Urinalysis And Body Fluids

Front 1

Diagram of a kidney

Back 1

Front 2

Flow of urine through the nephron

Back 2

Glomerulus>proximal tube> descending/ascending Loop of Henle> distal and collecting tubules

Front 3

Nephron physiology

Back 3

1. Major functional unit of the kidney

2. Approximately 1 million nephrons per kidney

3. Each nephron is composed of glomerulus and renal tubules

Front 4

Glomerulus physiology

Back 4

1. Coil of capillary vessels

2. Glomerulus is a NON-SPECIFIC filter of plasma substances less than 70,000 MW

3. Glomerular filtrate is composed of water, glucose, electrolytes, amino acids, urea, uric acid, creatinine, and ammonia

4. Filters 120 ml/minute, or 1/5 of renal plasma

Front 5

Function of the proximal tubule

Back 5

1. Reabsorbs water, sodium chloride (salt), bicarbonate, potassium, calcium, amino acids, phosphates, protein and glucose

2. Glucose: threshold substance, reabsorbs at 160-180 mg/dl or less

3. Secretes sulfates, glucuronides, hydrogen ions and drugs

Reminder: there should be no glucose in urine!

Front 6

Fuction of descending loop of henle

Back 6

Reabsorbs water

No solutes reabsorbed

As the filtrate travels down the loop of henle, the filtrate becomes more concentrated.

Front 7

Function of ascending loop of henle

Back 7

1. Reabsorbs solutes (sodium, chloride, calcium, magnesium)

2. NO WATER REABSORBED

As filtrate travels back up the ascending loop of henle, it becomes less concentrated. The ascending loop is the only point in the whole process where water cannot go in our out of the tubules!!!

Front 8

Distal convoluted tubule

Back 8

PH regulation

Reabsorption and secretion of H+ ions

Front 9

Collecting tubules functions

Back 9

Final point of water regulation!!

The body utilizes hormones to regulate the amount of water in our body (ADH- anti-dieurtic hormone)

Diurese: the act of urinating

Front 10

Functions of distal and collecting tubules

Back 10

1. Reabsorbs sodium

2. Secretes potassium, ammonia, and hydrogen ions

3. Potassium ions exchanged for sodium ions

Front 11

Reabaorption and secretion photo

Back 11

Front 12

Hormones that influence urine output

Back 12

1. Aldosterone: electrolyte concentrations

2. Angiotensin: blood pressure

3. Anti-dieurtic hormone: water

The process of regulating the amount of urine secreted by the body is controlled by hormones that respond in fluctuations in electrolyte concentrations, blood pressure, and water concentrations

Front 13

Normal urine output

Back 13

0.5 liters- 1.5 liters per day OR

1200-1500 ml per day

Front 14

Polyuria

Back 14

Increased urine output

>2500 ml per day

Diseases/causes: diabetes insipidus and mellitus, dieuretics, caffine, alcohol, excessive water intake

Front 15

Oliguria

Back 15

Decreased urine output

<500 ml per day

Diseases/causes: dehydration, vomiting, diarrhea, burns, perspiration

Front 16

Anuria

Back 16

Complete cessation (no urine output, or just DROPS)

Diseases/causes: kidney damage, decreased blood flow to kidneys

Front 17

Nocturia

Back 17

Increased volume at NIGHT

Front 18

Urine composition

Back 18

1. Urea (non-protein nitrogen): metabolic waste product produced in liver from breakdown of protein, 1/2 total urinary dissolved organic solids

2. Other organic solids (non-protein nitrogens): uric acid, creatinine

3. Inorganic solids: chloride (primary constitute), sodium, potassium

4. Water

Front 19

Hormones: aldosterone

Back 19

Source: adrenal cortex

Action: increases rate of sodium reabsorption

Front 20

Hormones: Arginine Vasopressin (AVP)

Back 20

**previously called ADH**

Source: posterior pituitary gland

Action: reabsorption of water from distal tubules

Deficiency of AVP: diabetes insipidus

Diabetes insipidus- disorder of salt and water metabolism marked by intense thirst and polyuria

Front 21

Hormones: erythropoietin

Back 21

Source: kidney

Action: stimulates production of erythrocytes

Front 22

Urine Collection methods

Back 22

1. Random (clean catch): most common, easiest to collect

2. First morning: ideal screening specimen (most concentrated)

3. Midstream clean catch: clean external genetalia, specimen of choice for bacterial cultures

4. Cath: insertion of cath directly into bladder via urethra, avoids external contamination, but my introduce infection

5. Pediatric: sterile, plastic bag, bag checked every 15 minutes, many sources of contamination

6. Suprapubic aspiration: needle through abdomen directly into bladder, BEST specimen for bacterial culture, invasive procedure

Front 23

24 hour urine

Back 23

1. Collected over 24 hours

2. First specimen discarded while all others collected

3. Used for quantitative urine studies

4. Completeness of collection method monitored by creatinine levels (should be >1.0 mg/dl)

Front 24

Analysis of urines

Back 24

Analyze within 1 HOUR of collection

Front 25

Effects of prolonged sitting of specimens at room temperature

Back 25

Increased: nitrates (bacterial growth), pH ( urea converted to ammonia), turbidity

Decreased: glucose (glycolysis due to bacteria and yeast), ketones (exposure to air), bilirubin (exposure to light), urobilinogen, cells and casts (lysis)

Changes in color occur due to oxidation or reduction of metabolites

Front 26

Specimen preservation

Back 26

The best urine sample is freshly voided, midstream clean catch.

Freeze: okay for chemical analysis, NOT UA

Refrigerate: okay for UA, may have crystal formation, slows down bacterial growth

Chemically preserve: BEST, boric acid powder

Front 27

Refrigeration of urine

Back 27

Preservation method of choice! (Up to 24 hours)

May result in precipitation of amorphous crystals

After removal from fridge, let sample return to room temperature before testing (about 15 minutes)

Front 28

Physical examination: odor

Back 28

Not evaluated, but may provide clues

1. Fruity- ketones

2. Ammonia- old urine

3. "Mousy"- PKU (phenylketonuria)

4. Maple syrup- maple syrup disease

Front 29

Physical examination: clarity

Back 29

Normal urine is clear

Any of the urinary elements (cells, casts, crystals) or bacteria may make the urine cloudy

Front 30

Physical examination: color

Back 30

Normal urine is a pale yellow (straw) to yellow color

Urochrome gives urine its normal color

Urochromes or urobilin are products of RBC metabolism

Front 31

Physical examination: pH

Back 31

Normal urine is slightly acidic (6.0)

Random samples: 4.5-8.0

Post prandial sample (2 hours post eating) may be alkaline

When urine stands at room temperature for some time, ot becomes alkaline

1. Acidic: metabolic or respiratory acidosis, high protein diet, cranberry juice

2. Alkaline: vegetarian

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Color: Red

Back 32

Hemoglobin

Red blood cells

Myoglobin

Porphrin

Uroerythrin

Front 33

Color: Red-brown

Back 33

Hemoglobin

Red blood cells

Myoglobin

Front 34

Color: yellow-brown or yellow-green

Back 34

Bilirubin

Biliverdin

Front 35

Color: yellow-orange

Back 35

Bilirubin

Urobilin

Pyridium (drug)

Front 36

Color: bright yellow

Back 36

Vitamin C

Front 37

Color: dark yellow

Back 37

Concentrated specimen

Bilirubin

Urobilin

Front 38

Color: brown-black

Back 38

Methemoglobin (oxidized RBC)

Homogentistic acid (Alkaptonuria)

Melanin

Front 39

Color: blue

Back 39

Indican (Tryptophane Metabolic Disorder)

Methylene blue

Front 40

Color: green-blue

Back 40

Old urine

Pseudomonas

Front 41

Color: port wine

Back 41

Porphyrin

Front 42

Specific gravity

Back 42

1. Offers the simplest way to check concentration and dilutiom function of kidney tubules

2. Normal: 1.002-1.035

3. Specific gravity is directly proportional to color, the higher the specific gravity, to darker the urine

Exception: a pale color urine with high specific gravity is most likely due to glucose! Urine is diluted due to loss of concentrating ability by diabetics

Front 43

Highest specific gravity the kidneys can concentrate

Back 43

1.040

Higher values are due to either large amounts of glucose or radiographic dyes from renal x-ray procedures.

Reagent strips for specific gravity are NOT affected by radiographic dyes

Front 44

Diabetes insipidus vs. Mellitus

Back 44

Polyuria- excess urine output (>2500)

Polydipsia- excess thirst

Specific gravity:

DM- increased, remember the kidneys have a hard time reabsorbing glucose, and excess glucose causes increase specific gravity

DI- decreased (excess water, less concentrated solutes)

Front 45

Refractometer- TS

Back 45

Measure: refractive index

No temperature corrections

Correct for large amounts of protein and glucose

Corrections:

Glucose- subtract 0.004 per gram

Protein- subtract 0.003 per gram

Front 46

Specific gravity reagent strip

Back 46

Measures: indirect- colorimetric

pKa change of polyelectrolytes (relative to ionic concentration)

Front 47

Chemical analysis of UA

Back 47

Specific gravity, pH, blood, leukocytes, nitrite, protein, glucose, bilirubin, urobilinogen

Front 48

Protein

Back 48

Proteins are produced by tubules in the kidneys (uromodulin)

Smaller proteins (microalbumins) can pass through the glomerulus, but mostbprotein that passes through the glomerulus is reabsorbed.

Front 49

Protein on reagent strips

Back 49

Principle: "protein error of indicators"

Albumin in urine binds to dye, changing color from yellow to green

The reagent strip is more sensitive tl albumin than globulin

False positive: highly alkaline urine

Front 50

Proteinuria

Back 50

1. First indicator of RENAL DISEASE or dysfunction (not detected on reagent strips)

2. Multiple myeloma

3. Orthostatic proteinuria (benign condition resulting in proteinuria after standing)

4. Filtration problem (in glomerulus) or reabsorption problem

5. Strenous exercise

Front 51

Microalbuminuria

Back 51

Detected by sensitive albumin tests (level too low to be detected by routine reagent strip)

Periodic monitoring benefits patients with diabetes, hypertension, and peripheral vascular disease

Enables patients with low levels of albuminuria to begin treatment

Several commercial methods for screening

Front 52

Protein confirmation

Back 52

Confirmed by SSA (sulfosalicyclic acid)

The acidic pH of SSA denatures yhe structure of proteins, causing them to precipitate

A urine sample positive for protein goes from clear to cloudy with the addition of SSA

Front 53

Glucose

Back 53

Should NEVER be in urine!!

Essentially all glucose that enters the kidney is reabsorbed by the tubules

The kidneys have a glucose reabsorption threshold of about 175 mg/dl

Normal blood glucose is 110 mg/dl

Front 54

Glucose on reagent strips

Back 54

Specific for glucose ONLY

Principle: glucose oxidase (double sequential enzyme reaction)- glucose oxidase turns glucose into gluconic acid and hydrogen peroxide

False positive: inteference by oxidizing agents (bleach or peroxide)

False negative: reducing substances (ascorbic acid or bacteria- it eats glucose!)

Front 55

Two causes for glucosuria

Back 55

1. Diabetes mellitus

2. Reabsorption problems

Front 56

Diabetes mellitus v. Insipidus

Back 56

Mellitus: HIGH blood sugar, caused by decreases insulin, increased specific gravity, sugar and ketones present

Insipidus: NORMAL blood sugar, caused by decreased ADH levels, decreased specific gravity, excessive thirst

Front 57

Clinitest tablet

Back 57

For glucose and other reducing sugars

Positive: galactose, lactose, fructose, maltose, and pentose

Screening test for galactosemia (rare congenital carbohydrate metabolic condition in pediatrics)

Principle: Benedict's copper reduction test

Front 58

Copper reduction test vs. reagent strip

Back 58

RS -/CRT + = non-glucose sugar or other reducing substance

RS +/CRT - = strip more sensitive to glucose than copper reduction

Front 59

Benedict's copper reduction test results

Back 59

Positive copper reduction test: sugar (or other reducing substance) other than glucose

Negative copper reduction test with positive strip: glucose, because strip is more sensitive than copper reduction method

False negative: ascorbic acid (vitamin C) in extremely high doses

Front 60

Ketones

Back 60

In the absence of sugar, your body uses its fat storage for energy

The metabolism of fat as a primary energy source reaults in the formation of ketone bodies

Ketone bodies seen in urine:

1. Beta-hydroxy-butyric acid: 78%

2. Acetoacetic acid (aka diacetic acid): 20%

3. Acetone: 2%

Front 61

Ketones on reagent strip

Back 61

Principle: sodium nitroprusside + ketones = PURPLE color

**acetoacetic (diacetic) acid is the only ketone body detected on reagent strips**

False positives: highly pigmented urine and levadopa metabolites, high specific gravity

False negative: left at room temperature (acetoacetic acid is concerted to acetone, which evaporates upon standing)

Front 62

Confirmation of ketones

Back 62

Acetest tablets

Specific for acetoacetic acid (diacetic acid) and acetone

Front 63

Increased ketones in urine seen in

Back 63

1. Uncontrolled diabetes mellitus

2. High protein diets

3. GI disturbances

Front 64

Blood in urine come in a few forms:

Back 64

1. Hematuria: intact red blood cells, cloudy, red

2. Hemoglobinuria: lysed red blood cells, clear, red

3. Myoglobinuria: muscle hemoglobin, more brown than hemoglobin

Front 65

Hematuria causes

Back 65

Intact red blood cells in urine

Pathogenic causes: trauma to bladder, systemic bleeding disorders, renal diseases, kidney stones (calculi), strenous excerise

Non-pathogenic causes: menstration

Front 66

Hemoglobinuria causes

Back 66

RBCs readily lyse in alkaline or dilute urine

In most cases, the lysing of RBCs happen AFTER the kidney! (Like in the bladder)

Causes for cell lysis before the kidney: sickle cell/hemolytic anemias, incompatible transfusions, maleria

Front 67

Myoglobinuria causes

Back 67

Myoglobin is heme-containing protein involved in the transport of oxygen in muscles

Anything that causes strain on the muscles can release myoglobin into the blood

Causes: muscle destruction, exercise, muscle trama, seizures, electric shock

Front 68

Blood on reagent strips

Back 68

2-step enzymatic process:

1. Peroxide on strip +blood= O2

2. O2 + chromagen = color change

False positive: bleach and other oxidizing substances

False negative: ascorbic acid (vitamin C), protein, high specific gravity, increased nitrates

Hemoglobin and myoglobin have peroxidase activity

Front 69

Lifespan and breakdown of bilirubin

Back 69

Bilirubin is a normal breakdown product of RBCs.

1. Bilirubin from RBCs floating in the blood. Albumin binds it up so it cannot get into cells (toxic to cells)

2. Uncongugated bilirubin: this albumin-bilirubin complex is too large to pass through glomerulus

3. The complex stays in circulation until it reaches the LIVER

4. Conjugated bilirubin: The liver removes the albumin and conjugates the bilirubin

5. Conjugated bilirubin can pass through the glomerulus. Almost all bilirubin is sent from liver to the intestines

6. The intestines break down bilirubin to urobilinogen

7. Most urobilinogen is broken down further and passed in feces

8. Some goes back into circulation where it ends up in kidneys

Front 70

Photo of breakdown of bilirubin

Back 70

Front 71

Pathology of bilirubin

Back 71

Jaundice

3 causes for disrupted bilirubin:

1. Pre-hepatic (before liver)

2. Hepatic (in the liver)

3. Post hepatic (after the liver)

Front 72

Post hepatic bilirubin causes

Back 72

Obstruction!!

Conjugated bilirubin never makes it to the intestines, not bilirubin is NEVER converted to urobilinogen

Increased urine bilirubin

**white/grey feces

Front 73

Bilirubin on reagent strip

Back 73

Diazo reaction: diazonium salts+ bilirubin= blue/purple color

Confirmed by Ictotest

False negative: ascorbic acid (vit C), strips exposed to light

Front 74

Bilirubinuria

Back 74

Associates with bile duct obstruction and liver damage (hepatitis or cirrhosis)

Front 75

Urobilinogen on reagent strips

Back 75

Principle:

Ehrlich's reaction: para-dimethylaminobenzaldehyde in acid buffer + urobilinogen = pink/ cherry red color

False negatives: formalin (preservative)

False positive: some medication, highly pigmented urine

Front 76

Increased urobilinogen

Back 76

Liver damage

Hemolytic disease

Front 77

Negative urobilinogen

Back 77

Indicates bile duct obstruction!

Front 78

Normal bilirubin/urobilinogen in urine

Back 78

Bilirubin: <0.02 mg/dL

Urobilinogen: <1 mg/dL

Front 79

Nitrites

Back 79

Nitrate is a common food byproduct passed in the urine

The bacteria that most often causes UTIs (E. Coli and Klebsiella) contain the enzyme nitrate reductase.

This enzyme breaks down the normally found nitrAte into nitrite

Front 80

Nitrites on reagent strips

Back 80

The nitrate pad contains an amine and aromatic compound. The nitrite changes the amine into a diazo salt

The diazo salt + aromatic compound = pink color change

Any shade of pink is considered to represent a clinically significant bacteria

Normal: negative

Front 81

False negatives on the nitrite reagent strip

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1. Lack of dietary nitrites

2. Urine not in bladder long enough (4 hours minimum) for bacteria to reduce nitrate to nitrite

3. Bacteria are present, but not nitrate reducers

4. Ascorbic acid (vit C)

Front 82

Leukocyte Esterase (enzymes)

Back 82

Enzyme produced by granulocytic white blood cells

Lymphs DO NOT produce

Front 83

Leukocytes on reagent strip

Back 83

Principle: leukocyte esterase splits an ester to form pyrrole compound which reacts with a diazo reagent = PURPLE

Positive indicates presence of leukocytes (pyuria)

False positive: vaginal discharge

Front 84

Positive strip correlations

Back 84

pH- nitrite, leukocyte, microscopic

Protein- blood, nitrite, leukocyte, micro

Glucose- ketone

Ketones- glucose

Blood- protein, microscopic

Bilirubin- urobilinogen

Urobilinogen- bilirubin

Nitrite- protein, leukocyte, microscopic

Leukocyte- protein, nitrite, microscopic

Specific gravity- none

Front 85

Reagent strip reactions: pH

Back 85

Reaction principle: 2 indicators provide wide spectrum of color changes

False positives/negatives: none

Significance: alkaline may indicate "old"

Front 86

Reagent strip reactions: protein

Back 86

Reaction principle: protein error of indicators- pH of strip = 3.0, dye changes color of strip

False positive: alkaline urine

False negative: high salt

Significance: proteinuria: best single indicator of early disease (glomerular involvement), can be elevated after strenous exercise

Front 87

Reagent strip reactions: glucose

Back 87

Reaction principle: glucose oxidase method (double sequential enzyme)

False positive: bleach

False negative: ascorbic acid, ketones, high SG, low pH

Significance: diabetes mellitus

Front 88

Reagent strip reactions: ketones

Back 88

Reaction principle: Na notroprusside + ketone = purple

False positive: highly pigmented urine, Levapoda metabolites

False negative: ascorbic acid, high specific gravity

Significance: uncontrolled diebetes mellitus, high protein diet, dehydration

Front 89

Reagent strip reactions: blood

Back 89

Reaction principle: peroxide +blood = O2 + color indicator = color change

False positive: bleach

False negative: ascorbic acid, ketones, high SG, low pH

Significance:

1. Hematuria (systemic bleeding, renal disease, cystitis, calculi, strenous exercise, menstruation),

2. Hemoglobinuria (incompatible blood transfusion, malaria, hemolytic anemia)

3. Myoglobin (muscle destruction)

Front 90

Reagent strip reactions: bilirubin

Back 90

Reaction principle: diazo salt + bilirubin = blue/purplish color

False positive: medication color

False negative: ascorbic acid, increased SG, nitrite

Significance: bile duct obstruction, liver damage (hepatitis and cirrhosis)

Front 91

Reagent strip reactions: urobilinogen

Back 91

Reaction principle: para-dimethylaminobinzaldehyde + urobilinogen = peach/pink/cherry red color (Ehrlich's reaction)

False positive: highly pigmented urine, some medication

False negative: nitrite

Significance: liver damage (hepatitis and cirrhosis), hemolytic anemias

Front 92

Reagent strip reactions: nitrite

Back 92

Reaction principle: nitrite+amine reagent =diazo compound (diazo compound+3-hydroxy-1.2.3.4 tetrahydrobenz)-quinolin =PINK color

False positive: medication color

False negative: ascorbic acid

Significance: bacteria (UTI)

Front 93

Reagent strip reactions: leukocytes

Back 93

Reaction principle: leukocyte esterase splits ester to form pyrrole compound. Pyrrole + diazo reagent = purple

False positive: bleach

False negative: glucose, protein, high SG, some antibiotics

Significance: WBC in urine most likely indicates presence of bacteria, reacts with granulocytes, NOT lymphocytes

Front 94

Reagent strip reactions: specific gravity

Back 94

Reaction principle: pKa change of polyelectrolyte

False positive: protein

False negative: alkaline urine

Significance: decreased in diabetes insipidus, radiopaque dye

Front 95

4 Urine Stains

Back 95

1. Supravital stain: most common is Sternheimer-Malbin, stains everything

2. Gram stain: stains bacteria

3. Hansel stain: stains eosinophils (ex. Patient may be allergic to catheter)

4. Fat stains: Sudan III or Oil Red O (only fat cells pick up stain, confirms presence of fat or triglyceride)

Front 96

Normal urine sediment constituents

Back 96

0-2 RBC

0-5 WBC

0-2 hyaline cast

Slight mucus

Front 97

Abnormal urine constitutes: red cells

Back 97

Normal 0-2

May indicate glomerular damage or menstrual contamination

May be altered by pH and osmltic pressure to form "ghost", crenated or swollen cells

May be confised with yeast cells and oil droplets; add 2% acetic acid to lyse RBC

Front 98

Abnormal urine constitutes: white cells

Back 98

May indicate inflammation or infection (pyuria)

Front 99

Casts

Back 99

Cylindrical form Having parallel sides

Formed in the lumen of the distal convoluted tubule and collecting duct

Major constitute of casts is uromodulin, a glycoprotein secreted by renal tubular epithelial cells

Front 100

Factors that influence cast formation:

Back 100

Decreased pH

Decreased output

Increased specific gravity

Increased protein

Front 101

7 types of casts

Back 101

1. Hyaline

2. Red cell cast

3. White cells cast

4. Granular cast

5. Waxy cast

6. Fatty cast

7. Broad cast

Front 102

Hyaline cast

Back 102

Most frequently seen

Primarily uromodulin protein

Seen in dehydration

Front 103

Red cell cast

Back 103

**Glomerular nephritis** (also known as intrinsic renal disease)

Extensive damage to the glomerulus, bleeding from nephron, glomerular dysfunction

Solid mass of tightly packed RBC with characteristic orange-red color (unstained sediment)

Front 104

Granular casts

Back 104

Severe dehydration

Disintegration of cellular casts

Front 105

Waxy cast

Back 105

End stage renal disease cast

Advanced stage of hyaline, granular, or cellular casts

Indicates prolonged urinsry stasis (chronic renal disease)

Square edges

Front 106

Fatty cast

Back 106

Breakdown of epithelial cell casts that contain oval fat bodies.

Rare

Significance: Nephrotic syndrome

Must do a confirmatory stain (sudan or oil red)

If cholesterol is present, the fat droplets will show a maltese cross pattern under polarized light

Front 107

Squamous epithelial cells

Back 107

Largest, abudant irregular cytoplasm, central nucelus (RBC size)

Notes: least significant, most frequently seen, normal in vaginal lining and lower uretha

Front 108

Transitional epithelial cell

Back 108

Round or pear shaped, central nucleus, absorbs water (swell to 3x normal size)

Notes: renal carcinoma, renal pelvis, bladder, upper urethra

Front 109

Renal tubular epithelial cells

Back 109

Most significant, round, eccentric nucleus, larger than WBC

Notes: tubular necrosis, renal tubules

Front 110

Crystals

Back 110

Most crystals are clinically insignificant, because they can be formed in relation to changes in pH, and temperature.

Significant Crystals are found in fresh urine!

Presence of crystals may indicate renal calculi (kidney stones), metabolic disorders or drug overdose

Front 111

Crystals in alkaline urine (pH >7.0)

Back 111

1. Amorphous phosphates: white precipitate in urine, microscopically identical to amorphous urates

2. Triple phosphate: "coffin lid"

3. Ammonium biurate: "thorny apple"

4. Calcium carbonate: dumbell

5. Calcium phosphate: needles in a flower shape

6. Calcium oxalate

Front 112

Abnormal crystals

Back 112

Indicate metabolic disorders or drug metabollites

1. Bilirubin: small yellow-brown cluster of fine needles

2. Cystine: colorless hexagonal plates

3. Cholesterol: tectangular plates with corner notches

4. Leucine: yellow-brown spheres with concentric circles

5. Tyrosine: fine, delicate needles (**when seen with leucine, liver disease indicated**)

6. Sulfonamide: needles or brown spheres, or fans

7. Radiographic dye: empty plates

8. Ampicillin: needles

Front 113

Review: crystals seen in normal acidic urine

Back 113

Calcium oxalate

Uric acid

Front 114

Review: crystals seen in normal alkaline urine

Back 114

Triple phosphate

Ammonium biurate

Calcium carbonate

Calcium oxalate

Front 115

Review: abnormal crystals

Back 115

Bilirubin

Cystine (memory: sweet 16- six sides!)

Leucine

Tyrosine

Cholesterol

Front 116

Other constitutes found in urine

Back 116

1. Bacteria- correlate with presence/absence of leukocyte esterase

2. Yeast- most often represents vaginal infection

3. Parasites- trich, enterobius vermicularis

4. Mucus- no significance

5. Clue cells- squamous epis with bacterial vaginosis

Front 117

Artifacts

Back 117

1. Powder (starch)

2. Fat/oil droplets

3. Fibers- fibers polarize, casts don't

4. Hair

Front 118

Inclusion bodies

Back 118

1. In viral infections, such as rubella and herpes, cells may contain inclusion bodies

2. CMV produces large intranuclear inclusions

3. Lead poisoning produces cytoplasmic inclusions

4. Hemosiderin (form of iron) contained in urine sediment indicates severe intravascular hemolysis, delayed transfusion reaction, PCH, or as a result of hemochromatosis

Front 119

Microscopic correlations: Red blood cell

Back 119

Physical appearance: turbidity, red color

Chemical: blood

Front 120

Microscopic correlations: white blood cells

Back 120

Physical appearance: turbidity

Chemical: protein, nitrites, leukocyte esterase

Front 121

Microscopic correlations: epithelial cells

Back 121

Physical appearance: turbidity

Chemical: protein

Front 122

Microscopic correlations: casts

Back 122

Physical appearance: none

Chemical: protein

Front 123

Microscopic correlations: bacteria

Back 123

Physical appearance: turbidity

Chemical: pH, nitrites, leukocyte esterase

Front 124

Microscopic correlations: crystals

Back 124

Physical appearance: turbidity

Chemical: pH

Front 125

Diseases of the urinary tract: glomerulonephritis

Back 125

RBC cast, increased blood, renal epis, WBCs

Symptoms: fever, edema, nausea, oliguria (low urine output)

Glomerulus involved,

Front 126

Diseases of the urinary tract: Nephrotic Syndrome

Back 126

Change in glomerular permeability, increased fat production

Symptoms: edema (due to sodium retention), increased lipids in blood, blood pressure changes

Clinical findings: increased protein**, blood, fatty cast, oval fat bodies, renal cells

Front 127

Diseases of the urinary tract: acute tubular necrosis (ATN)

Back 127

Tubular disease, causes the destruction of renal tubular cells. Possible afer trauma or post-surgical

Toxic buildup of hemoglobin and myoglobin

Symptoms: azotremia (BUN/creatinine), oliguria

Clinical findings: decresed specific gravity, renal epi cast***, renal epithelial cells***

Front 128

Diseases of the urinary tract: cystinuria

Back 128

Inherited disease where the proximal tubules cannot reabsorb cystine. Cystine readily precipitates in acidic urine and can cause kidney stones. People with cystinuria must always stay hydrated to prevent calculi formation

Front 129

Inherited metabolic disorders: Tyrosinuria

Back 129

Seen most often in newborns because the liver is immature.

May see tyrosine and leucine crystals in acid urine

Catecholamines (metabolic product of tyrosine) test is ordered, results will be decreased due to the body not breaking down tyrosine!

Front 130

Inherited metabolic disorders: Phenylketonuria (PKU)

Back 130

Increased urinary excretion of phenylpyruvate (keton) and its metabolites.

Can result in severe brain damage or other developmental disorders

This is why PKUs are done on ALL newborns!

Front 131

Inherited metabolic disorders: Maple Syrup Urine Disease

Back 131

Rare and most often seen in newborns. Its the accumulation of branched chain amino acids

**Distinct maple syrup or caramalized sugar odor**

Front 132

Inherited metabolic disorders: Galactosuria

Back 132

Galactosuria is a lack of the enzyme or a deficient enzyme needed to break galactose into glucose

Can result in liver damage, cataracts, ovarian failure, and brain damage

Front 133

Inherited metabolic disorders: Pyelonephritis (kidney disease)

Back 133

Acute: infection of renal tubules. Symptoms include flank pain, fever, nausea, increased frequency to urinate

Clinical: leukocyte esterase, nitrites**, increased WBC, bacteria

Chronic: long lasting inflammation of tubules. Urine is allowed to flush backwards from the bladder up into the renal pelvis and back into the kidney

Clinical: maybe leukocyte?, NO NITRITE, WBC cast, NO BACTERIA

Front 134

Pregnancy testing

Back 134

Human chorionic gondatropin (HCG), a glycoprotein composed of alpha and beta subunits is secreted by the placenta.

Can be detected as early as 8-10 days after ovulation

HCG peaks at 8-10 weeks

First morning specimen is preferred

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Renal function tests

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Used to test glomerular filtration and tubular function

Tests for glomerular filtration:

1. Clearance tests

2. B2-macroglobulin

3. Cystatin C

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Creatnine clearance

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Most commonlu used clearance test to access GFR (glomerular filtration rate)

This measures the amount of blood filtered to a particular substance in a given time

Production and excecretion of CREATININE is fairly constant day to day

24 hour urine

Creatinine >1 mg measures adequacy of collection

(Urine creatinine × volume) ÷ serum creatinine = creatinine clearance

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Creatinine clearance formula with correction for kidney mass

Back 137

Mililiters of plasma cleared of creatinine by the kidney per minute

(urine creatinine ÷ serum creatinine) × (urine volume ÷ 1440 minutes) ×

(1.73 ÷ body surface area)

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Normal creatinine clearance

Back 138

90-120 ml/minute for adults

Decreases with age

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Estimated GFR

Back 139

Assists in detecting chronic kidney disease

More sensitive than creatinine clearance

Calculation based on serum creatinine, patient's age, gender, and ethnicity

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B2-Microglobulin

Back 140

Useful marker of renal tubular function

Increased plasma concentration indicate a reduced GFR (not specific)

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Cystatin C

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May provide an equal or better detection of adverse changes in GFR

Disadvantages:

1. Higher cost than creatinine clearance

2. Possible variable results among individuals

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Lab findings of acute glomerulonephritis

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Gross hematuria

Smoky turbidity

RBC casts

Waxy casts

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Lab findings of chronic glomerulonephritis

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Hematuria

All types of casts, but only occasional to few RBC casts

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Lab findings of acute Pyelonephritis

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Turbidity

Positive nitrite

Positive leukocyte esterase

WBC casts

Bacteria

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Lab findings of chronic Pyelonephritis

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Positive nitrite

Positive leukocyte esterase

All types of casts, but only occasional WBC cast

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Lab findings of nephrotic Syndrome

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May see "free" fat droplets

Fatty casts

Oval fat bodies

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Lab findings of cystitis/ lower urinary tract infection

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Bacteria

WBCs

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Reasons for analysis of Cerebrospinal fluid (CSF)

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Meningitis

Encephalitis

Syphilis

Brain abcess/tumor

Intracranial hemorrhage

Leukemia/lymphoma with CNS involvement

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CSF characteristics

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1. Normally clear, colorless

2. Xanthochromia: pink, orange, or yellow CSF supernatant (usually due to hemoglobin)

Important to differentiate between intracranial hemorrhage and tramatic tap!!

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Differentiate between intracranial hemorrhage and tramatic tap

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Hemorrhage

Appears: all tubes equally bloody

Supernate: xanthochromic

Clots: none

Tramatic tap

Appears: clearing of blood in each tube

Supernate: clear

Clots: yes, due to fibrinogen

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Distribution of CSF tubes

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1. Chemistry/serology: protein, glucose, lactate, VDRL, latex agglutination tests

2. Microbiology: gram stain, culture, india ink

3. Hematology: cell count and diff

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Normal CSF lab values

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Protein: 15-45

Glucose: 60-70% plasma glucose

Cells: 0-5 WBC

Differential: 70% lymph, 30% mono

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CSF electrophoresis

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OLIGOCLONAL BANDING = Multiple sclerosis

Decreased glucose, increased protein

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Manual cell count calculation for body fluids

Back 154

(# cells × dilution)÷ (# squares x depth- 0.1)

**For CSF, pleural, pericardial and pertioneal fluids

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Differentiate causes of meningitis- CSF studies

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Bacterial

Protein: very increased

Glucose: decreased

WBC: neutrophils

Lactate: increased

Viral

Protein: increased

Glucose: normal

WBC: lymphocytes

Lactate: normal

Fungal

Protein: increased

Glucose: normal to decreased

WBC: lymphocytes and monocytes

Lactate: increased

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Reasons for semen analysis

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1. Infertility (most common)

2. Post vasectomy

3. Forensic medicine (presence of acid phosphatase confirms presence of semen in alleged rape cases; flavin in semen fluoresces on clothing under UV light)

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Male reproductive system

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Under the influence of testosterone, sperm are produced in the testicles and are stored in the epididymis

In the epididymis, the sprem mature and become motile

The sperm remain in the epididymis until ejaculation (sperm move to the vas deferens where they are carried to the ejaculatory duct)

In the ejaculatory duct, fluid from seminal vesicles are added

Semen is the joining of sperm and fluids!!

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Normal sperm morphology

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Counted as % of normal forms, normal range is greater than 50%

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Abnormal morphology

Back 159

Range: <30% abnormal forms

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Reference ranges of sperm analysis

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Volume: 2-5 ml

Count: 20-250 million/ml

Motility: >50%

Morphology: <30% abnormal forms

Viability: >75% live forms

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Viability

Back 161

Normal: >75% live forms

Azoospermia- no sperm

Oligospermia- <20 million/ml

(Normal count is 20-250 million/ml)

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Serous fluids and reasons for analysis

Back 162

Sepsis

Malignancy

Systemic disease

Pleural, pericardial, peritoneal (ascites)

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Pleural fluid source

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Thoracic cavity (around lungs)

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Pleural fluid appearance

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Normal: clear to pale yellow

Turbid: WBC cells, bacteria

Bloody: trauma, malignancy

Milky: chylous fluid

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Pleural fluid lab tests:

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Cell count

Glucose

PH

Amalyse

CEA (carcinoembryonic antigen)

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Pleural fluid: cell count significance

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Increased RBC: trauma, malignancy

Increaced neutrophils: bacteria

Increased lymphs: tuberculosis, malignancy

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Pleural fluid lab value clinical significance: glucose, pH, amalyse, CEA

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Decreased glucose: TB, rheumatoid inflammation, malignancy

Decreased pH: TB, malignancy, esophageal rupture

Increased amalyse: pancreatitis

Increased CEA: malignancy

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Pericardical fluid source

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Pericardial cavity (around heart)

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Pericardial fluid appearance

Back 169

Normal: clear to pale yellow

Turbid: infection, malignancy

Bloody: TB, tumor, cardiac puncture

Milky: lymphatic drainage

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Pericardial lab tests

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Cell counts

Glucose

CEA

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Pericardial fluid lab tests clinical significance

Back 171

Cell count:

Increased RBC: TB, tumor, cardiac puncture

Increased neutrophils: bacterial endocarditis

Decreased glucose: bacterial infection

Increased CEA: malignancy

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Peritoneal (ascites) fluid source

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Peritoneal cavity (around abdomen)

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Peritoneal fluid appearance

Back 173

Normal: clear to pale yellow

Turbid: pertionitis, cirrhosis

Bloody: trauma

Milky: chylous fluid (rich in fats)

Green: bile

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Peritoneal fluid lab tests

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Cell counts

Glucose

Amalyse

Alkaline phosphatase

Urea/creatinine

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Peritoneal lab tests significance

Back 175

Cell count

Increased RBC: trauma

Inceeased neutrophils: peritonitis

Decreased glucose: tubercular peritonitis, malignancy

Increased amalyse: pancreatitis, GI perforation

Increased ALKP: Intestinal periforation

Increased urea/creatinine: ruptured bladder

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Effusion

Back 176

Build up of a body fluid in a body cavity due to a pathologic process

Pleural, pericardial, and peritoneal

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Reasons for analysis for synovial fluid

Back 177

Sepsis

Hemorrhage

Crystal induced inflammation

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Synovial fluid source

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Synovial membrane (around joints)

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Synovial fluid appearance

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Normal: clear, pale yellow and viscous

Bloody: hemorrhagic arthritis

Milky: crystals, cells

Green tinge: bacteria

Deep yellow: inflammation

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Synovial fluid cell counts

Back 180

Normal:

<200 WBC

<2000 RBC

Increased RBC: hemorrhage

Increased neutrophils: sepsis (>25%)

Increased lymphs: non-septic infection

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Sweat

Back 181

Source: sweat glands (of skin)

Appearance: clear and colorless

Increased sweat electrolytes (sodium and chloride) confirms diagnosis of cystic fibrosis

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Gastric fluid source

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HCL and pepsin (secreted in stomach)

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Gastric fluid appearance

Back 183

Depends on diet

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Gastric fluid lab test and significance

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Titratable acidity

Increased: duodenal ulcer, Zollinger-Ellison syndrome

Decreased: pernicious anemia (no intrinsic factor)

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Reasons for amniotic fluid analysis

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Fetal well being

Fetal lung maturity- 3 tests

1. Lecithin/Sphingomyelin ratio (L/S)

2. Phosphatidylglycerol (PG)

3. Lamellar body counts

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Lectin/Sphingomyelin (L/S) ratio

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Measures the phospholipids lecithin and sphingomyelin to assess fetal lung maturity

If >2.0, fetal lungs are MATURE

**(for diabetic mothers-PG must be present for fetal lung maturity)

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Phosphatidylglycerol (PG)

Back 187

Lipid component of pulmonary surfactants

Not detected until about 35 weeks

Absence does not rule out mature fetal lungs

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Lamellar body counts

Back 188

Secreted into aveolar lumen at 20-24 weeks

Amniotic fluid is analyzed on automated instruments by using platelet count value

Advantages:

1. Small sample volume

2. Short turnaround time

3. Low cost

4. Easily interpreted

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Other amniotic fluid testing

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1. Alpha-fetoprotein (AFP): if INCREASED, associated with neural tube disorders such as Spina Bifida

2. Bilirubin: reliable estimate of fetal red cell destruction due to maternal antibody, increased in HDFN

3. Creatinine: fetal age

4. Foam stability index

5. Fluorescence Polarization Assay

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Amniotic fluid appearance

Back 190

Normal: clear and colorless

Yellow-green: bilirubin

Red: red cell destruction (HDFN)

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Transudate vs. Exudate: color

Back 191

Transudate: colorless

Exudate:

Yellow-white: inflammation

Red-brown: hemorrhage

Yellow-brown: bilirubin

Milky-green: chylous fluid (fatty)

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Transudate vs. Exudate: turbidity

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Transudate: clear, watery

Exudate: cloudy, viscous

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Transudate vs. Exudate: specific gravity

Back 193

Transudate: <1.015

Exudate: >1.015

Front 194

Transudate vs. Exudate: protein

Back 194

Transudate: <3 g/dl

Exudate: >3 g/dl

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Transudate vs. Exudate: LD (lactic dehydrogenase)

Back 195

Transudate: <200 IU

Exudate: >200 IU

Front 196

Transudate vs. Exudate: cell count

Back 196

Transudate: <1000/microliter

Exudate: >1000/microliter

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Transudate vs. Exudate: increases associated with...

Back 197

Transudate: congestive heart failure, changes in hydrostatic pressure

Exudate: infections and malignancies

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Differentiating benign and malignant cells in fluids chart picture

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