URINALYSIS Microscopic structure of kidneys:

➢ Renal Anatomy & Physiology NEPHRONS

➢ Introduction to Urinalysis
✓ functional units of kidney, approximately 1-1.5
➢ Physical Examination of Urine
million in number
➢ Chemical Examination of Urine
✓ a million of these things.
➢ Microscopic Examination of Urine
✓ The functional unit of the kidney, and its goal is to
➢ Urine Screening for Metabolic Disorders
process waste products from the blood to create
➢ Renal Disease
urine.
✓ Glomerulus
o Specialized mass of capillaries, surrounded by
ANATOMY AND PHYSIOLOGY
the Bowman’s capsule. Main function is for
filtration of blood. Blood pressure forces fluid
from the blood in the glomerulus into the
Bowman’s capsule, once the fluid in the
Bowman’s capsule which is called the filtrate:
o Water
o Glucose
o Amino acids
o Salts
o Hydrogen ions
o Bicarbonate Ions
o Medications & Vitamins
o Urea – nitrogenous wastes produced by
the liver that the body needs to get rid of
o The bowman’s capsule is a double walled and its
purpose is to collect the filtrate.
o The nephron is going to take the filtrate through
the ride of its life while it processes it. The
Kidneys:
filtrate is reabsorbed, meaning some of the
✓ Two bean shaped organs, located at retroperitoneally filtrate will cross the barrier of the nephron back
(at the back o behind the parietal peritoneum) into the fluid surrounding the nephron (Also
✓ The right side of the kidney is slightly lower than the called the interstitial fluid) and eventually,
left due to the size of the liver circulate again through the body
✓ Each kidney measures 10-12 cm in length, 5-7cm in ✓ Proximal Convoluted Tubule
width and 3cm in thickness. o Located in the cortex. Main function is for
o Kidney’s venous drainage – connected to reabsorption of necessary nutrients. It is the
inferior vena cava tubule nearest the glomerulus, salt and water are
inferior
o Renal vein – directly connected to superior reabsorbed and going to the interstitial fluid by
vena cava either active or passive transport. Other
o Blood supply – abdominal aorta which has a substances like, glucose, amino acids, potassium,
direct connection to the kidneys via renal and bicarbonate are also reabsorbed. While,
artery. Hydrogen ions, and Ammonium ions will be
o Aorta – gives the nutrients of the oxygen secreted.
o Superior vena cava – to drain ✓ Loop of Henle – extends going to medulla, and its
✓ If the blood is from the heart it will go to abdominal purpose is for concentration of urine
aorta, then, renal artery, and eventually enters the o Descending limb (going down) – has
kidneys. aquaporins, permeable to water (lumalabas na
✓ Once the oxygen and necessary nutrients are water)
obtained, the blood will go back to the heart, (it go to o Ascending limb (going up) – no aquaporins
the renal vein, eventually in inferior vena cava, to go impermeable to water (ang lumalabas ay
back to the heart) analytes)
Components of Nephrons: Eventually, everything will converge to the renal pelvis
until they meet to the ureter.
✓ Glomerulus
✓ Tubules The blood which consists of plasma, will be filtered by
the kidneys, that is why it is called glomerular filtrate,
TWO Types of Nephrons
since it is still in the tubules. But, when the filtered part
1. Cortical is already passed the collecting duct you may call it
2. Juxtamedullary urine, then it will flow from the renal pelvis to the
ureter, until it will go to the urinary bladder, then,
urethra, then it will be excreted to the body.
CORTICAL:

Location: Cortex
RENAL FUNCTIONS
Functions: Removal of waste products Reabsorption of
➢ Renal Blood Flow
nutrients
➢ Glomerular Filtration
➢ Tubular Reabsorption
MEDULLA: ➢ Tubular secretion

Location: Medulla

Functions: Concentration of urine

Blood from the heart will flow to the kidneys,

specifically in the glomerulus so it will be filtered. Then,
the filtered nutrients should be reabsorbed such as amino
acids, glucose, sodium, potassium, and water. However,
when the substances did not filter but they are
metabolizing and it needs to secrete, it will undergo to
tubular secretion. Aside from solute, we also reabsorbed
water especially if it is osmotic particle like sodium.

RENAL BLOOD FLOW

➢ RENAL ARTERY - blood supply (supplies oxygenated

blood to the kidney from the abdominal aorta) to the kidney
o Afferent arteriole - it delivers blood in the
glomerulus.
The Renal Cortex is where the nephrons begin. Each
o Efferent arteriole - take blood out of your
kidney has 1 million nephrons. The filtering unit of the
glomerulus
nephron is the glomerulus, and it is attached to a tubule
➢ 25% of cardiac output is received by the kidney
(proximal and distal convoluted tubules), which removes
➢ 1200mL - total renal blood flow
waste and returns the needed substances to your body.
➢ 600-700 mL/min: total renal plasma flow
The minor calyx surrounds the renal papillae of each ➢ Peritubular capillaries – surrounded the tubules of
pyramid which is serves as the converging point for nephrons so the reabsorption and secretion can occur.
collecting ducts responsible for transporting urine from ➢ Vasa recta – also surrounds the loop Henle, important in
the nephrons. When the two or more minor calyces concentrating urine, eventually it will become a renal vein
converge it will form a major calyx. From the major that connected to inferior vena cava that is connected to
calyces, the urine flows into the renal pelvis, that act as a heart.
funnel for urine flowing to the ureter.

The Renal Medulla is the innermost part of the kidney,

it is a huge factory that processes the body’s liquid
wastes with small units called renal pyramid. It has
Loops of Henle and collecting duct, renal pyramid helps
with blood filtration and water concentration regulation
within your kidneys.
GLOMERULAR FILTRATION o In Angiotensin II, it will cause vasoconstriction
meaning, causing an increase resistance, to
➢ The blood enters the glomerulus under high pressure,
increase the blood pressure
so the plasma, water, and small solute they will pass
o In Angiotensin II, promotes proximal convoluted
to the semi permeable membrane barrier to the
tubule sodium reabsorption which helps in
bowman’s capsule also called glomerular filtrate.
increasing the water reabsorption as well.
➢ GFR – is the volume filtrate form per minute by all
o In Angiotensin II, it stimulates adrenal cortex that
the nephrons in the kidneys. Normal GFR:
secrete aldosterone hormone, that also promotes
120mL/min
distal convoluted tubule sodium reabsorption
➢ GLOMERULUS- contains app. 8 capillary lobes
which helps in increasing the water reabsorption
with walls referred to as the glomerular filtration
o In Angiotensin II, stimulate the posterior pituitary
barrier
gland to release vasopressin or antidiuretic
➢ Location: within the Bowman’s Capsule (beginning
hormone (ADH) which helps in conserving water
of the renal tubule)
or water reabsorption in collecting duct that helps
➢ Function: non-selective filter of plasma substances
in increasing water so it will be back to normal.
with molecular weight less than 70,000
TUBULAR REABSORPTION:

➢ Basic Principles: Importance substance where

GLOMERULAR FILTRATION
essential nutrients must go back to the blood, from
THREE Glomerular Filtration Barrier cellular layers: the tubule back to the blood – reabsorption.
➢ Mechanisms: ACTIVE (utilizes energy/ATP) and
➢ Capillary wall membrane- (+) fenestrated (butas
PASSIVE (does not utilizes energy/ATP)
butas) endothelial cells
➢ Active Substances and Location:
➢ Basement membrane (basal lamina)
o Glucose, Amino Acids, Salts - PCT
➢ Visceral epithelium of Bowman’s capsule
o Chloride – Ascending loop of Henle
SHIELD OF NEGATIVITY repels molecules with a o Sodium – PCT and DCT
positive charge even though they are small enough to ➢ Passive Substances and Location
pass through the three layers of the barrier. o Water – PCT, Descending loop of Henle,
Collecting Duct
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
o Urea – PCT, Ascending loop of Henle
(RAAS)

➢ Responds to changes in blood pressure and plasma ➢ Maximal Reabsorptive Capacity of the Tubules (Tm)
sodium content that are monitored or controlled by o There’s a limit and already reached the urine
the juxtaglomerular apparatus (composed of ➢ Renal Threshold- plasma concentration at which
juxtaglomerular cells in the afferent arteriole and active transport STOPS
macula densa of the distal convoluted tubule) o 160-180 mg/dL renal threshold for glucose
➢ Activation of RAAS: o When the threshold succeeded expect that the
o The glomerular filtrate can measure the sodium substance will excrete out to the urine.
content, if it’s low, there’s a possibility that the
water is also decreased, as well as the blood ➢ COUNTERCURRENT MECHANISM - selective
pressure and plasma sodium. reabsorption process which serves to maintain the
o In this case, the secretion of renin will be osmotic gradient of the medulla
activated, and it will be converted into ➢ Final concentration of the filtrate through the
Angiotensin I which is the inactivated enzyme, reabsorption of water- begins in the LATE DISTAL
and in order for it to be activated, it will go to CONVULUTED TUBULE and continues in the
lung tissues to look for Angiotensin Converting COLLECTING DUCT.
Enzymes (ACE), then it will now become ➢ Reabsorption depends on:
Angiotensin II which is the powerful substance o Osmotic gradient in the medulla
since it will create many actions. o Hormone VASOPRESSIN/ADH
▪ Arterial Blood Pressure = Cardiac ➢ STATE OF BODY HYDRATION - determines
Output x Total Peripheral Resistance production of ADH
▪ Cardiac output = Venous return o Increase of body hydration = Decrease ADH =
▪ Increase Blood volume = Increase Increase of Urine Volume
Venous return o Decrease of body hydration =Increase ADH =
▪ Increase Sodium Reabsorption = Decrease of Urine Volume
Increasae H2O reabsorption
TUBULAR SECRETION: D. Filtration, secretion – Substance D: there are substances that are
filtered out and secreted in the urine.
➢ From the blood back to tubules, usually it happens to
substances that has a firm hold to proteins, because it
will not easily filter by the glomerulus, usually it
stays in the blood, but along the way, those
substances will eventually decrease there affinity to
proteins and will be attracted to tubular cells, so it
will go back to tubules and finally will be flow to the
urine.
TWO Major functions

➢ Eliminate waste products NOT filtered by the

glomerulus
➢ Regulate the acid-base balance in the body through
the secretion of hydrogen ions

PROXIMAL CONVOLUTED TUBULE- major site for

removal of nonfiltered substances (drug
Renal Function Test:
products/metabolites that has a carrier protein) CLEARANCE TEST
Factors to consider in selecting clearance test substance:
DISRUPTION: RENAL TUBULAR ACIDOSIS • Substance analyzed must be neither reabsorbed nor secreted by
the tubules
➢ Inability to produce an ACID urine
• Stability of substance in urine during a possible 24-hour
➢ Hydrogen ions are NOT excreted in the urine collection period (stable and not degraded concentration)
• Plasma level consistency (not fluctuating)
SUMMARY OF RENAL FUNCTION: • Substance availability to the body (endogenous)
• Availability of the tests to analyze substance
INULIN CLEARANCE
• ORIGINAL reference method
• GOLD STANDARD (from the book)
• INULIN: Polymer of fructose, extremely stable, not reabsorbed
or secreted by the tubules
• DISADVANTAGE: EXOGENOUS substance must be infused
by IV at a constant rate throughout the testing. (Not used test
today)
CREATININE CLEARANCE
• CREATININE: waste product of muscle metabolism,
produced enzymatically by creatine phosphokinase from
HORMONAL REGULATION OF KIDNEY creatine, which links with ATP to produce ADP and energy
FUNCTION: (endogenous)
• Some creatinine is secreted by the tubules, and secretion
➢ RAAS – important to regulate the kidney function increases as blood level rise
and blood pressure, release in response to low blood • It must be corrected for Body surface area unless normal is
volume assumed, and must always be corrected for children.
• Newer methods: developed using just the serum creatinine,
➢ ADH – important for water regulation
cystatin C, or beta2-microglobulin values
➢ Atrial Natriuretic Peptide (ANP) – release from the • Calculated glomerular filtration estimate using formula
atria of the heart, release in response to high blood developed by COCKGROFT & GAULT
volume, purpose is to reduce sodium reabsorption
and lower the blood pressure
➢ EPO – produce by the kidney especially in low • NOTE: Multiply result by 0.85 if patient is FEMALE
oxygen level, in respond to hypoxia.

BASIC KIDNEY PROCESSES THAT DETERMINE

COMPOSITION OF URINE:

Renal blood flow:

➢ The glomerular filtration will happen

➢ From the tubules, the substance will be back to the
peritubular capillaries or blood – known as
reabsorption
➢ However, if the substance which are metabolites that
needs to excrete out in the kidney, from the tubular
to peritubular capillaries back to the tubules – known
as secretion
➢ Lastly, you will have the Urinary excretion
Calculating the GFR INTRODUCTION TO URINALYSIS
• V = urine volume [mL/min] (calculated by dividing the number HISTORY
of milliliters in the specimen by the number of minutes used to SCIENTIST CONTRIBUTION/DISCOVERY
collect the specimen) Hippocrates Uroscopy
• U = urine creatinine concentration (mg/dL) Frederick Dekkers Albuminuria by boiling urine
• P = plasma creatinine concentration (mg/dL) Thomas Bryant Published a book about “pisse
prophets”/ charlatans
Thomas Addis Methods for quantitating urine
sediment
• Normal creatinine clearance values: approach 120 mL/min (mas Richard Bright Introduced concept of urinalysis
mataas muscle mass ng men compared with women kaya as part of a doctor’s routine
mataas yung values compared to women) patient examination
• Men: 107 to 139 mL/min William Wollaston Cysteine calculi
Ludwig Thudichum Urochrome (giving urine yellow
• Women: 87 to 107 mL/min
color)
• 0.5 to 1.5 mg/dL – normal reference range of plasma creatinine Archibald Garrod Alkaptonuria
• To adjust a clearance for body size, use this equation Ivan Folling Phenylketonuria
Domenico Cotugno Cerebrospinal Fluid (CSF)
URINE FORMATION
• ultrafiltrate of plasma
• With A being the actual body size in square meters of surface.
• Average daily urine output: 1200 mL
The actual body size may be calculated as: log A = (0.425 x log
URINE COMPOSITION
weight) + (0.725 x height) – 2.144
ESTIMATED GLOMERULAR FILATRATION RATES • General: UREA + other organic & inorganic chemicals
dissolved in water
• Used for routinely screening patients as part of a metabolic
• Normally: 95% Water, 5% Solutes
profile and also to monitor patients already diagnosed with renal
disease or at risk for renal disease • Factors affecting concentration of solutes: dietary intake,
physical activity, body metabolism, and endocrine functions
• Original MDRD Calculation: formula for MDRD calculation of
PRIMARY COMPONENTS IN NORMAL URINE
GFR when the serum creatinine method is not standardized to
IDMS. COMPONENT DESCRIPTION/ OTHER INFO
UREA Primary organic component
• GFR = 173 x serum creatinine ^ -1.354 x age ^ -0.209 x
Product of protein and amino acid
0.742 (if px is female) x 1.212 (if px is black)
metabolism
• The MDRD-IDMS traceable formula is: CREATININE Product of creatine metabolism by
• GFR = 175 x serum creatinine ^-1154 x age ^-0.203 x 0.742 muscle
(if px is female) x 1.202 (if px is black) URIC ACID Product of nucleic acid breakdown in
TUBULAR REABSORPTION TEST food and cells
• FREE WATER CLEARANCE- determined by first CHLORIDE Primary inorganic component. Found in
calculating the osmolar clearance using the standard clearance combination with sodium & many other
formula, then subtracting the osmolar clearance value from the inorganic substances
urine volume mL/min SODIUM Primary from salt, varied by intake
POTASSIUM Combined with chloride & other salts
PHOSPHATE Combines w/ sodium to buffer the blood
AMMONIUM Regulates blood and tissue fluid acidity
CALCIUM Combined with chloride, sulfate and
• Example: using a urine osmolality of 600mOsm (U), a urine phosphate
volume of 2 mL/min (V), and a plasma osmolality of 300 mOsm URINE VOLUME
(P), calculate the free water clearance • Normal daily urine output: 600 – 2000 mL
• OLIGURIA – decrease in urine output
• <1 mL/kg/hr – infants
• <0.5 mL/kg/hr – children
• <400 mL/day – adults
TUBULAR SECRETION & RBF TEST
• NOCTURIA – excretion of more than 500mL of urine at night
• PARA-AMINOHIPPURIC ACID (PAH) TEST with a specific gravity of less than 1.018
• Principle: same as in the clearance test for glomerular filtration • ANURIA – complete absence/severely reduced urine output
• Actual measurement renal plasma flow is rather than renal <100 mL/24hrs (Graff)
blood flow, because the PAH is contained only in the plasma • POLYURIA – increase in daily urine volume
portion of blood • >2.5 L/day - adults
• The standard clearance formula can be used to calculate the • 2.5 to 3 mL/kg/day - children
effective renal plasma flow
• Often associated with diabetes mellitus and diabetes insipidus
(pathologic condition) (DM: problem w/ glucose; insulin fails
to breakdown glucose resulting to glucose pulling more water)
(DI: problem w/ antidiuretic hormone/ ADH not recognized by
receptor, resulting into not conserving water)
Test Yourself!!!
• Artificially induced by diuretics, caffeine, or alcohol (ALL
1. The kidney receives 25% of the cardiac output
suppress ADH secretion)
2. Renal blood flow: 1200 mL/min
3. Renal Threshold of Glucose: 160 to 180 mg/dL
4. Only electrolyte that can be reabsorbed by active and passive
mechanism: sodium
5. What mechanism maintains the osmotic gradient of the
medulla? Countercurrent exchange
6. Final concentration of urine occurs in the collecting duct
7. Original reference method for clearance test: inulin clearance
8. Used in the actual measurement of PAH: renal plasma flow
9. Creatinine clearance is corrected for: body surface area
10. Effective renal plasma flow ranges from: 600 to 800
SPECIMEN COLLECTION: CONTAINERS SPECIMEN HANDLING: Specimen Preservation
• Clean, dry, leak-proof, disposable containers (for routine • Refrigeration at 2-8 deg C – most routinely used method of
purpose) preservation
• Bags with adhesive (for toddlers) • Urine for Culture – should be refrigerated during transit and
• Large containers (time spx collection) kept refrigerated until cultured up to 24 hours
• Individually packaged sterile containers w/ secure closures (3 rd • Before chemical testing by reagent strips specimen must return
photo for microbiologic exam) to Room temp
• Chemical Preservatives
• Light Protection
• Common issues that preservation helps prevent
• Bacterial growth – to prevent bacteria from multiplying
causing pH changes and breakdown urea to ammonia.
• Degradation of cells and casts – specially in alkaline urine
• Chemical reactions – glucose, bilirubin & urobilinogen
• Containers for routine UA
degrades when not properly preserved
• Wide mouth
• Crystallization – crystals when there is fluctuation in
• Flat bottom
temperature. May interfere with microscopic examination.
• Clear material
• Factors affecting the choice of preservative
• 50mL – recommended capacity; 12 mL needed for
• Analyte of Interest – (ex. glucose requires refrigeration;
microscopic analysis; enough room for the spx to be mixed
urobilinogen needs preservation with acidification)
by swirling the container
• Time Between Collection and Analysis (refrigeration is
enough for short term preservation, chemical preservatives
SPECIMEN COLLECTION: LABELS
or freezing for longer storage)
• Attached to the container • Intended Testing (some preservatives interfere w/ a certain
• Not to be detached if the container is refrigerated or frozen test. Ex. formalin can affect chemical testing, but it
• Label properly w/ the patient’s name and identification number, preserves cells. So therefore, the test methods must guide
the date and time of collection, and additional information the preservation strategy)
• Bacterial Contamination Risk (urine samples for culture and
SPECIMEN COLLECTION: REQUEST FORM need preservative like boric acid to avoid bacterial growth
• Must accompany specimens delivered to the laboratory w/out altering the chemical composition)
• Information on the form must match the information on the • Ideal Preservative (however this is not true all the time)
specimen label • Bactericidal
• Time of receiving the specimen – should be recorded on the • Inhibit urease
form • Preserve formed elements in the sediment
• Should not interfere w/ chemical tests
SPECIMEN REJECTION
• Reject specimen in the following unacceptable situations: METHODS OF URINE PRESERVATION
1. Specimen in unlabeled containers • Refrigeration (4-8 deg C)
2. Nonmatching labels and requisition forms • Chemical Preservatives
3. Specimens contaminated with feces or toilet paper • Freezing
4. Containers w/ contaminated exteriors
5. Specimens of insufficient quantity
Method: Refrigeration
6. Specimens that have been improperly transported
• Description: most commonly used method; slows bacterial
• Technical tip: never discard a specimen before checking with a
growth & minimizes chemical changes
supervisor!
• Preservation Mechanism: prevent breakdown of substances
such as glucose and urea
SPECIMEN HANDLING: Specimen Integrity
• Advantages: easy to implement & noninvasive; effective for
• W/in 2 hrs. - time required for the specimen to be delivered to
preserving most components for 24 hrs, prevents bacterial
the lab and tested
overgrowth and maintains integrity of chemical and
• Refrigerated or add chemical preservative – if a specimen microscopic elements
cannot be delivered w/in 2 hours
• Disadvantages: can lead to precipitation; amorphous urates and
CHANGE ANALYTE CAUSE
amorphous phosphates
INC. Odor Bacterial multiplication
• Clinical Applications: for routine urinalysis; w/in 24 hrs testing;
→breakdown of urea to
ideal for preventing degradation glucose and other labile
ammonia
substances
pH Breakdown of urea to
ammonia loss of CO2 • Considerations: spx from ref is not directly tested using reagent
Nitrite Multiplication of nitrite- strip, it needs to return to room temperature before performing
reducing bacteria chemical testing
Bacteria Multiplication
DEC. Clarity Bacterial growth & Method: Chemical Preservatives
precipitation of amorphous • Boric Acid – maintains bacteriostatic activity.
material • Description: preventing bacterial growth w/out significantly
Glucose Glycolysis and bacterial use altering the chemical composition
Ketones Volatilization & bacterial
• Preservation Mechanism: inhibits bacterial proliferation;
metabolism
ensuring the stability of the chemical and cellular
Bilirubin Exposure to light/
photooxidation to biliverdin component
Urobilinogen Oxidation to urobilin • Advantages: preserves urine for culture & sensitivity
RBC, WBC Disintegration in dilute testing; stable for 24 to 48 hrs w/out refrigeration; does not
& casts alkaline urine affect pH significantly.
Trichomonas Loss of motility; death • Disadvantages: can interfere with pH analysis & protein test
when too much boric acid used; may precipitate calcium,
therefore it may also affect microscopic analysis
• Clinical Applications: widely used in culture specimen;
urine culture specimen when immediate processing is not
feasible; also used in preserving routine sample for transport
in the laboratory
• Formalin (Formaldehyde) Method: Freezing
• Description: powerful fixative used primarily for preserving • Description: used to preserve urine samples when long term
cells and cast in urine for microscopic examination storage is required.
• Preservation Mechanism: preserves cellular formation of • Preservation Mechanism: freezing so biological and chemical
elements, cellular elements by crosslinking proteins activity by immobilizing water molecules and reducing
• Advantages: excellent for preserving cells, casts and other temperature sensitivity action
formed elements. Effective for long term preservation of • Advantages: suitable for long term storage; it preserves the
urine sediment integrity of most analytes like proteins, hormones & metabolites
• Disadvantages: can interfere w/ chemical test such as • Disadvantages: it may cause cellular lysis, degradation of
glucose, blood and urobilinogen. It is toxic and hazardous to formed elements, cells and casts. Crystals may also form, which
handle can affect microscopic exam
• Clinical Applications: for urine cytology, urine sediment • Clinical Applications: used for urine hormone and metabolite
analysis, preserving the structural integrity of cells and casts analysis; also ideal for research settings
is crucial
Summary: Specimen Handling: Urine Preservatives
• Thymol
• Description: less commonly used preservative; provides
antibacterial and antifungal properties
• Preservation Mechanism: inhibits microbial growth w/out
affecting the chemical components of urine
• Advantages: does not interfere w/ most chemical test; it is
easy to use in small concentration
• Disadvantages: may precipitate cells affecting microscopic
exam
• Clinical Application: useful for urine specimen that will be
cultured or stored for extended period

• Toluene
• Description: is an organic solvent that will form a thin layer Types of Urine Specimen
on the surface of the urine sample to prevent exposure to air • Random – most commonly received spx. May be collected at
• Preservation Mechanism: creates an anaerobic environment any time, but actual time of voiding should be recorded. For
thereby minimizing chemical changes by reducing contact routine screening test, initial assessment of UTI, general health
w/ oxygen evaluation.
• Advantages: does not interfere with chemical test; preserves • Considerations: has a variable concentration of analytes due
organic components such as ketones and bilirubin to dietary activity fluctuation, physical activity fluctuation,
• Disadvantages: less effective at preventing bacterial growth less ideal for quantitative measurement.
and it has a strong odor and potentially toxic • First Morning – “ideal screening spx, because it is highly
• Clinical Application: often used in combination w/ other concentrated” concentrated specimen (assuring detection of
preservatives; suitable for preserving urine for specific chemicals & formed elements that may not be present in a dilute
chemical analysis such as ketone and bilirubin testing. random spx. Collect the spx. immediately on arising & deliver
it to the lab w/in 2 hrs or keep it refrigerated) (important yung
• Sodium Carbonate px compliance)
• Description: an alkaline preservative; stabilize urine pH; • Applications: ideal for pregnancy testing, beta-HCG is high
prevents degradation of certain chemical components. during the morning. Useful for proteinuria screening. Useful
• Preservation Mechanism: By raising the pH, sodium for detecting orthostatic proteinuria.
carbonate inhibits the breakdown of substances like • 24-hour/Timed – required when the concentration of the
something-phenyl & urobilinogen substance to be measured changes with diurnal variations and
• Advantages: effective in stabilizing urobilinogen & with daily activities such as exercise, meals and body
propylene; useful for preserving urine in metabolic disorder metabolism. Px. must begin & end the collection period with an
screenings empty bladder.
• Disadvantages: not suitable for preserving cells or casts; • Collection method: px. is told that their first morning urine
may interfere w/ protein and pH measurement is discarded, then the following urine until the next day is
• Clinical Application: primarily used in specialized urine test collected in a giant container.
(porphyria and urobilinogen) • Clinical Application: includes a quantitative measurement
of substances like creatinine, urea nitrogen, proteins,
• Hydrochloric Acid hormones and electrolytes. It is also for assessment of
• Description: acidification typically with hydrochloric acid kidney function and hormonal disorders. Very important
will lower the pH of urine, preserve certain metabolite & yung patient cooperation and proper preservation. If
prevent bacterial growth incomplete collection, it will cause in accurate results
• Preservation Mechanism: lowering the pH, inhibits bacterial • Catheterized – collect under sterile conditions by passing a
activity, and will preserve specific analytes that are stable in hollow tube (catheter) through the urethra into the bladder
acidic concentration (performed usually by nurses, doctors trained for doing this
• Advantages: preserves urine for test of specific analyte like sterile technique)
calcium, phosphorus and hormones; prevents breakdown of • Clinical Application: when patients are unable to void
analytes; sensitive to higher pH level naturally. For example, px after their surgery, usually a
• Disadvantages: can interfere w/ some routine, chemical and catheter is inserted especially on old px. that are unable to
microscopic analysis; it is hazardous to handle pee naturally. For bacterial culture and sensitivity testing.
• Clinical Application: ideal for 24-hour urine collection; Not routinely used because of additional physical harm to
measures hormone, catecholamine & calcium. px
• Midstream Clean-Catch – (a urine sample collected mid wide
after cleaning the urethral opening; first and last portion of urine
is discarded; middle portion is collected) provides a specimen
that is less contaminated by epithelial cells and bacteria. More
representative of the actual urine than the routinely voided spx
• Suprapubic Aspiration – collected by external introduction of a
needle through the abdomen into the bladder
• Three-Glass, Pediatric, Drug Specimen
 TYPES OF URINE SPECIMEN

CATHETERIZED ● collected under sterile conditions by passing a hollow tube (catheter)

through the urethra into the bladder

MIDSTREAM CLEAN-CATCH ● provides a specimen that is less contaminated by epithelial cells and
bacteria
● more representative of the actual urine than the routinely voided
specimen

SUPRAPUBIC ASPIRATION ● collected by external introduction of a needle through the abdomen into
the bladder
- Above the urinary bladder as above the pubic area, sa
suprapubic aspiration mag iinsert ng needle in syringe
daretsyo na yan sa urinary bladder, this is performed under
sterling condition by a physician kasi mag insert ng needle
above the pubic bone to aspirate urine, clinical application
usually test a bacterial culture and sensitivity testing and also
useful in infants and children highly invasive

THREE GLASS COLLECTION ● Prior to collection the area is cleansed using the male midstream
- Usually this is used to test for prostatic infection clean-catch procedure.
● First urine passed: collected in a sterile container.
● Next, the midstream portion is collected in another sterile container.
● Massage prostate→ prostate fluid will be passed with the remaining
urine into a third sterile container

PEDIATRIC SPECIMEN ● For collecting routine specimens: Soft, clear plastic bags with
hypoallergenic skin adhesive to attach to the genital area of both boys
and girls
● Sterile Specimens- obtained by catheterization/suprapubic aspiration

DRUG SPECIMEN COLLECTION ● 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.
● 30-45 mL- recommended volume of specimen to be collected
TEST YOURSELF!!! CLARITY
1. Average daily urine output: 1200 ml ● transparency or turbidity of a urine specimen
2. Urine composition: 95% water, 5% solutes ● determined by visually examining the mixed specimen while holding it
3. Primary organic component: Urea in front of a light source, view through a newspaper print
4. Time required for the specimen to be delivered in the lab and tested. Within 2 ● NORMAL CLARITY: Freshly voided normal urine: usually clear
hours
5. Most routinely used method of preservation. Refrigeration at 2-8 deg C
6. Ideal screening specimen. First morning specimen
7. Specimen/s for bacterial culture. Catherized, Mid-stream, Suprapubic
8. In 24 hr urine, patient must begin and end the collection with an empty
bladder
9. In unpreserved urine, what happens to bilirubin? biliverdin
10. Disorders are usually associated with Polyuria. Diabetes mellitus and
Diabetes insipidus

PHYSICAL EXAMINATION OF THE URINE

NORMAL URINE COLOR

● Common Descriptions: pale yellow , yellow & dark yellow CAUSES OF URINE TURBIDITY
● Examine specimen under a good light source, looking down through
the container against a white background NON-PATHOLOGIC PATHOLOGIC
● Urochrome pigment responsible for the yellow color of urine, product of
endogenous metabolism & under normal conditions the body produces it ● Squamous epithelial cells (↑ ● RBCs
at constant rate 𝐹𝑒𝑚𝑎𝑙𝑒𝑠) ● WBCs
● Mucus ● Bacteria
FACTORS AFFECTING COLOR ● Amorphous phosphates, ● Yeast
carbonates, urates ● Non-Squamous Epithelial
● Hydration Status
● Semen, spermatozoa Cells
● Diet ● Fecal contamination ● Abnormal crystals
● Medications ● Radiographic contrast media ● Lymph Fluid
● Disease States ● Talcum powder ● Lipids
● Vaginal creams

LAB CORRELATIONS IN URINE TURBIDITY

Acidic Urine Alkaline urine

● Amorphous urates ● Amorphous phosphates

● Radiographic contrast media ● Carbonates

Soluble with Heat Soluble in Dilute Acetic Acid

● Amorphous urates ● RBCs

● Uric Acid Crystals ● Amorphous phosphates
● Carbonates

Insoluble in Dilute Acetic acid Soluble in Ether

● WBCs ● Lipids
● Bacteria ● Lymphatic fluid
● Yeast ● Chyle
● Spermatozoa

SPECIFIC GRAVITY
● Density of a solution compared with the density of a similar volume
of distilled water (SG 1.000) at a similar temperature
● 1.010 - specific gravity of the plasma filtrate entering the glomerulus
● ISOSTHENURIC - used to describe urine with a specific gravity of 1.010
● HYPOSTHENURIC - specimens below 1.010
● HYPERSTHENURIC - specimens ABOVE 1.010
● NORMAL RANDOM SPECIMENS SG: 1.002- 1.035
● SG < 1.002- probably NOT URINE
● Most random specimens: fall between 1.015 and 1.030
● 1.005 to 1.0030: normal range of urine specific gravity
● LOW SG: <1.005
● HIGH SG: > 1.030
● Fixed SG: 1.010

METHOD PRINCIPLE

Refractometry Refractive index

Osmolality Changes in colligative properties

by particle number

Reagent strip pKa changes of a polyelectrolyte

by ions present
Current Urine Specific Gravity Measurements
QUALITY CONTROL OF REAGENT STRIPS
● checked with both positive & negative control a minimum of once every
24 hours
ODOR CAUSE
● Testing is also performed when a new bottle of reagent strips is opened
FAINTLY AROMATIC Normal ● All quality control results must be recorded following laboratory
protocol.
FOUL AMMONIA-LIKE Bacterial decomposition, urinary tract ● Distilled water is not recommended as a negative control because
infection reagent strip chemical reactions are designed to perform at ionic
concentrations similar to urine
FRUITY, SWEET Ketones (diabetes mellitus, starvation, ● All readings of the negative control must be negative, and positive
vomiting)
control readings should agree with the published value. Results that do
MAPLE SYRUP Maple syrup urine disease not agree with the published values must be resolved through the testing
of additional strips and controls.
MOUSY, MUSTY Phenylketonuria ● Interfering substances in the urine, technical carelessness, and color o
blindness also produce errors
RANCID Tyrosinemia
pH
SWEATY FEET Isovaleric acidemia and glutaric acidemia
● Healthy individuals: urine pH may vary from 4.6 to 8 (Henry’s), first
CABBAGE, HOPS Methionine malabsorption morning specimen with a slightly acidic pH of 5.0 to 6.0 (Strasinger)
● ALKALINE TIDE: more alkaline pH is found following meals
BLEACH Contamination ● pH of normal random samples can range from 4.5-8.0
● MEASUREMENT OF URINE pH -must always be made on freshly
ROTTEN EGGS Cystinuria voided specimens
● On standing, the pH tends to rise
SWIMMING POOL Hawkinsinuria
● pH above 8.5 is associated with an Improperly preserved specimen and
ROTTING FISH Trimethylaminuria indicates that a fresh specimen should be obtained to ensure the validity
of the analysis
● Acidic pH: < 5.5 ; Alkaline pH: >7.5
TEST YOURSELF
1. Pigment responsible for the NORMAL color of urine Urochrome
2. Yellow foam when shaken indicates presence of bilirubin Parameter Principle RT Reagents
3. Color of urine of patient with porphyria port wine color
4. Color of urine of patient who takes Indican blue green pH Double indicator 60 sec Methyl red, bromthymol
5. Many particulates, print blurred through the urine cloudy system blue
6. Specimen with SG <1.002 is not urine
7. Urine odor of patients with Phenylketonuria mousy and musty
8. Urine odor of patients with Methionine malabsorption cabbage, hops
9. In using refractometer, correction for glucose is calculated by subtracting
0.004.
PROTEIN
10. Normal urine odor aromatic
● 150 mg of protein - normally excreted in the urine daily (Henry’s)
CHEMICAL EXAMINATION OF THE URINE ● Ave. Urine protein concentration: 2-10 mg/dL, depending on urine
● REAGENT STRIPS- simple, rapid means for performing medically volume
● Normal urine: usually, less than 10 mg/dL or 100 mg/24 hrs of protein
significant chemical analysis of urine
is excreted (Strasinger)
● 2 MAJOR TYPES OF REAGENT STRIPS
1. MULTISTIX (Siemens Healthcare Diagnostics, Deerfield, IN)) ● Test is more sensitive to ALBUMIN
2. CHEMSTRIP (Roche Diagnostics, Indianapolis, IN) ● Highly buffered alkaline urine - MAJOR SOURCE OF ERROR
● color-producing chemical reaction takes place when the absorbent pad ● Technical error of allowing the reagent pad to remain in contact with
the urine for a prolonged period may remove the buffer
comes in contact with urine

REAGENT STRIP TECHNIQUE

Parameter Principle RT Reagents

PROTEIN Protein error of 60 sec Multistix:Tetrabromoph

indicators enol blue
Chemstrip: 3’,3’’,5’,5’’-
tetrachlorophenol,
3,4,5,6-
tetrabromosulfonphthalei
n

SULFOSALICYLIC ACID TEST

- a cold precipitation test that reacts equally with all forms of protein
● Procedure
1. Add 3 mL of 3% SSA reagent to 3 mL of centrifuged urine
2. Mix by inversion and observe for cloudiness
HANDLING & STORING REAGENT STRIPS 3. Grade the degree of turbidity
● OPAQUE CONTAINERS WITH DESSICANT - used to protect the strips
from light and moisture
● Strips are removed just prior to testing, and the bottle is tightly resealed
immediately.
● Bottles should not be opened in the presence of volatile fumes.
● Room temperature below 30°C (but never refrigerated) - storage
temperature for reagent strips
● All bottles are stamped with an expiration date that represents the
functional life expectancy of the chemical pads. Reagent strips must not
be used past the expiration date.
● Care must be taken not to touch the chemical pads when removing the
strips.
● A visual inspection of the strip should be done each time a strip is used
to detect deterioration, even though the strips may still be within the
expiration date
 ● BENCE JONES PROTEIN coagulates at temperatures between 40°C
and 60°C and dissolves when the temperature reaches 100°C.
● A specimen that appears turbid bet. 40°C and 60°C and Clear at 100°C
can be suspected of containing Bence Jones protein
● MICROALBUMINURIA TESTING BLOOD
■ 24-hour urine specimen ● Hematuria, hemoglobinuria or myoglobinuria
■ Method: quantitative procedures for albumin - Hematuria is intake red blood cell present and it can be due to
■ Results: reported in mg of albumin/24 hours or as the albumin kidney stones infection or tumors, Hemoglobinuria due to
excretion (AER) in μg/min. conditions such as hemolytic anemia or transmission reaction,
■ microalbumin was considered significant when 30 to 300 mg of myoglobinuria condition of severe muscle damage such as
albumin is excreted in 24 hours or the AER is 20 to 200 μg/min rhabdomyolysis
■ REAGENT STRIP METHODS: ● 2 colored charts
○ Micral ■ free hemoglobin/myoglobin: Uniform color ranging from a
○ Immuno-dip negative yellow through green to a strongly positive green- blue
GLUCOSE appears on the pad.
● 160-180 mg/dL- renal threshold for glucose, blood level at which tubular ■ Intact red blood cells: results in a Speckled pattern on the pad
reabsorption stops
● GLYCOSURIA- presence of detectable amounts of glucose in urine
● Fasting prior to the collection of samples for screening tests is
recommended
● For DM monitoring: specimens are usually tested 2 hours after meals

● Copper Reduction Test (CLINITEST)

- ability of glucose and other substances to reduce copper sulfate
to cuprous oxide in the presence of alkali and heat Parameter Principle RT Reagents
● Classic Benedict solution
- copper sulfate, sodium carbonate, and sodium citrate buffer
● Clinitest tablet BLOOD Pseudoperoxidas 60 sec Multistix: Diisopropylbenzene
- copper sulfate, sodium carbonate, sodium citrate, and sodium e activity of dihydroperoxide , 3,3’,5,5’-
hemoglobin tetramethylbenzidine
hydroxide
Chemstrip:
dimethyldihydroperoxyhexane,
Parameter Principle RT Reagents tetramethylbenzidine

GLUCOSE Glucose 30 sec Multistix: Glucose

oxidase oxidase, Peroxidase,
BILIRUBIN
reaction Potassium iodide
Chemstrip: Glucose ● a highly pigmented yellow compound, is a degradation product of
oxidase, hemoglobin
Peroxidase,Tetramethylb ● Only conjugated bilirubin can appear in the urine when the normal
enzidine degradation cycle is disrupted
● AZODYE - with colors ranging from increasing degrees of tan or pink to
violet
● ICTOTEST TABLETS - confirmatory test for bilirubin

Parameter Principle RT Reagents

BILIRUBIN Diazo Reaction 30 sec Multistix: 2,4-dichloroaniline

diazonium salt
Chemstrip: 2,6
dichlorobenzenediazoniumsal
t

UROBILINOGEN
● Urobilinogen appears in the urine because, as it circulates in the blood
back to the liver, it passes through the kidney and is filtered by the
glomerulus.
● small amount of urobilinogen - <1 mg/dL or Ehrlich unit—is normally found
KETONE in the urine
● The test does not measure B- hydroxybutyrate and is only slightly
sensitive to acetone when glycine is also present Parameter Principle RT Reagents
● ACETEST
■ provides sodium nitroprusside, glycine, disodium phosphate, and
lactose in tablet form UROBILINOGE M: Ehrlich’s 60 sec Multistix: p-
N Aldehyde dimethylaminobenzaldehyde
■ The addition of lactose gives better color differentiation
Reaction
C: Diazo Chemstrip: 4-
Reaction methoxybenzenediazonium-
tetrafluoroborate

Parameter Principle RT Reagents

KETONE Sodium 40 sec Sodium

Nitroprusside nitroprusside
Reaction Glycine (Chemstrip)
NITRITE
● Urinary tract pathogens are able to reduce nitrate to nitrite, and thus
will generate a positive urine nitrite test when present in significant
numbers (>105 to 106 /mL bladder urine)
● does not measure the degree of bacteriuria
-take note; a negative test does not rule out in uti

Parameter Principle RT Reagents

NITRITE Greiss 60 sec Multistix: p-arsanilic acid

reaction Tetrahydrobenzo(h)-quinolin-
3-ol

Chemstrip: Sulfanilamide,
hydroxytetrahydro
benzoquinoline

LEUKOCYTE ESTERASE
● detects the presence of leukocytes that have been lysed, particularly in
dilute alkaline urine, and would not appear in the microscopic
examination.
● Test is not designed to measure the concentration of leukocytes

Parameter Principle RT Reagents

LEUKOCYTE LE Reaction 120 sec Multistix: Derivatized

ESTERASE pyrrole aminoacid ester,
Diazonium salt

Chemstrip:
Indoxylcarbonic acid
ester, Diazonium salt

SPECIFIC GRAVITY
● The polyelectrolyte ionizes, releasing hydrogen ions in proportion to the
number of ions in the solution.
● The higher the concentration of urine, the more hydrogen ions are
released, thereby lowering the pH.

Parameter Principle RT Reagents

SPECIFIC Change in 45 sec Multistix: Poly (methyl

GRAVITY pKa of a vinyl ether/maleic
polyelectrolyte anhydride) bromthymol
blue

Chemstrip: Ethylene
glycol diaminoethyl ether
tetraacetic acid,
bromthymol blue
ASCORBIC ACID
● used as an indication of adequate ascorbic acid therapy
● 2 to 10 mg/ dL is excreted daily, but after ingestion of large amounts of
ascorbic acid, levels in urine may rise to 200 mg/dL.
● Reagent Strip Test
■ C-STIX- detects 5 mg/dL of ascorbic acid in urine after 10
seconds.
■ STIX- detect about 25 mg/dL of ascorbic acid at 60 seconds

PORPHYRIN
● Watson-Schwartz Differentiation Test
■ used to separate causes of a positive Ehrlich reacting test
and to give an indication of large amounts of urobilinogen or
the presence of porphobilinogen
■ detects >6 mg/L of porphobilinogen
■ A positive result for porphobilinogen in the Watson-Schwartz test
can be further confirmed by the HOESCH TEST
● Hoesch test -for rapid screening or monitoring of urinary
porphobilinogen.
1. Two drops of urine are added to approximately 2 mL of Hoesch
reagent (Ehrlich reagent dissolved in 6 M HCl).
2. Immediately observed the top of the solution for the appearance
of a red color that indicates the presence of porphobilinogen. 3.
3. Shake the tube.

TEST YOURSELF!!!
1. Dip the reagent strip briefly in a completely mixed uncentrifuged urine
specimen.
2. Chemical parameters w/ shortest reading time: glucose
3. Chemical parameter w/ longest reading time: leucocyte esterase
4. Principle for Blood Pseudoperoxidase activity of hemoglobin
5. Principle for Nitrite Greiss reaction
6. Principle for Urobilinogen Ehrlich’s Aldehyde Reaction and Diazo
Reaction
7. Alkaline pH would produce blue-green color
8. Stix can detect 25 mg/dL of ascorbic acid at 60 seconds
9. Soluble at butanol but insoluble in chloroform erlich-reactive
10. Confirmatory test for Bilirubin Ictotest tablets
MICROSCOPIC EXAMINATION OF THE URINE URINE SEDIMENT STAIN
MACROSCOPIC Screening & Microscopic Correlations STAIN ACTION FUNCTION OTHER INFO
Screening Test Significance Sternheimer- Delineates Identifies Most
malbin stain structure and WBCs, commonly used
Color Blood
contrasting epithelial cells, stain; consists
Clarity Hematuria vs. Hemoglobinuria/myoglobinuria. colors of the and casts of crystal violet
Confirm pathologic or nonpathological cause nucleus and & safranin O
of turbidity cytoplasm.
Blood RBCs, RBC casts Toluidine Blue Enhances Differentiated A
Protein Casts, cells nuclear detail WBCs and renal metachromatic
Nitrite Bacteria, WBCs tubular stain
epithelial (RTE)
Leukocyte WBCs, WBC casts, bacteria
cells
esterase 2% Acetic Acid Lyses RBCs and Distinguishes Cannot be used
Glucose Yeast enhances nuclei RBCs from for initial
SPECIMEN COLLECTION & PREPARATION of WBCs WBCs, yeast, oil sediment
• Freshly collected, well-mixed midstream/ catheterized droplets, and analysis
crystals
urine sample: ideal for microscopic exam.
Lipid stains: Oil Stains Identify free fat Cholesterol
• CENTRIFUGATION: 10-12 mL, centrifuged at 1500 to 2000 Red O and triglycerides droplets and does not stain
rpm for 5-10 minutes; supernatant is discarded -> small Sudan III and neutral fats lipid-containing with these
orange-red cells and casts stains, but
volume of sediment for analysis.
capable of
• RESUSPENSION: sediment is resuspended in 0.5-1 mL of the polarization.
remaining urine by gently tapping the tube. Gram Stain Differentiates Identifies Dried, heat-
gram-positive bacterial casts fixed
• EXAMINATION: a drop of the resuspended sediment is
and gram- preparation of
placed on a clean glass slide and covered with a cover slip. negative the urine
The sample is examined under a microscope at low power bacteria sediment must
(10x) to scan for casts and large elements, and at high power be used
Hansel stain Methylene blue Identifies Performed on a
(40x) to identify cells and smaller structures. & eosin Y stains, urinary dried smear of
EXAMINING THE SEDIMENT eosinophilic eosinophils the centrifuged
• Consistent manner granules specimen or a
cytocentrifuged
• Minimum of 10 fields (lpf & hpf) preparation of
• Conventional Glass Slide Method: low power scanning of the sediment.
cover slip parameter – recommended. Prussian Blue Stains Identifies Stains the
Stain structures yellow-brown hemosiderin
• Bright-Field Microscopy: examine sediments under containing iron granules of granules; a blue
REDUCED light. hemosiderin in color
• Epithelial cell – point of reference in focusing correct plane. cells and casts
REPORTING THE MICROSCOPIC EXAMINATION
SEDIMENT MANNER OF REPORTING Addis Count
CASTS Average number per 10 low-power fields • Quantitative measure of formed elements (RBCs, WBCs,
(LPF) casts, and epithelial cells) in urine using hemocytometer.
RBCs and WBCs Average number per 10 high-power fields • Normal values:
(HPF) - RBCs: 0 to 500,000/12-hr urine
Squamous Rare, few, moderate or many per LPF - WBCs & ECs: 0 to 1,800,000/12-hr urine
Epithelial Cells
- Hyaline Casts: 0 to 5000/12-hr urine
Transitional Rare, few, moderate or many per HPF
epithelial cells, Urine Microscopy Technique
yeast TECHNIQUE FUNCTION
Renal Tubular Average number per 10 HPF BRIGHT FIELD MICROSCOPY Used for routine urinalysis
Epithelial Cells PHASE-CONTRAST MICROSCOPY Enhances visualization of elements
with low refractive indices such as
Oval Fat Bodies Average number per HPF
hyaline casts, mixed cellular casts,
Abnormal crystals Average number per LPF mucous threads, and trichomonas.
Quantitated None Rare Few Moderate Many POLARIZING MICROSCOPY Aids in identification of cholesterol
Epithelial per LPF 0 0-5 5-20 20-100 >100 in oval fat bodies, fatty casts, and
cells crystals
Normal per HPF 0 0-2 2-5 5-20 >20 DARK-FIELD MICROSCOPY Aids in identification of Treponema
crystals pallidum
Bacteria per HPF 0 0-10 10- 50-200 >200 FLUORESCENCE MICROSCOPY Allows visualization of naturally
50 fluorescent microorganisms or
Mucus per LPF 0 0-1 1-3 3-10 >10 those stained by a fluorescent dye
threads including labeled antigens and
antibodies.
INTERFERENCE-CONTRAST Produces a three-dimensional
a. Nomarski (Differential) microscopy image and layer by
b. Hoffman (Modulation) layer imaging of a specimen.
Bright field microscopes can be
adapted

URINE CAST
• Unique to the kidney
• SITE OF FORMATION: within the lumens of the distal
convoluted tubules and collecting dusts.
• UROMODULIN: major constituent of casts, excreted at
relatively constant rate, rate of excretion appears to
increase under conditions of stress and exercise.
• Cylindroids: Formation of casts at the junction of the
ascending loop of Henle and the distal convoluted tubule
may produce structures with a tapered end, same
significance as casts.
• Cylindruria: presence of urinary casts
URINARY CRYSTALS
• Primary reason for identification: to detect the presence of
the relatively few abnormal types.
• Formed by the precipitation of urine solutes.
• MANNER OF REPORTING: rare, few, moderate, or many per
hpf.
• Abnormal crystals may be averaged and reported per lpf.
NORMAL URINARY CRYSTALS IN ACID pH
CRYSTAL COLOR
Uric Acid Yellow-brown (rosettes, wedges)
Amorphous urates Brick dust or yellow brown
Calcium oxalate Colorless (envelopes, oval,
dumbbell)

NORMAL URINARY CRYSTALS IN ALKALINE pH

CRYSTAL COLOR
Amorphous phosphates White-colorless
Calcium phosphate Colorless
Triple phosphate Colorless (“coffin lids”)
Ammonium biurate Yellow-brown (“thorny apples)

ABNORMAL URINARY CRYSTALS

CRYSTAL pH
Cystine Acid
Cholesterol Acid
Sulfonamides Acid/Neutral
ABNORMAL URINARY CRYSTALS (present in liver disease) in diabetic patients or
CRYSTAL pH those on antibiotics
Leucine Acid/neutral Spermatozoa Tadpole-like cells with oval Usually not clinically
Tyrosine Acid/neutral head and long tail significant but may be
Bilirubin Acid seen in retrograde
ejaculation.
Casts
Hyaline Casts Colorless, homogenous, Non-specific, may appear
transparent cylinders after exercise,
dehydration or fever
RBC Casts Hyaline casts with Glomerulonephritis,
embedded red blood cells vasculitis, bleeding within
the nephron
WBC Casts Hyaline casts with Pyelonephritis, interstitial
ABNORMAL URINARY CRYSTALS embedded white blood nephritis
CRYSTAL pH cells
Radiographic Dye Acid Granular Coarse or finely granular, Acute tubular necrosis,
Casts from cellular degeneration chronic renal disease
Ampicillin Acid/neutral
Waxy Casts Highly refractile, rigid with Chronic renal failure, end
sharp edges and cracks stage renal disease
Fatty Casts Hyaline casts with fat Nephrotic syndrome,
droplets; “Maltese cross” severe renal damage
under polarized light
Crystals
Uric Acid Yellow to reddish brown Gout, high purine
Crystals rhombic, rosette, or metabolism, acidic urine
needle shapes
Calcium Colorless, envelope shaped Kidney stones,
Oxalate or dumbbell-shaped hyperoxaluria, acidic to
Crystals neutral urine
URINE SEDIMENT ARTIFACTS Triple Colorless, coffin lid shaped UTI caused by urea
Phosphate splitting bacteria, alkaline
(Struvite) urine
Cystine Colorless, hexagonal plates Cystinuria, a hereditary
Crystals disorder of amino acid
metabolism
Amorphous Fine, yellow to brown Usually not clinically
Urates granules significant, found in acidic
urine
Amorphous Fine, colorless or white Not clinically significant,
Phosphates granules found in alkaline urine
Artifacts
Fibers Long, thin, highly Contamination from
refractile, often irregular clothing or laboratory
shapes equipment; no clinical
relevance
Air bubbles Round, refractile spheres Introduced during sample
with a dark edge handling; no clinical
relevance
Type Appearance Clinical Significance Powder/Talc Fine, refractile particles Contamination from
Cells granules gloves or powders; no
Red Blood Smooth, biconcave disks Hematuria, clinical significance
Cells (RBCs) (7-9 um); may appear glomerulonephritis, TEST YOURSELF:
crenated or swollen. trauma, infection, kidney
stones 1. Frequently used urine volume used in microscopic exam 12ml
White Blood Larger than RBCs (12-14 Pyuria, urinary tract 2. Frequently used urine sediment volume 0.5 & 1.0ml
Cells (WBCs) um); multilobed nucleus; infection (UTI), interstitial 3. Observation of minimum of 10 fields under lpf & hpf is
glitter cells in hypotonic nephritis
urine
recommended
Squamous Large, flat, irregular with Contamination from 4. Most commonly used stain Sternheimer-Malbin Stain
epithelial small round nucleus urethra or vagina usually 5. Identifies urinary eosinophils Hansel stain
cells non-pathological
6. Stain structures containing iron Prussian Blue Stain
Transitional Round or pear-shaped, Bladder or renal pelvis
Epithelial central nucleus infection, urinary tract 7. Appearance of RBC in hypotonic urine ghost cells
Cells trauma 8. Major constituent of casts uromodulin
Renal Tubular Round, eccentrically Tubular damage (acute 9. 3 crystals seen in liver disease leucine, tyrosine, bilirubin
Epithelial placed nucleus tubular necrosis),
10. Cholesterol crystal is very similar in appearance to crystal
Cells nephrotoxicity
Bacteria Small rods (bacilli) or Urinary tract infection radiographic dye
spherical (cocci) (UTI); contamination
Yeast Oval, budding cells Fungal infection,
resembling RBCs commonly Candida; seen
URINE SCREENING FOR METABOLIC DISORDERS BRANCHED-CHAIN AMINO ACID DISORDERS
OVERFLOW RENAL DISORDERS DISORDER ETIOLOGY UA TEST/FINDINGS
Disruption of a normal metabolic Malfunctions in the tubular MAPLE SYRUP URINE Failure to inherit the Maple syrup odor
pathway that causes increased reabsorption mechanism. DISORDERS gene for the enzyme
plasma concentrations of the non- necessary to produce 2,4-dinitrophenylhydrazine
metabolized substances. oxidative (DNPH) test – (+)
decarboxylation of
these keto acids (a - Yellow turbidity or
ketoisovaleric, a - precipitate
ketoisocaproic, and a
-keto-b -
methylvaleric)
ISOVALERIC Deficiency of Sweaty feet urine odor
ACIDEMIA Isovaleryl coenzyme
CATEFORIES OF METABOLIC DISORDES DETECTED IN URINE A in the leucine
pathway
• Amino Acid Metabolism Disorders PROPRIONIC & Errors in the Methylmalonic acidemia: p-
• Carbohydrate Metabolism Disorders METHYLMALONIC metabolic pathway nitroaniline test= (+)
• Purine and Pyrimidine Metabolism Disorders ACIDEMIA converting isoleucine, EMERALD GREEN COLOR
valine, threonine, and
• Porphyrin Metabolism Disorders methionine to
DISORDERS: AMINO ACID succinyl coenzyme A
PHENYLALANINE TYROSINE DISORDERS
DISORDER ENZYME DEFICIENCY UA TEST/FINDINGS TRYPTOPHAN DISORDERS
PHENYLKETONURIA Phenylalanine • Mousy/must DISORDER ETIOLOGY UA TEST/FINDINGS
hydroxylase odor INDICANURIA excess indole is then Hartnup’s disease blue
• Ferric chloride reabsorbed from the staining of infant’s
tube test – intestine into the diaper OBERMAYER
used to detect bloodstream and TEST FeCl3 + urine +
presence of circulated to the liver, Chloroform = (+)
urine phenyl- where it is converted to VIOLET Color
pyruvic acid indican and then
(+) permanent excreted in the urine
(Blue-green 5-HYDROXYINDOLE- due to excess amounts Silver Nitroprusside
color) ACETIC ACID of serotonins Test- (+) Purple- Black
TYROSYLURIA Fumarylacetoacetate • Rancid color color
hydrolase (type 1) • Nitroso-
Naphthol test-
Tyrosine orange red
aminotransferase color (tyrosine
(type 2) metabolites)

p-
hydroxyphenylpyruvi
c acid dioxygenase
(type 3)
MELANURIA • Dark urine
ALKAPTONURIA Homogentisic oxidase • Black urine
• Benedict’s
Test (+)
• Homogentisic
Acid test- (+)
black color
CYSTINE DISORDERS
DISORDER ETIOLOGY UA TEST/FINDINGS
CYSTINURIA Inability of renal Rotten egg urine odor
tubules to reabsorb
cysteine filtered by Cyanide Nitroprusside
the glomerulus test- (+) Red-purple
color
CYSTINOSIS defect in the Infantile
lysosomal membranes nephropathic
prevents the release cystinosis
of cystine into the
cellular cytoplasm for Polyuria
metabolism Generalized
incomplete aminoaciduria.
metabolism of cystine (+) Clinitest for urinary
results in crystalline substances Lack of
deposits of cystine in urinary concentration
many areas of the
body
 HOMOCYSTINURIA Defects in the Cyanide DISORDERS: PURINE
metabolism of the Nitroprusside test- (+) Lesch-Nyhan Syndrome
amino acid red purple color.
Methionine • Etiology: Failure to inherit the gene to produce the enzyme
Silver Nitroprusside hypoxanthine guanine phosphoribosyl transferase which is
Test- (+) red purple responsible for the accumulation of uric acid throughout
color
the body.
• Clinical Manifestation: motor defects, mental retardation, a
DISORDERS: PORPHYRIN
tendency toward self-destruction, gout, and renal calculi.
PORPHYRIAS
• UA findings: Uric acid crystals, hematuria

DISORDERS: CARBOHYDRATE
• GALACTOSURIA: inability to properly metabolize galactose
to glucose.
• URINE SCREENING: (+) Clinitest
• ETIOLOGY: deficiency in any of three enzymes
1. galactose-1-phosphate uridyl transferase (GALT) ->
severe possibly fatal symptoms, (+) NBS
2. galactokinase -> (-) NBS, deficiency result in cataract in
adults
3. UDP-galactose-4-epimerase -> (-) NBS, may be
asymptomatic or produce mild symptoms.
• Fructosuria: deficiency in fructokinase, leading to the
excretion of fructose in urine.

TEST YOURSELF
1. Caused by disruption of normal metabolic pathway - overflow
• Free erythrocyte protoporphyrin (FEP) as a screening test
2. Enzyme deficient in PKU – Phenylalanine hydroxylase
for lead poisoning, whole blood is analyzed.
3. Ferric chloride tube test + result – blue green color
PORHYRIA ENZYME ELEVATED LAB TESTING
DEFICIENCY COMPOUNDS 4. Enzyme deficient in alkaptonuria – Homogentisic oxidase
Acute Uroporphyrinogen ALA Urine/ 5. 2-4 DNPH Test + result – yellow turbidity
Intermittent synthase Porphobilinogen Ehrlich’s 6. Silver Nitroprusside Test + result – purple black
porphyria reaction
7. Screening test for lead poisoning - FEP
Porphyria Uroporphyrinogen Uroporphyrin Urine
cutanea tarda decarboxylase Fluorescence 8. GALT deficiency is the only one detected in NBS among patients
Congenital Uroporphyrinogen Uroporphyrin Urine or with galactosuria
erythropoietic cosynthase Coprophyrin feces 9. CTAB test + result – Thick white turbidity forms
porphyria fluorescence
10. Enzyme deficient in both erythropoietic porphyria & lead
Variegate Protoporphyrinogen Coproporphyrin Bile or feces
porphyria oxidase fluorescence poisoning – Ferrochelatase
Erythropoietic Ferrochelatase Protoporphyrin Blood FEP
protoporphyria Bile or feces RENAL DISEASE: GLOMERULAR
fluorescence
DISORDER ETIOLOGY
Lead poisoning Aminolevulinic acid ALA Acetoacetic
synthetase acid + urine/ Acute Glomerulonephritis • Immune complex deposition
Ehrlich • Formed in conjunction w/ Grp A
Ferrochelatase Protoporphyrin reaction FEP Streptococcus infection
Rapidly progressive • Immune complex deposition
glomerulonephritis from systemic immune disorders
DISORDERS: MUCOPOLYSACCHARIDE Good pasture Syndrome • Attachment of a cytotoxic
• Acid-albumin and cetyltrimethylammonium bromide antibody formed during viral
(CTAB) turbidity tests, metachromatic staining spot tests - respiratory infections to glomerular
& alveolar basement membranes.
most frequently used screening test, (+) Thick white
Wegener granulomatosis • Antineutrophilic cytoplasmic
turbidity forms. autoantibody binds to neutrophils
• Turbidity is usually graded on a scale of 0 to 4 after 30 in vascular walls producing damage
minutes with acid-albumin after 5 minutes with CTAB. to small vessels in the lungs and
glomerulus
DISORDER DESCRIPTION
Henoch-Schonlein Purpura Decrease in platelets disrupts
Hurler Abnormal skeletal structure vascular integrity
Hunter Severe mental retardation
Membranous Glomerulonephritis Thickening of glomerular
San Filippo Mental retardation membrane following IgG immune
complex deposition
 Membranoproliferative Cellular proliferation affecting the Nephrotic Syndrome Heavy proteinuria (>3.5 g/day),
Glomerulonephritis capillary walls or the glomerular lipiduria (oval fat bodies), fatty
basement membrane, possibly casts, waxy casts, granular casts
immune-mediated Acute Tubular Necrosis (ATN) Mild proteinuria, RTE cells and
IgA nephropathy Deposition of IgA on the casts, granular casts, muddy brown
glomerular membrane resulting casts, low specific gravity
from increased levels of serum IgA Acute Interstitial Nephritis Hematuria, WBCs (without
Nephrotic Syndrome Disruption of the shield of bacteria), WBC casts, mild
negativity and damage to the tight proteinuria, eosinophils (with
podocyte barrier special staining)
Minimal Change Disease Disruption of the podocytes Pyelonephritis Leukocyturia, bacteriuria, WBC
occurring primarily in children casts, hematuria, mild proteinuria
following allergic reactions & Chronic Kidney Disease (CKD) Fixed specific gravity (1.010), broad
immunizations and waxy casts, varying degrees of
Focal Segmental Disruption of podocytes in certain proteinuria, hematuria
Glomerulosclerosis areas of glomeruli associated with Fanconi Syndrome Glucosuria (without
heroin and analgesic abuse and hyperglycemia), aminoaciduria,
AIDS phosphaturia, bicarbonaturia, mild
Diabetic Nephropathy Deposition of glycosylated proteinuria
(Kimmelstiel-Wilson Disease) proteins on the glomerular
basement membranes
RENAL FAILURE
Alport Syndrome Genetic disorder showing
lamellated & thinning glomerular
basement membrane

RENAL DISEASE: TUBULAR

DISORDER ETIOLOGY
ACUTE TUBULAR NECROSIS Damage to renal tubular cells
caused by ischemia or toxic agents
FANCONI SYNDROME Inherited in association with
cystinosis and Hartnup disease or
acquired through exposure to toxic RENAL LITHIASIS
agents
UROMODULIN-ASSOCIATED Inherited defect in the production • KIDNEY STONES: form in the calyces and pelvis of the
KIDNEY DISEASE of normal uromodulin by the renal kidney, ureters, and bladder
tubules and increased uric acid Type of Composit Risk factors Urine pH Urinalysis Clinical
causing gout renal ion Findings relevance
NEPHROGENIC DIABETES Inherited defect of tubular stone
INSIPIDUS response to ADH or acquired from Calcium Calcium Hypercalciuria, Acidic or Calcium Most
medications oxalate Oxalate hyperoxaluria, neutral oxalate common
RENAL GLUCOSURIA Inherited autosomal recessive trait stones low citrate crystals stone type;
levels, (envelope associated
RENAL DISEASE: INTERSTITIAL dehydration or with
DISORDER ETIOLOGY dumbbell metabolic
shaped) disorders
CYSTITIS Ascending bacterial infection of
like
the bladder
hypercalciu
ACUTE PYELONEPHRITIS Infection of the renal tubules and
ria
interstitium related to interference
High oxalate Hematuria
of urine flow to the bladder, reflux
intake (spinach,
of urine from the bladder, and
nuts),
untreated cystitis
gastrointestinal
CHRONIC PYELONEPHRITIS Recurrent infection of the renal
disorders
tubules and interstitium caused by
structural abnormalities affecting Calcium Calcium Hypercalciuria, Alkaline Calcium Common in
the flow of urine Phosphat Phosphat renal tubular phosphate conditions
ACUTE INTERSTITIAL NEPHRITIS Allergic inflammation of the renal e Stones e acidosis, crystals causing
interstitium in response to certain alkaline urine, high urine
medications hyperparathyroi calcium and
dism alkaline
urine
RENAL DISEASE – SUMMARY Struvite Magnesi Urinary tract Alkaline Triple Associated
Renal Disorder Significant UA Findings stones um infections with phosphate with UTIs,
Acute Glomerulonephritis Hematuria, RBC cast, moderate (infection ammoniu urease- crystals often large
proteinuria, dysmorphic RBCs, stones) m producing (coffin-lid and may
granular casts, leukocyturia phosphat bacteria shaped) form
Chronic Glomerulonephritis Hematuria, heavy proteinuria, e (Proteus staghorn
broad and waxy casts, granular Klebsiella) calculi
casts, decreased urine specific Chronic UTIs, Alkaline
gravity bladder urine pH
dysfunction (>7.5)
Uric Acid Uric Acid Gout, High- Acidic Uric acid Common in
Stones purine diet (red (<5.5) crsytals conditions
meat, seafood), (rhomboid with high
dehydration, or rosette- uric acid,
chemotherapy shaped, including
yellow- gout and
brown) tumor lysis
syndrome
Hyperuricosuria Acidic urine
, obesity pH (<5.5)
Cystine Cystine Cystinuria Acidic Cystine Rare,
Stones (inherited crystals caused by
disorder of (hexagonal) genetic
amino acid disorder;
transport) typically,
recurrent if
untreated
Genetic Acidic urine
predisposition pH
dehydration

TEST YOURSELF:
1. Immune complex deposition from systemic disorders - Acute
Glomerulonephritis
2. Attachment of cytotoxic antibody - Good pasture Syndrome
3. Antineutrophilic cytoplasmic antibody is diagnostic for – Wegener
Granulomatosis
4. Thickening of glomerular membrane following IgG immune
complex deposition - Membranous Glomerulonephritis
5. Disruption of podocytes occurring primarily in children – Minimal
Change Disease
6. Inherited in association with cystinosis & Hartnup disease – Fanconi
Syndrome
7. Inherited defect of tubular response to ADH - NEPHROGENIC
DIABETES INSIPIDUS
8. Ascending infection of the bladder - Cystitis
9. Allergic inflammation of the renal interstitium - ACUTE
INTERSTITIAL NEPHRITIS
10. Septicemia causes what type of renal failure – Pre-renal