Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

○ Chemstrip: 5.0 to 9.0 in 1.0

Reagent strip technique increments
● Interferences:
Errors caused by improper technique ○ No known interfering
substances
● Unmixed specimen; should be swirled ○ Run-over from adjacent pads
before dipping the reagent strip due to ○ Old specimens
rbc and wbc and other urinary ● Correlations:
sediments sinking at the bottom ○ Nitrite
● Leaching of reagents from the pads; ○ Leukocytes
cutting the reagent strip in lengthwise ○ Microscopic
position ■ pH 5.0 - amorphous
● Run-over between chemicals on urates (below 7.0)
adjacent pad: blot the reagent strip with ■ pH 8.0 - amorphous
tissue after dipping phosphate (above 7.0)
● Good light source for reading;
subjective, it varies from one technician
to another
● Timing of reaction (depends on the
guidelines of manufacturer)
○ pH: immediate
○ LE (leukocyte esterase): 120s or
2mins Renal tubular acidosis
○ Rest of the parameters; read - Disorder wherein a person has an
between 60s-120s depending on inability to produce an acid urine due to
the parameter and impaired production of ammonia
manufacturer
Parameter: protein
Parameter: pH (first parameter) ● Principle: protein error of indicator
● Principle: double indicator system ● Reagent strip reaction: protein error of
■ Methyl red and indicators to produce a visible
bromothymol blue colorimetric reaction
○ Methyl red to red to yellow (pH ● Chemstrip: 3’,3”,5’,5” -
is 4-6) tetrachlorophenol, 3,4,5,6-
○ Bromothymol blue > yellow to tetrabromosulfonphtalein
blue (pH is 6-9) ● Multistix tetrabromophenol blue and an
○ Orange from pH 5 through acid buffer to maintain the pH at a
yellow; green to final deep blue constant level
at pH 9 ● pH 3.0 appears yellow, if there is no
● Sensitivity: presence of protein
○ Multistix: 5.0 to 8.5 in 0.5
increments

1
Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

● As protein concentration increases ● Reagent strip reaction (glucose oxidase)

appears as various shades of green to ● Glucose oxidase testing method by
blue impregnating the testing area with a
● Trace value of <30 mg/dL mixture of glucose oxidase, peroxidase,
● Negative, trace, 1+, 2+, 3+, 4+ (30 chromogen, and buffer to produce a
mg/dL, 100 mg/dL, 300 mg/dL, 2000 double sequential enzyme reaction
mg/dL) ● Reagents:
● Sensitivity: ○ Multistix: glucose oxidase,
○ Multistix: 15-30 mg/dL albumin peroxidase, potassium iodide
(type of protein) ○ Chemstrip: glucose oxidase,
○ Chemstrip: 6 mg/dL albumin peroxidase,
(sensitive) tetramethylbenzidine
● Interferences: ● Sensitivity:
○ False positive: ○ Multistix: 75 to 125 mg/dL
■ Highly buffered ○ Chemstrip: 40 mg/dL
interference alkaline ● Interferences:
urine ○ False positive
■ Pigmented specimen ■ Contamination by
phenazopyridine oxidizing agents and
■ Quaternary ammonium detergents
compounds ○ False negative
(detergents) ■ High levels of
■ Antiseptics, ascorbic acid
chlorhexidine ■ High levels of ketones
■ Loss of buffer from ■ High specific gravity
prolonged exposure to ■ Low temperatures
the specimen reagent ■ Improperly preserved
■ High specific gravity specimens
○ False negative ○ Correlations
■ Proteins other than ○ Ketones
albumin ○ Protein
■ Microalbuminuria ● Reagent strip reaction: copper reduction
○ Correlations test, clinitest
■ Blood ○ Relies on the ability of glucose
■ Nitrite and other substances to reduce
■ Leukocytes copper sulfate to cuprous oxide
■ Microscopic in the presence of alkali and
heat
Parameter: glucose ○ A color change progressing from
a negative blue (CuSO4)
Principle: double sequential enzymatic reaction through green, yellow, and

2
Analysis of Urine and Other Body Fluids (Lecture)
Chemical Urine Examination
Prof: Jen Gaytano-Bautista
orange/red when the reaction
takes place
○ Reducing sugar: glucose
○ Non-reducing sugar: sucrose
○ Detects other reducing sugar
other than sucrose
● Pass through phenomenon
○ Interference of other reducing
sugars (galactose, lactose,
fructose, maltose, pentoses,
ascorbic acid, certain drug
metabolites, and antibiotics
such as cephalosporins)
○ Color changes due to over time
Parameter: ketones
● Principle: nitroprusside reaction
● Reagent strip reaction: sodium
nitroprusside (nitroferricyanide) reaction
to measure ketones
● Acetoacetic acid in an alkaline medium
reacts with sodium nitroprusside to
produce a purple color
Additional notes
● Ketones: 3 immediate products of fat
metabolism
○ Acetone (2%) - sensitive in the
presence of glycine
○ Acetoacetic acid (20%)
○ B-hydroxybutyrate (78%)
● Reagents:
○ Sodium nitroprusside
○ Glycine in chemstrip
● Sensitivity:
○ Multistix: 5-10 mg/dL
acetoacetic acid
○ Chemstrip: 9 mg/dL acetoacetic
acid; 70 mg/dL acetone
● Interferences:
○ False positive
■ Phthalein dyes
■ Highly pigmented red
urine
■ Levodopa
■ Medications containing
free sulfhydryl groups
○ False negative:
■ Improperly preserved
specimens
○ Correlations
■ Glucose
Parameter: blood
● Principle: pseudoperoxidase activity of
hemoglobin
● Reagent strip reaction:
○ Pseudoperoxidase activity of
hemoglobin to catalyze a
reaction between the heme
component of both hemoglobin
and myoglobin and the
chromogen
tetramethylbenzidine to produce
an oxidized chromogen, which
has a green-blue color
● Reagent:
○ Multistix: diisopropylbenzene,
dihydroperoxide and
3,3’,5,5’-tetramethylbenzidine
○ Chemstrip:
dimethyldihydroperoxyhexane
and tetramethylbenzidine
● Sensitivity:
○ Multistix: 5-20 RBCs/mL, 0.0015
to 0.062 mg/dL hemoglobin
○ Chemstrip: 5 RBCs/mL
hemoglobin corresponding to 10
RBCs/mL (more sensitive)
● Interferences:
○ False positive:
■ Strong oxidizing agents
3
Analysis of Urine and Other Body Fluids (Lecture)
Chemical Urine Examination
Prof: Jen Gaytano-Bautista
■ Bacterial peroxidases
■ Menstrual
contamination
○ False negative:
■ High specific
gravity/crenated cells
■ Formalin
■ Captopril
■ High concentrations of
nitrite
■ Ascorbic acid greater
than 25 mg/dL
■ Unmixed specimens
○ Correlations:
■ Protein
■ Microscopic
Hematuria: presence of intact RBCs
Pathologic causes:
● Disorders of renal or genitourinary origin
(trauma or damage)
○ Renal calculi, glomerular disease
Non-pathologic causes:
● Strenuous exercise, menstruation
Reagent strip reaction:
● Speckled pattern on reagent strip pad
○ Presence of intact RBCs
Hemoglobinuria: presence of hemoglobin in
urine
● Results from the lysis of red blood cells
produced in the urinary tract,
particularly in dilute, alkaline urine
● Intravascular hemolysis
Reagent strip reaction:
● Uniform color ranging from a negative
yellow through green to a strongly
positive green-blue appears on the pad
Myoglobinuria: presence of myoglobin in urine/
coca-cola like (clear red-brown urine)
● Result of muscle destruction
(rhabdomyolysis)
● Myoglobin: heme-containing protein
found in muscle tissue (heme portion is
toxic to renal tubules > acute renal
failure)
Reagent strip reaction:
● Uniform color ranging from a negative
yellow through green to a strongly
positive green-blue appears on the pad
Parameter: bilirubin
● Principle: diazo reaction
● Reagent strip reaction: uses the diazo
reaction
● Bilirubin combines with
2,4-dichloroaniline diazonium salt or 2,6
dichlorobenzene-diazonium-tetrafluorob
orate in an acid medium to produce an
azodye, with colors ranging from
increasing degrees of tan or pink to
violet
● Reporting:
○ Negative, small, moderate, or
large, or as negative, 1+, 2+, or
3+
○ ICTOTEST TABLETS
● Sensitivity:
○ Multistix: 0.4 to 0.8 mg/dL
bilirubin
○ Chemstrip: 0.5 mg/dL bilirubin
● Interferences:
○ False positive:
■ Highly pigmented urines
■ Phenazopyridine
■ Indican (intestinal
disorders)
4
Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

■ Metabolites of lodine ● Sulfonamides

○ False negative: ● Methyldopa
■ Specimen exposure to ● Procaine
light ● Chlorpromazine
■ Ascorbic acid greater ● Highly
than 25 mg/dL pigmented
■ High concentration of urine
nitrite ■ False negative:
○ Correlation: ● Old specimens
■ Urobilinogen ● Preservation in
formalin
Parameter: urobilinogen ● P
r
● Principle: ehrlich's reaction (M) diazo e
reaction (c) s
e
● Reagent strip reaction: r
○ Multistix: uses ehrlich's v
aldehyde reaction, in which a
urobilinogen reacts with t
p-dimethylaminobenzaldehyde i
(ehrlich reagent) to produce v
colors ranging from light pink to e
dark pink f
● Reagent: o
○ Multistix: r
p-dimethylaminobenzaldehyde u
○ Chemstrip: r
4-methoxybenzenediazonium-te i
traflouroborate n
● Sensitivity: a
○ Multistix: 0.2 mg/dL r
urobilinogen (more sensitive) y
○ Chemstrip: 0.4 mg/dL s
urobilinogen e
● Interferences: d
○ Multistix: i
■ False positive: m
● Porphobilinogen e
● Indican n
● P-aminosalicylic t
acid s

5
Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

○ Chemstrip: ○ Chemstrip: 0.05 mg/dL nitrite

■ False positive: ion
● Highly ● Interferences:
pigmented ○ False negative:
urine ■ Non-reductase-containin
■ False negative: g bacteria
● Old specimens ■ Insufficient contact time
● Preservation in between
formalin ■ Bacteria and urinary
● High nitrate
concentration of ■ Lack of urinary nitrate
nitrite ■ Large quantities of
■ Correlations: bacteria converting
● Bilirubin nitrite to nitrogen
■ Presence of antibiotics
Parameter: nitrite ■ High concentrations
● Principle: griess reaction of ascorbic acid
● Reagent strip reaction: ■ High specific gravity
○ Nitrite at an acidic pH reacts ○ False positive:
with an aromatic amine ■ Improperly preserved
(para-arsanilic acid or specimens
sulfanilamide to form a ■ Highly pigmented urine
diazonium compound that then ○ Correlations:
reacts with tetrahydrobenzo ■ Protein, leukocytes,
quinoline compounds to produce microscopic
a pink colored azodye
○ Ability of certain bacteria to Parameter: leukocyte esterase
reduce nitrate, a normal
constituent of urine, to nitrite, ● Principle: hydrolysis of ester
which does not normally appear ● Reagent strip reaction:
in the urine ○ Uses action of LE (leukocyte
● Reagents: esterase) to catalyze the
○ Multistix: p-arsanilic acid, hydrolysis of an acid ester
tetrahydrobenzo embedded on the reagent pad
(h)-quinolin-3-ol to produce an aromatic
○ Chemstrip: sulfanilamide, compound and acid
hydroxytetrahydrobenzoquinolin ○ The aromatic compound then
e combines with a diazonium salt
● Sensitivity: present on the pad to produce a
○ Multistix: 0.06 to 0.1 mg/dL purple azodye
nitrite ion ● LE reaction requires the longest time of
all reagent strip reactions (2 minutes)

6
Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

● Reporting: reagent pad measures the

○ Trace, small, moderate, and change in pH
large or trace, 1+, 2+, and 3+ ■ As the specific gravity
● Reagents: increases, the indicator
○ Multistix: derivatized pyrrole, changes from blue
amino acid ester, diazonium salt (1.000, alkaline)
○ Chemstrip: indoxyl carbonic acid through shades of
ester, diazonium salt green to yellow (1.030,
● Sensitivity: acid)
○ Multistix: 5-15 WBC/hpf (more ■ Reading time is 30s but
sensitive) it depends on the
○ Chemstrip: 10-25 WBC/hpf manufacturer
● Interferences: ● Random urine
○ False positive: sample has a
■ Strong oxidizing agents specific gravity
■ Formalin of 1.015-1.030
■ Highly pigmented urine, ○ Reagents:
nitrofurantoin ■ Multistix: poly (methyl
○ False negative: vinyl ether/maleic
■ High concentrations of anhydride)
protein, glucose, oxalic bromothymol blue
acid, ascorbic acid, ■ Chemstrip: ethylene
gentamicin, glycol diamonoethyl
cephalosporins, ether tetraacetic acid,
tetracyclines bromothymol blue
■ Inaccurate timing ○ Sensitivity:
○ Correlations: ■ 1.000- 1.030
■ Protein ○ Interferences:
■ Nitrite ■ False positive:
■ Microscopic ● High
concentrations
Parameter: specific gravity of protein
● Principle: change in pKa of ■ False negative:
polyelectrolytes ● Highly alkaline
● Reagent strip reaction: urines (greater
○ Based on the change in pKa than 6.5)
(dissociation constant) of a
polyelectrolyte in an alkaline Parameter: ascorbic acid (ascorbate)
medium ● Principle: action of ascorbic acid to
○ Incorporation of the indicator reduce a dye in the impregnated pad
bromothymol blue on the ● Positive result in reagent strip: can deter
AA concentration as low as 7.0 mg/dL

7
Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

and consistently detect 20 mg/dL of AA ● Butanol top layer, if it turns red, it

(ascorbic acid) in 90% urine tested means that the compound you’re
● Significance of AA in reagent strip: looking for is soluble in
○ High levels of AA cause false
negative result on glucose,
blood (>25 mg/dL), bilirubin
(>25 mg/dL), nitrite, leukocyte
esterase

Benedict’s test
● Glucose (other reducing sugar)
● principle : copper reduction
● Reporting:

Sulfosalicylic acid precipitation (SSA) test

● Protein
● Principle: precipitation of urine protein
by strong acid
● Cold precipitation test that reacts
equally with all forms of protein
● Reporting:

Watson - Schwartz test

● Classic test for differentiation
urobilinogen and porphobilinogen
● Chloroform always at the bottom layer, if
it turns red, it means that the compound
you’re looking for is soluble in
chloroform

8
Analysis of Urine and Other Body Fluids (Lecture)

Chemical Urine Examination

Prof: Jen Gaytano-Bautista

● Normally 10 mg/dL or 100 mg/24 hrs

albumin in urine

Albuminuria
● Presence of albumin in urine, >200
mg/L
Microalbuminuria
● Albumin in urine 20-200 mg/L

Micral test:
● Highly specific for human albumin

Albumin concentration of an average urine

specimen should not exceed between 15-20
mg/L

3 morning urine sample

● Kahit dalawa lang sa 3 urine sample
magkaroon ng albumin level na >20
mg/L to indication na na merong
microalbuminuria

Page 29-25, 39-45

9
Analysis of Urine and Other Body Fluids
Microscopic Examination
Prof: Jen Gaytano-Bautista
Specimen preparation
● Specimen should be examined (within
2hrs) while fresh or adequately
preserved
● Refrigeration: (2-8 degreeC)
○ Amorphous urates (acidic,
pink sediments)/phosphates
(alkaline, white) and other
non-pathologic crystals
○ Warming @37 degrees C might
dissolve some crystals
(amorphous urates) (leave at
room temp instead)
Specimen volume
● 10-15 mL standard amount
● 12 mL frequently used
● 50-60 mL submission for analysis
○ Oliguria (decreased urine
output)
○ Anuria (no urine output or
cestated)
■ Catheterized
Centrifugation
● 5 minutes at 400 RCF (rpm in the
philippines)
○ Decantation
Sediment preparation
● 0.5-1mL frequently used
● 0.02 mL or 20uL for conventional glass
slide
Examination of sediment:
● Always look for epithelial cell
○ Largest urinary sediment
○ For point of reference
■ Signals that you’re in
the right path or
direction in viewing the
slide
○ Minimum of 10 fields (LPO and
HPO)
LPO detects:
● Casts
● Ascertain the general composition of
sediment
HPO detects:
● Identification of urinary sediments
Conventional glass slide:
● Casts are usually on the edge of the
glass cover
○ Low power scanning of the
coverslip perimeter is
recommended
Reporting of microscopic examination:
Average number per LPF: casts
Average number per 10 HPF: rbc’s and wbc’s
Semi-quantitative
● Rare 1+ (present but hard to find)
● Few 2+ (one or more present in almost
any field of view)
● Moderate 3+ (easy to find)
● Many 4+ (prominent)
● Packed (crowded)
○ Epithelial cells, crystals and
other sediments
Sediment stains:
Sternheimer-Malbin Stain (not commonly
used in Philippines)
● Most frequently used
● Components:
○ Crystal violet and safranin O
(red)
● Commercially available:
○ Sedi stain
○ KOVA stain
● Delineates structure and contrasting
colors of the nucleus and cytoplasm
● Acidic - violet
10
Analysis of Urine and Other Body Fluids
Microscopic Examination
Prof: Jen Gaytano-Bautista
● Basic -
Lipid stain:
● Oil red O and Sudan III + polarizing
microscope
● Stain triglycerides and neutral fats
orange-red
● Do not stain cholesterol (capable of
polarization)
● Identify free fat droplets and lipid
containing cells and casts
Gram stain:
● Identification of bacterial casts (can be
confused from granular casts)
● Components: VIAS
○ Crystal violet (10 stain)
○ Iodine (mordant)
○ Alcohol (decolorizer)
○ Safranin (counterstain)
● Gram positive bacteria (purple/violet)
● Gram negative bacteria (e.coli) (red)
Hansel stain
● For detection of urinary eosinophil
○ Drug induced allergic reaction of
the renal interstitium
Components
● Methylene blue and eosinophil Y
Microscopy
● Bright-field microscopy
○ objects appear dark against a
light background
○ Frequently used in the clinical
lab
○ Used for routine urinalysis
● Phase contrast microscopy
○ Enhances the visualization of
elements with low refractive
index such as
■ Hyaline casts
■ Mixed cellular casts
■ Mucous threads
■ Trichomonas vaginalis
● Polarizing microscopy
○ Aids in identification of
cholesterol crystals in oval
bodies, fatty casts, and crystals
● Dark field microscopy
○ Identification of treponema
pallidum
● Fluorescence microscopy
○ Visualization of naturally
fluorescent microorganisms
○ Uses fluorescent dye
● Interference-contrast
○ Produces three-dimensional
microscopy image
○ 2-types
■ Hoffman
(modulation-contrast
microscopy)
■ Nomarski (differential
interference-contrast
microscopy)
11
Analysis of Urine and Other Body Fluids

Microscopic Examination
Prof: Jen Gaytano-Bautista

Sediment examination technique ● Hypersthenuric (concentrated)

● Cytodiagnostic urine testing ○ Shrinked due to loss of water,
○ For detection of malignancies of will appear irregularly shaped
the lower urinary tract (crenated)
○ Preparation of permanent slides ○ SG: >1.010
using cytocentrifugation ● Hyposthenuric (diluted)
followed by staining with ○ Lysed rbc due to absorbance of
papanicolaou stain water due to swelling of RBC
■ Pap’s stain component (ghost cell)
(HOE) ○ SG: <1.010
● OG6 (Orange ● Dysmorphic RBC
G6) ○ Cellular protrusions,
● EA50 (eosin fragmented)
azure 50) ■ Associated with
● Harris glomerular bleeding
hematoxylin ● Clinical significance
○ Associated with glomerular
Addis Count: membrane
● First procedure to standardize the ○ Vascular injury within the
quantitation of formed elements (1926) genitourinary tract
● Hemocytometer (to count the number of ○ Number of cells present can be
RBCs, WBCs, casts, epithelial cells in a an indication of the extent of
12-hour specimen the damage or injury
● Used to monitor the course of diagnosed ● Macroscopic hematuria
cases of renal disease ○ Cloudy with a red-brown color
○ Frequently associated with
Urinary sediments: advanced glomerular damage
● Originates throughout the urinary tract ○ Also seen with damage to the
○ glomerulus>urethra vascular integrity of the urinary
○ Can also come from tract caused by trauma, acute
contamination infection or inflammation, and
■ Menstruation coagulation disorders
■ Spermatozoa ● Microscopic hematuria
■ Fibers ○ Can be critical to the early
■ Starch granules diagnosis of glomerular
disorders and malignancy of the
urinary tract and to confirm the
presence of renal calculi
1. RBC 2. WBC (pus cells)
● Smooth, non-nucleated biconcave disc ● Pyuria
● 7mm ○ Increased in urinary WBC
● Must be identified using HPO (40 obj,
400 magni)

12
Analysis of Urine and Other Body Fluids
Microscopic Examination
Prof: Jen Gaytano-Bautista
○ Indicated the presence of
infection or inflammation in the
genitourinary system
● Neutrophil
○ Predominant
● Hypotonic
○ Absorbs water and swell)
○ Granules exhibit brownian
movement
■ Appears as glitter cells
● Lymphocytes
○ Seen in increased numbers in
the early stages of renal
transplant rejection
○ Resembles RBC
○ Smallest WBC
○ ○ Smaller than SEC
● Primary concern in identification of WBC
in urine:
○ Differentiation of mononuclear
cells and disintegrating
neutrophils from round renal
tubular epithelial cells (RTE)
■ Usually larger than WBC
● Supravital staining/addition of acetic
acid
○ Used to enhance nuclear detail
● Eosinophil
○ Drug-induced interstitial
nephritis
○ Hansel stain
○ Associated with UTI, renal
transplant rejection
○ More than 1% of eosinophil is
considered significant
3. Yeast
● Small refractile oval structures (may or
may not contain bud)
● Candida albicans
○ DM
○ Vaginal moniliasis
○ Immunocompromised individual
4. Mucus
● Uromodulin
○ Major constituent
● Threadlike structures (low refractive
index)
● Frequently seen in female patients
(normal)
5. Epithelial cells
● Squamous EC
○ normal , sloughing off
○ Largest cells found in urine
sediment
○ Point of reference
○ Represent normal cellular
sloughing and have no
pathologic significance
● Transitional cells (urothelial)
○ Can be spherical, polyhedral,
and caudate
○ Difference are caused by the
ability of the transitional EC to
absorb large amounts of water
○ Originates from the lining of the
renal pelvis, calyces, ureters,
bladder, and from the upper
portion of the male urethra
○ If seen in clumps, it is called as
syncytia
● Renal tubular epithelial cell
○ If they appear in group of 3 it is
called renal fragments
○ If seen in groups, it is called
renal fragments
○ PCT
■ Larger than RTE cells
■ Rectangular in shape
(columnar)
○ DCT
■ Can be mistaken as
WBC or spherical
transitional EC
■ Collecting duct
13
Analysis of Urine and Other Body Fluids
Microscopic Examination
Prof: Jen Gaytano-Bautista
● Appears as
cuboidal and
never round
● Oval fat bodies
○ Containing lipid RTE cells
● Bubble cells
○ RTE cells containing non-lipid
filled vacuoles (acute tubular
necrosis)
● Clue cells
○ Squamous EC covered with
gardnerella coccobacillus
(bacterial vaginosis)
● Clinical significance:
○ Transitional cells:
■ If seen in clumps, it is
called as syncytia, no
pathologic significance
■ If numbers increased
with an abnormal
morphology (irregular
nuclei, vacuole) it can
be an indication of
malignancy or viral
infection
○ RTE cells
■ If present in large
number or appears in
urine, it can be an
indication of tissue
destruction or necrosis
in tubules of the kidney
■ > 2 or more than 2
RTE/HPF (tubular
injury)
■ RTE W/ colored
cytoplasm (golden
brown or yellow) it a
sign that hemosiderin
granules is present
which is an indication of
destruction of rbc
6. Crystals
● Appearance
○ True geometrically structure or
amorphous materials
○ Factors that influence the
formation of crystals
■ Concentration of the
solute in the urine
■ Urine pH
■ Flow of urine through
the tubules
○ Crystal formation within the
nephrons can cause significant
tubular damage
● Uric acid:
○ pH: acid
○ Rhombic, four sided flat plates
wedges, rosettes
○ Highly birefringent
distinguishing feature from
cystine crystals
○ Significantly increased in gout,
lesch-nyhan syndrome
● Amorphous urates
○ Urine pH
■ Alkaline
○ Appearance:
■ Similar to amorphous
urates (distinguished by
urine pH)
○ Refrigeration
■ White sediment
○ Macroscopic appearance
■ White to beige
precipitate
● Calcium oxalate CaOx
○ Urine pH
■ Acid, neutral, alkaline
○ Dihydrate (most common form)
■ Colorless, octahedral
envelope or as two
14
Analysis of Urine and Other Body Fluids

Microscopic Examination
Prof: Jen Gaytano-Bautista

pyramids joined at their covered

base
○ Monohydrate
■ Oval or dumbbell
shaped (ethylene glycol
“antifreeze” poisoning)
○ Majority of renal calculi is
composed of CaOx
● Calcium phosphate
○ Urine pH
■ Alkaline
○ Appearance
■ Colorless
■ Flat rectangular plates
■ Thin prisms in rosette
form
○ Confused w/ sulfonamide
crystals (when urine pH is in
neutral range)
○ Distinguished by addition of
dilute acetic acid
■ Calcium phosphate
(dissolves)
■ Sulfonamide (does not
dissolve)
● Triple phosphate
○ Urine pH
■ Alkaline
■ Ammonium magnesium
phosphate
■ Prism shape resembles
coffin lid
■ Fern like form can be
induced by addition of
ammonia
● Ammonium biurate
○ Urine pH
■ Alkaline
■ Appearance:
● thorny apples
(spicules
spheres)
■ Dissolves at 60 degC
■ Convert into uric acid
crystals when glacial
acetic acid/conc hcl is
added
■ Most often encountered
in old specimen
● Calcium carbonate
○ Urine pH
■ Alkaline urine
○ Appearance
■ Small
■ Colorless
■ Dumbbell or spherical
shapes
○ Resemble amorphous material
■ Distinguished by acetic
acid, gas forms
● Cystine
○ Appearance
■ Colorless
■ Hexagonal plates (thick
or thin)
○ Distinguished from uric acid
crystals (highly birefringent)
○ Confirmation
■ Cyanide nitroprusside
test
○ Cystinuria
■ Metabolic disorder that
prevents reabsorption of
cysteine by renal
tubules
● Cholesterol crystals
○ Appearance
■ Rectangular plates with
notch on one or more
corners

15
Analysis of Urine and Other Body Fluids

Microscopic Examination
Prof: Jen Gaytano-Bautista

■Can be seen in ■ Yellow-brown spheres

nephrotic syndrome in (concentric circles with
conjunction fatty casts radial striations)
and oval fat bodies ○ Should be accompanied by
● Radiographic dye/radiographic tyrosine crystals
contrast media ○ Indication of liver disorder
○ Appearance: ● Tyrosine
■ Colorless flat plates ○ Appearance
■ Similar to cholesterol ■ Fine
■ Absence of notch at ■ Colorless to yellow
edges needles (in clumps or
○ SG rosettes)
■ Markedly elevated ○ Seen in conjunction with leucine
● Sulfonamides crystals & (+) chemical test for
○ Appearance bilirubin
■ Colorless to ○ Liver disorder
yellow-brown ● Bilirubin
■ Needles ○ Appearance
■ Rhomboids ■ Yellow
■ whetstones ■ Clump needles or
■ Sheaves of wheat granules
■ Rosettes ○ (+) bilirubin in urine
○ Distinguished from calcium ○ Liver disorder
phosphate
○ Does not dissolve upon addition
of dilute acetic acid
● Ampicillin
○ Appearance
■ Colorless needles
● Tend to form
bundles
following
refrigeration
○ Indication
■ Precipitation of
antibiotics following
massive dosage of this
penicillin compound
without adequate
hydration
7. Casts
● Leucine
● Only elements found in urine
○ Appearance
○ Unique to the kidney

16
Analysis of Urine and Other Body Fluids
Microscopic Examination
Prof: Jen Gaytano-Bautista
● Cylindruria
○ Presence of urinary casts
● The width of the cast depends on the
size of the tubule in which it is formed
○ DCT-CD (completely formed
cast)
● Core matrix
○ Uromodulin
○ Tamn horsfall
● Cylindroids
○ Incomplete cast formation
○ Cast disintegration (not totally
formed)
● Hyaline cast
○ Most frequently seen
○ 0-2/LPF
○ Normally increased in
strenuous exercise,
dehydration, heat exposure,
emotional stress
○ Pathologically increased in
acute glomerulonephritis,
pyelonephritis, chronic renal
disease, CHF
○ Colorless if unstained
○ SM stain, pink in color
● RBC casts
○ Blood cast/ muddy brown cast
○ Indication of bleeding within the
nephron
○ Glomerular
damage/glomerulonephritis
■ Associated with
proteinuria and
dysmorphic erythrocytes
○ Orange red - SM stain
● WBC cast
○ Leukocyte embedded in hyaline
cast matrix
○ Non-bacterial inflammation
■ Acute interstitial
nephritis
○ Bacterial inflammation
■ Pyelonephritis
○ Signifies infection or
inflammation within the nephron
○ Associated with pyelonephritis
and are a primary marker for
distinguishing pyelonephritis
(upper UTI) from cystitis (lower
UTI)
● Bacterial cast
○ Bacterial inflammation
■ Pyelonephritis
○ Bacterial casts containing bacilli
both within and bound to the
protein matrix are seen in
pyelonephritis
○ Pure bacterial cast are mixed
with WBCs
○ Resembles granular cast
○ Confirmation: gram stain
● Epithelial cell casts
○ Significant if cast containing RTE
cells
○ Indication: advance tubular
obstruction
● Fatty casts
○ Lipiduria
■ Fatty casts + oval fat
bodies + free fat
droplets
○ Frequently associated with
nephrotic syndrome
● Mixed cellular casts
○ Casts containing multiple cell
types
○ Glomerulonephritis
■ RBC + WBC casts and
or WBC + RTE cell casts
○ Pyelonephritis
■ WBC + bacterial cells
casts
○
● Granular casts
○ Result of cellular disintegration
17
Analysis of Urine and Other Body Fluids
Microscopic Examination
Prof: Jen Gaytano-Bautista
○Increased cellular metabolism
occurring during periods of
strenuous exercise accounts for
the transient increase of
granular casts that accompany
the increased hyaline casts
● Waxy casts
○ Appearance
■ Fragmented with jagged
ends and have notches
on sides
■ Indication: extreme
urine stasis (chronic
renal failure)
○ Represent as
■ Advanced stage of other
casts
● Hyaline,
granular,
cellular
■ Transformed during
urinary stasis
● Broad casts
○ Renal failure casts
○ Indication
■ Destruction “widening”
of the tubular walls
8. Artifacts
● Starch
○ Highly refractile sphere with
dimpled center
● Oil droplets
● Air bubbles
● Pollen grains
○ Appears as spheres with a cell
wall and occasional concentric
circles
● fibers/hair
○ May resemble casts but polarize
while casts do not
● Fecal contamination
○ Appear as plant and meat fibers
or as brown amorphous material
9. Parasite
● Trichomonas vaginalis
○ Most frequent parasite
encountered in urine
○ Sexually transmitted
○ Vaginal inflammation
○ Jerky motility
○ Might disintegrate if not
properly preserved
■ Might look like WBC
● Male
○ Present in urethra/prostate
■ Asymptomatic
● Schistosoma haematobium
○ Bladder parasite (ova)
○ Associated with bladder cancer
in other countries
● Enterobius vermicularis
○ Most common fecal
contamination
10. Spermatozoa
● Routine UA: do not report, unless asked
by the physician
○ For male: if there was recent
ejaculation
○ Retrograde ejaculation
■ Spermatozoa in bladder
instead in urethra,
might be an indication
of male infertility
11. Bacteria
● Not normally present in urine
● Cocci
○ Spherical shaped
● Bacilli
○ Rod-shaped
● Enterobacteriaceae
○ Gram-neg rods
○ Associated with UTI
○ E.coli
● Significant UTI:
○ Should be accompanied by WBC
● LE +
18
Analysis of Urine and Other Body Fluids

Microscopic Examination
Prof: Jen Gaytano-Bautista

○ WBC
● Nitrite
○ Bacteria producing nitrite

19
Analysis of Urine and Other Body Fluids
Other Body Fluids
Prof Jen Gaytano-Bautista
Renal Diseases
● Can be classified:
○ Glomerular (immune
mediated)
○ Tubular (due to
autoinfection/toxic substance)
○ Interstitial (due to
infection/toxic substance)
○ Vascular (renal perfusion)
Glomerular disorders
● Glomerulus has 8 capillary lobes
● Non-immunologic causes or
glomerular damage
○ Exposure to chemicals and
toxins
○ Disruption of electrical
membrane charges
(nephrotic syndrome)
○ Deposition of amyloid
material from systematic
disorders (chronic
inflammation/ acute-phase
reactants)
○ Thickening of basement
membrane (diabetic
nephropathy)
Glomerulonephritis
● Sterile inflammatory process
affecting glomerulus
● Associated with (in urine):
○ Blood
○ Protein
○ Casts
● There are types and some may
progress to another
○ Rapidly progressive
glomerular nephritis >
chronic glomerulonephritis >
nephrotic syndrome > renal
failure)
Acute Poststreptococcal Glomerulonephritis
(AGN)
● Sudden onset of symptoms with
damage in glomerular membrane
with edema
● Deposition of immune complex
● Occur in children and young adults
after respiratory infections
● Cause:
○ Group-A beta-hemolytic
streptococci with M protein
● Lab findings:
○ Macroscopic hematuria,
proteinuria, oliguria
(microscopic hematuria lasts
until membrane is repaired)
○ RBC casts, dysmorphic RBC,
hyaline & granular casts,
WBC’s
○ Blood Urea Nitrogen (BUN) -
high in acute stage
○ Detection of antistreptolysin
O > high ASO titer (blood) =
streptococcal origin
■ Non-streptococcal:
● Bacteria:
pneumococci
● Virus: mumps,
HBV
● Parasite:
malaria
Analysis of Urine and Other Body Fluids

Renal Disease
Prof Jen Gaytano-Bautista
Rapidly Progressive (Crescentic) ● Lab Findings:
○ Hematuria, proteinuria
Glomerulonephritis (RPGN)
○ RBC Casts
○ BUN
● Serious form of acute glomerular ○ High serum creatinine
disease ○ Serum + ethanol = perinuclear
● Poorer prognosis may result to renal pattern (p-ANCA)
○ Serum + formalin = granular in
failure
cytoplasm (c-ANCA)
● Cause: deposition of immune
complexes in the glomerulus
(immunoglobulins)
HENOCH-SCHONLEIN PURPURA
● Often a complication of another ● Occurs in children after viral upper
glomerulonephritis or immune system respiratory infections
disorder such as Systemic lupus ● Decrease in platelets disrupts vascular
erythematosus (SLE) integrity
● Lab Findings: ● Raised, red patches on skin (purpura) >
○ Macroscopic Hematuria, proteinuria blood in sputum & stool > renal involvement
○ RBC Casts ● Complete recovery is common but may result
○ Creatinine and eGFR to ESRD
● Lab Findings:
○ Macroscopic hematuria, proteinuria
GOODPASTURE SYNDROME
○ RBC Casts
● Morphological changes to the glomeruli
○ Stool Occult Blood
during viral respiratory infections
(glomerular/alveolar basement membrane)
- Petechiae = <3mm
● Resembles RPGN
- Purpura = 3mm-1cm
● Cytotoxic auto-antibody (anti-glomerular
- Ecchymosis = > 1cm
basement membrane antibody – AGBM)
attaches to the basement membrane >
capillary destruction
MEMBRANOUS GLOMERULONEPHRITIS
● Lab Findings: (MGN)
○ Microscopic hematuria ● “Membranous Glomerulosclerosis”
○ Proteinuria (similar to nephrotic ● Pronounced thickening of the glomerular
syndrome) basement membrane with systemic disorders
○ RBC casts ● Cause: Deposition of IgG immune
complexes
GRANULOMATOSIS WITH POLYANGIITIS ● May progress to nephrotic syndrome /
remission
(GPA)
● Associated with SLE, Sjogren syndrome,
● “Wegener granulomatosis”
secondary syphilis, HBV, gold and mercury
● Granuloma-producing inflammation of the
treatments & malignancy
small blood vessels in kidney and respiratory
● Lab Findings:
system
○ Microscopic Hematuria, proteinuri
● Antineutrophilic cytoplasmic antibody (ANCA)
○ Antinuclear antibody
in serum
○ HBV surface antigen
● ANCA binds to the neutrophils in vascular
○ FTA-ABS - Fluorescent treponemal
walls > immune response > granuloma
antibody-adsorption
formation
● Hemoptysis > renal involvement > end stage
renal failure

21
Analysis of Urine and Other Body Fluids

Renal Disease
Prof Jen Gaytano-Bautista
MEMBRANOPROLIFERATIVE ALPORT SYNDROME
GLOMERULONEPHRITIS (MPGN) ● Inherited disorder of collagen-production
● Marked by alterations in the cellularity of the affecting glomerular basement membrane
glomerulus and peripheral capillaries ● Lamellated appearance with thinning
● Thickening of glomerular membrane due to ● sex-linked/autosomal
leukocyte infiltration ● NS > ESRD
● Poor prognosis ● Lab Findings:
● Type 1 (HYPERCELLULARITY): Increased ○ Similar with NS
cellularity in the subendothelial cells of the ○ Genetic testing
mesangium (interstitial area of the Bowman’s ○ Microalbuminuria
capsule) > nephrotic syndrome
● Type 2 (HYPOCELLULARITY): dense NEPHROTIC SYNDROME (NS)
deposit disease; extremely dense deposits in ● Non-immunologic cause of glomerular
the glomerular basement membrane, damage
tubules, and Bowman’s capsule > chronic ● Due to exposure to chemicals and toxins
glomerulonephritis ● Acute onset after systemic shock > renal
● Type 3: combination of both subendothelial failure
and subepithelial deposits ● Symptoms:
● Lab Findings: ○ Massive proteinuria (3.5g/day;
○ Hematuria, proteinuria normal: 100mg/day)
○ Decreased serum complement (hypoproteinemia - plasma
levels albumin <3/dL)
CHRONIC GLOMERULONEPHRITIS (CGN) ○ High serum lipids
● Slow and silent onset (hyperlipidemia) and pronounced
● Gradual worsening of other glomerular edema
disorders ○ Increased permeability of the
● Decreased renal function > renal failure glomerular membrane
● 80% have previous glomerulonephritis; 20% ● Damage to the shield of negativity and
form unrecognized podocytes (produces a less tightly connected
● Lab Findings: barrier)
○ Hematuria, proteinuria, glucosuria ● Loss of plasma proteins (high-molecular
○ Cellular and granular casts weight), lipids, and negatively charged
○ Waxy and broad casts albumin
○ BUN, serum creatinine, eGFR, ● Lab Findings:
Electrolytes ○ Microscopic hematuria, Proteinuria
○ RTE cells
○ Oval Fat Bodies
IgA NEPHROPATHY
○ Fat Droplets
● “Berger Disease”
○ Fatty and Waxy Casts
● IgA deposits in glomerular membrane
○ Serum albumin, Cholesterol,
(mesangium)
Triglycerides
● Most common cause of glomerulonephritis
● Lab Findings:
○ Early Stage: Macro/recurrent micro MINIMAL CHANGE DISEASE (MCD)
hematuria (Serum IgA) ● Lipid Nephrosis/Nil Disease
○ Late Stage: Chronic ● Unknown etiology
Glomerulonephritis ● Associated with allergic reactions,
immunization, possession of human
leukocyte antigen B12 (HLA-B12)

22
Analysis of Urine and Other Body Fluids

Renal Disease
Prof Jen Gaytano-Bautista
● Disorder of T Cells; complete remission after ■ Antibiotics
corticosteroid treatment ■ Antifungal (amphotericin
● Lab Findings: B)
○ Proteinuria, Transient hematuria ■ Radiographic dye
○ Fat droplets ■ therapeutic/chemotherape
○ Serum albumin utic drugs
○ Cholesterol ■ Recreational drugs
○ Triglycerides ■ Industrial chemicals
● Lab Findings:
FOCAL SEGMENTAL ○ Microscopic hematuria, Proteinuria
○ RTE cells, RTE casts
GLOMERULOSCLEROSIS
○ Hyaline, granular, waxy and broad
● Affects only a number / area of the glomeruli
casts
while others are normal
○ Hemoglobin, hematocrit, cardiac
● One of the most common causes of primary
enzymes
glomerular disease in adults
● Resemble NS and MCD
● Disruption of podocytes with heroin and FANCONI SYNDROME
analgesics use and HIV and Hepatitis ● Inherited and associated with tubular
● Immune deposits of IgM and Complement 3 dysfunction on PCT
(C3) ● Associated with cystinosis and Hartnup
● Lab Findings: disease or toxic agents
○ Proteinuria, Micro/Macro hematuria ● Glucose, amino acids, phosphorous, sodium,
○ HIV tests water, bicarbonate and potassium are
affected (leakage)
● Lab Findings:
TUBULAR DISORDERS ○ Glucosuria
○ Cystine crystals
ACUTE TUBULAR NECROSIS (ATN) ○ Serum and urine electrolytes
● Damage to the RTE Cells ○ Amino acid chromatography
● May be ischemic (lack of oxygen >
decreased blood flow) > Hypotensive TUBULAR DYSFUNCTION (PCT DEFECT)
(decreased perfusion of kidneys) 1. Renal Glucosuria - inability to reabsorb glucose
○ Sepsis, shock, trauma 2. Cystinuria (Dibasic AA and Cystine) &
○ Anaphylaxis, hemorrhage Hartnup Disease (Monoamino acid &
● or presence of nephrotoxic agents Monocarboxylic AA) - inability to reabsorb
○ Endogenous (normal substances specific AA
but toxic in excess): 3. Bartter's Syndrome - inability to reabsorb
■ Hemoglobin > sodium
Hemoglobinuria > severe 4. Renal Tubular Acidosis Type II - inability to
hemolysis reabsorb bicarbonate (alkaline urine)
■ Myoglobin > 5. Idiopathic Hypercalciuria - inability to reabsorb
myoglobinuria > calcium
rhabdomyolysis 6. Hypocalciuric Familial Hypercalcemia -
■ Uric Acid excessive reabsorption of calcium
■ Immunoglobulin Light 7. Gordon Syndrome - excessive reabsorption of
Chain sodium
○ Exogenous (ingested/absorbed 8. Pseudohypoparathyroidism - excessive
substances): reabsorption of phosphate
■ Aminoglycoside 9. Fanconi Syndrome - Loss of PCT function

23
Analysis of Urine and Other Body Fluids

Renal Disease
Prof Jen Gaytano-Bautista
● Cause: Sex-linked recessive gene / acquired
TUBULAR DYSFUNCTION (DCT DEFECT) from medications with lithium and
1. Familial Hypophosphatemia (Vitamin D amphotericin B
Resistant Rickets) - inability to reabsorb ● Lab Findings:
phosphate ○ Low SG; Polyuria
2. Idiopathic Hypercalciuria - inability to reabsorb
calcium RENAL GLYCOSURIA
3. Renal Tubular Acidosis Type I and IV - ● Failure to reabsorb glucose
inability to acidify urine ● Cause: autosomal recessive trait; benign
4. Renal Salt Losing Disorder - inability to retain ● Renal Glucosuria - decrease of glucose
sodium transporters or affinity of glucose
5. Nephrotic Diabetes - inability to concentrate transporters
urine ● Maximal Tubular Reabsorption
6. Liddle’s Syndrome - Excessive reabsorption of Capacity for Glucose (TMg): 160-180
sodium mg/dL
7. Renal Phosphaturia - inability to reabsorb ● Lab Findings:
inorganic phosphates ○ Glucosuria
○ Blood glucose
UROMODULIN-ASSOCIATED KIDNEY
DISEASE INTERSTITIAL DISORDERS
● Uromodulin - only glycoprotein produced in (TUBULOINTERSTITIAL)
kidney (PCT, DCT)
● Decrease of normal uromodulin; Increased URINARY TRACT INFECTION
production of abnormal uromodulin ● LOWER UTI:
● Cause: autosomal mutation in the ○ Urethra (Urethritis)
uromodulin gene (UMOD) found in ○ Bladder (Cystitis)
Chromosome 16p11 ■ Painful urination (Dysuria)
● Lab Findings: ■ Burning
○ RTE Cells ■ Frequent urge to urinate
○ Serum Uric Acid ● UPPER UTI:
DIABETIC NEPHROPATHY ○ Renal Pelvis (Pyelitis)
● Most common cause of ESRD ○ Renal Pelvis + Interstitium
● Glomerular membrane thickening, increased (Pyelonephritis)
proliferation of mesangial cells, increased ● Most frequently encountered is Cystitis
deposition of cellular and noncellular which can progress to a serious upper UTI if
material in glomerular matrix > accumulation left untreated (ascending bacterial infection
of solid substances in capillaries of bladder)
● Associated with deposition of glycosylated ● Lab Findings:
proteins (HbA1c) from poorly controlling ○ Leukocyturia, Bacteriuria
blood glucose ○ Microscopic hematuria, Mild
● Lab Findings: proteinuria
○ Microalbuminuria ○ Alkaline pH; Urine culture

NEPHROGENIC DIABETES INSIPIDUS ACUTE PYELONEPHRITIS

● ADH action is disrupted in DCT and CD ● Infection of both tubules and interstitium
● Inability of renal tubules to respond to ADH and renal pelvis
(nephrogenic) or failure to produce ADH ● Ascending movement of bacteria from lower
(neurogenic) UTI to tubules and interstitium; interference

24
Analysis of Urine and Other Body Fluids

Renal Disease
Prof Jen Gaytano-Bautista
of urine flow to the bladder, urine reflux and RENAL FAILURE
untreated cystitis
● Hematogenous infection: bacteria
VASCULAR DISEASES
● Reduced perfusion/urine output due to
localizing in blood vessels of kidney
morphologic/functional changes in kidney
● Lab Findings:
vessels
○ Microscopic hematuria, proteinuria
● RAAS is affected
○ Leukocyturia, bacteriuria
○ WBC Casts, Bacterial Casts
○ Urine culture ACUTE RENAL FAILURE
● Clinically sudden:
○ Decrease in GFR (<25mL/min)
CHRONIC PYELONEPHRITIS
○ Azotemia (steady rising serum BUN
● Permanent damage to the renal tubules and
and creatinine)
possible progression to chronic renal failure
○ Oliguria (Urine Output: <400mL)
● Permanent scarring of renal tissue >
● Pre-Renal (20% of cases) - Nephron
permanent scarring of renal calyces and
damage
pelvis (structural abnormalities affecting flow
○ Decrease of renal blood flow
of urine)
○ Urine sodium concentration is low >
● Lab Findings:
increased sodium reabsorbed)
○ Leukocyturia, Bacteriuria
○ Cause: decreased blood
○ WBC Casts, Bacterial Cats
pressure/cardiac output,
○ Granular, waxy, broad casts
hemorrhage, burns, surgery,
○ Hematuria, proteinuria
septicemia
○ Urine culture, BUN, Creatinine,
● Renal (5% of cases)
eGFR
○ Glomerular, tubular, or vascular
disease
ACUTE INTERSTITIAL NEPHRITIS (AIN) ○ Increased urinary excretion of
● Most common Cause: acute sodium
allograft/rejection of transplanted kidney ○ Cause: AGN, ATN, Acute
● Allergic reaction/inflammation within renal pyelonephritis, AIN
interstitium due to medications ● Post Renal (10% of cases)
● Renal dysfunction with skin rashes; resolves ○ Urine flow obstruction
after termination of medication and ○ Cause: renal calculi, tumor
treatment with corticosteroids
CHRONIC ACUTE RENAL FAILURE
● Lab Findings:
● Progressive loss of renal function
○ Leukocyturia, WBC Casts
● Cause: irreversible and intrinsic renal
○ Hematuria, proteinuria
disease
○ Eosinophils, BUN, Creatinine, eGFR
● Decreasing GFR (slow and continuous)
● “End Stage Renal Disease/End Stage Kidneys
YEAST INFECTION - CRF that progresses to advanced renal
● Cause: Candida albicans (normal flora of GI disease
Tract) ● Lab Findings:
● Proliferation due to changes in pH, adversely ○ Leukocyturia, Bacteriuria
disrupted by antibiotics
● Lab Findings:
RENAL LITHIASIS
○ Leukocyturia, WGC Casts
● Renal calculi - renal calyx, pelvis, bladder,
ureter

25
Analysis of Urine and Other Body Fluids
Renal Disease
Prof Jen Gaytano-Bautista
● Mainly composed of Calcium (oxalate,
phosphate, etc), Triple phosphate, uric acid,
cystine
● Lithotripsy - use high-energy shock waves
to break stones located in the upper urinary
tract into pieces to be passed in the urine.
Stones can also be removed surgically
● Large Staghorn Calculi
○ Resemble shape of renal pelvis with
smooth, round bladder stones with
diabetes of 2 or more inches
● Small Calculi
○ May be passed in urine
METABOLIC DISORDERS
QUALITATIVE TESTS: SCREENING OF
METABOLIC DISORDERS
● Ferric Chloride Test
○ Alkaptonuria (Homogentisic acid)
○ Maple Syrup Urine Disease
○ Melanoma (Melanin)
○ Phenylketonuria (PKU)
● Ammoniacal Silver Nitrite
○ Alkaptonuria
● Benedict’s Test
○ Alkaptonuria (Homogentisic Acid)
● Nitrosonaphthol Test
○ Tyrosinemia
● Hoesch Test
○ Porphyria (Porphobiinogen)
● Watson-Schwartz Test
○ Porphyria (Porphobilinogen)
NEWBORN SCREENING ACT (RA 9288)
● Must be done after 24 hours of life but not
more than 3 days
● Screens for 6 metabolic disorders (PH
Set-up)
○ Congenital Hypothyroidism
○ Congenital Adrenal Hyperplasia
○ Phenylketonuria
○ Maple Syrup Urine Disease
○ Galactosemia
○ Glucose-6-phosphate
dehydrogenase
AMINO ACID DISORDERS
● Liver and Kidney are actively involved in AA
metabolism
● Transamination: Interconversion of AA
● Deamination: Degradation of AA
● AA > formation of ammonium ions > Urea
formation > urea eliminated from the body
AMINOACIDURIA
● Overflow Aminoaciduria
○ Cause: increase in AA plasma
levels
○ Renal threshold for AA reabsorption
exceeded > additional AA excreted
in urine
● No-Threshold Aminoaciduria
○ AA not reabsorbed by the tubules
○ Increase in blood = Increase in
Urine
● Renal Aminoaciduria
○ Normal AA plasma levels
○ Cause: defect in tubules
(congenital/acquired) > not
reabsorbed by the tubules =
increased amount in urine
PRIMARY AMINOACIDURIA
● “Inborn errors of metabolism”
● Inherited defect
● Types of Defect
○ Defective Enzyme (Deficient) in
specific AA metabolic pathway
○ Tubular Reabsorptive Dysfunction
CYSTINURIA
● Autosomal Recessive
● Cause: Nephrons (PCT) = inability to
reabsorb cystine. Dibasic AA (arginine,
lysine, ornithine
● Inherited defect
CYSTINOSIS
● Autosomal recessive
● Lysosomal Stage disease > deposition of
cystine in lysosomes of cells throughout the
body (kidneys, eyes, bone marrow, spleen)
● Types of Cystinosis
○ Nephropathic
26
Analysis of Urine and Other Body Fluids

Renal Disease
Prof Jen Gaytano-Bautista
■ Most common and severe ● Cause: tyrosine levels in plasma is
■ Cystine crystallizes in PCT abnormally high
> generalized tubular
dysfunction > fanconi MELANURIA
syndrome ● Melanin - color of eyes, hair, skin
■ Evident in first year of life ● Hypomelanosis/Albinism - defective
○ Intermediate melanin production
■ Rare ● Increased excretion of melanin = increased
■ Same with nephropathic production of melanin and its colorless
■ Evident in adolescence precursors (melanogen)
■ If left untreated >
permanent kidney failure
DIABETES MELLITUS
○ Ocular
● Polyuria; High SG
■ Rare
● Presence of glucose in urine
■ Cystine deposition in
● Mellitus: Sweet
cornea > ocular
impairment (photophobia)
> loss of vision
DIABETES INSIPIDUS
● Polyuria; Low SG
● ADH; issue in water retention
MAPLE SYRUP URINE DISEASE (MSUD)
● Insipidus: Bland
● Autosomal recessive
● Accumulation of branched chain AA (leucine,
isoleucine, valine) and their alpha-keto acids
GALACTOSEMIA
in blood, urine and CSF ● Enzymes:
● Deficient Enzyme: Branched chain a-Keto ○ Galactose 1-phosphate uridyl
Acid Dehydrogenase (BCKD) transferase (GALT)
○ Galactokinase (GALK)
○ Uridine dipho
PHENYLKETONURIA
● Autosomal recessive
● Increased excretion of phenylpyruvic acid
(ketone) nd its metabolites
● Deficient Enzyme: Phenylalanine
Dehydrogenase
● Mousy/Musty Odor of urine, sweat and
breath caused by Phenylacetic acid

ALKAPTONURIA
● Autosomal recessive
● Excretion of large amount of homogentisic
acid (HGA)
● Unusual darkening of urine when alkali is
added
● Deficient Enzyme: Homogentisic acid
oxidase

TYROSINEMIA
● Increased amount of tyrosine in urine

27
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

brain to the abdomen (peritoneum)

Cerebrospinal fluid (CSF) or heart (atrium)
● V-P SHUNT
● 3RD major body fluid
○ ventricular -peritoneal shunt
● 1st recognized by Catugno in 1764
(abdomen)
● NOT an ultrafiltrate of plasma
● V-A SHUNT
Functions: ○ Ventricular-atrial shunt (heart)
● Supply nutrient to nervous tissue
Formation and physiology
● Remove metabolic wastes
● Meninges
● Cushion the brain and spinal cord against
○ Lines the brain and the spinal cord
trauma
● 3 layers
CSF volume ○ Dura mater (closer to skull and
● Adults: 140-170 ml bone, outermost layer)
● Neonates: 10-60 ml ○ Arachnoid (middle layer, web-like
Ventricular shunt: structure)
● Purpose: ■ Subarachnoid space (CSF
○ reduce the amount of CSF in the flow) Pia mater (innermost
brain by draining it to the abdomen layer)
or directly into the chambers of the Choroid plexus
heart ● Capillary that forms the CSF
● Shunting of CSF ● blood-brain barrier (BBB): light fitting
○ Helps reduce the pressure on the endothelial cells
brain ● produces : 20 ml/hr of fluid

CSF collection
Procedure:
● Lumbar tap/ lumbar puncture
○ 3rd, 4th, & 5th lumbar vertebrae
● Before aspirating:
○ Opening pressure is measured first
● Ideally:
○ Tests are performed on STAT
(shorter around time) basis
○ Test should be performed
immediately after collection
○
CSF collection tubes
● 3 sterile tubes
○ Numbered in order they are
withdrawn
○ IF POSSIBLE: 4th tube may be
withdrawn for microbiology section
● SHUNT:
○ Hollow plastic tube that is placed in
the ventricle of the brain
○ Tube is attached to the valve and is ● Room temperature for test tube 2&4: 20-24
threaded under the skin from the DegC
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

○ Adult:
Appearance ■ 0-5 cells/uL
● Crystal clear: normal ■ Predominant cells:
● Cloudy, milky, turbid: protein, lipid, WBC LYMPHOCYTES
● Bloody: intracranial hemorrhage, traumatic ○ Neonates:
tap ■ 0-30 cells/uL
● XANTHOCHROMIC (pink, orange, yellow) : ■ Predominant: MONOCYTES
hemoglobin, bilirubin, carotene, inc. protein, Methods:
melanin ● Manual: neubauer counting chamber
● Clotted: clotting factors induced by traumatic ● Automated: automated cell counters
tap QC:
● Pellicle: tubercular meningitis, seen after ● Results of manual count should agree with
overnight of refrigeration (on the top part of the automated count by +- 25%
the fluid)
● Oily: radiographic contrast media Calculation of CSF cells counts
● Follows the standard calculation formula
used for blood cell counts
● Counting of cells: 4 larger corner square and
large center square
Volume:
● Area x depth (const. 0.1mm)
Calculation of CSF cells counts

Traumatic tap:
● Uneven distribution of blood
● Clot formation
● Supernatant: NOT Xanthochromic

Intracranial hemorrhage Total cell count

● Even distribution of blood RBC COUNT: SIGNIFICANT
● No clot formation ● Traumatic tap has occurred
● Supernatant: Xanthochromic ● Noted for correction of WBC count and CSF
○ Additional: protein results
■ Erythrophagocytosis Clear specimens may be counted undiluted
(microscopic) ● NSS (normal saline soln): used as diluent
■ (+) D-Dimer ● Should use calibrated, automatic pipettes
● Cells may be counted in 4 corner squares
and the center squares
Must LYSE RBC prior to WBC count
● 3% glacial acetic acid: diluent
● May add methylene blue to the diluting fluid
● If dilution is not necessary: rinse pipette with
Pleocytosis the diluting fluid prior to aspiration
● Elevated number of cells in CSF Corrections for contamination
● Normal values:

29
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

● Calculations made to correct for WBCs ● Bands are located in the GAMMA region of
introduced in the CSF because of traumatic the protein electrophoresis
tap

Correct WBC count = actual WBC count - WBC added

If the peripheral WBC and RBC: normal

● Subtract 1 WBC for every 700 RBCs present
in the CSF
● Example:
○ 1,400 RBC/uL and 100 WBC/uL =
98 WBC/uL Interpretation:
Oligoclonal bands in CSF only
CSF electrophoresis ● Many sclerosis
● Primary purpose: ● Other: neurologic disorder, encephalitis,
○ Detection of OLIGOCLONAL bands neurosyphilis, guillain-barre syndrome
● Can determine if a fluid is indeed CSF
Procedure:
● Protein separated through electrophoresis
● Cellulose acetate strips with anti-serum is
placed over
● Wash
● Strips are stained

Most common method:

● Agarose gel electrophoresis
● Coomassie brilliant blue staining

Oligoclonal bands in the CSF and serum

● HIV infection
Oligoclonal bands in serum only
● Leukemia, lymphoma, viral infections
● May produce CSF banding because of BBB
leakage or blood contamination during
lumbar tap

Oligoclonal bands
● Indicates immunoglobulin production

30
Analysis of Urine and Other Body Fluids
Other Body Fluids
Prof Jen Gaytano-Bautista
Myelin basic protein
● Indicates recent destruction of the myelin
sheath that protects the axon of the neurons
(demyelination)
● Measurement can be used to monitor the
course of multiple sclerosis
○ Theorized that the inflammatory
response in MS is triggered by
molecular mimicry
Myelin basic protein
● EBV, measles, HSV, VZV, Rubella influenza C,
HHV-6
● It may also provide a valuable measure of
the effectiveness of current & future
treatments
CSF glucose
● Value: 60-70% of plasma glucose
● Example:
○ Plasma glucose: 100 mg/dL
○ CSF Glucose: 65 mg/dL
● Blood glucose should be drawn 2 hours prior
to lumbar tap (CSF)
● Clinical significance: can be used to
determine the cause of meningitis
● Increased levels: result of plasma elevations
● Decreased levels: caused by alteration in
transport in BBB and increased used by brain
cells
LACTATE
(low oxygen concentration in a certain part of the
brain)
● Destruction of tissue within the CNS due to
hypoxia (dec. oxygen level or concentration)
causes the production of increased CSF
lactate
● Aid in the diagnosis and management of
meningitis cases
○ Elevation is consistent with:
bacterial, tubercular, and fungal
meningitis
○ Level declines rapidly when
treatment is successful
● Used to monitor severe head injuries
● Falsely elevated: obtained from
xanthochromic or hemolyzed samples
CSF glutamine
● Preferred over direct measurement of CSF
ammonia
○ Ammonia is volatile
● Normal values: 8-18 mg/dL
○ Elevated levels: associated with
liver disorder that result in
increased blood and CSF ammonia
● Glutamine produced from ammonia and
a-ketoglutarate by the brain cells
○ This process serves to remove
ammonia from the CNS
○ Ammonia is toxic to CNS tissue
31
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

○ Glutamine is an indirect test for the

presence of excess ammonia in CSF
● Frequently requested procedure for patients
with coma of unknown origin
○ Increased in approximately 75% of
children with REYE SYNDROME /
CRYPTOCOCCUS NEOFORMANS
REYE’S SYNDROME
● Cryptococcal meningitis
MICROBIOLOGY TEST ○ One of the frequently occurring
● Identification of causative agent in
complications of AIDS
meningitis
● Laboratory findings
● Microorganism must be recovered by
○ India ink: thick encapsulated
growing it on the appropriate culture
organism
medium
○ Gram stain: starburst pattern
○ 24 hrs in cases of bacterial
■ May be seen more often
meningitis
than a positive india ink
○ 3 wks for tubercular meningitis
○ Associated with increased
● Specimen concentration: CSF centrifuged at
eosinophils
1500 g for 15 minutes: sediment used for
slides and culture

CSF CULTURE
● Confirmatory rather than diagnostic
procedure
● Microbiology laboratory test for a preliminary
diagnosis
○ Gram stain
○ Acid fast stain
○ India ink preparation
○ Latex agglutination test

Limulus lysate test

● Diagnosis of meningitis caused by gram (-)
GRAM STAIN bacteria
● Routinely performed on CSF from all ○ Limulus amebocyte reacts with
suspected cases of meningitis bacterial endotoxin of gram (-)
● Value lies in the detection of bacterial and bacteria
fungal organism ● Reagent:
● Use of cytocentrifuge: provides highly ○ Blood cells of horseshoe crab
concentrated specimens (limulus polyphemus)
● Result:
○ Coagulation within 1 hr of
incubation at 37DegC

32
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

Rapid test: ○ Neutrophils <30%

● Detection of bacterial antigen 2. Autoimmune disorders
1. Latex agglutination ● inflammatory /immunologic
2. ELISA method ● Cloudy, yellow, poor viscosity
3. Bacterial antigen test ● WBCs 200-75,000/mL
○ Neutrophils >50%
Serologic testing:
3. Gout, pseudogout
● Performed to detect the presence of
● Clear or milky, low viscosity
Neurosyphilis
● WBCs up to 100,000/mL
● Venereal disease research laboratories
○ Neutrophils <75%
(VDRL)
○ Procedure recommended by CDC to
4. Septic
diagnose neurosyphilis (CAUSATIVE
● Infection
AGENT: TREPONEMA PALLIDUM)
● Cloudy, yellow-green, low viscosity
● Fluorescent treponemal antibody-absorption
● WBCs 50,000-100,000/mL
(FTA-ABS) test
○ Neutrophils >75%
○ More sensitive than VRDL
○ Prevent contamination with blood
5. Hemorrhagic
because FTA-ABS remains positive
● Trauma, coagulation disorders
in the serum of treated cases of
● Cloudy, red, low viscosity
syphilis
● WBCs and neutrophils equal to blood values

Synovial fluid
● Located in the cavities between the movable
joints
● Synoviocytes
○ Secretes hyaluronic acid which is a
large molecule that produces the
viscosity of the fluid
● Damage to the joints produces arthritis
Color
● Normal: colorless to pale yellow

Classification of arthritis
1. Osteoarthritis
● Non-inflammatory
● Clear, yellow, good viscosity
● WBCs <1000/mL

33
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

Viscosity test vertical to the slow

● The ropes or mucin clot test detects and vibration
measures hyaluronic acid ■ Elevated serum uric acid
● Normal: 4-6m levels aid in the
● Addition of acetic acid to normal synovial identification
fluid will form a firm mucin clot surrounded
by clear liquid
○ Clots and becomes less firm as the
viscosity decreases
● Addition of acetic acid to a questionable fluid
identifies it as synovial fluid

○ Calcium pyrophosphate dihydrate

seen in pseudogout
■ rhombic , often seen
intracellularly in neutrophil
vacuoles (phagocytized
monosodium urate crystals
puncture the cell
membrane)
■ Blue when aligned with the
slow vibration and
Cell count compensated polarized
light and yellow when
● Do not use normal WBC diluting fluid (acetic
vertical to the slow
acid), use normal saline (NSS)
vibration
● Normal WBC count is less than 200 cells/mL
Differential cell counts
● Incubate fluid with hyaluronidase
(papalbnawin) before slide preparation
● Primary cells are monocytes and
macrophages, followed by neutrophils at less
than 25% and lymphocytes at less than 15%
and occasional synoviocytes
Crystal identification
● Primary crystals:
○ Monosodium urate seen in gout
■ Needle-shaped, strongly
birefringent under ● Identify using polarized and compensated
polarized light polarized light
■ Yellow when aligned with Microbiology
the slow vibration of ● Gram stains and cultures are routinely run
compensated polarized on synovial fluid specimens
light and blue when

34
Analysis of Urine and Other Body Fluids
Other Body Fluids
Prof Jen Gaytano-Bautista
● Cultures require enriched agar (chocolate)
for detection of possible Haemophilus sp.
And Neisseria gonorrhea
Serous fluid
Physiology:
● Serous fluid is located between the parietal
and visceral membranes that line the closed
body cavities
○ Mesothelial cells line the membrane
● Cavities:
○ Pleural, pericardial, and peritoneal
● Serous fluid is normally produced and
reabsorbed at a constant rate: disruption of
this process produces an effusion
Transudates and exudates
● TRANSUDATES: (elevated)
○ Effusion by systematic disorders
● EXUDATES: (decreased)
○ Effusion caused by membrane
disorders
Pleural fluid
● Collected by thoracentesis
Appearance:
● Milky:
○ Thoracic duct leakage (chylous
effusion), chronic effusion
(pseudochylous effusion)
● Bloody:
○ Hemothorax, hemorrhagic effusion
(embolus, tuberculosis, malignancy)
● Viscous:
○ Malignant mesothelioma producing
hyaluronic acid
Differential count:
● Neutrophils: pneumonia, pancreatitis
● Lymphocytes: tuberculosis, viral infections
● Eosinophils: pneumothorax
● Mesothelial cells: normal, decreased with
tuberculosis
● Plasma cells: tuberculosis
● Malignant cells: small cell and
adenocarcinoma, metastatic carcinoma cells
Chemistry test
● pH less than 7.0 indicates the need of tube
drainage
● pH less than 6.0 indicates esophageal
rupture
● Pleural fluid cholesterol: equal to or less than
45-60 mg/dL (transudate), higher (exudate)
Microbiology:
● Acid-fast stains
○ Detection of acid fast
■ MTB
Pericardial fluid:
● Collected by pericardiocentesis
Appearance:
● Cloudy, blood-streaked: infection,
malignancy
● Grossly bloody: cardiac puncture,
anticoagulant medications
Hematology
● Increased neutrophils are seen in bacterial
endocarditis
● Refer metastatic malignant cells for cytologic
examination
Microbiology
● Gram stains and cultures are performed on
concentrated specimens
● Acid fast stains for tuberculosis are
associated with acquired immunodeficiency
syndrome
Peritoneal fluid
● Collected by paracentesis
● Often called ascitic fluid, effusion is ascites
● Effusion are caused by liver disorders
(cirrhosis), intestinal infection (peritonitis),
and malignancy
Transudates and exudates
● The serum-ascites albumin gradient is the
recommended method for differentiation
● Measure serum and ascites albumin levels
● Serum albumin - fluid albumin = 1.1 or
higher is a transudate
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Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

● Serum albumin - fluid albumin 1.1 or lower is ● Stabilize the temperature to protect the fetus
an exudate from extreme temperature changes
Appearance ● Permits proper lung development
● Turbid: infection
● Green: gallbladder or pancreas disorder
● Blood-streaked: trauma, infection,
malignancy
● Milky: lymphatic trauma or blockage
Hematology
● Normal WBC count: less than 350/mL
● Absolute neutrophil count distinguishes
between cirrhosis and peritonitis
● More than 250 neutrophils/mL or 50% of the
differential indicates peritonitis
(inflammatory response)
Differential count
● Additional cells seen include abundant
mesothelial cells, lipophages, yeast, Volume:
Toxoplasma gondii, and malignant colon,
● AF volume is regulated by a balance
prostate, and ovarian cells
between:
○ Production of fetal urine and lung
Chemistry fluid
● Glucose: decreased in infection and ○ Absorption from fetal swallowing
malignancy and intramembranous flow
● Amylase: elevated in pancreatitis and ○ 3rd trimester: approx. 800-1200 mL
gastrointestinal (GI) perforations (gradually decrease prior to
● Alkaline and phosphatase: elevated in delivery)
intestinal perforation
● BUN and creatinine: bladder rupture or
puncture
● Tumor markers: carcinoembryonic antigen
and CA125
Microbiology
● Gram stains and cultures for aerobic and
anaerobic organisms
● Blood cultures aid in the detection of
anaerobic organisms
Polyhydramnios
Amniotic fluid ● Amniotic fluid >1200 mL
● Amnion ○ Due to: failure of the fetal lung to
○ Membranous sac that surrounds the begin swallowing
fetus ○ Secondary associated with: fetal
Primary function of amniotic fluid structural anomalies, cardiac
● Provide protective cushion for the fetus arrhythmias, congenital infections,
● Allow fetal movement chromosomal abnormalities

36
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

Oligohydramnios ○ Allow to completely dry at room

● Amniotic fluid <800mL temp
○ Due to: elevated fetal lung ○ Observed microscopically
swallowing urinary tract deformities ○ + screen for amniotic fluid:
membrane leakage presence of “fern-like” crystals due
to protein and sodium chloride

Collection of amniotic fluid

● Collected through amniocentesis
○ AF is obtained by needle aspiration
Composition of amniotic fluid into the amniotic sac (ultrasound
1st trimester guided)
● Volume approx. 35mL ○ Maximum of 30mL collected in the
● Composition similar to maternal plasma sterile syringe
● Contains small amount of sloughed fetal cells ○ 1st 2-3 ml collected is discarded
○ Basis for cytogenetic analysis ○ Safe if performed after 14th week
3rd trimester gestation
● Volume reaches a peak of 1L - gradually ■ Chromosome analysis:
decreases prior to delivery ● Fluid collected at
16th week
Major volume contributor in fetal urine gestation
● Elevated creatinine, urea, uric acid ■ Fetal distress and maturity
● >2 mg/dL creatinine=fetus >36 weeks test:
● AF creatinine does not exceed 3.5 mg/dL ● Performed later in
and urea 30 mg/dL the 3rd trimester
○ Decreased glucose and protein Procedures:
1. Transabdominal amniocentesis
● Most frequently used
2. Vaginal amniocentesis
● Great risk of infection
Fern test
● Used to evaluate premature rupture of the
membranes
○ Vaginal fluid specimen is spread on
the glass slide

37
Analysis of Urine and Other Body Fluids
Other Body Fluids
Prof Jen Gaytano-Bautista
Specimen handling and storage:
● Bilirubin testing
○ For detection of hemolytic disorder
of newborn
○ Protected from light
○ Place in amber colored tubes or
black plastic cover for container
● Fluid for chemical testing
○ Separated from cellular element
and debris
Cytogenetic studies
● Stored at RT or body temperature (37DegC)
FLM (fetal lung maturity)
● Low speed centrifugation not >5 minutes
● Filtration recommended prior to testing
● Delivered in ICE
● Refrigerated prior to testing (testes within 72
hrs)
Color and appearance
Normal AF:
● Colorless
● Transparency: slight to moderate turbidity
(from cellular debris, particularly in later
stages of fetal development)
Tests for fetal distress
Hemolytic disease of the newborn (HDN)
● Evaluates the presence of bilirubin
● Oldest routinely performed laboratory test on
amniotic fluid evaluates the severity of the
fetal anemia produced by HDN
Rh-negative mother - Rh-positive newborn
● Initial exposure to foreign red cell antigen
occurs during:
○ Stimulates the mother to produce
antibodies against the antigen
● Gestation
● Delivery of the placenta
● Previous pregnancy (when fetal RBCs enter
the maternal circulation)
● Presence of (red blood cell degradation
product): unconjugated bilirubin (amniotic
fluid) → due to destruction of fetal red blood
cells
● Due to destruction of fetal red blood cells
Neural tube defects (NTD)
● Most common birth defects in the US
● Can be detected by: maternal serum
alpha-fetoprotein (MSAFP), high resolution
ultrasound and amniocentesis
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Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

● Elevated AFP (both maternal circulation and
AF): indicative of NTD (e.g Anencephaly and
spina bifida)
AFP: major protein produced by the fetal liver during
early gestation (prior to 18 weeks)
● Sphingomyelin: lipid that is produced at a
constant rate after about 26th week of
gestation

Amniotic acetylcholinesterase (AChE) – more specific ● Falsely elevated L/S ratio: AF contaminated
than AFP with blood of meconium
● Not to be performed in bloody specimen → Phosphatidyl glycerol
blood contains AChE ● Lung surface lipid
Respiratory distress syndrome (RDS) ● Can be detected after 35 weeks’ gestation
● Most frequent complication of early delivery ● Production of PG
● 7th most common cause of morbidity and normally–parallel–with–lecithin
mortality in premature infant ○ Production is delayed: in cases of
● Cause by insufficiency of lung surfactant maternal diabetes
production and structural immaturity of the Foam stability index
fetal lungs ● Foam or shake test
Surfactant ● Mechanical screening test
● Normally appears in mature lungs and allows ● Measure the individual lung surface lipid
the alveoli (air sacs of the lung) to remain concentrations
open throughout the normal cycle of Procedure:
inhalation and exhalation 1. Amniotic fluid + 95% ethanol
● Keeps the alveoli from collapsing by 2. Shakr for 15 secs
decreasing surface tension and allows them 3. Allowed to sit undisturbed for 15 mins
to inflate with air more easily 4. Surface of the fluid is observed for: presence
● Decrease surfactant: collapsed alveoli = RDS of continuous line of bubbles around the
outside edge
● Presence of the bubbles: indicates a
sufficient amount of phospholipids
● Falsely mature index result: AF contaminated
with blood or meconium

Lecithin-sphingomyelin ratio
● L/S ratio: reference method for FLM
● Lecithin: primary component of the of the
surfactants (phospholipids, neutral lipids,
and proteins)
○ Produced at a relatively low and
constant rate until the 35th week of
gestation
`lamellar bodies

39
Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

● Densely packed layers of phospholipids that ● Classification can be based on four factors:
represent a storage form of pulmonary illness duration, mechanism, severity, and
surfactant stool characteristics
● Secreted by the type II pneumocytes of the
fetal lung at about 24 weeks of gestation
● Absorbed into the alveolar spaces to provide
surfactant

Major mechanisms of diarrhea

1. Secretory
● Increased secretion of water
○ bacterial , viral, and protozoan
infection produce increased
secretion of water and electrolytes,
which override the absorptive ability
of the large intestine, leading to
secretory diarrhea
● Enters the AF at about 26th week gestation
○ Other causes of secretory diarrhea
● Increase in concentration from
are: drug, stimulant laxatives,
50,000-200,000/mL by the end of the 3rd
hormones, inflammatory bowel
trimester
disease (Crohn disease, ulcerative
● Fetal lung mature = increased lamellar body
colitis, lymphocytic colitis,
production=increased amniotic fluid
diverticulitis), endocrine disorders
phospholipids and L/S ratio
(hyperthyroidism, zollinger-ellison
syndrome, VIPoma), neoplasms,
Fecal analysis and collagen vascular disease
● Fecal specimen analysis fits into the category
of a “necessary evil”
● Normal fecal specimen contains bacteria,
cellulose, undigested foodstuffs, GI
secretions, bile pigments, cells from the
intestinal walls, electrolytes, and water
● Approx. 100-200 g of feces is excreted in a
24 hour period
● Bacterial metabolism produces the strong
odor associated with feces intestinal gas
(flatus)
Diarrhea 2. Osmotic
● Increase in daily stool weight above 200 g, ● Caused by poor absorption that exerts
increased liquidity of stools, and frequency osmotic pressure across the intestinal
of more than 3x per day mucosa

40
Analysis of Urine and Other Body Fluids
Other Body Fluids
Prof Jen Gaytano-Bautista
● Maldigestion (impaired food digestion) and
malabsorption (impaired absorption by the
intestine) contribute to osmotic diarrhea
3. Altered motility
● Describes conditions of enhanced motility
(hypermotility) or slow motility (constipation)
● Seen in Irritable Bowel Syndrome (IBS)
INTESTINAL HYPERMOTILITY
● Excessive movement of intestinal contents
through the GI tract that can cause diarrhea
Rapid gastric emptying (RGE) dumping
syndrome
● Hypermotility of the stomach and shortened
gastric emptying half-time, which causes the
small intestine to fill too quickly with
undigested food from the stomach. It is the
hallmark of early dumping syndrome (ESD)
Steatorrhea (fecal fat)
● Useful in diagnosing pancreatic insufficiency
and small-bowel disorders that cause
malabsorption
● Absence of bile salts that assist pancreatic
lipase in the breakdown and subsequent
reabsorption of dietary fat (primarily
triglycerides) produces an increase in stool
fat (steatorrhea) that exceeds 6g per day
D-xylose test
● Used to distinguish maldigestion and
malabsorption
○ If urine D-xylose test is low, the
resulting steatorrhea indicates an
malabsorption condition
○ Normal d-xylose: indicates
pancreatitis
Macroscopic screening
1. Color
● Brown color of the feces results from
intestinal oxidation of stercobilinogen to
urobilin
● Pale (acidic) stools signify blockage of bile
duct
● black , tarry stools: upper GI bleeding
● Red stools: lower GI bleeding, medications,
foods (beets)
● Green stools: oral antibiotics, green
vegetables or food coloring
2. Appearance
● bulky/frothy
○ Bile duct obstruction, pancreatic
disorder
● Ribbon-like
○ Intestinal constriction
● Mucus or blood streak
○ Dysentery, malignancy, constipation
Microscopic screening
1. Fecal leukocytes
● Primarily neutrophils, are seen in
the feces in conditions that affect
the intestinal mucosa, such as
ulcerative colitis and bacterial
dysentery
● Present if bacterial pathogens
causes diarrhea: salmonella,
shigella, campylobacter, yersinia,
and enteroinvasive E.coli
● Fecal neutrophils is absent in if
caused by bacterial producing toxin
such as staphylococcus aureus and
vibrio spp., viruses and parasites
2. Muscle fibers
● Helpful in diagnosing and monitoring
patients with pancreatic insufficiency such as
cases of cystic fibrosis
● Increased amounts of striated fibers may
also be seen in biliary obstruction and
gastrocolic fistulas
3. Qualitative fecal fats
● Screened for presence of excess fecal fats
(steatorrhea)
● Monitor patients undergoing treatment so
malabsorption disorders
Chemical testing for feces
1. Occult blood (hidden blood) detection
● Fecal occult blood testing (FOBT)
○ Done if no visible signs of bleeding
is present
● Guaiac based fecal occult blood (gFOBT)
○ Based on detecting the
pseudoperoxidase activity of
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Analysis of Urine and Other Body Fluids

Other Body Fluids

Prof Jen Gaytano-Bautista

hemoglobin resulting in lactose intolerance. m

● Immunochemical fecal occult blood test
(iFOBT)
○ Specific for the globin portion of of
human hemoglobin and uses
polyclonal anti-human hemoglobin
antibodies
● porphyrin -based fecal occult blood test
○ Offers a porphyrin-based FOBT
fluorometric test for hemoglobin
based on the conversion of heme to
fluorescent porphyrins. The test
measures both intact hemoglobin
that has been converted to
porphyrins
Quantitative testing for feces
● Confirmatory test for steatorrhea
○ Requires collection of timed 3 day
specimen
○ Maintain fat diet of 100 g/day
APT test (fetal hemoglobin)
● Grossly bloody stools and vomitus are
sometimes seen in neonates as the result of
swallowing maternal blood during delivery
● Necessary to distinguish between the
presence of fetal blood or maternal blood in
an infant’s stool or vomitus
Fecal enzymes
1. Fecal chymotrypsin
● Is more resistant to intestinal degradation
and is a more sensitive indicator of less
severe cases of pancreatic insufficiency
2. Elastase I
● Is an isoenzyme of the enzyme elastase and
is the enzyme form produced by the
pancreas. Specific in differentiating
pancreatic from non pancreatic causes in
patients with steatorrhea
3. Carbohydrates
● Presence of increased carbohydrates in the
stool produces osmotic diarrhea from the
osmotic pressure of the unabsorbed sugar in
the intestine drawing in fluid and electrolytes
● Carbohydrates in feces may be present as a
result of intestinal inability to reabsorb
carbohydrates, as is seen in celiac disease,
or lack of digestive enzymes such as lactase

42