Quality Assessment and Management in the Urinalysis Laboratory

 Quality assessment (QA)

 overall process of guaranteeing quality patient care and is regulated throughout the total testing system
 Quality system
 all of the laboratory’s policies, processes, procedures, and resources needed to achieve quality testing.
 Quality control (QC)
 quality assessment program includes not only testing controls, but also encompasses preanalytical
factors, analytical factors, postanalytical factors and documentation that the program is being
meticulously followed.

Pre-analytical Factors

 Variables that occur before the actual testing of the specimen

o Patient misidentification
o Wrong test ordered
o Incorrect urine specimen type collected
o Insufficient urine volume
o Delayed transport of urine to the laboratory
o Incorrect storage or preservation of urine

Analytical Factors

 Processes that directly affect the testing of specimens.

o Sample misidentification
o Erroneous instrument calibration
o Reagent deterioration Poor testing technique
o Instrument malfunction
o Interfering substances present
o Misinterpretation of quality control data

Post-analytical Factors
o Factors are processes that affect the reporting of results and correct interpretation of data.
o Patient misidentification
o Poor handwriting
o Transcription error
o Poor quality of instrument printer
o Failure to send report
o Failure to call critical values
o Inability to identify interfering substances
Renal Disease
Classification of Renal Disease

Type of Renal Disease Comment

Glomerular Disorders • disorders associated with the glomerulus

• immunologic disorders

Tubular Disorders affecting the renal tubules include those in which tubular function is disrupted
as a result of actual damage to the tubules and those in which a metabolic or
hereditary dis- order affects the intricate functions of the tubules.

Hereditary and Metabolic Disorders affecting tubular function may be caused by systemic conditions
Tubular Disorders that affect or override the tubular reabsorptive maximum (Tm) for particular
substances normally reabsorbed by the tubules or by failure to inherit a gene
or genes required for tubular reabsorption.

Interstitial Disorders disorders affecting the interstitium also affect the tubules (tubulointerstitial
disease ) due to close proximity.

Renal Failure • exists in both acute and chronic forms

Renal Lithiasis • Renal calculi (kidney stones)

• Lithotripsy procedure using high-energy shock waves, used to break
stones located in the upper urinary tract into pieces that can then be
passed in the urine

Summary of Glomerular Disorders

Disorder Primary Other Significant Etiology Clinical Course

Urinalysis Tests
Result

Acute Macroscopic Antistreptolysin O Deposition of Rapid onset of

glomerulonephritis hematuria titer immune complexes, hematuria and
Proteinuria Anti–group A formed in conjunction edema Permanent
RBC casts streptococcal with group A renal damage seldom
Granular casts enzymes Streptococcus infec- occurs
tion, on the
glomerular
membranes

Rapidly progressive Macroscopic BUN Deposition of Rapid onset with

glomerulonephritis hematuria Creatinine immune complexes glomerular damage
Proteinuria Creatinine from sys- temic and possible
RBC casts clearance immune disorders on
 the glomerular progression to end-
membrane stage renal failure

Goodpasture Macroscopic Antiglomerular Attachment of a Hemoptysis and

syndrome hematuria basement cytotoxic antibody dyspnea followed by
Proteinuria membrane formed during viral hematuria
(Autoimmune
RBC casts antibody respiratory infections
Disease) Possible progression
to glomerular and
to end-stage renal
alveolar basement
failure
membranes

Wegener’s Macroscopic Antineutrophilic Antineutrophilic Pulmonary symptoms

granulomatosis hematuria cytoplasmic cytoplasmic auto- including hemoptysis
Proteinuria antibody antibody binds to develop first followed
RBC casts neutrophils in by renal involvement
vascular walls and possible
producing damage to progression to end-
small vessels in the stage renal failure
lungs and glomerulus

Other Glomerular Disorders

Henoch-Schönlein purpura Membranous glomerulonephritis

Membranoproliferative glomerulonephritis Chronic glomerulonephritis

IgA nephropathy Nephrotic syndrome

Minimal change disease Focal segmental glomerulosclerosis

Alport Syndrome
Summary of Metabolic and Tubular Disorders

Disorder Primary Urinalysis Other Significant Etiology Clinical Course

Result Tests

Acute • Microscopic • Hemoglobin Damage to the renal Acute onset of renal

tubular hematuria tubular cells caused dysfunction usually
• Hematocrit
necrosis by ischemia or toxic resolved when the
• Proteinuria
• Cardiac enzymes agents underlying cause is
• Renal tubular corrected
epithelial cells
• RTEcell casts
• Hyaline, granular,
waxy, broad casts

Fanconi Glucosuria Serum and urine Inherited in Generalized defect

syndrome Possible cystine electrolytes Amino acid association with in renal tubular
crystals chromatography cystinosis and reabsorption
Hartnup disease or requiring supportive
acquired through therapy
exposure to toxic
agents

Nephrogenic Low specific gravity ADH testing Inherited defect of Requires supportive
diabetes tubular response to therapy to prevent
Polyuria
insipidus ADH or acquired dehydration
from medications

Renal Glucosuria Blood glucose Inherited Benign disorder

glucosuria autosomal recessive
trait
Summary of Interstitial Disorders

Disorder Primary Urinalysis Other Significant Etiology Clinical Course

Result Tests

Cystitis  Leukocyturia Urine culture Ascending bacterial Acute onset of

 Bacteriuria infection of the urinary frequency
 Microscopic bladder and burning resolved
hematuria with antibiotics
 Mild proteinuria
 Increased pH

Acute  Leukocyturia Urine culture Infection of the renal Acute onset of

pyelonephritis  Bacteriuria tubules and urinary frequency,
Blood cultures
 WBC casts interstitium related to burning, and lower
 Bacterial casts interference of urine back pain resolved
 Microscopic flow to the bladder, with antibiotics
hematuria reflux of urine from
 Proteinuria the bladder, and
untreated cystitis

Chronic  Leukocyturia Urine culture Recurrent infection Frequently

pyelonephritis  Bacteriuria Blood cultures of the renal tubules diagnosed in
 WBC casts BUN and interstitium children; requires
 Bacterial casts Creatinine caused by structural correction of the
 Granular, waxy, abnormalities underlying structural
Creatinine
broad casts affecting the flow of defect
clearance
 Hematuria urine Possible progression
 Proteinuria to renal failure

Acute  Hematuria Urine eosinophils Allergic inflammation Acute onset of renal

interstitial  Proteinuria of the renal dysfunction often
BUN
nephritis  Leukocyturia interstitium in accompanied by a
Creatinine
 WBC casts response to certain skin rash
Creatinine medications
Resolves following
clearance
discontinuation of
medication and
treatment with
corticosteroids
Urine Screening for Metabolic Disorders

Overflow Versus Renal Disorders

 Overflow disorder 
 Result from the disruption of a normal metabolic pathway that causes increased plasma
concentrations of the nonmetabolized substances.
 Renal Disorder 
 caused by malfunctions in the tubular reabsorption mechanism
 Inborn Error of Metabolism
 Disruption of enzyme function  failure to inherit the gene to produce a particular enzyme
NOTE:
Mostly encountered metabolites  appearance is classified into functional defect

Abnormal Metabolic Constituents or Conditions Detected in the Routine Urinalysis

Color Odor Crystal

• Homogentesic acid • Phenylketonuria • Cystine

• Maple syrup urine disease
• Melanin • Leucine
• Isovaleric acidemia
• Indican • Cystinuria • Tyrosine
• Cystinosis
• Porphyrins • Homocystinuria • Lesch-Nyhan disease

Major Disorders of Protein and Carbohydrate Metabolism Associated

With Abnormal Urinary Constituents Classified as to Functional Defect

Overflow Inherited Metabolic Renal

• Phenylketonuria • Infantile tyrosinemia • Hartnup disease

• Tyrosinemia
• Melanuria • Cystinuria
• Alkaptonuria
• Maple syrup urine disease • Indicanuria
• Organic acidemias
• 5-Hydroxy-indoleacetic acid
• Cystinosis
• Porphyria • Porphyria
• Mucopolysaccharidoses
• Galactosemia

• Lesch-Nyhan disease
Most of these disorders are caused by build up of unmetabolized ingredients of food therefore early detection
of the disorder is important  Newborn screening
 Blood is collected in infant heel for screening  tandem mass spectrophotometry (MS/MS)

 AMINO ACID DISORDERS

Amino Acid Disorders with Urinary Screening

Tests

• phenylketonuria (PKU)
• tyrosyluria
• alkaptonuria
• melanuria
• maple syrup urine disease
• organic acidemias
• indicanuria
• cystinuria
• cystinosis

NOTE:
• Phenylalanine and tyrosine metabolism
• PKU, Tyrosyluria andAlkaptonuria are the most common disorders in this pathway producing excessive
amounts of melanin
 Phenylketonuria (PKU)

 most well known of the aminoacidurias

 if undetected, results in severe mental retardation
 Phenylpyruvic oligophrenia
 Ivan Følling in 1934 (Norway)
 Peculiar mousy odor of urine
 Increased urinary ketoacids + phenylpyruvate due to disruption in the conversion of phenylalanine to
tyrosine
 caused by failure to inherit the gene to produce the enzyme phenylalanine hydroxylase
NOTE:
• Occurs in 1 of every 10,000-20,000 births
• Decrease pigmentation of skin  light skinned/fair complexine due to decreased production of tyrosine
leading to decreased melanin
• Dietary changes can prevent the disorder  eliminate phenylalanine in diet  constituent of milk to
avoid excessive buildup of phenylalanine in serum  avoid damage to child’s mental capability

Tests for Phenylketonuria

Test Comment Result

Phenylalanine Blood • Increased 2-6 weeks prior to the urinary normal results is lowered
Level excretion of phenylpyruvic acid from 4 mg/dL to 2 mg/dL
• Detected as early as 4 hours after birth

Phenylpyruvic acid • based upon the ferric chloride reaction permanent blue-green
Urine Test performed by tube test. color

Guthrie’s microbial • blood from a heelstick is absorbed into Bacterial growth with
inhibition assay filter paper circles. The blood-impregnated around the paper disks.
disks are placed on culture media with
Bacillus subtilis. If increased
phenylalanine levels are present in the
blood, it will counteracts the action of
beta-2-thienylalanine, an inhibitor of B.
subtilis that is present in the media

• the ferric chloride test is a nonspecific reaction and will react with many other amino acids and
commonly ingested medications
 Tyrosyluria/Tyrosinemia

 Accumulation of excess tyrosine in the plasma (tyrosinemia) producing urinary overflow

 Inhirited or metabolic defect
 Urine metabolites:
o p-hydroxyphenylpyruvic acid
o p-hydroxyphenyllactic acid

 urine may contain excess tyrosine

 transitory tyrosinemia  (most common); seen in premature infants
underdevelopment of the liver function to produce enzyme for tyrosine metabolism
NOTE:
Test positive with FeCl3 test  confused with PKU  green color fades rapidly when tyrosine is present

Type Enzyme Def. Comment

Type 1 Fumarylacetoacetate hydrolase (FAH) Produces a generalized renal tubular disorder

and progressive liver failure in infants soon
after birth

Type 2 tyrosine aminotransferase Persons develop corneal erosion and lesions

on the palms, fingers, and soles of the feet
believed to be caused by crystallization of
tyrosine in the cells

Type 3 p-hydroxyphenylpyruvic acid result in mental retardation if dietary

dioxygenase restrictions of phenylalanine and tyrosine are
not implemented

Test for Tyrosyluria/Tyrosinemia

Test Comment Result

nitroso-naphthol test • Nonspecific, reacts with compounds other Orange-red color

(urinary screening than tyrosine and its metabolites.
test)
Reagent:
• 2.63N nitric acid
• 21.5% sodium nitrite
• 1-nitroso-2-napthol

MS/MS • Used to confirm nitro-naphthol test

 Melanuria

 Increased urinary melanin  darkening of urine after exposure to air

 2 Metabolic pathways of converting tyrosine into melanin:
o Eumelanin Pathway  from brown to black
o Pheomelanin  from yellow to red
NOTE:
• Absence will lead to albinism
• Elevation of urinary melanin is a serious finding that indicates the overproliferation of the normal
melanin- producing cells (melanocytes) producing a malignant melanoma

Test for Melanuria

Test Comment Result

Ferric Chloride Tube Test Oxidation of chromogen Gray or black ppt

sodium nitroprusside test Screening test Red color

Interference  add glacial Hac • Purple

(reverts color greenish-black)
• amber
• Acetone
• Creatinine

 Alkaptonuria (Alkali lover)

 One of the six original inborn errors of metabolism described by Garrod in 1902
 Darkened urine after becoming alkaline from standing at room temperature.
 occurs from failure to inherit the gene to produce the enzyme homogentisic acid oxidase
 brown-stained or black-stained cloth diapers and reddish- stained disposable diapers
NOTE:

 enzyme homogentisic acid oxidase. Without this enzyme, the phenylalanine-tyrosine pathway cannot
proceed to completion, and homogentisic acid accumulates in the blood, tissues, and urine.
Test for Alkaptonuria

Test Comment Result

FeCl3 Test • Screening test for metabolic transient deep blue color in test
disorder tube

Clinitest • Test for reducing substance Yellow ppt

urinary homogentisic acid • Screening test observe for darkening of the color
Test
• add alkali to freshly voided (Ascorbic Acid interferes the test)
urine

Ammoniacal Silver Nitrate • Addition of silver nitrate and Black Urine

Test ammonium hydroxide to
urine

 Maple Syrup Urine Disease

 amino acids involved are leucine, isoleucine, and valine

 Failure to inherit the gene for the enzyme necessary to produce oxidative decarboxylation of keto acids
results in their accumulation in the blood and urine
o α-ketoisovaleric
o α-ketoisocaproic
o α-keto-β-methylvaleric

 strong odor of urine resembling maple syrup

Test for MSUD

Test Comment Result

2,4-dinitro-phenylhydrazine • urine screening test most frequently Yellow turbidity or

(DNPH) reaction performed for keto acids ppt

Interference:
• Large doses of ampicillin
• a positive reagent strip test result for ketones
produce a positive DNPH result
 Organic Acidemias

Point of reference Isovaleric Propionic Methylmalonic acidemia

acidemia Acidemia

Characteristic odor Sweaty feet odor of

urine

Special charateristic Accumulation of immediate

isovalerylglycine precursor to
methylmalonic
acid

Cause isovaleryl errors in the metabolic pathway converting isoleucine,

coenzyme A def. in valine, threonine, and methionine to succinyl coenzyme A
the leucine
pathway.

Test method MS/MS p-nitroaniline urine Test (emerald

green)

NOTE:

 Generalized symptoms of the organic acidemias include early severe illness, often with vomiting
accompanied by metabolic acidosis; hypoglycemia; ketonuria; and increased serum ammonia

 TRYTOPHAN DISORDERS

NOTE:

 The major concern of the urinalysis laboratory in the metabolism of tryptophan is the increased urinary
excretion of the metabolites indican and 5-hydroxyindoleacetic acid (5-HIAA)
 Indicanuria
 increased amounts of tryptophan are converted to indole (Hartnup disease)
 Excess indole is reabsorbed in the intestine  circulated to liver  converted to indican  excreted in
urine
 Colorless when oxidized turns indigo blue
 Blue diaper syndrome
 FeCl3 Test  deep blue/violet color  chloroform extraction
NOTE:

 Trptophan enter the instestine then converted to indole by intestinal bacteria  excreted in the feces

 5-Hydroxyindoleacetic Acid

 Serotonin  stimulation of smooth muscle

o produced from tryptophan by the argentaffin cells in the intestine
 5-HIAA  degradation product (urine metabolite)
 Foods rich in serotonin 
• Bananas
• Pineapples
• Tomatoes

Test Comment Result

Nitroso-naphthol Test • Normal daily excretion = 2-8mg Purple to black color

(depending on 5-
Reagent: • >25mg/24h  argentaffin cell tumors
HIAA level)
nitrous acid
1-nitroso-2-naphthol

• Requirement:
• 24h sample
• Preservative: HCl or Boric Acid
• Strict diet
• Hold medication (phenothiazines and
acetanilids) for 72h prior to sample
collection

NOTE:
• The test can be performed on a random or first morning specimen; however, false-negative results can
occur based on the specimen concentration and also because 5-HIAA may not be produced at a
constant rate throughout the day.
CYSTINE DISORDERS

Point of Reference Cystinuria Cystinosis Homocystinuria

Characteristic elevated a.a. cystine in crystalline deposits increase in homocystine

urine of cystine in many throughout the body.
areas of the body
(+) cystine crystals in urine

Cause inability of the renal defect in the Defect in methionine

tubules to reabsorb cystine lysosomal metabolism
filtered by the glomerulus. membranes

Test & Result Cyanide-nitroprusside Test Positive test results (+) cyanide-nitroprusside
(red-purple color) for reducing test plus (+) silver-
substances nitroprusside test

Porphyrin disorder

Disorder Comment Test

Porphyria Collective term for disorders of

porphyrin metabolism

Porphyrinuria observation of a red or port wine color Ehrlich reaction (Watson-

to the urine after exposure to air Schwartz) and fluorescence Test

Mucopolysaccharide (glycosaminoglycans) Disorders

Point of Reference Hurler syndrome Hunter syndrome Sanfilippo

syndrome

Characteristic skeletal structure is abnormal and there is severe mental Mental retardation
Abnormality retardation

mucopolysaccharides accumulate
in the cornea of the eye.

Treatment Bone marrow transplants and gene replacement therapy

Test • acid-albumin (turbidity after 30 mins)

• cetyltrimethylammonium bromide (CTAB) turbidity tests (turbidity after 5
mins)
• Metachromatic staining (blue spot)
NOTE:
• accumulation of the incompletely metabolized polysaccharide portions in the lysosomes of the
connective tissue cells and their increased
• excretion in the urine.

Purine Disorder (Lesch-Nyhan Disease)

Cause Characteristics Test

Failure to inherit the gene to • severe motor defects Microscopic  presence of

produce increased uric acid crystals in
• mental retardation
pediatric urine specimens
the enzyme hypoxanthine
• tendency toward self-
guanine phosphoribosyl-
destruction
transferase
• Gout
• renal calculi
• Presence of uric acid crystals
resembling orange sand in
diapers

Carbohydrate Disorder

Melituria Comment Test

pentosuria one of Garrod’s original six IEMs Test for reducing

galactosuria
(inability to properly metabolize
galactose to glucose)
substance
(Clinitest)
deficiency in any of three enzymes, galactose-
1-phosphate uridyl transferase (GALT),
galactokinase and UDP-galactose-4-epimerase

Lactosuria seen during pregnancy and lactation

Fructosuria • parenteral feeding

• ingestion of large amounts of fruit