TOXICOLOGY HAND OUTS – 6 INSTRUCTOR: RALPH EPHRAIM PALABRICA

URINE

Analyzing urine was actually the beginning of laboratory

medicine. References to the study of urine can be found in the drawings
of cavemen and in Egyptian hieroglyphics, such as the Edwin Smith
Surgical Papyrus. Pictures of early physicians commonly showed them
examining a bladder-shaped flask of urine. Often these physicians
never saw the patient, only the patient’s urine. Although these
physicians lacked the sophisticated testing mechanisms now available,
they were able to obtain diagnostic information from such basic
observations as color, turbidity, odor, volume, viscosity, and even
sweetness (by noting that certain specimens attracted ants or tasted
sweet). These same urine characteristics are still reported by laboratory
personnel. However, modern urinalysis has expanded beyond physical
examination of urine to include chemical analysis and microscopic
examination of urinary sediment. Many well-known names in the history
of medicine are associated with the study of urine, including
Hippocrates, who, in the 5th century BCE, wrote a book on “uroscopy.”

During the Middle Ages, physicians concentrated their efforts

very intensively on the art of uroscopy, receiving instruction in urine
examination as part of their training. By 1140 CE, color charts had been
developed that described the significance of 20 different colors.
Chemical testing progressed from “ant testing” and “taste testing” for
glucose to Frederik Dekkers’ discovery in 1694 of albuminuria by
boiling urine.

The invention of the microscope in the 17th century led to the examination of urinary sediment and to the
development by Thomas Addis of methods for quantitating the microscopic sediment. Richard Bright introduced
the concept of urinalysis as part of a doctor’s routine patient examination in 1827. By the 1930s, however, the
number and complexity of the tests performed in a urinalysis had reached a point of impracticality, and urinalysis
began to disappear from routine examinations. Fortunately, development of modern testing techniques rescued
routine urinalysis, which has remained an integral part of the patient examination.

Two unique characteristics of a urine specimen account for this continued popularity:

1. Urine is a readily available and easily collected specimen.

2. Urine contains information, which can be obtained by inexpensive laboratory tests, about many of the
body’s major metabolic functions.

Urine Formation:

The kidneys continuously form urine as an ultrafiltrate of plasma. Reabsorption of water and filtered
substances essential to body function converts approximately 170,000 mL of filtered plasma to the average daily
urine output of 1200 mL.

Urine Composition:

In general, urine consists of urea and other organic and inorganic chemicals dissolved in water. Urine is
normally 95% water and 5% solutes, although considerable variations in the concentrations of these solutes can
occur owing to the influence of factors such as dietary intake, physical activity, body metabolism, and endocrine
functions.
 Urea, a metabolic waste product produced in the liver from
the breakdown of protein and amino acids, accounts for nearly
half of the total dissolved solids in urine. Other organic sub-
stances include primarily creatinine and uric acid. The major
inorganic solid dissolved in urine is chloride, followed by
sodium and potassium. Small or trace amounts of many
additional inorganic chemicals are also present in urine.
Dietary intake greatly influences the concentrations of these
inorganic compounds, making it difficult to establish normal
levels.

Other substances found in urine include hormones,

vitamins, and medications. Although not a part of the original
plasma filtrate, the urine also may contain formed elements,
such as cells, casts, crystals, mucus, and bacteria. Increased
amounts of these formed elements are often indicative of
disease.

Urine Volume:

Urine volume depends on the amount of water that the kidneys excrete. Water is a major body constituent;
therefore, the amount excreted is usually determined by the body’s state of hydration. Factors that influence
urine volume include fluid intake, fluid loss from non-renal sources, variations in the secretion of antidiuretic
hormone, and need to excrete increased amounts of dissolved solids, such as glucose or salts. Taking these
factors into consideration, although the normal daily urine output is usually 1200 to 1500 mL, a range of 600 to
2000 mL is considered normal.

Oliguria, a decrease in urine output (which is less than 1 mL/kg/hr in infants, less than 0.5 mL/kg/hr in
children, and less than 400 mL/day in adults), is commonly seen when the body enters a state of dehydration as
a result of excessive water loss from vomiting, diarrhea, perspiration, or severe burns.

Anuria, cessation of urine flow, may result from any serious damage to the kidneys or from a decrease in
the flow of blood to the kidneys.

An increase in the nocturnal excretion of urine is termed nocturia.

Polyuria, an increase in daily urine volume (greater than 2.5 L/day in adults and 2.5 to 3 mL/kg/day in
children), is often associated with diabetes mellitus and diabetes insipidus; however, it may be artificially induced
by diuretics, caffeine, or alcohol, all of which suppress the secretion of antidiuretic hormone. Diabetes mellitus
and diabetes insipidus produce polyuria for different reasons, and analysis of the urine is an important step in
the differential diagnosis.

Specimen Collection:

Urine is a biohazardous substance that requires the observance of Standard Precautions. Gloves should be
worn at all times when in contact with the specimen.

Specimens must be collected in clean, dry, leak-proof containers. Disposable containers should be used
because they eliminate the chance of contamination owing to improper washing. These disposable containers
are available in a variety of sizes and shapes, including bags with adhesive for the collection of pediatric
specimens and large containers for 24-hour specimens. Properly applied screw-top lids are less likely to leak
than are snap-on lids.
 All specimens must be labeled properly with the patient’s name and identification number, the date and time
of collection, and additional information such as the patient’s age and location and the healthcare provider’s
name, as required by institutional protocol. Labels must be attached to the container, not to the lid, and should
not become detached if the container is refrigerated or frozen.

The most routinely used method of preservation is refrigeration at 2°C to 8°C, which decreases bacterial
growth and metabolism. If the urine is to be cultured, it should be refrigerated during transit and kept refrigerated
until cultured up to 24 hours. The specimen must return to room temperature before chemical testing by reagent
strips.
Drug Specimen Collection:

Urine specimen collection is the most vulnerable part of a drug-testing program. Correct collection
procedures and documentation are necessary to ensure that the results are those of the specific individual
submitting the specimen. The chain of custody (COC) is the process that provides this documentation of proper
sample identification from the time of collection to the receipt of laboratory results. The COC is standardized
form that must document and accompany every step of drug testing, from collector to courier to laboratory to
medical review officer to employer.
For urine specimens to withstand legal scrutiny, it is necessary to prove that no tampering of the
specimen occurred, such as substitution, adulteration, or dilution. All personnel handling the specimen must be
noted. The specimen must be handled securely, with a guarantee that no unauthorized access to the specimen
was possible. Proper identification of the individual whose information is indicated on the label is required. Either
photo identification or positive identification by an employer representative with photo ID is acceptable.
Urine specimen collections may be “witnessed” or “unwitnessed.” The decision to obtain a witnessed
collection is indicated when it is suspected that the donor may alter or substitute the specimen or it is the policy
of the client ordering the test. If a witnessed specimen collection is ordered, a same-gender collector will observe
the collection of 30 to 45 mL of urine. Witnessed and unwitnessed collections should be immediately handed to
the collector.
The urine temperature must be taken within 4 minutes from the time of collection to confirm the
specimen has not been adulterated. The temperature should read within the range of 32.5°C to 37.7°C. If the
specimen temperature is not within range, the temperature should be recorded and the supervisor or employer
contacted immediately. Urine temperatures outside of the recommended range may indicate specimen
contamination. Recollection of a second specimen as soon as possible will be necessary. The urine color is also
inspected to identify any signs of contaminants. The specimen is labeled, packaged, and transported following
laboratory-specific instructions.
 The physical examination of urine includes the determination of the urine color, clarity, and specific
gravity. Early physicians based many medical decisions on the color and clarity of urine. Today, observation of
these characteristics provides preliminary information concerning disorders such as glomerular bleeding, liver
disease, inborn errors of metabolism, and urinary tract infection. Measurement of specific gravity aids in the
evaluation of renal tubular function. The results of the physical portion of the urinalysis also can be used to
confirm or to explain findings in the chemical and microscopic areas of urinalysis.
The color of urine varies from
almost colorless to black. These
variations may be due to normal
metabolic functions, physical activity,
ingested materials, or pathologic
conditions. A noticeable change in urine
color is often the reason that a patient
seeks medical advice; it then becomes
the responsibility of the laboratory to
determine whether this color change is
normal or pathologic. The more common
normal and pathologic correlations of
urine colors.
Terminology used to describe the color
of normal urine may differ slightly among
laboratories but should be consistent
within each laboratory. Common
descriptions include pale yellow, yellow,
and dark yellow. Care should be taken to
examine the specimen under a good
light source, looking down through the
container against a white background.
The yellow color of urine is caused by
the presence of a pigment, which
Thudichum named urochrome in 1864.
Urochrome is a product of endogenous
metabolism, and under normal
conditions the body produces it at a
constant rate. The actual amount of
urochrome produced is dependent on
the body’s metabolic state, with
increased amounts produced in thyroid
conditions and fasting states.
Urochrome also increases in urine that
stands at room temperature.
Clarity of Urine:
Freshly voided normal urine is usually clear, particularly if it
is a midstream clean-catch specimen. Precipitation of
amorphous phosphates and carbonates may cause a white
cloudiness. Freshly voided normal urine is usually clear,
particularly if it is a midstream clean-catch specimen.
Precipitation of amorphous phosphates and carbonates may
cause a white cloudiness.
Odor of Urine:
Freshly voided urine has a faint aromatic odor.
As the specimen stands, the odor of ammonia becomes
more prominent. The breakdown of urea is responsible
for the characteristic ammonia odor. Causes of unusual
odors include bacterial infections, which cause a strong,
unpleasant odor similar to ammonia, and diabetic
ketones, which produce a sweet or fruity odor. A serious
metabolic defect results in urine with a strong odor of
maple syrup and is appropriately called maple syrup
urine disease. This and other metabolic disorders with
characteristic urine odors. Ingestion of certain foods,
including onions, garlic, and asparagus, can cause an
unusual or pungent urine odor. Studies have shown that
although everyone who eats asparagus produces an
odor, only certain genetically predisposed people can
smell the odor.
Chemical Analysis of Urine using Reagent Strips:
Routine chemical examination of urine has changed
dramatically since the early days of urine testing, due to the
development of the reagent strip method for chemical analysis.
Reagent strips currently provide a simple, rapid means for performing
medically significant chemical analysis of urine, including pH, protein,
glucose, ketones, blood, bilirubin, urobilinogen, nitrite, leukocytes,
and specific gravity. The two major types of reagent strips are
manufactured under the trade names Multistix (Siemens Healthcare
Diagnostics, Deerfield, IN) and Chemstrip (Roche Diagnostics,
Indianapolis, IN). These products are available with single-or multiple
testing areas, and the brand and number of tests used are a matter of
laboratory preference. Certain variations relating to chemical
reactions, sensitivity, specificity, and interfering substances occur
among the products and are discussed in the following sections.
Reagent strip brands are also specified by instrumentation
manufacturers.

Microscopic Analysis of Urine:

The purpose of Microscopic Analysis of the urine is
to detect and to identify insoluble materials present in the
urine. The blood, kidney, lower genitourinary tract, and
external contamination all contribute formed elements to the
urine. These include red blood cells (RBCs), white blood cells
(WBCs), epithelial cells, casts, bacteria, yeast, parasites,
mucus, spermatozoa, crystals, and artifacts. Because some
of these components are of no clinical significance and others
are considered normal unless they are present in increased
amounts, examination of the urinary sediment must include
both identification and quantitation of the elements present.
Specimen Preparation:
Specimens should be examined while fresh or adequately preserved. Formed elements—primarily
RBCs, WBCs, and hyaline casts disintegrate rapidly, particularly in dilute alkaline urine. Refrigeration may cause
precipitation of amorphous urates and phosphates and other non-pathologic crystals that can obscure other
elements in the urine sediment. Warming the specimen to 37°C prior to centrifuging may dissolve some of these
crystals. The midstream clean-catch specimen minimizes external contamination of the sediment. As with the
physical and chemical analyses, dilute random specimens may cause false-negative readings. Care must be
taken to thoroughly mix the specimen prior to decanting a portion into a centrifuge tube.
A standard amount of urine that is needed for all tests usually between 10 and 15 mL and is centrifuged
in a conical tube. This provides an adequate volume from which to obtain a representative sample of the
elements present in the specimen. A 12-mL volume is frequently used because multiparameter reagent strips
are easily immersed in this volume, and capped centrifuge tubes are often calibrated to this volume.
Centrifuge:
The speed of the centrifuge and the length of time the specimen is centrifuged should be consistent.
Centrifugation for 5 minutes at a relative centrifugal force (RCF) of 400 produces an optimum amount of sediment
with the least chance of damaging the elements. To correct for differences in the diameter of centrifuge heads,
RCF rather than revolutions per minute (RPM) is used. The RPM value shown on the centrifuge tachometer can
be converted to RCF using nomograms available in many laboratory manuals or by using the formula:
RCF = 1.118 × 10–5 × radius in centimeters × RPM2
Centrifugation calibration should be routinely performed.Use of the braking mechanism to slow the
centrifuge causes disruption of the sediment prior to decantation and should not be used. To prevent
biohazardous aerosols, all specimens must be centrifuged in capped tubes.

Red Blood Cells (RBC) Neisseria Gonorrhoeae White Blood Cells (WBC)

Yeast Trichomonas Vaginalis Parasite Bacteria