32 2 CORE BIOCHEMISTRY
16 Urinalysis
Urinalysis is so important in screening
for disease that it is regarded as an inte-
gral part of the complete physical exami-
nation of every patient, and not just in
the investigation of renal disease. Uri-
nalysis comprises a range of analyses
that are usually performed at the point
of care rather than in a central labora-
tory. Examination of a patient’s urine
should not be restricted to biochemical
tests. Figure 16.1 summarizes the differ-
ent ways urine may be examined.
Procedure
Biochemical testing of urine involves the
use of commercially available disposa-
ble strips (Fig 16.2). Each strip is impreg-
nated with a number of coloured reagent
‘blocks’ separated from each other by
narrow bands. When the strip is manu-
ally immersed in the urine specimen,
the reagents in each block react with a
specific component of urine in such a
way that (a) the block changes colour if
Gross appearance
Microscopy
Volume and
colour
Cells, casts,
crystals, bacteria
Fig 16.1  The place of biochemical testing in urinalysis.
(a)
Fig 16.2  Multistix testing of a urine sample: (a) Immersion of test strip in urine specimen. (b) Excess urine removed. (c) Test strip is compared with
colour chart on bottle label.
the component is present, and (b) the
colour change produced is proportional
to the concentration of the component
being tested for.
To test a urine sample:
n fresh urine is collected into a clean
dry container
n the sample is not centrifuged
n the disposable strip is briefly
immersed in the urine specimen;
care must be taken to ensure that all
reagent blocks are covered
n the edge of the strip is held against
the rim of the urine container to
remove any excess urine
n the strip is then held in a horizontal
position for a fixed length of time
that varies from 30 seconds to 2
minutes
n the colour of the test areas are
compared with those provided on a
colour chart (Fig 16.2). The strip is
held close to the colour blocks on
the chart and matched carefully, and
then discarded.
Biochemistry
Na+
Glucose
H+
pH, osmolality, protein,
urea, creatinine, glucose
(b)
The range of components routinely
tested for in commonly available com-
mercial urinalysis strips is extensive and
includes glucose, bilirubin, ketones, spe-
cific gravity, blood, pH (hydrogen ion
concentration), protein, urobilinogen,
nitrite and leucocytes (white blood
cells).
Urinalysis is one of the commonest
biochemical tests performed outside the
laboratory. It is most commonly per-
formed by non-laboratory staff. Although
the test is simple, failure to follow the
correct procedure may lead to inaccu-
rate results. A frequent example of this
is where test strips are read too quickly
or left too long. Other potential errors
may arise because test strips have been
stored wrongly or are out of date.
Glucose
The presence of glucose in urine (glyco-
suria) indicates that the filtered load of
glucose exceeds the ability of the renal
tubules to reabsorb all of it. This usually
reflects hyperglycaemia and should,
therefore, prompt consideration of
whether more formal testing for diabe-
tes mellitus is appropriate, e.g. by meas-
uring fasting blood glucose. However,
glycosuria is not always due to diabetes.
The renal threshold for glucose may be
lowered, for example in pregnancy, and
glucose may enter the filtrate even at
normal plasma concentrations (renal
glycosuria).
Blood glucose rises rapidly after a
meal, overcoming the normal renal
threshold temporarily (alimentary gly-
cosuria). Both renal and alimentary gly-
cosuria are unrelated to diabetes.
(c)

Bilirubin
Bilirubin exists in the blood in two
forms, conjugated and unconjugated.
Only the conjugated form is water-
soluble, so bilirubinuria signifies the
presence in urine of conjugated bilirubin.
This is always pathological. Conjugated
bilirubin is normally excreted through
the biliary tree into the gut where it is
broken down; a small amount is reab-
sorbed into the portal circulation, taken
up by the liver and re-excreted in bile.
Interruption of this so-called enterohe-
patic circulation usually stems from
mechanical obstruction, and results in
high levels of conjugated bilirubin in the
systemic circulation, some of which
spills over into the urine.
Urobilinogen
In the gut, conjugated bilirubin is broken
down by bacteria to products known
collectively as faecal urobilinogen, or
stercobilinogen. This too undergoes
an enterohepatic circulation. However,
unlike bilirubin, urobilinogen is found
in the systemic circulation and is often
detectable in the urine of normal sub-
jects. Thus the finding of urobilinogen
in urine is of less diagnostic significance
than bilirubin. High levels are found in
any condition where bilirubin turnover
is increased, e.g. haemolysis, or where its
enterohepatic circulation is interrupted,
e.g. by liver damage.
Ketones
Ketones are the products of fatty acid
breakdown. Their presence usually indi-
cates that the body is using fat to provide
energy rather than storing it for later
use. This can occur in uncontrolled dia-
betes, where glucose is unable to enter
cells (diabetic ketoacidosis), in alcohol-
ism (alcoholic ketoacidosis), or in asso-
ciation with prolonged fasting or
vomiting.
Specific gravity
This is a semi-quantitative measure of
urinary density, which in turn reflects
concentration. A higher specific gravity
indicates a more concentrated urine.
Assessment of urinary specific gravity
usually just confirms the impression
gained by visually inspecting the colour
of the urine. When urine concentration
needs to be quantitated, most people
will request urine osmolality, which has
a much wider working range.
16 Urinalysis 33
pH (hydrogen ion concentration) possibilities ranging from malignancy
Urine is usually acidic (urine pH sub- through urinary tract infection to con-
stantially less than 7.4 indicating a high tamination from menstruation. Dipstick
concentration of hydrogen ions). Meas- tests for blood are able to detect haemo-
urement of urine pH is useful either in globin and myoglobin in addition to red
cases of suspected adulteration, e.g. drug blood cells – the presence in the urine
abuse screens, or where there is an sediment of large numbers of red cells
unexplained metabolic acidosis (low establishes the diagnosis of haematuria.
serum bicarbonate). The renal tubules The absence of red cells, despite a
normally excrete hydrogen ions by strongly positive dipstick test for blood,
mechanisms that ensure tight regula- points towards myoglobinuria or
tion of the blood hydrogen ion concen- haemoglobinuria.
tration. Where one or more of these
mechanisms fail, an acidosis results Nitrite
(so-called renal tubular acidosis or RTA; This dipstick test depends on the con-
see p. 30). Measurement of urine pH version of nitrate (from the diet) to
may, therefore, be used to screen for nitrite by the action in the urine of bac-
RTA in unexplained metabolic acidosis; teria that contain the necessary reduct-
a pH less than 5.3 indicates that the ase. A positive result points towards a
renal tubules are able to acidify urine urinary tract infection.
and are, therefore, unlikely to be
responsible. Leucocytes
The presence of leucocytes in the urine
Protein suggests acute inflammation and the
Proteinuria may signify abnormal excre- presence of a urinary tract infection.
tion of protein by the kidneys (due
either to abnormally ‘leaky’ glomeruli or
to the inability of the tubules to reab-
sorb protein normally), or it may simply
reflect the presence in the urine of cells
or blood. For this reason it is important Clinical note
to check that the dipstick test is not also Microbiological testing of
positive for blood or leucocytes (white a urine specimen (usually
cells); it may also be appropriate to a mid-stream specimen or MSSU)
screen for a urinary tract infection by is routinely performed to confirm
sending urine for culture. Proteinuria the diagnosis of a urinary tract
and its causes are discussed in detail on infection. These samples should be
pages 34–35. collected into sterile containers and
sent to the laboratory without delay
for culture and antibiotic sensitivity
Blood
tests.
The presence of blood in the urine (hae-
maturia) is consistent with various
Case history 11 
A patient attending an obesity clinic is found to have ketonuria on urinalysis. There is no
glycosuria and point-of-care glucose measurement using a strip test is 5.9 mol/L.
 What might explain these findings?
Comment on page 165.
Urinalysis
n Urinalysis should be part of the clinical examination of every patient.
n Chemical analysis of a urine specimen is carried out using commercially available
disposable strips.
n The range of components routinely tested for includes glucose, bilirubin, ketones, specific
gravity, blood, pH, protein, urobilinogen, nitrite and leucocytes.