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162 Cards in this Set
- Front
- Back
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Urinalysis is... |
-essential procedure for indivudals being admitted to the hospital or pre-surgical pts
-intergral part of PE -useful indication of a healthy or diseased state -part of routine OB checks |
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Urine is...
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-readily available
-easily collected -provides info about metabolic functions |
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Urine is diagnostic for...
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-abdominal or back pain
-dysurea -hematurea -frequency/urgency |
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Value of Urine Testing...
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-evaluates metabolic problems and other diseases (monitors/detects dz specific metabolites excreted in the urine)
-evaluates condition of the kidney/urinary tract -evaluates endocrine problems |
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How can urine evaluate endocrine problems?
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-hormones produced in the kidney that can be detected
-hormones produced outside the kidney can effect its function -hormones excreted by the kidney in some form -evaluates fcn (physiology) and structure (anatomy) |
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Urinary Tract/Kidney functions
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-removel of waste products via blood filtering and active secretion from the blood (nitrogenous waste, metabolic acid waste)
-retention of substanced that the body needs -maintenance of acid/base balance -maintenance of water and electroyte balance and BP (RAAS and ADH) -hormone synthesis and regulation (renin, eryhhtropoetin, vitamin D are sctivated by the kidney) |
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Glomeruli
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-removal of meterials that need to be excreted
-prevent loss of proteins and cells into urine |
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Tubules
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-reabsorb solutes that need to be conserved
-regulate Na,K, bicarb -excrete/preserve H+ as needed |
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Collecting Ducts
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-regulate the amount of water conserved or exccreted
-urine concentrated here |
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Composition of normal urine:
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-water
-organic wastes (urea, creatinine, uric acid) -inorganic wastes (chloride, sodium, potassium, ammonia, H+) -miscellaneous - hormones, vitamins, smaller peptides, AA, trace urobilinogen, some crystals, vaginal contaminiation) |
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Composition of Urine in Disease:
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-cells (RBC, WBC, renal epithelial)
-casts, protein -mucous, bacteria -glucose, bilirubin, increased or decreased urobilinogne, ketones, lipids -pathological crystals |
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Renal Tests
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-examination of urine
-examination of blood to measure substances affected by renal function (BUN, Creatinine) -Dynamic measurement of blood flow, urine formation, and substance excretion |
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Urine Volume: Normal Adult
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600-2500 mg/24 hours
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Urine Volume: anuria
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<100 mg/24 hours
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Urine Volume: oliguria
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<200 ml/24 hours
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Urine Volume: polyurea
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>2500 ml/24 hours
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Types of urine specimens
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-random
-first AM void -clean-catch -mid-stream -catheter collection -supra-pubic aspitation |
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Routine urinalysis includes:
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-physical exam of urine specimen
-chemical testing/screening -microscopic exam of sediment |
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Standard Urinalysis includes:
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-color/appearance
-pH -specific gravity -protein -glucose -ketones -WBCs -hemoglobin -bilirubin -urobilinogen -nitrates -microscopic evaluation of sediment if needed |
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Color of urine: normal
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amber, clear
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Color of urine is due to...
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pigement urochrome
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Color of urine is affected by...
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foods, meds, dyes, blood
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Urine color: Red
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-blood
-should be considered pathologic until proven otherwise -most common cause is menstrual blood -tumor, trauma, stones, infection |
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Urine color: brown
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-melanin
-blood |
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Urine color: dark orange
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-bile
-pyridium |
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Urine Color: pink
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-urates
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Dark urine
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-sweating
-fever -dehydration -jaundice |
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Colorless urine
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-drug therapy (diuretics)
-overhydration -diabetes insipidis -glycosurea |
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normal clarity of urine..
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clear to slightly hazy
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Cloudy urine:
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-alkaline urine from phosphates, carbonates
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Tubidity of urine:
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-mucus, WBCs, semen
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Specific gravity
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-relative proportaion of dissolved solid components to total volume of urine
-compares weight of urine to weight of distilled water (has specific gravity of 1.000) -used to evaluate concentrating and excreting power of the kidney |
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Specific gravity can be measured by...
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-refractometer
-reagent strip -urinometer |
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Specific Gravity: Normal range
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1.005 - 1.030
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Low specific gravity may indicate...
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-dilute urine
-diabetes indipidis -glomerulonephritis -pyelonephritis |
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High specific gravity may indicate...
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-concetrated urine
-adrenal insufficiency -hepatic disease -CHF -high solutes (glucose, protein) -dehydration (vomiting0 |
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Osmolarity
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-number of particles of solute per unit of solution
-more exact measure of concentration |
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Urinalysis: pH
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-measurement of hydrogen ion concentration
-reflects works of the kidneys to maintain normal pH homeostasis -useful for evaluation and identification of crystals and predisposition to kidney stones |
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What helps the body maintain a normal acid/base balance?
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-tubular sodium reabsorption and secretion of H+ and ammonium ion
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pH normal range
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4.5-8.0 (usually 5-6)
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Acidic pH
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<7.0
-mediciations -systemic acidosis -uncontrolled diabetes -starvation |
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Alkaline pH
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->7.0
-medications (streptomycin, neomycin, kanamycin) -UTI |
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Urinalysis: Blood
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-normally, no blood in urine
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Urinalysis: Hematuria
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-intact red blood cells in the urine
-lower UTI, lupus, strenuous exercise, anticoagulants, stones, hemophilia, glomerulonephritis, trauma, menstruation, CA |
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Urinalysis: Hemaglobinurea
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-free hemoglobin in the urine
-burns, crush injuries, transfusion reactions, malaria |
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Leukocyte Esterase
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-INDIRECT test that detects the presence of WBCs and indirectly the presence of infection (specifically UTI)
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Leukocyte esterase: normal
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negative
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Leukocyte esterase: sensitivity/specificity
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sensitivity: 76-95%
specificity: 65-95% |
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Nitrite
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-indirect test for bacteruria (usually UTI)
-most gram negative bacteria will reduce nitrate to nitrite |
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Nitrite: normal
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negative
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What bacteria do not convert nitrate to nitrite?
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staph and strep (gram positive)
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Does negative nitite test indicate that there is NO UTI?
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NO, it does not necessarily mean that there is no UTI
-it takes time for the conversion from nitrate to nitrite so it make get flushed out before it converts AND many gram positives do not convert nitrate to nitrite |
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What specimen would be best for nitrite?
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-first morning void (long bladder incubation)
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Ketones
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-formed from metabolism of FFA and fat
-consist of 3 substances: beta-hydroxybuteric acid, acetoacetic acid, acetone |
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ketoacidosis occurs when...
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carbohydrate metabolism is altered and fat becomes the predominant fuel
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Causes of ketourea...
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-diabetes (most common)
-high fat/low carb, or high protein diets -starvation -prolonged vomiting -glycogen storage diseasee -increased metabolic states (hyperthyroidism, pregnancy, lactation, acute illness, stress, fever) |
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Who is particularly prone to developing ketourea?
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children
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Ketones: sensitivity
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5-10 mg/dl
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Ketones: false negatives d/t
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-drugs
-high Sg low pH urine |
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Most chemical tests for ketones employ which reagant?
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nitroprusside reagant
reacts with acetoacetic acid in urine but not with the other consituents (beta hydroxybuteric acid, acteone) |
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Bilirubin
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formed from breakdown of hemoglobin
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unconjugated bilirubin
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-indirect bilirubin
-linked to albumin -water insuluble -NOT found in urine |
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conjugated bilirubin
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-direct bilirubin
-water solubale -may be found in urine -conjugated in liver and excreted in bile |
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Increased bilirubin levels are secondary to ....
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biliary tract obstruction
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2 types of biliary obstruction:
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1. extrahepatic
2. intrahepatic |
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Extraheptatic obstruction
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-common duct obstruction
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Intrahepatic obstruction
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-liver cell injury such as cirrhosis or viral hepatitis
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What color does Bilirubin color the urine?
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dark orange
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Bilirubin: normal
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negative
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bilirubin presence may indicate...
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liver disease
galls stones drug toxicity |
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Is there increased unconjugated bilirubin in the urine for hemolytic disease?
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NO, increased levels are NOT found
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Urobilinogen
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formed by the breakdown of bilirubin in the intestine (some reabsorbed by the portal system and removed by the liver)
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Urobilinogen: normal
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0.1-1.0 Ehrlich units/ml
1-4 mg/24 hours |
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causes of increased urobilinogen..
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-hemolytic anemia
-pernicious anemia -hemolysis d/t drugs -hematoma -excessive ecchymosis |
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Causes of decreased urobilinogen...
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-biliary obstruction
-cholestasis (gall stones) |
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Urobiulinogen: sensitivity
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one of the most sensitive tests to show impaired liver function and one of the earliest signs of acute liver cell damage
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Protein: normal
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negative or trace
1-14 mg/24 hours |
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Urine protein consists of...
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1/3 albumin
2/3 globulins |
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Increased proteins suggests..
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renal disease
if more than trace protein found in urine, it must be reconfirmed by a second sample or 24 hour collection |
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Severe loss of protein in urine results in...
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hypoproteinemia
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Hypoproteinemia results in...
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edema
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hypoproteinemia + edema =
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nephretic syndrome
(losses of greater than 3000 mg/24 hours) |
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Qualitative protein collection
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-random sample collected tested by reagent strip or by chemical analysis
negative trace (20 mg/dl) 1+ (50 mg/dl) 2+ (200 mg/dl) 3+ (500 mg/dl) 4+ (1 gm/dl) |
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Quantitative protein collection
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24 hours collection
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Protein in urine can be 1 of 3 types:
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1. pre-renal
2. renal proteinuria 3. post-renal proteainuria |
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Pre-renal proteinuria
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-not associated with primary renal disease
-fever or toxic conditions -venous congestion (HF, abd pressure/compression of renal veins) -renal hypoxia (severe dehydration, shock, severe acidosis, severe anemia) -HTN -myxedema -bence jones proteins |
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Renal proteinuria
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-renal disease
-glomerulonephritis -nephrotic syndrome -destructive parenchymal lesions (tumor, infection, infarct) |
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Post renal proteinuria
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-proetin added after the kidney
-cystitis -urethriris -prostatitis -contamination with vaginal secretions -infection of renal pelvis or ureter |
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Functional protein
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-not associated with easily demonstrated systemic or renal damage
-sever muscular exertion -pregnancy -fever |
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Bence Jones protein
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-immunogloblin light chains (small in easily fit through the membrane spaces)
-formed by plasma cells |
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Presence of BJ proteins indicates
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-multiple myeloma (found 75% of MM pts)
-bone tumor metastasis -Chronic lymphocytic leukemia -macroglobulinemia -amyloidosis |
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What can be used to detect Bence jones proteins?
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-sulfasalicylic acid
-diptick will NOT detect it |
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Protein Test methods
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1. heat with acetic acid
2. sulfasalicylic acid 3. dipstick 4. 24 hour |
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Sulfasalicylic acid test
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-to test protein
-detects as little as 10 mg/dl -will detect bence jones protein (globulins) -used series of standards and compares amount of precipitation to the known standard solution |
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Dipstick test
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-test for protein
-detects 20-30 mg/dl -will react with hemoglobin but little else interferes -false negatives if strip is left in the urine too long |
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24 hour urine measurements: Advantages
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-degree of concentration may influence results in a random UA but not with a 24
-individuals may vary with interpretation of random UA -results are far more accurate if properly done |
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24 hour urine measurements:
Disadvantages |
-incomplete sample collection
-inconvenient -methodologies vary between labs with poor reproducibility |
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Increases in Microalbumin suggest...
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-ongoing renal damage (usually associated with DM)
-HTN |
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Diabetic microalbumin =
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20-200 ug/min
OR 30-300 mg/24 hours found in 2 out of 3 samples collected within 6 months of each other |
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Types of glucose tests
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1. reduction test (clinitest)
2. enzyme test (glucose oxidase) |
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Reduction test (clinitest)
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-based on copper sulfate reduction by reducing substances (sugars)
-not glucose specific -may be affected by creatinine, uric acid, fructose -color change in test indicates presence of reducing substances |
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Enzyme test (glucose oxidase)
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-specific for glucose
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Microscopic exam
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-urine is centrifuged and a drop of teh sediment is examined under low power and high-dry objectives for:
-cellular elements (RBC, WBC, Epithelial cells) -casts -crystals -bacterial/protozoa |
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Casts
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-cylindrical masses of protein and or cells fromed in the renal tubules
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Crystals
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-often associated with stones
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Microscopic RBCs: normal
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0-3 per hpf
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Hematurea of renal origin is often assoicated with...
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casts or proteinurea
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Increased microscopic RBCs may indicate...
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-renal disease (stones, pyelonnephritis, cycstitis, prostatitis, malignancies)
-systemic disease (SLE, TB, Hemophilia, malignant HTN) -bleeding into the urinary tract (trauma, tumor, thrombocytopenia, ASA overdose) |
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RBC casts: normals
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0 per LPF (100x)
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RBC casts may have...
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-intact RBCs
-degenerated RBCs -homeglobin only |
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Presence of RBC casts incicates:
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-bleeding into to nephron and is ALWAYS PATHOLOGIC
-acute inflammatory or vascular disorders in the gllomerulus -acute glomeruloneprhitis -renal infarction -collagen disease -kidney involvement in subacute bacterial endocarditis |
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RBC and RBC casts casutions:
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-R/O presence of mentrual blood, vaginal bleeding, or perineal trauma
-some drugs can increase the number of RBC in urine -Heavy smokers may have persistant RBCs in urine |
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Microscopic WBCs: normal
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0-4 hpf
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WBCs may originate from...
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anywhere is the GU tract
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What test should be done in the presence of eleavted WBCs in the urine?
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urine culture
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What may contaminate the urine WBC specimen?
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vaginal discharge
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Increased WBC in urine may incdicate:
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>50/hpf indicated bacterial infection
-all renal disease -fever -strenuous exerise -bladder tumors -chonic pyelonephritis |
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WBC casts: normal
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o per lpf
may be difficular to identify |
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WBC casts always come from ...
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kidney
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Increased WBC casts indicates...
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-parencyhmal infection
-pyelonephritis (most common cause) -acute glomerulonephritis -intersitital inflammatio of the kidneys |
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3 types of Epithelial cells
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1. renal tubular
2. bladder epithelial cells 3. squamous epithelial cells |
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Renal tubular Cells
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-epithelial cell
-round and slightly larger than WBC -single nucleus -normal 0-2 per HPF -come from the kidney itself -associated with renal disease |
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Bladder epithelial cells
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-epithelial cells
-larger than renal tubular cells -shape varies from flar to columnar |
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Squamous epithelaial cells
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-epiethelial cell
-large flat irregular borders -single nucelus -come from bladder, urethra, vagina -common to have some in normal urine samples |
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How are Renal tubular cell casts formed?
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-formed from cast of epithelial cells that degenerate
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increase in renal tubular cell casts indicates...
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-tubular damage
-nephrosis -tubule necrosis -glomerulonephritis -heavy metal poisoning -salicylate intoxication |
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Urine Hylaine casts:normal
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0-2 per LPF
clear colorless casts |
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How are urine hylaine casts formed?
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-formed when Tamm-Horsfall protein in tubules precipitates and gels
-clear colorless casts |
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Presence or urine hylaine casts depends on...
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pH, flow rates, amount of protein
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Does the presnce of Urine hylaine casts represent kidney damage?
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It may or may not
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Increased urine hyaline casts indicates...
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-nephritis
-malignant HTN -chronic renal disease -diabetic nephropathy |
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Temporary increase in urine hylaine casts represents...
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-stress
-strenuous exercise -fever |
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Granular casts:normal
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0-2 per LPF
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Describe granular casts
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-homogenous
-granular -colorless -dense |
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Increased granular casts may indicate...
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-degeneration of epithelial cells
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Waxy casts: normal
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negative
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How are waxy casts formed?
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-from degenerating hylaine or granular casts collecting in the collecting tubules
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Describe waxy casts
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big broad casts formed in kidney
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Presence of waxy casts indicates...
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SERIOUS RENAL DISEASE!!
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Fatty casts:normal
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negative
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How are fatty casts formed?
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-in nephrotic syndome, fat accumulated in tubular cells and slughs off to form oval fat bodies or fatty casts
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Describe fatty casts
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-oval fat bodies
-fat droplets |
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Fatty casts are the hallmark sign of ...
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-nephrotic syndrome
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Urine crystals are identified by...
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-shape
-size -solubility characteristics -pH of urine |
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Urine cystals may indiacte...
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presence of stone
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are most crystals pathologic?
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No
also often present with no symtoms |
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Assessing renal functions
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-assess the dynamics of secretion, excretion, and osmolar regulation
-measure glomerular filtration rate |
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Glomerular Filtration rate
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-amount of fluid flwoing thorugh all glomeruli in a given period of time
-depends on blood flow, effective pressure across the glomerular capillary bed and tubular pressure |
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How is GFR measure?
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Creatinin Clearance test
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Creatinine clearance test
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-measures GFR
-creatinine is usaally 100% excreted in the first pass through the kidney -creatinine is a byproduct of muscle breakdown and is prodcued at a predictable rate -amount excreted is proportainal to muslce mass -disorders of the kidney prevent maximum excretion |
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Creatinine Clearance Test: normal
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Men 85-125 ml/min
Females 75-112 ml/min normals are age and sex dependent |
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Decreased creatinine clearance indicates...
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-impaired kidney function
-renal disease -glomerulonephtirits -shock -hemorrhage -CHF -hepatic failure |
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Increased creatinine clearance indicates...
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-high CO
-pregnancy -burns -CO poisening |
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Other renal test include..
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-BUN/Creatinine
-urine osmolality -radiologic and nuclear medicine procedures to assess blood and urine flow as well as function and structure of kidney |
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Urine pregnancy test
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-simple one step process for qualitative detection of human chorionic gonadiotropic (hCG)
-CLIA approved -had built in control to ensure it is working properly |
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Urine pregnancy test detection sensitivity:
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-detects as little as 25 mlU/ml
-detection is possible in as few as 7-10 days after conception |
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hCG
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-human chorionic gonadotropic hormone
-produced by developing placenta shortly after implantation |
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hCG levels:
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-100 mlU/ml by first missed period
-100,000-200,000 by the 1th to 12th wk of pregnancy |
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False negatives may be produced by...
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-hCG levels below sensitivity of the test
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False positives may be produced by...
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-trophoblastic diseasee and certain non-trophoblastic tumors
-testicular CA, prostate CA, breast CA, some lung CA |
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Other limitations of urine pregnancy test..
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-very dilute samples may not contain representitive levels of hCG
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Which void is best for pregnancy test?
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-first morning void
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