URINALYSIS Physical appearance of urine are noted, and the urine chemistries are performed using a reagent strip
(dipstick), with pads that change color ("Multistix" or "Chemstrip³ or ³ChoiceLine´). Appearance -yellow color of concentrated urine is due to "urochrome"; -amber urine: conjugated bilirubin -Red urine: hemoglobin, myoglobin, porphyria, drugs (phenolphthalein, deferoxamine, some phenothiazines), beets (in the diet) -Smoky/brown urine: altered blood (acid hematin), alkaptonuria (turns brown on standing), rhubarb (alkaline urine), cascara (some people) -Dark orange urine: drugs (pyridium, rifampin, others) -Bright blue urine: drugs (methylene blue, others) -Fluorescent yellow: vitamins. -Foamy urine: proteinuria, conjugated bilirubin, pyridium -Turbid/cloudy urine: WBC's, urates, phosphates
Specific gravity uses a hygrometer, refractometer, or osmometer (best, but expensive ), or an electrolyte-sensitive pad on some "dipstick" reagent strips. (The strips really measures ionic strength, and is fairly accurate. Specific gravity osmolality. Falsely elevated with radiocontrast media or high glucosuria. - Hyposthenuria: specific gravity <1.007 diabetes insipidus, fluid loading. -Isosthenuria: sp gr fixed at 1.010 as in renal tubular diseases e.g. tubulointerstitial nephritis, polycystic kidneys, pyelonephritis pH - color change of an indicator on the reagent strip. Urine pH reflects metabolic adjustments, and checking urine pH can detect renal tubular acidosis. Normally, urinary pH rises after a meal (alkaline tide) because the parietal cells of the stomach pump alkali into the bloodstream. Strongly alkaline urine usually indicates urea-splitting by bacteria like Proteus and Morganella sp.
Protein This is measured using the protein error of indicators. Normal adults lose <150 mg/24 hr. Dipstick approximations: negative... 0-50 mg/dL trace... 50-150 mg/dL 1+... 150-300 mg/dL 2+... 300-1000 mg/dL 3+... 1-3 gm/dL 4+... >3 gm/dL False positives for protein are caused by highly alkaline or highly buffered urine. Hemoglobin and vaginal secretions are also sources of protein. Proteinuria is the single most sensitive indicator of most renal disease, though not specific. Postural proteinuria (also called orthostatic): 3-5% of healthy young adults pass excess protein during the day, not at night. Functional proteinuria: occurs with fever, cold exposure, stress, pregnancy, eclampsia, CHF, shock, severe exercise (persists up to 3 days following). Bence Jones globulin: plasma cell myeloma, macroglobulinemia, lymphoma. Reagent strips may miss light chain proteins. Ask for a urine protein electrophoresis.
Glucose - uses glucose oxidase ; very sensitive and specific. False negatives can result from megadose vitamin C. Strong falsepositives will result in the presence of hypochlorite bleach or detergent. Ketones (2 of 3 types measured - acetoacetic acid and acetone; strips do not detect beta-hydroxybutyrate) The reagent strip uses the nitroprusside reaction. Many fasting/starving people have some ketones in the urine. Large amounts indicate diabetic ketoacidosis or aspirin poisoning. Blood The reagent strips detect peroxidase from blood, and are as sensitive as microscopy. Hematuria is "microscopic" if the urine isn't red but the urinary sediment contains > 5 red cells per high power field. Urine becomes grossly blood tinged at > 50 rbc/hpf. False Positives also result from hemoglobinuria (intravascular hemolysis), and myoglobinuria (crush injury, electrocution, rhabdomyolysis) and Hypochlorite bleaches. False negatives result from megadose vitamin C or formaldehyde. Hematuria is an important sign of glomerulonephritis, stones, tumors, TB, endocarditis, coagulopathy, UTI, vasculitis, schistosomiasis, leptospirosis, etc.
Nitrite The presence of nitrite suggests bacterial action. The reagent strips detect nitrite by its reaction with an azo dye. Infection may be defined as: > 105 colony-forming units / mL of clean-catch voided urine > 104 colony-forming units / mL of catheter-obtained voided urine > 103 colony-forming units / mL of urine obtained by suprapubic aspiration Bilirubin The reagent strips detect conjugated bilirubin by a diazo reaction. False negatives result from delay in testing the urine (the bilirubin-glucuronic acid bond breaks) or certain drugs. Urobilinogen uses Ehrlich aldehyde reaction. Urobilinogen is colorless and very labile in acid pH or light, and the reaction is not analytically specific. Increased levels may screen for hemolysis (but other tests for hemolysis are much more sensitive and specific), or hepatocyte dysfunction. Leukocyte alkaline esterase - on some reagent strips detects polymorphonuclear wbc in UTI patients; uses protein sulfosalicylic acid test. False-positives result from radiocontrast media.
MICROSCOPIC URINALYSIS Shake the urine, pour some into a test tube, spin it down (2000 rpm), decant supernate and resuspend the sediment in 1 mL of urine. Look at the sediment at high power using phase microscopy or polarized light. Use the supernatant for Bence-Jones protein determination, electrophoresis, sugar chromatography, etc. Red blood cells -appear as 7 micron pale discs. Hypertonic urine crenates -them, & hypotonic urine makes them swell. Normally 1-2/hpf. -In glomerular hematuria only, red cells are likely to show certain dysmorphic features (acanthocytes, stomatocytes). Best appreciated with a phase-contrast microscope. Polymorphonuclear leukocytes Granular spheres ("glitter cells"), 12 microns across. 10 or more WBC/mm3 of urine indicate UTI, especially when the history and physical exam positive. Renal tubular cells - cuboidal cells, seen in renal tubular disease (pyelonephritis, ATN). Lipid-laden cells - tubular cells plus absorbed lipids (cholesterol esters polarize as Maltese crosses triglycerides require fat stain) indicative of nephrotic syndrome or diabetic nephropathy.
Other cells -Transitional cells (if bladder CA suspected, send urine for cytology), squamous cells (vaginal secretion), sperms, trichomonads, - Eosinophils are easy to see if you use Wright's stain or Hansel's stain; > 5% eosinophils suggests acute allergic interstitial nephritis. Bacteria ± estimated as rare, moderate or abundant; increased with longstanding urine Casts - precipitated protein and matrix secretion (Tamm-Horsfall mucoprotein) from ascending loop of Henle and distal convoluted tubules. Casts form when there is slow flow of concentrated, acidic urine in the nephron. All cellular casts undergo degeneration to granular/waxy casts Hyaline casts: normal find. Excess number is "cylindriuria³ , no real significance. WBC casts: acute pyelonephritis (sometimes, lupus or other interstitial nephritis) RBC casts: nephritic syndrome or necrotizing glomerulonephritis Granular casts (coarse or fine): like hyaline, may have little significance Epithelial cell casts: think of tubulointerstitial disease Fatty casts (i.e., fat within tubular epithelium) - nephrotic syndrome. Waxy and broad casts: seen in advanced renal disease or CRF.
Acid urine: - calcium oxalate (octahedrate): vitmn C megadose, ileitis, ethylene glycol poisoning, or high vegetarian diet -cystine (colorless hexagons): cystinuria with or without stones -uric acid (brick dust, rhomboids, hexagons, square plates): normal but if numerous, think of gout or leukemia -leucine (bicycle wheels) and tyrosine (sheaves): severe liver -sulfa drugs: birefringent crystals may appear in the urine. Alkaline urine: - magnesium ammonium phosphate ("triple phosphate", "struvite"; "coffin lids"): infection with urea splitting bacteria *ammonium biurate ("thorn apples"): same significance as struvite *calcium phosphate (amorphous dust): no real significance except in stone disease
MEN: 1. Retract foreskin (if not circumcised). 2. Cleanse the urethral opening with a single stroke directed from the ring of the glans toward the tip. 3. Void into the toilet and interrupt the stream after about 3 seconds to collect urine into the supplied container. 5. Close the container, complete information on label, and attach it to the specimen container. WOMEN: 1. While seated on the toilet spread the outer folds (labia majora). 2. Wipe the inner side of one inner fold (labium minor) by using a single stroke from front to back with clean moist tissue or towelette. Repeat on the opposite side 3. Also cleanse urethral (urinary) opening with a single front-to-back stroke. 4. Void into the toilet and continue to void, but interrupt stream to collect urine into the supplied container. 5. Close the container, complete information on the label, and attach it to the specimen container.