine. Stool with a much darker brown/black of Color Plate 5 !•? color A. Xanthochromia of cerebrospinal fluid mined that the patient's effusion is (CSF) samples may be due to increased A. A 13-year-old ice skater is having her 45. What condition is suggested by the B. no pathology C. A patient has been diagnosed with an in the blood. Hyaline casts and waxy casts. a B. following measurements could be used? A. ized by an increased number of the urinary Her first morning urinalysis results component seen in Color Plate 52M? include color = straw. A pleural effusion is found to have 3000 D. appearance = A. A. All D.

Which of the following statements applies B. C. Patients with diabetes insipidus tend to 55. shown in Color Plate 53B? A. Which methods may be used to quantify are done. Synovial B. protein in both cerebrospinal fluid and urine specimens? 58. Which of the following is characteristic of D. Bromcresol green and Coomassie B. Which of the following characteristics is produce urine in volume with true of the primary urinary components specific gravity. Coomassie brilliant blue and D. Spinal found dissolved in the urine is that they B. Presence indicates an inborn error of trichloroacetic acid metabolism . Appear yellowish in brightfield microscopy viscosity is useful in evaluating which type of fluid? 56. Appear insoluble in alkaline urine brilliant blue D. The third tube collected should be used for bacteriologic studies. Never should appear in a freshly collected sample blue C. Decreased. a culture D. CSF collected in the evening should A. Organic 52. Absence of fibrinogen A. The estimation of hyaluronic acid concentration by measurement of D.0 g/dL CSF? D. Which of the following characteristics is A. gravity of urine? C. Increased. Pleural A. Ponceau S and Coomassie brilliant A. Trichloroacetic acid and bromcresol true for the urinary components shown in Color Plate 54B? green B. Inorganic C. Waste products an exudate effusion? A. before cell counts 54. 53. decreased process D. Presence always indicates a disease C. Refractometer B. The second tube collected should be used for chemistry analyses. TS meter D. Which of the following systems utilizes polyelectrolytes to determine the specific B. Protein concentration <3. With low-volume specimens. Decreased. Clear appearance to the proper collection and handling of C. Can also resemble cysteine crystals C. increased B. Increased. A characteristic of substances normally A. increased C. Reagent strip is performed first. Water soluble D. Peritoneal are all C. Consist of uromodulin protein B. Leukocyte count >1000/uL 57.842 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 50. Osmometer be refrigerated and assays performed only by day-shift personnel. Can be observed with polarized microscopy 51. decreased A.

department and they told me that my D. D. I was studying in the library A. Compared to the fecal occult blood test. clear. A. B. Bilirubin from the general blood circulation? D. recently. when I felt lightheaded and passed out. Erythroblastosis fetalis obtained on a 40-year-old white male C. are clinically significant in which of the B. blood—negative. thirst. The tests need to be repeated because D. an online consumer health Web site: "I am which of the following is a disadvantage a 22-year-old female who experienced of performing a DNA-based test to detect increasing headaches. Your lab results pattern suggests spermatozoa? diabetes mellitus. The DNA test is less sensitive. 60. colon cancer? ing energy. pattern. B. Presence of red or white cells and they could not possibly occur together. Evaluation should include assessment B. Bile duct obstruction screening tests. glucose was 500 mg/dL. Which urinalysis reagent strip test will 64. bilirubin— moderate. C. These results anti-hCG to react with patient hCG. The two results do not fit any disease normal morphologic characteristics. Multiple sclerosis clinical examination. Internal controls provided within the C. Which of the following statements dark brown. determine pregnancy? ketones—negative. The DNA test is more invasive. and decreas. The DNA test is more expensive. Additional diet restrictions are needed serum Acetest® was 40 mg/dL and urine for the DNA test. Urobilinogen within the central nervous system and not C. protein—negative. Hepatitis kit will assess if the patient's specimen D. Papanicolaou stain may be used. A. D. What does this 63. External quality control is not needed with these methods. originating from B. A small number of sperm should have C. Multiple myeloma whose skin appeared yellowish during the D. A random urine specimen is the following conditions? preferred specimen for pregnancy A. I was taken to a hospital emergency C. Nitrite A. Color and clarity— 65. The following urinalysis results were B. Protein the cerebrospinal fluid. You probably have been crash dieting of 1000 spermatozoa. Which condition is characterized by never be reported out as "negative"? increased levels of immunoglobulins in A. A patient sends the following question to 62. Which of the following may be associated mean?" How would you reply? with morphologic examination of A. Cirrhosis C. Gout 61. Immunoassays will use reagent urobilinogen—0. pertains to screening methods used to glucose—negative. epithelial cells need not be noted. .2 mg/dL. REVIEW QUESTIONS • 943 59. Hemolytic anemia was collected correctly. B.

Which of the following is a true state- results were obtained from a 4-month-old ment? infant who experienced vomiting and A. gain weight: pH—6. ketone—negative. Red blood cells in acid urine (pH 4. Clinitest®—2+. Galactosemia method of choice for the collection of pericardial fluid. B. These results are clinically significant in C.5) glucose—negative. C. Bacteria introduced into a urine which of the following disorders? specimen at the time of the collection A. acidity. protein—negative. Pilocarpine iontophoresis is the D. Starvation D. Ketosis level of nitrite in the specimen. will usually be crenated because of the bilirubin—negative. The following urinalysis biochemical 67.944 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 66. Renal tubular cells originate from the diarrhea after milk ingestion and failed to renal pelvis. . Diabetes mellitus will have no immediate effect on the B.

If the urine analysis because it is the most concentrated spec- is allowed to stand at room temperature for imen of the day. D. 5. a substance derived from tyrosine. Qualitative screening tests for the nation of urinary sediment. is 4. present in a urine sample will increase. the color of normal urine. In cases of metastatic melanoma. pH is a representative symbol for the hydro- D. However. D. showing no diurnal or retaining hydrogen ions. 3. Protein and nitrite testing is bet- 24 hours. 945 . the basis of a postprandial specimen. In some malignancies. the tumor or mole takes on a process will cause an alkalinization of the urine. The bac- is responsible for the pigmentation of the eyes. ing kidney will excrete urine with a pH between which may range from straw to deep amber. ter performed on a concentrated specimen. 2. B. Urochrome is base balance of body fluids by either excreting excreted at a constant rate. the melanogen is oxidized to melanin. ney and the volume of urine excreted. known to ammonia. 4. Therefore. is principally responsible for the important role in the maintenance of the acid- yellow coloration of normal urine. as are imparting a dark brown or black coloration to the specific gravity determination and the exami- the specimen. depending on the overall acid-base dependent on the concentrating ability of the kid- needs of the body. The kidney plays an from urobilin. Urochrome. a yellow-brown pigment derived gen ion concentration. darkly pigmented appearance because of the melanin present. A normally function- variation. The first-voided morning urine specimen is melanogen. The ammonia formed through this as melanomas. and hair. because of detection of melanin in urine use ferric chloride the lack of food and fluid intake during the night. the amount of bacteria C. At room temperature. teria are capable of metabolizing the urinary urea skin. which is a colorless precursor of the most desirable for chemical and microscopic melanin. is excreted in the urine.5 and 8.0. Melanin. answers rationales i. or sodium nitroprusside as the oxidation reagent glucose metabolism may be better assessed on systems.

Bence D.5-8. C. the buffering capacity indicating a semiquantification of the amount of of the strip may be exceeded. If the shaken specimen shows a white foam. it is recommended that both positive and negative controls be used daily. The use of positive and negative controls will act C. The principle of the reagent strip method for suppressed. or mucoprotein.010. Hypersthenuria refers to urines of any volume containing increased levels of dis. In ence of severe renal damage in which both the diluting ability and the concentrating ability of fact. on the technique employed. On the average. tion of the presence of protein in the urine. color change in an indicator system. . before the development of the chemical the kidneys have been severely affected. a urine pH greater than 8. 9. Although the strip test is a acid. uric the disorder present. term used to describe the excretion of a urine volume in excess of 2000 mL/day. rapid screening method for the detection of uri- nary protein. it must be noted that this method is more sensitive to the presence of albumin in the 1L specimen than to the presence of globulin. "Polyuria" is a person or instrument performing the test. that is buffered to pH 3. is little. and on the inteipretive ability of the 1200-1500 mL of urine daily. "Isosthenuria" is a term applied to a series of Jones protein. the detection of protein in urine is based on a solved solute. such as tetrabromophenol blue. The presence of vitamin C. Normal urine does not foam on being shaken. tests. Serum proteins are classified as tive color change in the impregnated area will being albumin or globulin in nature.0. In isosthenuria there 8. between urine specimens from the same patient. The buffering capacity of the strip is sufficient 7. When protein is present in the urine. In oliguria. It is necessary that any deterioration of the strips be detected in order to avoid false-positive or false-negative results. and a false-posi- protein present. increased urine protein can be suspected. For quality control of reagent test strips. With the colorimetric reagent test strips change color. variation of the specific gravity C. and in anuria the urine formation is completely D. a normal adult excretes as a check on the reagents. 10. In healthy individuals the amount of protein Within the normal urine pH range of 4. and the type reflect the pH of the urine rather than the pres- of protein excreted in the urine is dependent on ence of protein. provided that the urine pH does not exceed 8. urine containing bilirubin will exhibit This condition is abnormal and denotes the pres- yellow foaming when the specimen is shaken.0. the daily urine excretion is less than 500 mL. However. if any. a excreted in the urine should not exceed 150 change in color in the reagent strip is an indica- mg/24 hr. urine specimens that exhibit a fixed specific grav- ity of approximately 1.946 CHAPTER 11: URINALYSIS AND BODY FLUIDS 6. A. or glucose in urine will not affect the test for protein. the foam test was actually the first test for bilirubin.

Preanalytical components of laboratory test. a negative glucose reaction accompanied by a positive ketone reaction is 14. . critical values. handling of the results generated (reporting units. it is not detected by the sodium nitro- D. other conditions may cause the urine sodium and potassium would be 130 and 70 mmol/ ketone test to show positive results while the day. presence of interfering sub. min. it can be seen that a negative resulting in a buildup of intermediary products reagent strip test result for protein but a positiveknown as ketone bodies. fat catabolism is sis of the specimen (temperature. ecule found in urine. the sulfosalicylic acid (SSA) test is litus. and Bence Jones protein in a speci. The excretion of the inorganic molecules mellitus. urine glucose test shows negative results. as in diabetes day. Under normal metabolic conditions. C. or Bence Jones B. able to detect not only albumin but also globulin.16. The term "ketone bod- sulfosalicylic acid test result is possible when theies" is used collectively to denote the presence protein present is some protein other than albu. acceptability of quality control). ketones. body is unable to completely degrade the fat. ANSWERS & RATIONALES • 947 12. there is an increased utilization of fat. the reagent body metabolizes fat to carbon dioxide and strip test may give a negative result because the water. such as correct collection tech. prior to analysis. presence of acetoacetic acid and acetone in urine specimens. ketones is most commonly associated with Glucose excretion will average less than 1 mmol/ increased urinary glucose levels. Postanalytical factors affect the final and excreted in the urine. Analytical factors affect the actual analy. sometimes seen. beta-hydroxybutyric acid. In these cases. the protein is present in a urine specimen. or with inadequate than to the presence of other proteins in urine.seen when a child is suffering from an acute ing include all variables that can affect the febrile disease or toxic condition that is accom- integrity or acceptability of the patient specimen panied by vomiting or diarrhea. Although beta-hydroxybutyric acid accounts for approximately 78% of the total 13.decreased intestinal absorption. Its level in a nor. urea is the major organic molecule excreted. as with diabetes mel- However. mal 24-hour urine with a glomerular filtration C. Although a positive result on a urine test for rate of 125 mL/min would be 400 mmol/day. of acetoacetic acid. respectively. 15. Ketones in the urine may be A. the mucoprotein. men. Because of this increased fat metabolism. mucoprotein. Therefore. In young children. known as ketone bodies. When globulin. carbohydrate metabolism. condition of increased to such an extent that the intermediary equipment. Urea is a waste product of protein/amino acid metabolism.products. For this reason the sulfosalicylic acid test isand acetone. as strip is more sensitive to the presence of albumin with dieting and starvation.prusside test. Although sodium is the major inorganic mol.because of either decreased food intake or nique. Reagent test strips impregnated run as a test for urinary protein if the presence ofwith sodium nitroprusside are able to detect the abnormal proteins is suspected. are formed stances). With inadequate carbohydrate intake. timing.

such as dia. cose levels are known to increase refractometer myoglobin will react. obstructive jaundice will usually not experience proteinuria. Like ity results obtained with a reagent strip method hemoglobin. with urine glucose levels over 2 g/dL. of neutrophilic leukocytes in the urine. The presence of conjugated Association defines microalbuminuria as between bilirubin in a urine specimen may be detected by 30 and 299 mg/g. myoglobin also has a peroxidase versus using a refractometer. The ratio of urine albumin to creatinine in a gated with glucuronic acid or sulfuric acid. The test strips are would be "macroalbuminuria. the bilirubin is conju. it may not be excreted in the urine. To iden- tify correctly any white blood cells present in a 18. or nitrite. Only dissolved solutes affect specific gravity (e. This random specimen is commonly used to evaluate conjugated bilirubin is water soluble. is used.4-dichloroaniline. In the liver. the urine reaction may be inhibited. causing D. glucose). formaldehyde. it should be noted that only dissolved ions C. If the reagent strip method . urine specimen. of the bilirubin in the blood has been processed by the liver. Cells. thus requiring correction. The remainder 21. Because unconjugated bilirubin is not water soluble. yielding false-positive results. Bilirubin is a compound that is formed as a specimen as soon as possible after collection. The peroxidase activity of mellitus. The American Diabetes iary tract diseases. Values greater than 299 mg/g use of the reagent test strips. regard- less of concentration.948 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 17.g. hemoglobin catalyzes the oxidation of the dye there may be a discrepancy between specific grav- with peroxide to form a colored compound. especially in patients with dia- this portion that is excreted in increased amounts betes mellitus. In such instances as diabetes organic peroxide. crystals.5 grams per day. acid as a preservative. or any other formed elements will have no effect. results. because such glu- activity and. B.min per gram creatinine." Nephrotic syn- impregnated with a diazonium salt.in excess of 3. is known as unconjugated bilirubin. and it is microalbuminuria. result of hemoglobin breakdown.. The colorimetric reagent strip test for the will contribute to specific gravity results. The majority This is necessary because leukocytes tend to of bilirubin in the blood is bound to albumin and lyse easily when exposed to either hypotonic or alkaline urine. mucus. 19. antibiotics containing ascorbic 20. when present in a urine specimen. which forms a pur.drome is characterized by excretion of albumin zotized 2. Thus detection of hemoglobin in urine utilizes a glucose would not affect reagent strip results at buffered test zone impregnated with a dye and any concentration. This patient's ratio is 114 mg albu- in the urine in some hepatic and obstructive bil. In the presence of large amounts of ascorbic acid.A. Patients with plish azobilirubin compound with bilirubin. it is necessary to examine the D. The majority of renal and urinary tract dis- eases are characterized by an increased number false-negative results.

Phase microscopy tends to enhance the outline of the formed elements. and the presence of oval fat bodies. blood cells may be better visualized using phase- contrast microscopy. would indicate pathology. are more eas. cellular. or oval fat bodies is primarily choles. their physical appearance becomes altered.ular cast degeneration.casts are found in the urine sediment. 25. This is especially true for the identi. less cytoplasm than a squamous cell causes the neutrophilic contents to refract in would have. B. Formed elements in blunt-ended waxy casts are formed. therefore.ure will have multiple types of casts present plifying the identification process. 26. Casts and red (hyaline. Both budding yeast and white blood 24. the impli- ily differentiated by the use of phase-contrast cation is that there is nephron obstruction caused microscopy. This Brownian movement of the granules 15-20 um)." collection. The epithelial cells visualized in tend to swell and the cytoplasmic granules con.this field are transitional and not squamous. symptoms of periorbital swelling and edema A.They can be distinguished by their size (about ment.the granular casts lyse. fatty will have many more red blood cells. fatty). Ketone bodies will be solu- ble and. B. such as cells and casts. ANSWERS & RATIONALES • 949 22.ing red blood cell casts. . The patient's 23. There are fewer than 5 red blood cells in this field. fication of the more translucent elements such as the hyaline casts. infections because of the increased glucose in Under hypotonic conditions. increased urine protein (with serum albumin sig- nificantly decreased). allowing them to stand out and be more easily C. tained within the cells exhibit Brownian move. 21. Waxy casts represent the final phase of gran- diseases. Polarized microscopy is especially ment into the tissue spaces. not seen in a urine sediment. scopic method available. Chronic renal fail- Maltese cross formation becomes visible. As the fine granules of ment carefully by the most appropriate micro. whereas transitional cells. smooth. highly refractive. sim. Fatty materials in urinary sediment may be reflect the loss of oncotic pressure because of the identified by means of staining techniques using excretion of albumin. the hyaline and fatty casts. the effect is such that a immunoglobulin light chains. When cholesterol molecules are exposed not show increased urine albumin but rather to polarized microscopy. if greater than 5 cells/hpf. Its loss from the vascular Sudan III and oil red O or by means of polarized compartment will induce plasma water move- microscopy. Glomerulonephritis useful when the composition of fatty casts. Multiple myeloma will terol.by tubular inflammation and degeneration. it is necessary to examine urinary sedi. and that would be below the sensitivity of the blood pad on the reagent strip. Nephrotic syndrome is suggested by the distinguished. There are minimal bacteria present in Color Plate 46B. the neutrophils their urine. When neutrophils are exposed to hypotonic with diabetes mellitus are prone to such yeast urine. cells predominate this microscopic field. When waxy the urine. and their central nucleus. waxy. Increased such a way that the cells appear to glitter—thus squamous epithelial cells would suggest improper the name "glitter cells. granular. includ- droplets. Patients D. To better diagnose renal and urinary tract D.

29. less liquid that may be described as a modified D. ketone body forma- of homogentisic acid. red or white blood cells. at room temperature for 24 hours. whereas an upper urinary tract infection will.will be detectable by both reagent strip and SSA mally catalyzes the oxidation of homogentisic methods. level. Bacteria of the Enterobacter.950 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 28. a positive nitrite test result is upper or lower UTIs is contamination by enteric an indirect indication of the presence of bacteria gram-negative bacteria. Cystitis is a lower urinary tract infection of a black coloration in urine that is left standing affecting the bladder but not the kidney itself. passive diffusion are involved in the passage of stance known as serotonin from the amino acid glucose from the blood into the CSF. or the central nervous system. 33. 31. This infection will not exhibit increased protein. Alkaptonuria is a rare hereditary disease that B. Proteus. produce a sub. which nor. Citrobacter. In cases of metastatic carcinoid fasting CSF glucose levels range between 50 and tumors. Therefore. In hyperglycemia deamination to form the metabolite 5-hydrox. the acid to maleyl acetoacetic acid. a substance normally because both urine protein excretion and cast found in urine. with plasma glucose levels of 300 mg/dL. Urine containing increased globulin light chains (Bence Jones pro- homogentisic acid turns black on standing teins) excreted will only be detectable by SSA because of an oxidative process. Normally. representing approximately 60-70% duced.because the reagent strip is more sensitive to albu- ing test for alkaptonuria consists of the detection min. Klebsiella. The major C.patients will be normal or decreased. tryptophan. This is the reduction of nitrate. the yindole acetic acid (5-HIAA). the large amounts of albumin excreted enzyme homogentisic acid oxidase. however. and excess utilization of glucose by microorganisms. distinguishing features between upper and lower Escherichia. ultrafiltrate of blood. Decreased CSF glucose levels are associ- ated with hypoglycemia. to nitrite. . Serotonin may then undergo oxidative of the blood glucose level. The most common source of either urine. and Pseudo- UTI include the presence of protein and casts in monas species produce enzymes that catalyze an upper UTI and not in a lower UTI. thus the screen. In multiple myeloma. C. 32. tion (UTI). D. It is the quantification of 5-HIAA maximum response. C. also known as cystitis. Blood glucose levels in such phenylalanine and tyrosine metabolism. accu. This acid. Reagent test strips have formation reflect what is happening within the been developed that are able to detect nitrite in kidney itself. color- 30. 80 mg/dL. Their presence will not in the urine specimen. The intestinal enterochromaffin cells. the product of tion will increase. some. intensive dieting. a faulty active transport mechanism. This student has a lower urinary tract infec. Both active transport and times called the argentaffin cells. Cerebrospinal fluid (CSF) is a clear. which is excreted active transport mechanism reaches a point of in the urine. Because of increased lipid metabolism in is characterized by excessive urinary excretion long-term. In nephrotic mulates in urine because of a deficiency in the syndrome. so that CSF glucose levels that is diagnostically significant because it reflect approximately 30% of the plasma glucose reflects serotonin production. be found in glomerulonephritis or with urinary stones (nephro = "kidney" + lith = "stone"). excessive amounts of serotonin are pro.

Constituents such as glucose. as seen in Color Plate 47 •. In addition to hemoglobin. These crystals can be identified by the characteristic "coffin lid" appearance. ing at room temperature for an excessive period. but instead A. This calculation is considered more accurate than multiplication of bacteria will occur. most bin and myoglobin possess pseudoperoxidase likely placed in the sample at the time of collec- activity detected by the "blood" chemistry test. from hemoglobin in urine by an ammonium sul. gender. fringed end. hormone. duct provide water reabsorption through the ble in 80% ammonium sulfate and give a positive action of antidiuretic hormone (vasopressin). respectively. and race. It does not use a urine sample at all. Values less than 60 mL/ not be examined within 1 hour after collection. leads to pressure alterations detected by receptors tein and granular cast results. .73 m2). strongly suggests that this is a fiber artifact. The filtrate blood reaction after the precipitation of renin-angiotensin-aldosterone system is respon- hemoglobin. These changes trigger the production of renin and antidiuretic 35. Both hemoglo. The patient's pathology involves sible for sodium reabsorption by the distal and neither red blood cells nor bilirubin.73 m2 are considered abnormal and need to should be refrigerated to help preserve the be followed up. The distal convoluted tubule and collecting fate screening test. tion. 39. C. causing the urine to become more alka- nine method used. When urine is left stand- stage 3 kidney damage (35-59 mL/min/1. Myoglobin can be distinguished 38. ammonia. the muscle pro. D. Refer to Color Plate 48 •. and urobilinogen will also be lost from the specimen. but there are limi. Casts. ANSWERS & RATIONALES 951 34. They usu- ally do not indicate any pathology. being a small molecule. Decreased plasma volume stress may be responsible for both the urine pro. 37. The bacteria the Cockgroft-Gault formula. This patient's value places him in integrity of the specimen. The eGFR calculation is based on the "modi- fication of diet and renal disease" formula rec- ommended by the American Kidney Foundation. Normal alkaline (or neutral) urine may con- tain triple phosphate crystals. C. located in the kidney's juxtaglomerular apparatus and the right atrium of the heart. A. Myoglobinuria can lead to acute renal failure. Only freshly voided urine specimens should requires only a serum creatinine and the patient's be used for urinalysis testing. The fringed appear- tein myoglobin can cause a positive blood result ance at the one end of the major formed element in chemical reagent strip testing. The severe collecting tubules. are capable of converting urea in the urine to tations based on the standardization of the creati. is readily excreted by the kidneys. Loss of carbon dioxide from the specimen will also contribute to the alkalinization of the urine. If the specimen can- age. will not have such a release myoglobin from the muscle. bin. The myoglo. bilirubin. taking the shape of the tubule within Muscle-crushing injuries (rhabdomyolysis) will which they are formed. D. line. Myoglobin will remain solu. it min/1.

If the tamination may introduce increased numbers of disease is detected at an early stage. carotenoids. and red blood cells A. The basis for the disease lies in the fact calculi. The presence of cystine crystals in a patient D.dehydrate form. whereas vaginal discharge con- other derivatives being excreted in the urine. The nephrotic syndrome is characterized is needed for the conversion of phenylalanine to by heavy proteinuria. reaction with nitroprusside. Phenylketonuria is inherited as an autosomal Increased or large numbers of RBCs are com- recessive trait that manifests itself in the homozy. dation may be avoided by restricting the dietary intake of phenylalanine. Neither formed the intestine. .cium oxalate crystals. Calcium oxalate seen here is the to reabsorb the amino acids cystine. more readily than the other amino acids. Using brightfield microscopy. granules in the casts shown. renal gous form.monly seen with acute glomerulonephritis. 43. The major formed elements in Color Plate chloride do not contribute to the color of the 50B are hyaline casts and mucus fibers. Cystine will crystallize in acid pH element is usually associated with pathology. with other findings. A. red blood cells (RBCs) occur in small numbers (0-2/hpf) in a normal urine. phenylalanine levels rise in the blood. lysine. and ornithine in either the renal tubules or appear oval or dumbbell shaped. Because of this enzyme defi. and waxy and fatty ciency. Among those substances are oxyhe- will be soluble in the sample and give a positive moglobin. and protein. unstained RBCs appear as colorless 42. Refer to Color Plate 52B. Tyro- sine forms needle-shaped crystals whereas leucine will appear round and oily with concen. are normal in the numbers shown in this field. Glucose. The appearance of the specimen by itself is not usually specific for a particular disease state. casts. which specimen. A variety of substances in CSF specimens form crystals in the urine.white blood cells.44 tric rings. Isoleucine and phenylalanine will not B. but it may provide useful information in comparison 41.have been associated with a xanthochromic hydroxybutyric acid are two ketone bodies that appearance. and D. is absent.lar epithelial cells. acute infections. mental retar. The monohydrate form will nine. Erythrocytes or are not present. Both formed elements are tion of the physician. discs with an average size of 7 jam in diameter. and menstrual contami- that the enzyme phenylalanine hydroxylase. argi. Biliary tract obstruction will show pale- increased amounts of phenylpyruvic acid and colored stools. bilirubin. magnesium. renal tubu- tyrosine. Acetoacetate and (3. which nation. Color Plate 51B demonstrates sperm and cal- sample is always a cause for immediate notifica. with casts. B. Waxy casts will appear yellowish with charac- teristic serrated edges. Cystinuria is an autosomal found in correctly collected normal urines from recessive disorder characterized by the inability either gender. oval fat bodies. There are no obvious 45.952 • CHAPTER 11: UR1NALYSIS AND BODY FLUIDS 40.

Diabetes insipidus is caused by a deficiency D. The alveolar concentrations of the various in antidiuretic hormone. and because these changes at the distal and collecting tubules. nine and urea nitrogen are anywhere from 10 to 50 times the amniotic fluid concentrations. 47. This patient's results suggest are not predictably different. being noninflam- of little use for this purpose because their rela- matory. Stools with red streaks are with maternal urine should be considered in more likely to result from a lower gastrointesti- evaluating specimens submitted for amniotic nal bleed. The con. Increased mucus fluid analysis.49. Because the viscosity C. 50. This affects are reflected directly in the amniotic fluid. Measurements of albumin. preventing bilirubin from entering the A. concentrations increase rapidly after 32-34 weeks of gestation. The term "mucin" in travels the entire intestinal tract. or lactate dehydrogenase would be and total protein. and an increased concentration of either in the amni. Excreted solute amounts analysis of the fluid can provide good predictive will be the same. ANSWERS & RATIONALES • 953 46. will have low numbers of cells and less tive concentrations in urine and amniotic fluid than 3 g/dL protein. as from the colon. contamination then into urobilin. Transudates. This will make the mucin clot test is a misnomer. time the hemoglobin is excreted. Clay-colored .results in high urine volumes and low final solute centrations of sphingomyelin and phosphatidyl concentrations. Conversely. The low solute will lead to low inositol increase until about 32-34 weeks of specific gravities in these patients' specimens. as in assessment of erythroblastosis fetalis. A. and their concentrations relative to D. of bilirubin in the sample. and poor mucin clot formation are indications of the decreased hyaluronate concentration of syn- ovial fluid. the distinguishing characteristics are cell number total protein. gestation and then decline. Such deficiencies will phospholipids (surfactants) change during fetal result in the kidney's inability to reabsorb water lung development. and nary contamination. Decreased viscosity assessing the development of fetal lung maturity. otic fluid would be sensitive indicators of uri- B. This distress syndrome in the newborn. it can be cells in an upper gastrointestinal bleed will have estimated by the length of string formed when the time to become denatured and oxidized as it fluid drops from a syringe. Urinary concentrations of creati- will be associated with intestinal inflammation. Synovial fluid is a form of plasma ultrafiltrate those of the other phospholipids are useful in with added hyaluronic acid. Effusions can be transudates or exudates. indication of inflammation. A delta absorbance she has an exudate due to the high number of at 410 nm would be used to assess the presence cells and large amount of protein. a only water reabsorption and not the reabsorption number of investigations have shown that of other urinary solutes. because mucin the stool become much darker in color by the is not present in synovial fluid. lecithin (phosphatidyl choline) and phosphatidyl glycerol 51. but the water volume into information for the development of respiratory which they are excreted will be larger. stools will result from an obstruction of the bil- iary duct. The hemoglobin released from red blood of synovial fluid is normally very high. Because there may be technical problems intestines to be converted into urobilinogen and associated with amniocentesis. Either of these findings is usually an 48.

Pon- are characterized by protein levels less than ceau S is used in serum protein electrophoresis 3. will change color because of a pKa change in the A. pressure. pleural capillary hydrostatic pressure. of a solution's refractive index with its solute concentration to determine the specific gravity of urine. Solutes can be inorganic (e.984 • CHAPTER 11: UR1NALYSIS AND BODY FLUIDS 52. The TS meter is a specific type of however. 54. A dye also present in the strips 56. As seen in Color Plate 53B. urea). The color obtained is or organic (e. Exudates are complexes with the dye. the most commonly observed cast. Some excreted solutes. are creati- color correlating with a different specific gravity nine. hyaline casts are or intrapleural pressure. Polyelectrolytes are incorporated into urinalysis reagent strips.0 g/dL. usually through its relation- ship to freezing point depression. less exudates or transudates on the basis of certain than 100 mg/dL. sensitivity for detecting small quantities of pro- and the presence of a sufficient amount of fib.. transudates and is used to quantify albumin in serum. line casts per low-power field. each meaning end products of metabolism. Phase-contrast microscopy may be used specific gravity is a measure of the proportion of to visualize the casts better.. The refractive index is the ratio of the velocity of light in air to the velocity of light in a solution. A clinically useful test for assessing the con. The pKa varies with the ionic soluble. Transudates are gener- ally formed as the result of noninflammatory pro- cesses. A reference urine may contain 0-2 hya- 53. Trichloroacetic acid is a turbidimetric method flow of body fluids. this being comparable to the number of dissolved particles in that solution. urea. in cerebrospinal fluid (CSF) and characteristics. In contrast. Bromcresol green is selective for albumin rinogen to cause clotting. compared with a set of standard colors. Coomassie brilliant blue is a in response to inflammation or infection with colorimetric dye binding method in which protein concomitant capillary wall damage. and they con- sist completely of uromodulin (Tamm-Horsfall) protein. including alterations in plasma oncotic 55. Excreted waste products. . leukocyte counts greater than 1000/uL. To be found in urine. leukocyte counts less than 300/uL. An osmome- ter measures the concentration of dissolved solute in the sample. sodium) concentration of the urine. A.0 g/dL. Effusions result from an imbalance of the D. Effusions are classified as used to quantify small amounts of protein. dissolved solids in a given volume of solvent. Hyaline casts D. are not present as waste but as over- refractometer that utilizes the close correlation load. concentration. The urine.appear translucent using brightfield microscopy centrating and diluting ability of the kidneys is because they have a refractive index similar to the determination of urine specific gravity. the absence of fibrinogen. This method also exhibits the necessary 3. and methods to stain both albumin and globulins. tein. and uric acid. Exudates are generally formed urine specimens. A. forming a soluble blue characterized by protein levels greater than complex.g. such as glucose or sodium. a solute must be water poly electrolytes.g.

it is critical that personnel on all shifts be on to the intestinal tract. use of a acid oxidation occurring in light of the inacces. include no diet or medica- betes mellitus. Tubes used for chemistry and bacteriologic studies should be 61. Uric acid crystals. with mutations occurring later in the detectable reaction signal. especially to skeletal that far exceeds that of the FOB test (13-35%) muscle. There is an increased rate of fatty tion restrictions prior to the testing. however. Because the analysis of CSF should be performed immedi. may be pathologically increased in cases of gout and after chemotherapy.positive Ictotest. C. Cerebrospinal fluid (CSF) must be collected the method's sensitivity. concentration of the analyte that will result in a and p53. cubes. sensitive than colonoscopy. lism. associated with larger adenomas. the second tube is lowest reportable value. Gene mutations associ- ated with colorectal cancer include APC (adeno- 60. mens need to be cultured first (to ensure sterility) bilirubin is conjugated with glucuronic acid to form water-soluble conjugated bilirubin. In the intestine." Uro- bilinogen's readout color scale begins with its in sterile tubes. called "negative. cate a positive reagent strip test for bilirubin. DNA-based tests for detecting mutations within colon cells are generally more expensive 59. and the ciated with concentrations less than this. however.2 mg/dL) uro- fused with cysteine. and may even have six sides and be con. but there is no pad asso- employed for bacteriologic examination. as seen in Color Plate 54B. into the intestinal tract to complete its metabo- B. and a sensitivity (50-73%) sibility of the glucose. A positive urine glucose plus a positive the pseudoperoxidase property of hemoglobin. it is reduced by intestinal bacteria to form urobilino- able to perform the necessary testing. barrels. serum ketone strongly suggest uncontrolled dia. gen. Advantages.conjugated bilirubin passes into the bile duct and ately. Bile duct obstruction is characterized by an obstruction of the flow of conjugated bilirubin 58.single stool sample. The conjugated bilirubin. rosettes. K-ras. B. the for detecting colon cancer. which can detect 95% of colon cancers. the nor- an alkaline urine. ANSWERS & RATIONALES • 9S5 57. In the hepatic phase of bilirubin metabolism. because uric acid is soluble at mal production of urobilinogen is decreased. Using brightfield microscopy. Because they are a reflection bilinogen (because there is no reagent strip pad of the excretion of purine waste products. and nitrite readout color scales each have a color . If the patient had only been dieting. process. uric Therefore. bilirubin. It is. associated with analyte concentrations less than D. CSF should remain uncentrifuged for cell counts. matous polyposis coli) on chromosome 5. The first tube is generally used for chemistry and serology studies. will be excreted by the kidney. which is water are commonly encountered in normal acidic urine soluble. The before any other test is performed. than the fecal occult blood (FOB) methods using A. Low-volume speci. centrifuged before use. The sensitivity of a method is the lowest a mutation that often occurs after APC mutation. less glucose would be negative. alkaline pH. they for "negative" urobilinogen). Because but may be observed in neutral urine and rarely in bilirubin is not entering the intestines. They show birefringence 62. The protein. and "normal" (0.A. the urine biochemical test will indi- acid crystals appear as diamonds. third tube is used for cell counts. (multiple colors) under plane polarized light.

lows: The glucose oxidase reagent strip test is tion (e. Benedict's test procedure. When oil immer- sion is used. even in sufficient num- preanalytical variables. When this microscopic analysis is per.956 • CHAPTER 11: URINALYSIS AND BODY FLUIDS 63. it is generally established that at least 60% of 66. D. mens. 67. formed. thus giving a false negative. like specimen handling or ber. The condition may result in liver disease. A. multiple sclerosis) or from increased specific for glucose. mental retardation. a minimum of 200 spermatozoa detect low levels of patient hCG. milk as a constituent of the disaccharide lactose. lyse at high nizing one subunit of hCG (alpha or beta). the glucose will be transport from the blood plasma (compromised negative.g. positive. the conflicting results for ent at less than 1 mg/dL in the CSF. alkaline pH. however. In the biochemi- D. Use of a random urine may be too dilute to crystal violet. erythoblasto. Renal tubular cells originate from the renal ticated methods exist currently for determining medulla or cortex. . the presence of erythrocytes. The Clinitest®. Galactosemia. internal quality con. and microorganisms should be galactose. Bacteria correctly. it is the preferred specimen for such screen- ings. cal analysis of the urine.. In addition. a monosaccharide that is contained in indicated. is characterized by the inability to metabolize epithelial cells. Internal controls in these kits will numbers of bacteria present in the urine. The nitrite reaction requires (a) a suf- whereas other kits may use both anti-a-hCG and ficient dietary source of nitrate. the sperm should have normal morphologic fea- tures. Many simplified yet immunologically sophis. Most kits will use an antibody recog. therefore. tion if not treated or controlled. convert urine nitrate to nitrite. basic fuchsin. and (c) only check if the procedural steps were performed sufficient incubation time (>4 hours). urine pH. will not have had sufficient incubation time to appropriateness. the Clinitest® is levels. distinguishing "positive" from "negative" speci- C. should be evaluated for morphologic characteris- tics. Other stains used include Kemechtrot. day. The morphologic characteristics of sperma. detects most reducing sis fetalis (isoimmunization syndrome). Thus galactose appears in elevated levels in the blood and urine. Increased the two glucose tests may be explained as fol- CSF IgG can result from increased CSF produc. Red blood cell crenation is a pregnancy. Because galactose is present in the multiple myeloma produces increased CSF IgG urine and is a reducing substance. a modification of the blood-brain barrier). Although sources differ as to the exact num- ber. Pilocarpine ion- trol cannot be used to assess the kit's accuracy in tophoresis is the collection method for sweat. an inborn error of metabolism. nor substances. Neither gout. and cataract forma- 64. Because the first tozoa are best evaluated by means of smears morning specimen is the most concentrated of the stained with Papanicolaou stain. (b) sufficient anti-p-hCG. They cannot detect problems with any introduced at collection. and hematoxylin. Only the use of external quality control specimens can accomplish this. All are based on the reaction between phenomenon reflecting increased solute concen- patient human chorionic gonadotropin (hCG) and tration (hyperosmolality) and is not caused by anti-hCG. C. 65. leukocytes. Red cells will. Giemsa. Immunoglobulins (IgGs) are normally pres.

R. Fundamentals of Urine and Body Fluid Analysis.) (2006). Henry's Clinical Diagnosis and Management by Laboratory Methods. Philadelphia: F. M. 18th ed. Strasinger.. (2007). (Ed. Davis Co. ANSWERS & RATIONALES • 957 REFERENCES Beers. and Linne. Brunzel. K. Philadelphia: W. and DiLorenzo. S. Urinalysis and Body Fluids. (2008). McPherson. (2004). S. J.. N. Philadelphia: Elsevier. B. Ringsrud. St. (1995). . The Merck Manual of Diagnosis and Therapy. Whitehouse Station. A. H. NJ: Merck Research Laboratories. J. Louis: Mosby-Year Book. Saunders. M. M. 21st ed. M. A. A. K. R. 2nd ed.. 5th ed. Urinalysis and Body Fluids—A Color Text and Atlas. and Pincus.