Laboratory Interpretation

Made Easy

Diana Tamondong-Lachica, MD, FPCP

OUTLINE
l  Urinalysis
l  Renal Function Tests

l  Complete Blood Count

INFORMATION THAT CAN BE
OBTAINED BY SIMPLE URINALYSIS
Appearance
Specific gravity
Chemical tests
pH, Protein, Glucose, Ketones,
Blood, Urobilinogen, Bilirubin,
Nitrites, Leukocyte esterase
Cells
Casts
Crystals
URINE COLOR CAUSES
Faint yellow Normal

White Pus, Chyle, Phosphate crystals

Pink / red / brown Red blood cells, Hemoglobin,

( tea colored ) Myoglobin, Beets, Senna,
Methyldopa, Metronidazole,
Food coloring

Yellow / Orange Bilirubin, B complex, Rifampicin,

Iron, Nitrofurantoin, Phenytoin

Brown / black Methemoglobin, melanin

Blue / green Pseudomonas, Dye, Chlorophyll

PHYSICAL CHARACTERISTICS

Normal Clinical Value

Values
Specific 1.003 – 1.000-1.005 Diabetes insipidus
gravity 1.030
>1.030 Dehydration, contrast
dyes, glucose,
mannitol

Turbidity Clear Infection, crystals.

Chyluria (milky white)
CHEMICAL CHARACTERISTICS

Normal values Comments

Urine 4.5 - 6 Alkaline urine - vegetarian diet,
pH UTI, Renal Tubular Acidosis

Acidic urine – uric acid

crystals

Urine negative Regular Dipsticks detects only

protein (Total protein albumin> 300 mg / L
<150mg/24hrs)
(Albumin <30mg/
24hrs)
WAYS TO QUANTIFY PROTEINURIA

24 hr urine collection – cumbersome, prone to

collection error

Albumin / creatinine ratio is a simple and accurate

method of quantifying proteinuria
Ex. A/C ratio of 200 mg protein/Gm crea equivalent
to urine protein of 200mg/24h

Urine Electrophoresis – to determine type of protein

MICROALBUMINURIA

•  Marker of silent DM nephropathy

•  Significant predictor or overt nephropathy

•  First manifestation of injury to the

glomerular filtration barrier
TYPES OF PROTEINURIA
•  ORTHOSTATIC or POSTURAL
•  FUNCTIONAL
- High fever, exercise, heat stroke, CHF
•  GLOMERULAR
•  TUBULAR
•  OVERFLOW
- Hyperglobulinemic states
URINE MICROSCOPY
Crystals
Urates, calcium, oxalate, triple
phosphates, cystine, drugs

Cells Red blood cells, white blood cells,

tubular cells, fat bodies, squamous
cells
Casts
Hyaline, granular, RBC, WBC, broad,
waxy

Organisms Bacteria, yeasts, trichomonas

Miscellaneous Spermatozoa, mucus treads
 URINE MICROSCOPY
CELLS AND NORMAL PATHOLOGY
CASTS
Leucocytes 1-4 /HPF UTI, interstitial nephritis

Erythrocytes 0-2 /HPF Stones, obstruction, UTI,

glomerular
Tubular cells FEW Renal failure

Hyaline casts FEW Dehydration

Course granular NONE CKD

casts
Muddy brown cast NONE Acute tubular necrosis

WBC casts NONE Pyelonephritis

RBC cast NONE Glomerulonephritis

HEMATURIA

May originate anywhere from the glomerulus to the

urethral meatus

Normal: RBC in the urine is between 0 – 2 / HPF

Abnormal: > 3 RBC / HPF

Shape of RBC is important:

Normal shape RBC – originate from collecting system
Dysmorphic RBC - originate from glomerulus
CAUSES OF HEMATURIA AND
URINALYSIS FINDINGS

Hematuria with Proteinuria , RBC Glomerular pathology

casts

Hematuria coincident with URTI, IgA nephropathy

occasional proteinuria

Hematuria days or weeks after Acute post-streptococcal

URTI glomerulonephritis

Hematuria with Pyuria UTI, Glomerulonephritis

Hematuria, Crystals Stone disease

OTHER CELLS

Eosinophils – seen in allergic interstitial nephritis,

atheroembolism

Epithelial cells
squamous cells – contaminant
transitional cells – from pelvis to urethral lining
renal tubular cells - large amount seen in ATN
OTHER CAUSES OF PYURIA
Contamination during collection
Vaginal secretions
Foreskin secretions
Non-infectious causes
VesicoUreteral Reflux Hypercalcemic nephropathy
Analgesic Nephropathy Lithium toxicity
Uric acid nephropathy Hyperoxalosis
Polycystic kidney Heavy metal toxicity
ATN Carcinoma of Urinary tract
Transplant rejection Renal calculi
Allergic interstitial nephritis Sickle cell disease
Sarcoidosis Idiopathic interstitial cystitis
Radiation nephritis Glomerulonephritis
Infectious diseases
TB, chlamydial / gonococcal urethritis, Leptospirosis, Viral cystitis
Infections adjacent to urinary tract
Appendicitis, diverticulitis
CLINICAL SYNDROMES OF
RENAL DISEASE
SITE OF URINALYSIS EXAMPLES
INJURY FINDINGS
GLOMERULUS Hematuria Nephritic syndrome
(dysmorphic) Nephrotic syndrome
Pyuria IgA nephropathy
Proteinuria
Cells, casts
TUBULES Abnormal urine Urinary tract infection
INTERSTITIUM specific gravity, pH Urinary tract
Proteinuria obstruction
Hyaline casts Renal tubular acidosis
Hematuria, pyuria (RTA)
VASCULAR Bland sediments Hypertension
(no cells, hyaline casts
Differentiation between nephrotic and
nephritic syndromes
Features Nephrotic Nephritic
ONSET insidious abrupt

EDEMA ++++ ++

BP normal raised

JVP norma/low raised

PROTEINURIA ++++ ++

HEMATURIA may/may not occur +++

RBC CASTS absent Present

ALBUMIN low Normal/sl. decreased

Serum Creatinine

l  Mainly derived from metabolism of creatine/creatine

phosphokinase from skeletal muscle cells

l  Produced in almost constant rate

l  Steady state concentration dependent on renal

excretion w/c mainly reflects of GFR
Cockcroft-Gault Formula*

(140 – Age ) X Wt in kgs

______________________
72 X Cr in mg/dl

*Multiply result by 0.85 for female

CrCl normal values = 90 – 120 ml/min
Normal decline rate 1 ml/min/yr after age 40

SERUM CREATININE ALONE IS NOT A GOOD

INDICATOR OF ESTIMATED GFR
Creatinine Clearance
l  Widely used method to estimate GFR

l  CrCl = (Ucr)(V) / Pcr

(Timed urine collection)

l  Quick estimation of creatinine clearance use

Cockcroft-Gault formula and MDRD formula
Factors that can affect BUN levels
Increase levels – high protein intake, hyperalimentation
GI bleeding, Catabolic states, Steroids
Tetracyclines, volume depletion

Decrease levels – liver disease, pregnancy

BUN to Creatinine ratio

Normal = 10 – 20 : 1
Volume depletion ( Prerenal ) = > 20 : 1
Factors Affecting Markers of
Kidney Function
RIFLE classification of
Acute Kidney Injury

UO < 0.3 ml/kg/h x24h or

Outcome
 Differentiating Acute vs
Chronic Renal Failure
Points favoring CRF:
1) History
Prior history of DM, HPN, Renal or GU disease
Review of old medical records
Onset of nocturia
2) PE
Pallor, Skin changes
3) Lab
Severe anemia, elevated PTH and phosphorus,
low serum calcium
4) Radiology
Bilateral small kidneys, osteodystrophy (bone changes)

Note: Acute injury on top of chronic kidney is common

EXERCISES  
 
25  y/o,  female  pa4ent  with  Urinalysis  result  showing:  
 Protein  =  +++  
 RBC          =    15  –  20  /  hpf  
 WBC        =    10  –  15  /  hpf  
 
 
Which  part  of  the  kidney  is  most  likely  injured  ?  
 A.  Glomerular  area  
 B.  Tubulo-­‐inters44al  area  
 C.  Vascular  area  
 
POST  -­‐  TEST:  
 
25  y/o,  female  pa4ent  with  Urinalysis  result  showing:  
 Protein  =  +++  
 RBC          =    15  –  20  /  hpf  
 WBC        =    10  –  15  /  hpf  
 
 
Which  part  of  the  kidney  is  most  likely  injured  ?  
 A.  Glomerular  area  
 B.  Tubulo-­‐inters44al  area  
 C.  Vascular  area  
 
50  y/o,  male,  with  recent  treatment  for  Herpes  Zoster,    
No  genitourinary  symptoms,  had  urinalysis  result  of:            
 Specific  Gravity  =  1.010  
 Protein  =  trace  
 Glucose  =  +1  
 RBC    =  0  -­‐  2  /  hpf  
 WBC  =  25  –  30  /  hpf  
Urine  C/S  =  nega4ve  
 
The  pa4ent  most  likely  has:    
 A.  Urinary  tract  infec4on  
 B.  Glomerulonephri4s  
 C.  Tubulo-­‐Inters44al  nephri4s  
50  y/o,  male,  with  recent  treatment  for  Herpes  Zoster,    
No  genitourinary  symptoms,  had  urinalysis  result  of:            
 Specific  Gravity  =  1.010  
 Protein  =  trace  
 Glucose  =  +1  
 RBC    =  0  -­‐  2  /  hpf  
 WBC  =  25  –  30  /  hpf  
Urine  C/S  =  nega4ve  
 
The  pa4ent  most  likely  has:    
 A.  Urinary  tract  infec4on  
 B.  Glomerulonephri4s  
 C.  Tubulo-­‐Inters44al  nephri4s  
sCr 120 µmol/L 120 µmol/L

Question:
Both of them have equivalent renal function
True
False
sCr 120 µmol/L 120 µmol/L

Question:
Both of them have equivalent renal function
True
False
Given a 70 y/o, male, diabetic patient,
with body wt = 72 kg
Serum Creatinine of 1 mg/dl

What is the Creatinine Clearance of the patient ?

A. CrCl of 100 ml/min
B. CrCl of 70 ml/min
C. CrCl of 50 ml/min

To which Stage of Chronic Kidney Disease

should the patient be classified ?
A. CKD Stage 1
B. CKD Stage 2
C. CKD Stage 3
Given a 70 y/o, male, diabetic patient,
with body wt = 72 kg
Serum Creatinine of 1 mg/dl

What is the Creatinine Clearance of the patient ?

A. CrCl of 100 ml/min
B. CrCl of 70 ml/min
C. CrCl of 50 ml/min

To which Stage of Chronic Kidney Disease

should the patient be classified ?
A. CKD Stage 1
B. CKD Stage 2
C. CKD Stage 3
 Complete Blood Count
PARAMETER NORMAL REMARKS
VALUES
Hemoglobin M: 133 - 162 g/L Consider transfusion if with acute
F: 120 - 158 g/L blood loss, symptomatic chronic
anemia
Caution with hemolysis
Hematocrit M: 0.38 - 0.46
F: 0.35 - 0.44
Mean corpuscular 79-93.3 fL Decreased in iron deficiency,
volume (MCV) thalassemia
Increased in megaloblastic anemia,
structural hemoglobinopathies
Mean corpuscular 26.7 - 31.9 pg Same as MCV
hemoglobin (MCH)

Mean corpuscular 323-359 g/L Increased in hereditary spherocytosis

hemoglobin
concentration (MCHC)
Complete Blood Count

White blood 4.0-11.0 x 109/ Increased in leukemia/

cell count L leukemoid reaction

Platelet count 150-450 x 109/ Increased in iron

L deficiency, CML
Reticulocyte 0.8-2.3% Increased in hemolysis
count/ < 14.5% Decreased in bone marrow
Red cell failure states
distribution
width (RDW)
Complete blood count
l  Different labs have different normal values
l  Correlate with findings with your patient

l  Any abnormalities in two cell lineages -->

bone marrow aspiration (exclude nutritional
anemia, sepsis)
 Common Hematologic
Diseases
Disease CBC Finding Clinical Profile

Iron deficiency Microcytic, hypochromic Females in reproductive age

anemia (IDA) anemia group
Thrombocytosis Persons with chronic blood
loss, CKD
IDA in elderly male: colon CA
Megaloblastic Big RBCs (high MCV) Alcoholics, vegetarians
anemia Gastric bypass surgery

Hemolysis Low hemoglobin, high Pallor, jaundice

RDW/retic ct, high serum Signs of sepsis
indirect bilirubin
Anemia of Normocytic, normochromic CKD, CLD, malignancy
chronic anemia (may proceed to
disease hypo, micro)
 When Should You Transfuse?
Indications Cutoffs/Details Remarks

Acute blood loss > 40% blood If 30-40%, may transfuse if elderly,
volume with pre-existing anemia or
comorbids
Hemoglobin levels < 60 mg/L If Hgb 60-100, may transfuse if with
symptoms, ongoing bleeding or
elderly
Chronic anemia < 60 mg/L May transfuse if Hgb < 70, if with
ongoing blood loss, cardiac/pulmo/
cerebrovascular risk factors
Peri-operative If Hgb < 70 and asymptomatic, may transfuse if with
scheduled surgery is expected to produce significant
blood loss or if anesthetic risk is high

New York State Council on Human Blood and Transfusion Services Guidelines 2004
When Should You Transfuse?
l  Transfuse whole blood or pRBC + FFP +
cryosupernate for significant blood loss

l  FFP transfusion - hemophiliacs*, HUS/TTP, dengue

hemorrhagic fever

l  Platelet transfusion

l  Platelet count < 10 x 109/L
l  Platelet count < 50 x 109/L if with bleeding or for surgery

* Better to transfuse cryoprecipitate (Hemophilia A),

cryosupernate (Hemophilia B) or specific factor components
Hazards of Blood Transfusion
l  HIV, HBV, HCV
l  Volume overload

l  Transfusion reactions

l  Hypocalcemia, hyperkalemia, hypothermia

l  Be careful!
Questions?