Urinalysis

Front 1

normal urine composition

Back 1

-ultrafiltrate of plasma
-95% water and 5% dissolved substances
-protein metabolites (urea, uric acid, creatinine)
-electrolytes (Na, K, Cl, Ca, Mg)
-small amt of protein and urobilinogen
-small # of cells

Front 2

renal threshold

Back 2

When plasma concentration of a substance
that is normally reabsorbed reaches maximal
concentration of tubular reabsorption,
substance appears in urine

-Renal threshold of glucose=150-180 mg/dL

Front 3

indications for urinalysis

Back 3

1. wellness screening (controversial)- preschoolers, obese ppl, >65 yo, DM, hx of gest DM
2. dx and monitoring of metabolic and systemic disease that affects kidneys (HTN, pheochromocytoma))
3. dx of endocrine diseases
4. screen for diseases of urinary tract and kidneys
5. screen for pregnant pts
6. drug screening

Front 4

urine specimens

Back 4

1. Random: most common and convient, collected any time, used for screening
2. First morning specimen: more concentrated- use when there is concern about a FN
3. random clean catch/midstream
4. catheter: urinalysis and culture
5. Suprapubic aspiration sample: sterile needle inserted through abd into bladder; urinalysis, culture and cytology

Front 5

time specimens

Back 5

-urines collected at specific time intervals
-removes variables due to time of day, exercise, metabolism
-24 hr urine specimen: used for quantitative determination in chemistry
-fractional specimen

Front 6

urinalysis quality control

Back 6

1. use clean and dry container
2. analyze urine w/in 1-2hrs or use preservative/refrigeration
3. mix urine before testing
4. keep urine strips in a tightly capped container at room temp, free from moisture and direct lt.
5. record all reagent lot numbers and expiration dates

Front 7

physical analysis- reference ranges

Back 7

Color: pale - straw - yellow- amber
Odor: normally has an odor (sweet = ketones; ammonia = bacteria; food odors
appearance: clear or cloudy

Front 8

color

Back 8

-varies with concentration and types of food or drugs ingested
-urochrome pigment gives urine its yellow color
-see chart
red: drugs, dyes, beet, rhubarb, senna or pathological causes like hemoglobin or myglobin
orange, yellow, brown, black

Front 9

urine color

Back 9

white and cloudy: Amorphous phosphates, white blood cells, bacteria, epithelial cells, crystals, mucus, yeast, sperm
pink and cloudy: Amorphous urates
smokey brown: Red blood cells
milky: lipids

Front 10

urine volume

Back 10

nml: 600-2500 ml/ 24 hrs
day time > night time
kids > adults
-polyuria >2500 ml/24 hr
-oliguria <200 ml/24 hr
-anuria <100 ml/24 hr

Front 11

urine chemical analysis

Back 11

1. use reagent strips w/1-10 colored pads treated with different chemical regents
2. each pad has a color change rxn when it comes in contact with urine
3. read color changes against a color chart or automated analyzer
4. timing of reading strips is critical for accuracy
5. semi-quantitative results
6. urine should be room temp & well mixed

Front 12

urinalysis reagent strips- storage and handling reccomendations

Back 12

1. Protect from light, moisture and heat
2. Keep work area free from detergents and other contaminants
3. Keep unused strips in original bottle
4. Do not remove desiccant
Only remove strip when ready for use
5. Recap bottle immediately after use
6. Do not touch reagent pads

Front 13

chemical analysis procedure

Back 13

1. Collect fresh urine specimen in a clean, dry container
2. Mix urine well before testing
3. Remove 1 strip from bottle and replace cap
4. Completely immerse reagent strip into urine and remove immediately while running the edge of strip against urine container to remove excess
5. Hold strip horizontally close to (not on the) bottle and compare strip to color chart at appropriate time intervals

Front 14

chemical analysis- glucose

Back 14

-test strips specific for glucose
-concentration is dependent on GFR and degree of tubular reabsorption
-clinical implications of increased urine glucose: DM, large carb intake, renal tubular dysfunction

Front 15

glucose false positives

Back 15

-Hypochlorite bleach
-Dip sticks uncovered for few days

Front 16

glucose false negatives

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-Large amount of bacteria
-Large doses of vitamin C
-High specific gravity

Front 17

CLINITEST confirmation method for glucose

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-detects all reducing substances, including lactose and galactose
-not as sensitive to glucose as test strips
-BE CAREFUL: tube gets hot
-recommended for pts < 2yo- detect other underlying pathologies

Front 18

chemical analysis- bilirubin
(look at pic)

Back 18

-metabolite of hemoglobin
-strip detects only conjugated bilirubin
-clinical implications of increased bilirubin: biliary/bile duct obstruction; hepatic damage and tumors
(urine bilirubin may be + before symptoms of jaundice appear)

Front 19

bilirubin- test strip false positives and false negatives

Back 19

FP: metabolites of drugs (e.g. Pyridium)
FN: specimen exposed to light; delay in testing; high Vit C concentration

Front 20

ICOTEST confirmation method for bilirubin

Back 20

-more sensitive & easirer to read color change
-order test if concerned about smll concentrations of bilirubin
-special reagent pad concentrates urine
-FP: pigmented urine

Front 21

chemical analysis - Ketones

Back 21

-formed in liver, should be negligible in urine
-fatty acid metabolites
-reagent strip is specific for acetone and acetoacetic acid

Front 22

clinical implications of increased ketones

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1. Diabetic ketoacidosis
2. Decreased intake of carbohydrates
3. Starvation
4. Prolonged vomiting
5. Dehydration
6. Hypermetabolic states
7. ASA poisoning
8. Improper strip storage

Front 23

ketones test strips false positives and false negatives

Back 23

FP:
1. highly pigmented urine: phthalein dyes, pyridium
2. medication metabolites: L-DOPA metabolites, metformin, captopril
FN: delay in testing

Front 24

chemical analysis- specific gravity

Back 24

-concentrating ability of the kidney
-highest in the morning
-clinical implications of low SG: diabetes insipidus, tubular damage
-clinical implications of increased SG: DM, excessive H2O loss
-Isothenuria (1.010)

Front 25

specific gravity false positives and false negatives

Back 25

FP: moderate to large quantity of protein or glucose; radiopaque dyes
-FN: alkaline urines

Front 26

blood

Back 26

-strip detects intact RBC, hemoglobin, myoglobin
-impt indicator of renal disease/ damage

Front 27

clinical implications of hematuria

Back 27

1. Glomerulonephritis
2. Urinary tract infections
3. Renal stones
4. Urinary tumors
5. Urinary trauma
6.Coagulopathies (bleed more easily)
7. Menses blood
(a work-up for hematuria is required for confirmed positive dip stick results)

Front 28

clinical implications of hemoglobinuria

Back 28

-means RBCs have to be broken
-indicates intravascular hemolysis
1. hemolytic anemia
2. transfusion rxn
3. strenuous exercise
4. disseminated intravascular coagulation (clotting and bleeding happening at the same time)

Front 29

blood- false positives and false negatives

Back 29

FP: hypochlorite bleach exposure, nephrotoxic drugs, blood thinning agents
FN: high dose Vit C, reagent strips left uncapped, captopril use, high urine SG

Front 30

chemical analysis- pH

Back 30

-indicator of acid base balance
-clinical implications of acidic urine: DM, starvation, high protein
-clinical implications of alkaline urine: bacterial infxs, chronic renal failure

Front 31

chemical analysis- protein

Back 31

-single most sensitive indicator of renal disease
-reagent strip is sensitive to ALBUMIN
-clinical implications of proteinuria: glomerular or tubular damage, excess overflow

Front 32

nonrenal causes of proteinuria

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1. fever
2. sepsis
3. ecclampsia
4. orthostatic proteinuria

Front 33

protein- false positives and false negatives

Back 33

FP: highly alkaline urine, gross hematuria, exposure to cold, strenuous exercise, emotional stress, seizures, contamination with chlorhexidine
FN: high salt concentration, Bence Jones protein or gamma globulins

Front 34

confirmation method for protein

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-sulfosalicyclic acid precipitation test
-detects all proteins
-neg, trace, 1+, 2+. 3+, 4+

Front 35

chemical analysis: urobilinogen

Back 35

-byproduct of heme breakdown
-highest excretion b/t 12-4pm
-clinical implicatios of increased urobilinogen: hemolytic disease, liver disease
FP: inc ambient temp at testing
FN: fomalin in sample, excessive exposure of sample to light, abx tx

Front 36

Clinical Comparison of Urine Urobilinogen and Urine Bilirubin Values

Back 36

look at chart

Front 37

chemical analysis: nitrate

Back 37

-detects bacteria that reduce nitrate to nitrite (Eschericia coli, Proteus species, Enterobacter species, Klebsiella species, Pseudomonas species)
-clinical implications of + nitrite test: UTI

Front 38

nitrite false positives and false negatives

Back 38

FP: old specimen, large amt of urine bilirubin
FN: abx therapy, no dietary nitrate, urine not in bladder for at least 4 hrs, organism doesn't reduce nitrate to nitrite, high concentration of vit c, high urine SG

Front 39

chemical analysis leukocyte esterase

Back 39

-detects whole or lysed WBC
-clinical implications of positive test:
1. upper or lower UTI
2. renal inflammation
(a urine specimen positive of nitrites and leukocytes, should be sent for C &S)

Front 40

leukocyte false positives and false negatives

Back 40

FP: aspirin toxicity, strenuous exercise, vaginal contamination
FN: high levels of Vit C, high levels of glucose, high urine SG, medication interferences (tetracycline, cephalexin etc.)

Front 41

mircroscopic analysis

Back 41

-confirm results of physical & chemical analysis
-examine urine sediment specimen under low and high magnification
-semi-quantitative results

Front 42

microscopic analysis procedure

Back 42

1. pour specimen into tube
2. centrifuge @ 2000 rpm for 5-10min
3. discard most of supernatant
4. re-suspend sediment w/1ml supernatent
5. place 1 drop onto glass slide; cover
6. examine under low power (10x) and count casts
7. examin under high power (40x) and count cells and crystals
8. report # of findings/LPF or HPF

Front 43

microscopic analysis RBCs

Back 43

-colorless biconcave disks 7microns
-clinical apps: acute glomerulonephritis, renal trauma, renal infarct, urinary tumors, renal stones, acute tubular necrosis, UTI, acute febrile illness, nephrotoxins, hemophilia, physical stress
-can be confused with yeast, oil droplets, air bubbles

Front 44

types of RBCs

Back 44

ghost cells: hypotonic urine RBCs swell and lyse
crenated RBC: hypertonic urine RBCs shrivel
dysmorphic RBC: glomerular disease

Front 45

microscopic analysis WBCs

Back 45

-dull grey colored sphees w/nucleus/granules
-clinical apps: UTIs, strenuous exercise, bladder tumors, Tb, Lupus, glomerulonephritis
-consider vaginal, cervical, urethral infx contaminant

Front 46

microscopic analysis squamous epithelial cels

Back 46

-large, flat, irregular with abundant cytoplasm and small central nuclei
-most common epitherlial cell
-originate from urethra in urinary tract

Front 47

microscopic analysis- transitional epithelial cells

Back 47

-round or pear shaped, with tail like projections and large nuclei
-line urinary tract from renal pelvis to proximal urethra
-clinical apps: few cells can be nml, bladder disease, renal pelvis disease, can be seen after catheterization

Front 48

microscopic analysis- renal epithelial cells

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-round cells with large nuclei
-originate in tubules
-clinical apps: tubular disease, viral infxs, heavy metal poisoning
-bubble cells and oval fat bodies

Front 49

casts

Back 49

-cylindrical structures that form in distal convoluted tubule & collecting ducts
-Tamm-Horsefall protein
-parallel borders and rounded edges
-often accompanied by proteinuria
-dissolve in alkaline urine
-can be in nml and abnl urine

Front 50

requirements for cast formation

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1. urine stasis
2. low pH
3. high solute concentration
4. Tamm-Horsefall protein
clinical apps: some indicate renal disease

Front 51

Hyaline casts

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-colorless, homogenous, semitransparent
-clinical apps: can be found in healthy individuals after strenuous exercise; when seen in large 3's can indicate mild-seere rena ldisease

Front 52

cylindroid

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Hyaline cast with tapered “tail”
Formed at junction of loop of Henle and distal convoluted tubules
Same clinical significance as hyaline casts

Front 53

RBC casts

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-RBCs in a yellow-red hyalin matrix
-extremely fragile, degenerate to granular cast
-clinical apps: ACUTE TO CHRONIC GLOMERULONEPHRITIS

Front 54

WBC cast

Back 54

-WBCs in a hyaline cast
-clinical apps: PYELONEPHRITIS, renal inflamm, actue glomerulonephritis, lupus, interstitial nephritis

Front 55

granular cast

Back 55

-degenration of cellular component casts
-fine to coarse granules
-many sizes, shapes and colors
-clinical apps: healthy ppl with prolonged exercise or severe stress, acute & chronic renal diseases, nephrotic syndrome, pyelonepritis

Front 56

fatty cast

Back 56

-fat globules, free fat or oval fat bodies contained in a transparent matrix
-highly refractive
-clinical apps: nephrotic syndreom, DM, mercury poisoning, lupus

Front 57

broad casts

Back 57

-wider casts, usually granular or waxy
-indicate cast formation in dilated convoluted tubules or CDs
-sig urinary stasis w/obstructie disease
-clinical apps: END STAGE KIDNEY DISEASE

Front 58

waxy casts

Back 58

-homogeneous casts with well defined edges and cracking
-clinical apps: acute and severe chronic renal disease, malignant HTN, DM, nephrotic syndrome

Front 59

crystals

Back 59

-normally not found in urine
-depends on saturation of particular crystal compound or a change in the solubility, pH
-many have little significance
-some seen in renal stones, metabolic disorders

Front 60

crystal appearance

Back 60

-Appearance: shape, color, refractive properties
-Solubility properties
-pH
-interfering factors: dyes, refrigeration, old specimens

Front 61

alkaline crystals

Back 61

1. Calcium phosphate-colorless, prism seen in absence of disease & w/renal stones
2. triple phosphate: colorless prisms (coffin lids); renal stones, UTI, enlarged prostate
3. amorphous phosphates: colorless granular patches; forms white precipitate when refrigerated

Front 62

acidic crystal

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1. calcium oxalate
2. uric acid
3. Amorphous urates

Front 63

Calcium oxalate

Back 63

1. Colorless envelopes with intersecting diagonal lines (may be dumb bell or elliptical)
2. May be seen in patients with renal stones, ethylene glycol poisoning, diabetes, liver disease and chronic renal disease

Front 64

Uric acid

Back 64

1. Yellow to reddish brown diamond, lemon shaped, wedge, needle or rhombic plates in clusters
2. Seen in patients with kidney stones, chronic nephritis, gout, high purine metabolism, acute febrile illness

Front 65

amorphous urates

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-yellow to red-brown small granular crystals
-form pink precipitate upon refrigeration
-salts of Na, K, Mg, Ca
-no clinical significance
-soluble if heated

Front 66

cystine

Back 66

-abnl crystal
-colorless hexagonal plates
-in acidic or neutral urine
-inherited metabolic defect w/inability to reabsorb cystine

Front 67

tyrpsine

Back 67

-abnl crystals
-black o yellow w/presence of bilirubin
-highly refractive needles occuring in sheaths or clusters
-found in acidic urine
-seen in severe liver disease and tyrosinosis

Front 68

leucine

Back 68

-abnl crystals
-yellow-brown oily looking spheres
-highly refractive
-seen in maple syrup disease, severe liver disease

Front 69

cholesterol

Back 69

-abnl crystal
-singular or many transparent plate with 1 notched corner
-seen in excessive tissue, breakdown, lipiduria, lipidemia, nephritis, and nephrotic syndrome

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sulfa

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-abnl crystals
-colorless, brown to yellow needle-like shapes seen in bundles, fans or sheaths
-"stack of wheat"
-may occur when pt is taking sulfa drug

Front 71

bacteria and yeast

Back 71

bacteria: colorless rods or cocci; UTI
yeast: colorless oval budding cells +/- hyphae; candida; skin or vaginal contaminant; urinary candidiasis seen in DM and immunocomp pts

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sperm

Back 72

-may be seen after sex, in presence of prostate disease or as vag contaminant

Front 73

trichamonas vaginalis

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-mobile flagellated organisms
-seen in infxs of the vag, vulva, or urethra

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mucus stands

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-long thin waxy transparent threads
-increased #s indicate inflamm or irritation of the urinary tract

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other artifacts in urine

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-cotton fibers
-starch granules
-oil droplets
-hair

Front 76

changes observed in urine left sitting at room temp

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1. color becomes darker
2. clarity becomes cloudy
3 pH increases
4. urobilinogen decreases
5. bilirubin decreases
6. ketones, glucose decrease
7. bacteria inc
8. RBC, WBC & casts lyse
9. crystal may dissolve or precipatate