Professional Documents
Culture Documents
Pre-analytical Factors
Analytical Factors
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
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.
Glomerular Disorders
The majority of the disorders associated with the glomerulus are of immune origin, resulting from
immunologic disorders throughout the body, including the kidney.
Immune complexes formed as a result of immunologic reactions and increased serum immunoglobulins,
such as immunoglobulin A (IgA), circulate in the bloodstream and are deposited on the glomerular
membranes.
Components of the immune system, including complement, neutrophils, lymphocytes, monocytes, and
cytokines, are then attracted to the area, producing changes and damage to the membranes.
Depending on the immune system mediators involved, damage may consist of cellular infiltration or
proliferation resulting in thickening of the glomerular basement membrane, and complement-mediated
damage to the capillaries and basement membrane.
Nonimmunologic causes of glomerular damage include exposure to chemicals and toxins that also affect
the tubules, disruption of the electrical membrane charges as occurs in the nephrotic syndrome, deposition
of amyloid material from systemic disorders that may involve chronic inflammation and acute-phase
reactants, and the basement membrane thickening associated with diabetic nephropathy.
Interstitial Disorders
Considering the close proximity between the renal tubules and the renal interstitium, disorders affecting the
interstitium also affect the tubules, resulting in the commonly used term tubulointerstitial disease.
The majority of these disorders involve infections and inflammatory conditions.
The most common renal disease is UTI.
Infection may involve the lower urinary tract (urethra and bladder) or the upper urinary tract (renal pelvis,
tubules, and interstitium).
Most frequently encountered is infection of the bladder (cystitis), which if untreated can progress to a more
serious upper UTI.
Cystitis is seen more often in women and children who present with symptoms of urinary frequency and
burning.
Renal Failure
Renal failure exists in both acute and chronic forms.
As discussed in conjunction with many of the previous disorders, this may be a gradual progression from
the original disorder to chronic renal failure or end-stage renal disease.
The progression to end-stage renal disease is characterized by a marked decrease in the glomerular
filtration rate (less than 25 mL/min); steadily rising serum
BUN and creatinine values (azotemia); electrolyte imbalance; lack of renal concentrating ability producing
an isothenuric urine; proteinuria; renal glycosuria; and an abundance of granular, waxy, and broad casts,
often referred to as a telescoped urine sediment.
Acute renal failure (ARF), in contrast to chronic renal failure, exhibits a sudden loss of renal function and is
frequently reversible. Primary causes of ARF include a sudden decrease in blood flow to the kidney
(prerenal), acute glomerular and tubular disease (renal), and renal calculi or tumor obstructions (postrenal).
As can be seen from the variety of causes, patients may present with many different symptoms relating to
the particular disorder involved; however, a decreased glomerular filtration rate, oliguria, edema, and
azotemia are general characteristics.
Similar to clinical symptoms, urinalysis findings are varied; however, because they relate to the primary
cause of the ARF, they can be diagnostically valuable.
For example, the presence of RTE cells and casts suggests ATN of prerenal origin; RBCs indicate
glomerular injury; WBC casts with or without bacteria indicate interstitial infection or inflammation of renal
origin; and postrenal obstruction may show normal and abnormal appearing urothelial cells possibly
associated with malignancy.
Renal Lithiasis
Renal calculi (kidney stones) may form in the calyces and pelvis of the kidney, ureters, and bladder. In
renal lithiasis, the calculi vary in size from barely visible to large, staghorn calculi resembling the shape of
the renal pelvis and smooth, round bladder stones with diameters of 2 or more inches.
Small calculi may be passed in the urine, subjecting the patient to severe pain radiating from the lower
back to the legs.
Larger stones cannot be passed and may not be detected until patients develop symptoms of urinary
obstruction.
Lithotripsy, a procedure using high-energy shock waves, can be used to break stones located in the upper
urinary tract into pieces that can then be passed in the urine. Surgical removal also can be employed
Summary of Glomerular Disorders
Alport Syndrome
Henoch-Schönlein Pupura
Henoch-Schönlein purpura is a disease occurring primarily in children following upper respiratory
infections, decrease in platelets disrupts vascular integrity
As its name implies, initial symptoms include the appearance of raised, red patches on the skin.
Respiratory and gastrointestinal symptoms, including blood in the sputum and stools, may be present.
Membranous Glomerulonephritis
a pronounced thickening of the glomerular basement membrane resulting from the deposition of
immunoglobulin G immune complexes.
Disorders associated with the development of membranous glomerulonephritis include systemic lupus
erythematosus, Sjögren syndrome, secondary syphilis, hepatitis B, gold and mercury treatments, and
malignancy.
ETIOLOGY: Thickening of the glomerular membrane following IgG immune complex deposition associated
with systemic disorders
Membranoproliferative Glomerulonephritis
Membranoproliferative glomerulonephritis (MPGN) is marked by two different alterations in the cellularity of
the glomerulus and peripheral capillaries.
Type 1 displays increased cellularity in the subendothelial cells of the mesangium (interstitial area of
Bowman’s capsule), causing thickening of the capillary walls, whereas type 2 displays extremely dense
deposits in the glomerular basement membrane.
ETIOLOGY: Cellular proliferation affecting the capillary walls or the glomerular basement membrane,
possibly immune-mediated
Chronic Glomerulonephritis
Depending on the amount and duration of the damage occurring to the glomerulus in the previously
discussed glomerular disorders, progression to chronic glomerulonephritis and end-stage renal disease
may occur.
Gradually worsening symptoms include fatigue, anemia, hypertension, edema, and oliguria.
ETIOLOGY: Marked decrease in renal function resulting from glomerular damage precipitated by other
renal disorders
Immunogloblin A Nephropathy
Also known as Berger disease, IgA nephropathy, in which immune complexes containing IgA are deposited
on the glomerular membrane, is the most common cause of glomerulonephritis.
ETIOLOGY: Deposition of IgA on the glomerular membrane resulting from increased levels of serum IgA
Nephrotic Syndrome
marked by massive proteinuria (greater than 3.5 g/d), low levels of serum albumin, high levels of serum
lipids, and pronounced edema.
ETIOLOGY: Disruption of the electrical charges that produce the tightly fitting podocyte barrier resulting in
massive loss of protein and lipids
Minimal Change Disease
As the name implies, minimal change disease (also known as lipid nephrosis) produces little cellular
change in the glomerulus, although the podocytes appear to be less tightly fitting, allowing for the
increased filtration of protein.
ETIOLOGY: Disruption of the podocytes occuring primarily in children following allergic reactions and
immunizations
Focal Segmental Glomerulosclerosis
affects only certain numbers and areas of glomeruli, and the others remain normal. Symptoms may be
similar to the nephrotic syndrome and minimal change disease owing to damaged podocytes.
ETIOLOGY: Disruption of podocytes in certain areas of glomeruli associated with heroin and analgesic
abuse and AIDS
Alport Syndrome
Alport syndrome is an inherited disorder affecting the glomerular basement membrane. The syndrome can
be inherited as a sex-linked or autosomal genetic disorder.
ETIOLOGY: Genetic disorder showing lamellated and thinning of glomerular basement membrane
Diabetic Nephropathy
Diabetic nephropathy, also known as Kimmelstiel-Wilson disease, is currently the most common cause of
end-stage renaldisease.
Summary of Metabolic and Tubular Disorders
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
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
• 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)
• 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)
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
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
Melanuria
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.
FeCl3 Test • Screening test for metabolic transient deep blue color in test
disorder tube
urinary homogentisic acid • Screening test observe for darkening of the color
Test • add alkali to freshly voided (Ascorbic Acid interferes the test)
urine
o α-ketoisocaproic
o α-keto-β-methylvaleric
Interference:
• Large doses of ampicillin
• a positive reagent strip test result for ketones
produce a positive DNPH result
Organic Acidemias
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
• 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
Test & Result Cyanide-nitroprusside Test Positive test results (+) cyanide-nitroprusside
(red-purple color) for reducing test plus (+) silver-
substances nitroprusside test
Porphyrin disorder
Characteristic skeletal structure is abnormal and there is severe mental Mental retardation
Abnormality retardation
mucopolysaccharides accumulate
in the cornea of the eye.
NOTE:
• accumulation of the incompletely metabolized polysaccharide portions in the lysosomes of the
connective tissue cells and their increased
• excretion in the urine.
Carbohydrate Disorder