A class on urine analysis and its interpretation
- 3. What is Urinalysis? ■It provides information about: – The state of the kidney and urinary tract. – Metabolic or systemic (non-kidney) disorders. ■Urinalysis can reveal diseases that have gone unnoticed because they do not produce striking signs or symptoms. – Examples include diabetes mellitus, various forms of kidney failure, and chronic urinary tract infections.
- 4. Specimen Collection – Spontaneous Voiding – Ureteral catheterization – Percutaneous bladder puncture – Analyzed within 2 hours of collection
- 5. Collection of urine ■Early morning sample-qualitative ■Random sample- routine ■24hrs sample- quantitative ■Midstream sample-UTI ■Post prandial sample-D.M
- 6. 24 hour urine sample 1. For quantitative estimation of proteins 2. For detection of AFB in urine 3. For detection of microalbuminuria
- 7. −Macroscopic Examination −Chemical Analysis (Urine Dipstick) −Microscopic Examination −Cytological Examination Types of Analysis
- 8. Macroscopic urinalysis Is the direct visual observation of the urine, noting its quantity, color, clarity or cloudiness, etc Normal urine is typically light yellow and clear . Obvious abnormalities in the color, clarity, and cloudiness may suggest possibility of an infection, dehydration, blood in urine, liver disease, break down of muscle or red blood cells in the body.
- 9. Odor: − Ammonia-like: (Urea-splitting bacteria) − Foul, offensive: Old specimen, pus or inflammation − Sweet: Glucose − Fruity: Ketones − Maple syrup-like: Maple Syrup Urine Disease Color: − Colorless Diluted urine − Deep Yellow Concentrated Urine, Riboflavin − Yellow-Green Bilirubin / Biliverdin − Red Blood / Hemoglobin − Brownish-red Acidified Blood (Acute GN) − Brownish-black Homogentisic acid (Melanin)
- 10. Turbidity: − Typically cells or crystals. − Cellular elements and bacteria will clear by centrifugation. − Crystals dissolved by a variety of methods (acid or base). − Microscopic examination will determine which is present.
- 12. Chemical Analysis Urine Dipstick Glucose Bilirubin Ketones Specific Gravity Blood pH Protein Urobilinogen Nitrite Leukocyte Esterase
- 13. Negative Trace (100 mg/dL) + (250 mg/dL) ++ (500 mg/dL) +++ (1000 mg/dL) ++++ (2000+ mg/dL) The Urine Dipstick: Glucose Glucose + 2 H2O + O2 ---> Gluconic Acid + 2 H2O2 Glucose Oxidase 3 H2O2 + KI ---> KIO3 + 3 H2O Horseradish Peroxidase Chemical Principle Read at 30 seconds RR: Negative
- 14. Significance – Diabetes mellitus. – Renal glycosuria. Limitations – Interference: reducing agents, ketones. – Only measures glucose and not other sugars. – Renal threshold must be passed in order for glucose to spill into the urine Uses and Limitations of Urine Glucose Detection
- 15. Negative + (weak) ++ (moderate) +++ (strong) The Urine Dipstick: Bilirrubin Bilirubin + Diazo salt ---------> Azobilirubin Acidic Chemical Principle Read at 30 seconds RR: Negative
- 16. Significance - Increased direct bilirubin (only conjugated bilirubin is passed in urine) Limitations - Interference: prolonged exposure of sample to light - Only measures direct bilirubin--will not pick up indirect bilirubin(hemolysis) - presence of bilirubin in urine not very sensitive for detecting liver disease - Serum test for total and direct bilirubin is more informative Uses and Limitations of Urine Bilirrubin Detection
- 17. Negative Trace (5 mg/dL) + (15 mg/dL) ++ (40 mg/dL) +++ (80 mg/dL) ++++ (160+ mg/dL) The Urine Dipstick: Ketones Acetoacetic Acid + Nitroprusside ------> Colored Complex Chemical Principle Read at 40 seconds RR: Negative
- 18. Significance - Diabetic ketoacidosis - Prolonged fasting Limitations - Interference: expired reagents (degradation with exposure to moisture in air) - Only measures acetoacetate not other ketone bodies (such as in rebound ketosis). Uses and Limitations of Urine Ketone Detection
- 19. 1.000 1.005 1.010 1.015 1.020 1.025 1.030 X+ + Polymethyl vinyl ether / maleic anhydride ---------------> X+ -Polymethyl vinyl ether / maleic anhydride + H+ H+ interacts with a Bromthymol Blue indicator to form a colored complex. Chemical Principle Read up to 2 minutes RR: 1.003-1.035 The Urine Dipstick: Specific Gravity
- 20. Significance - Diabetes insipidus Limitations - Interference: alkaline urine - Does not measure non-ionized solutes (e.g. glucose,urea,albumin) Other Tests - Refractometry - Hydrometer Uses and Limitations of Urine Specific Gravity
- 21. Negative Trace (non-hemolyzed) Moderate (non-hemolyzed) Trace (hemolyzed) + (weak) ++ (moderate) +++ (strong) The Urine Dipstick: Blood Diisopropylbenzene dihydroperoxide + Tetramethylbenzidine ------------> Colored Complex Heme Chemical Principle Lysing agent to lyse red blood cells Read at 60 seconds RR: Negative
- 22. Significance - Hematuria (nephritis, trauma, etc) - Hemoglobinuria (hemolysis, etc) - Myoglobinuria (rhabdomyolysis, etc) Limitations - Interference: reducing agents, microbial peroxidases - Cannot distinguish between the above disease processes Other Tests - Urine microscopic examination - Urine cytology Uses and Limitations of Urine Blood Detection
- 23. 5.0 6.0 6.5 7.0 7.5 8.0 8.5 The Urine Dipstick: pH H+ interacts with: Methyl Red (at high concentration; low pH) and Bromthymol Blue (at low concentration; high pH), to form a colored complexes (dual indicator system) Chemical Principle Read up to 2 minutes R.R.: 4.5-8.0
- 24. Significance - Acidic : metabolic acidosis, high-protein diet - Alkaline : renal tubular acidosis (>5.5), diuretic therapy, vomiting, gastric suction Limitations - Interference: bacterial overgrowth (alkaline or acidic), eg. Urea splitting organism causes a very alkaline urine Uses and Limitations of Urine pH Detection
- 25. Negative Positive The Urine Dipstick: Nitrite Diazo compound + Tetrahydrobenzoquinolinol ----------> Colored Complex Nitrite + p-arsenilic acid -------> Diazo compound Acidic Chemical Principle Read at 60 seconds RR: Negative
- 26. Significance - Gram negative bacteriuria Limitations - Interference: bacterial overgrowth - Only able to detect bacteria that reduce nitrate to nitrite - Correlate with leukocyte esterase ,Urine microscopic examination (bacteria), Urine culture Uses and Limitations of Nitrite Detection
- 27. Negative Trace + (weak) ++ (moderate) +++ (strong) The Urine Dipstick: Leukocyte Esterase Derivatized pyrrole amino acid ester ------------> 3-hydroxy-5-phenyl pyrrole Esterases 3-hydroxy-5-phenyl pyrrole + diazo salt -------------> Colored Complex Read at 2 minutes RR: Negative Analytic Sensitivity: 3-5 WBCs Chemical Principle
- 28. Significance - Pyuria - Acute inflammation - Renal calculus Limitations - Interference: oxidizing agents, menstrual contamination Uses and Limitations of Leukocyte Esterase Detection
- 29. Preservation - Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp. - Refrigeration for up to 48 hours (little loss of cells). Specimen concentration - Ten to twenty-fold concentration by centrifugation. Types of microscopy - Phase contrast microscopy - Polarized microscopy - Bright field microscopy with special staining (e.g., Sternheimer-Malbin stain) Microscopic Examination General Aspects
- 30. High urine conc. and low pH help preserve formed elements So a first void morning specimen is preferable
- 31. Microscopic Examination Per High Power Field (HPF) (400x) – > 3 erythrocytes – > 5 leukocytes – > 2 renal tubular cells – > 10 bacteria Per Low Power Field (LPF) (200x) – > 3 hyaline casts or > 1 granular cast – > 10 squamous cells (indicative of contaminated specimen) – Any other cast (RBCs, WBCs) Presence of: – Fungal hyphae or yeast, parasite, viral inclusions – Pathological crystals (cystine, leucine, tyrosine) – Large number of uric acid or calcium oxalate crystals Abnormal Findings
- 32. Hematuria ■ Transient hematuria - relatively common in young subjects, not indicative of disease ■ Persistant hematuria- gross or microscopic – Morphology is important, usually uniform and round with extrarenal bleeding – Dysmorphic appearance with renal lesions, I.e. blebs, budding, segmental loss of membrane
- 38. ETIOLOGY ✓Diseases of the urinary system—the most common cause Vascular arteriovenous malformation arterial emboli or thrombosis arteriovenous fistula nutcracker syndrome renal vein thrombosis coagulation abnormality excessive anticoagulation
- 39. Glomerular IgA nephropathy thin basement membrane disease (incl. Alport syndrome) other causes of primary and secondary glomerulonephritis Interstitial allergic interstitial nephritis analgesic nephropathy renal cystic diseases acute pyelonephritis tuberculosis
- 40. Uroepithelium malignancy vigorous exercise trauma papillary necrosis cystitis/urethritis/prostatitis(usually caused by infection) parasitic diseases (e.g. schistosomiasis) nephrolithiasis or bladder calculi Multiple sites or source unknown hypercalciuria hyperuricosuria
- 41. --Approach to the patient– HEMATURIA proteinuria (>500mg/24h) Dysmorphic RBC or RBC casts Pyuria,WBC casts urine culture eosinophils serologic and hematologic evaluation: blood culture, anti-GBM Ab, ANCA, complement, cryoglobulin HBV,HCV,VDRL,HIV, ASLO renal biopsy Hb electrophoresis, urine cytology, UA of family member, 24h urinary calcium/uric acid IVP+/-renal ultrasound As indicated: retrograde pyelography or arteriogram of cyst aspiration cystoscopy CT scan biopsy open renal biopsy follow (-) (-) (-) (-) (-) (-) (+) (+) (+) (+) (+) ANCA:antineutrophil cytoplasmic antibody, VDRL:venereal dis. research laboratory, ASLO: antisteptolysin O, IVP: intravenous pyelography
- 42. Pyuria ■White cells are larger than red cells, granular cytoplasm and multilobed nuclei ■Pyuria alone usually indicated infection ■Less diagnostic value when seen with other elements such as cellular casts, and/or proteinuria ■Eosinophils may indicate allergic interstitial nephritis, cholesterol emboli disease ■Lymphocytes seen in disorders associated with infiltration of kidney by lymphocytes, such as chronic tubulointerstitial disease
- 47. Microscopic Examination Oval Fat Body
- 48. Bacteria - Bacteriuria More than 10 per HPF Yeasts - Candidiasis Most likely a contaminant but should correlate with clinical picture. Viruses - CMV inclusionsProbable viral cystitis. Microscopic Examination Bacteria & Yeasts
- 53. Casts ■Conform to the shape of the renal tubule in which they form ■Organic matrix composed mostly of Tamm-Horsfall mucoprotein ■Types of casts: hyaline, red cell, white cell, epithelial, granular, waxy, broad
- 54. Erythrocyte Casts: Glomerular diseases Leukocyte Casts: Pyuria, glomerular disease Degenerating Casts: - Granular casts Nonspecific (Tamm-Horsfall protein) - Hyaline casts Nonspecific (Tamm-Horsfall protein) - Waxy casts Nonspecific - Fatty casts Nephrotic syndrome (oval fat body casts) Microscopic Examination Casts
- 55. Theory of Casts Genesis
- 56. Microscopic Examination RBCs Cast - Histology
- 58. Microscopic Examination RBCs Cast - Histology
- 66. ©2005 UpToDate ® e-mail this to a colleague
- 68. Bacterial Casts Single Leukocytes Leukocyte Casts Single Erythrocytes Erythrocyte Casts Single Bacteria Significance of Cellular Casts
- 69. - Urate Ammonium biurate Uric acid - Triple Phosphate - Calcium Oxalate - Amino Acids Cystine Leucine Tyrosine - Sulfonamide Microscopic Examination Crystals
- 75. Microscopic Examination Calcium Oxalate Crystals
- 76. Microscopic Examination Calcium Oxalate Crystals Dumbbell Shape
- 77. Microscopic Examination Triple Phosphate Crystals
- 81. Microscopic Examination Ammonium Biurate Crystals
- 84. Common Findings in: Acute Tubular Necrosis Decreased + / - + / - Microscopic: • Renal tubular epithelial cells • Pathological casts Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen
- 85. Increased Increased Microscopic: • Erythrocytes (dysmorphic) • Erythrocyte casts • Mixed cellular casts Common Findings in: Acute Glomerulonephritis Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen
- 86. Decreased Increased Increased Common Findings in: Chronic Glomerulonephritis Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen Microscopic: • Pathological casts (broad waxy casts, RBCs)
- 87. Trace Positive Positive Microscopic: • Bacteria • Leukocytes • Leukocyte, granular, and waxy casts • Renal tubular epithelial cell casts Common Findings in: Acute Pyelonephritis Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen
- 88. ++++ Microscopic: • Oval fat bodies • Fatty casts • Waxy casts Common Findings in: Nephrotic Syndrome Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen
- 89. + Common Findings in: Eosinophilic Cystitis Microscopic: • Numerous eosinophils (Hansel’s stain) • NO significant casts. Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen
- 90. Common Findings in: Urothelial Carcinoma Microscopic: • Malignant cells on urine cytology (urine sample should be submitted separately to cytology, void or 24 hrs.) Glucose Bilirubin Ketones S.G. Blood pH Protein Nitrite L.E. Urobilinogen +
- 91. THANK YOU