Urinalysis                 Course: IDPT 5005                 School of Medicine, UCDHSC       Francisco G. La Rosa, MD    ...
SpecimenCollection–   First morning voiding (most concentrated)–   Record collection time–   Type of specimen (e.g. “clean...
Urine Specimens   Collected for a number of tests:    – Clean voided specimens          For routine urinalysis    – Clea...
Obtaining Samples   Clients need varying degrees of instruction    and assistance to provide clean voided    specimens. ...
Directions for Collection   The nurse should explain that all    specimens must be free of fecal    contamination, so voi...
Obtaining Specimen   When the specimen is obtained, put    the lid tightly on the container to    prevent spillage and co...
Obtaining TimedSpecimens   All timed urine specimens should be    refrigerated to prevent bacterial growth    and decompo...
Obtaining TimedSamples   Alert signs are placed in the client’s    room to remind staff of the test in    progress.   Sp...
Obtaining TimedSamples   Clients need to be told why the test is being    done and how they can assist.   Instructions s...
Obtaining TimedSamples   The collection period is started by    having the client void in the toilet,    bedpan, or urina...
Clean Catch
SpecimenCollection        Supra-pubic Needle Aspiration
Types of Analysis −   Macroscopic Examination −   Chemical Analysis (Urine     Dipstick) −   Microscopic Examination −   C...
Macroscopic ExaminationOdor:−   Ammonia-like:       (Urea-splitting bacteria)−   Foul, offensive:    Old specimen, pus or ...
Macroscopic ExaminationTurbidity:−   Typically cells or crystals.−   Cellular elements and bacteria will clear by    centr...
Appearance   Including color and clarity   Color : normally , pale to dark yellow    (urochrome)     Abnormal color :   ...
Red Urine   Causes of Asymptomatic Gross Hematuria by    Incidence   Acute Cystitis (23%)   Bladder Cancer (17%)   Ben...
Appearance   Clarity : normally, clear    Abnormal color : cloudy urine    Causes: 1. crystals or nonpathologic salts    ...
Urine volume   The average adult : 1000ml to 2000ml/24h   Increase     polyuria ---more than 2000ml of urine in    24   ...
Urine volume   Decrease     Oliguria ---less than 400ml of urine in 24 hours     Anuria ---less than 100ml of urine in 24...
Chemical Analysis
Chemical Analysis                    Urine Dipstick                     Glucose                     Bilirubin             ...
Typical Test Strip           Test         Sensitivity_        Glucose     –   4 to 7 mmol/L        Bilirubin   –   7 to 14...
The Urine Dipstick:                                        Glucose                             Chemical Principle   Negati...
Uses and Limitations of Urine GlucoseDetection Significance    – Diabetes mellitus.    – Renal glycosuria. Limitations    ...
Detection of Reducing Sugars* byCuSO 4     Sugar                   Disease(s)    - Galactose            Galactosemias    -...
Urine versus Blood GlucoseUrinalysis Glucose Result                             ++                              +         ...
The UrineDipstick:                                  Bilirrubin   Negative                   Chemical Principle   + (weak) ...
Uses and Limitations of Urine BilirrubinDetectionSignificance  - Increased direct bilirubin (correlates with urobilinogen ...
The UrineDipstick:                                Ketones    Negative                              Chemical Principle    T...
Uses and Limitations of Urine Ketone Detection Significance   - Diabetic ketoacidosis   - Prolonged fasting Limitations   ...
The UrineDipstick:                                  Specific                                           Gravity    1.000   ...
Uses and Limitations of Urine Specific GravitySignificance  - Diabetes insipidusLimitations  - Interference: alkaline urin...
The UrineDipstick:                                        Blood   Negative                                        Chemical...
Uses and Limitations of Urine Blood DetectionSignificance  - Hematuria (nephritis, trauma, etc)  - Hemoglobinuria (hemolys...
The UrineDipstick:                                    pH     5.0     6.0                Chemical Principle                ...
Uses and Limitations of Urine pH Detection Significance   - Acidic (less than 4.5): metabolic acidosis, high-protein diet ...
pH Run Over Effect      Glucose      Bilirubin      Ketones      Specific Gravity     Buffers from the protein area of    ...
The UrineDipstick:                                     Protein                                  Chemical Principle        ...
Causes ofProteinuriaFunctional                     Renal  - Severe muscular exertion    - Glomerulonephritis  - Pregnancy ...
Nephrotic Syndrome (> 3.5 g/dL in 24h)  Primary    - Lipoid nephrosis (severe)    - Membranous glomerulonephritis    - Mem...
Uses and Limitations of Urine ProteinDetection Significance   - Proteinuria and the nephrotic syndrome. Limitations   - In...
Proteins in “Normal” UrineProtein           % of Total                Daily MaximumAlbumin              40%               ...
The UrineDipstick:                             Urobilinogen    0.2 mg/dL            Chemical Principle    1 mg/dL     Urob...
Uses and Limitations of UrobilinogenDetection Significance   - High: increased hepatic processing of bilirubin   - Low: bi...
The UrineDipstick:                                       Nitrite                                 Chemical Principle       ...
Uses and Limitations of Nitrite Detection  Significance    - Gram negative bacteriuria  Limitations    - Interference: bac...
The UrineDipstick:                                 Leukocyte                                           Esterase           ...
Uses and Limitations of Leukocyte Esterase Detection Significance   - Pyuria   - Acute inflammation   - Renal calculus Lim...
Microscopic Examination                                             General AspectsPreservation  - Cells and casts begin t...
Microscopic Examination                                          Abnormal FindingsPer High Power Field (HPF) (400x)   –   ...
Microscopic Examination                                                       CellsErythrocytes  - “Dysmorphic” vs. “norma...
Microscopic Examination                    RBCs
Microscopic Examination                    RBCs
Microscopic Examination                    WBCs
Microscopic Examination                 Squamous Cells
Microscopic Examination                Tubular Epithelial                      Cells
Microscopic Examination                 Transitional Cells
Microscopic Examination                 Transitional Cells
Microscopic Examination                 Oval Fat Body
Microscopic Examination                   LE Cell
Microscopic Examination                         Bacteria & Yeasts  Bacteria  - Bacteriuria      More than 10 per HPF  Yeas...
Microscopic Examination                   Bacteria
Microscopic Examination                    Yeasts
Microscopic Examination                    Yeasts
Microscopic Examination                 Cytomegalovirus
Microscopic Examination                                                 CastsErythrocyte Casts:            Glomerular dise...
Microscopic Examination                    Casts
Microscopic Examination                 RBCs Cast -                  Histology
Microscopic Examination                  RBCs Cast
Microscopic Examination                 RBCs Cast -                  Histology
Microscopic Examination                  WBCs Cast
Microscopic Examination               Tubular Epith. Cast
Microscopic Examination               Tubular Epith. Cast
Microscopic Examination                 Granular Cast
Microscopic Examination                 Hyaline Cast
Microscopic Examination                  Waxy Cast
Microscopic Examination                  Fatty Cast
Significance of Cellular Casts                      Erythrocyte Casts                      Leukocyte Casts                ...
Microscopic Examination                           Crystals      - Urate        Ammonium biurate        Uric acid      - Tr...
Microscopic Examination            Calcium Oxalate Crystals
Microscopic Examination            Calcium Oxalate Crystals                         Dumbbell                          Shape
Microscopic Examination           Triple Phosphate Crystals
Microscopic Examination               Urate Crystals
Microscopic Examination              Leucine Crystals
Microscopic Examination              Cystine Crystals
Microscopic Examination           Ammonium Biurate Crystals
Microscopic Examination             Cholesterol Crystals
Cytological ExaminationStaining:  – Papanicolau  – Wright’s  – Immunoperoxidase  – Immunofluorescence
Cytology: Normal
Cytology: Normal
Cytology: Reactive
Cytology: Reactive
Cytology: Polyoma (DecoyCell)
Cytology: Polyoma (DecoyCell)Immunoperoxidase to SV40 ag
Cytology: TCC Low Grade
Cytology: TCC Low Grade
Cytology: TCC HighGrade
Cytology: TCC HighGrade
Cytology: Squamous CellCa.
Cytology: Renal Cell Ca.
Cytology: ProstaticCarcinoma
Urinalysis  Disease Diagnosis
Case          Diluted urine, request a voided urine in the morning                  If persisting low SG, possible diabete...
Case                Possible gallbladder or hepatic disease.                  No hemolytic anemia. Perform bilirubins in s...
Case            Possible UTI, request culture and antibiotic sensitivity                      Negative Nitrite test: Gram ...
Case                              Diabetes                   May be decompensated and with ketoacidosis  4               K...
Case                             Glomerulonephritis                        RBC casts reveals renal cortex involvement  5  ...
Case                          “Functional” proteinuria?                         Microscopic may reveal a few leukocytes  6...
Common Findings in:                           Acute Tubular Necrosis  Glucose  Bilirubin  Ketones    S.G.       Decreased ...
Common Findings in:                           Acute Glomerulonephritis  Glucose  Bilirubin  Ketones                       ...
Common Findings in:                       Chronic                       Glomerulonephritis  Glucose  Bilirubin  Ketones   ...
Common Findings in:                          Acute Pyelonephritis  Glucose  Bilirubin  Ketones                      Micros...
Common Findings in:                      Nephrotic Syndrome  Glucose  Bilirubin  Ketones    S.G.                   Microsc...
Common Findings in:                   Eosinophilic Cystitis  Glucose  Bilirubin  Ketones    S.G.                 Microscop...
Common Findings in:                   Urothelial Carcinoma  Glucose  Bilirubin  Ketones    S.G.                 Microscopi...
Acknowledgment:   Dr. Brad Brimhall
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  1. 1. Urinalysis Course: IDPT 5005 School of Medicine, UCDHSC Francisco G. La Rosa, MD Francisco.LaRosa@uchsc.edu Assistant Professor, Department of Pathology University of Colorado at Denver Health Science Center, Denver, Colorado
  2. 2. SpecimenCollection– First morning voiding (most concentrated)– Record collection time– Type of specimen (e.g. “clean catch”)– Analyzed within 2 hours of collection– Free of debris or vaginal secretions
  3. 3. Urine Specimens Collected for a number of tests: – Clean voided specimens  For routine urinalysis – Clean-catch or midstream urine specimens  For urine culture – Timed urine specimens  For a variety of tests that depend of the client’s specific health problem
  4. 4. Obtaining Samples Clients need varying degrees of instruction and assistance to provide clean voided specimens. About 120 ml (4 oz) of urine is generally required. Clients who are seriously ill, physically incapacitated, or disoriented may need to use a bedpan or urinal in bed. Others may require supervision and/or assistance in the bathroom.
  5. 5. Directions for Collection The nurse should explain that all specimens must be free of fecal contamination, so voiding needs to occur at a different time from defection. Instruct female clients to discard toilet tissue in the toilet or in a waste bag rather than in the bedpan or hat, since tissue in the specimen makes laboratory analysis more difficult.
  6. 6. Obtaining Specimen When the specimen is obtained, put the lid tightly on the container to prevent spillage and contamination. Label the specimen.
  7. 7. Obtaining TimedSpecimens All timed urine specimens should be refrigerated to prevent bacterial growth and decomposition of the urine components. Each voiding of urine is collected in a clean container and then emptied immediately into the large refrigerated bottle.
  8. 8. Obtaining TimedSamples Alert signs are placed in the client’s room to remind staff of the test in progress. Specimen identification labels need to indicate the date and time of each voiding in addition to the usual identification information.
  9. 9. Obtaining TimedSamples Clients need to be told why the test is being done and how they can assist. Instructions should include the following: – All urine must be saved and placed in the specimen containers once the test starts. – The urine must be free of fecal contamination and toilet tissue. – Each specimen must be given to the nursing staff immediately so that it can be placed in the appropriate specimen bottle.
  10. 10. Obtaining TimedSamples The collection period is started by having the client void in the toilet, bedpan, or urinal. – This urine is usually discarded, but check facility procedure. All subsequent urine specimens are collected.
  11. 11. Clean Catch
  12. 12. SpecimenCollection Supra-pubic Needle Aspiration
  13. 13. Types of Analysis − Macroscopic Examination − Chemical Analysis (Urine Dipstick) − Microscopic Examination − Culture (not covered in this lecture) − Cytological Examination
  14. 14. Macroscopic ExaminationOdor:− Ammonia-like: (Urea-splitting bacteria)− Foul, offensive: Old specimen, pus or inflammation− Sweet: Glucose− Fruity: Ketones− Maple syrup-like: Maple Syrup Urine DiseaseColor:− Colorless Diluted urine− Deep Yellow Concentrated Urine, Riboflavin− Yellow-Green Bilirubin / Biliverdin− Red Blood / Hemoglobin− Brownish-red Acidified Blood (Actute GN)− Brownish-black Homogentisic acid (Melanin)
  15. 15. Macroscopic ExaminationTurbidity:− Typically cells or crystals.− Cellular elements and bacteria will clear by centrifugation.− Crystals dissolved by a variety of methods (acid or base).− Microscopic examination will determine which is present.
  16. 16. Appearance Including color and clarity Color : normally , pale to dark yellow (urochrome) Abnormal color : some drugs cause color changes 1. red urine : causes: hematuria hemoglobinuria myoglobinuria 2. yellow-brown or green-brown urine : bilirubin cause : obstructive jaundice
  17. 17. Red Urine Causes of Asymptomatic Gross Hematuria by Incidence Acute Cystitis (23%) Bladder Cancer (17%) Benign Prostatic Hyperplasia (12%) Nephrolithiasis (10%) Benign essential hematuria (10%) Prostatitis (9%) Renal cancer (6%) Pyelonephritis (4%) Prostate Cancer (3%) Urethral stricture (2%)
  18. 18. Appearance Clarity : normally, clear Abnormal color : cloudy urine Causes: 1. crystals or nonpathologic salts phosphate, carbonate in alkaline urine (dissolve---add acetic acid) uric acid in acid urine (dissolve---warming to 60℃) 2. various cellular elements: leukocytes, RBCs, epithelial cells
  19. 19. Urine volume The average adult : 1000ml to 2000ml/24h Increase polyuria ---more than 2000ml of urine in 24 hours 1. physiological states: water intake, some drugs, intravenous solutions 2. pathologic states: diabetes mellitus, diabetes insipidus
  20. 20. Urine volume Decrease Oliguria ---less than 400ml of urine in 24 hours Anuria ---less than 100ml of urine in 24 hours 1. prerenal: hemorrhage, dehydration, congestive heart failure 2. postrenal: obstruction of the urinary tract (may be stones, carcinoma) 3. renal parenchymal disease: acute tubular necrosis, chronic renal failure
  21. 21. Chemical Analysis
  22. 22. Chemical Analysis Urine Dipstick Glucose Bilirubin Ketones Specific Gravity Blood pH Protein Urobilinogen Nitrite Leukocyte Esterase
  23. 23. Typical Test Strip Test Sensitivity_ Glucose – 4 to 7 mmol/L Bilirubin – 7 to 14 µmol/L Ketone – 0.5 to 1.0 mmol/L (Acetoacetic acid) Blood – 150 to 620 µg/L (Hemoglobin) Protein – 0.15 to 0.3 g/L (Albumin) Nitrite – 13 to 22 µmol/L Leukocytes – 5 to 15 cells/ µL pH – pH 5.0 to 8.5Specific Gravity – 1.000 to1.030 Urobilinogen – 0.2 to 8 µmol/L BioMedica Diagnostics Inc. / D. Jette / March 25 2003
  24. 24. The Urine Dipstick: Glucose Chemical Principle Negative Glucose Oxidase Trace (100 mg/dL) Glucose + 2 H2O + O2 ---> + (250 mg/dL) Gluconic Acid + 2 H2O2 ++ (500 mg/dL) Horseradish Peroxidase 3 H2O2 + KI ---> KIO3 + 3 H2O +++ (1000 mg/dL) Read at 30 seconds ++++ (2000+ mg/dL) RR: Negative
  25. 25. Uses and Limitations of Urine GlucoseDetection Significance – Diabetes mellitus. – Renal glycosuria. Limitations – Interference: reducing agents, ketones. – Only measures glucose and not other sugars. – Renal threshold must be passed in order for glucose to spill into the urine. Other Tests – CuSO4 test for reducing sugars.
  26. 26. Detection of Reducing Sugars* byCuSO 4 Sugar Disease(s) - Galactose Galactosemias - Fructose Fructosuria, Fructose Intolerance, etc. - Lactose Lactase Deficiency - Pentoses Essential Pentosuria - Maltose Non-pathogenic * NOT Sucrose because it is not a reducing sugar
  27. 27. Urine versus Blood GlucoseUrinalysis Glucose Result ++ + trace Negative 200 400 600 800 1000 Blood Glucose (mg/dL)
  28. 28. The UrineDipstick: Bilirrubin Negative Chemical Principle + (weak) Bilirubin + Diazo salt Acidic Azobilirubin ---------> ++ (moderate) Read at 30 seconds +++ (strong) RR: Negative
  29. 29. Uses and Limitations of Urine BilirrubinDetectionSignificance - Increased direct bilirubin (correlates with urobilinogen and serum bilirubin)Limitations - Interference: prolonged exposure of sample to light - Only measures direct bilirubin--will not pick up indirect bilirubinOther Tests - Ictotest (more sensitive tablet version of same assay) - Serum test for total and direct bilirubin is more informative
  30. 30. The UrineDipstick: Ketones Negative Chemical Principle Trace (5 mg/dL) + (15 mg/dL) Acetoacetic Acid + Nitroprusside ------> Colored Complex ++ (40 mg/dL) +++ (80 mg/dL) Read at 40 seconds RR: Negative ++++ (160+ mg/dL)
  31. 31. Uses and Limitations of Urine Ketone Detection Significance - Diabetic ketoacidosis - Prolonged fasting Limitations - Interference: expired reagents (degradation with exposure to moisture in air) - Only measures acetoacetate not other ketone bodies (such as in rebound ketosis). Other Tests - Ketostix (more sensitive tablet version of same assay) - Serum glucose measurement to confirm DKA
  32. 32. The UrineDipstick: Specific Gravity 1.000 Chemical Principle 1.005 X+ + Polymethyl vinyl ether / maleic anhydride 1.010 ---------------> X+-Polymethyl vinyl ether / maleic anhydride + H+ 1.015 H+ interacts with a Bromthymol Blue indicator to 1.020 form a colored complex. 1.025 Read up to 2 minutes RR: 1.003-1.035 1.030
  33. 33. Uses and Limitations of Urine Specific GravitySignificance - Diabetes insipidusLimitations - Interference: alkaline urine - Does not measure non-ionized solutes (e.g. glucose)Other Tests - Refractometry - Hydrometer - Osmolality measurement (typically used with water deprivation test)
  34. 34. The UrineDipstick: Blood Negative Chemical Principle Trace (non-hemolyzed) Lysing agent to lyse red blood cells Moderate (non-hemolyzed) Diisopropylbenzene dihydroperoxide + Tetramethylbenzidine Trace (hemolyzed) Heme ------------> Colored Complex + (weak) ++ (moderate) Read at 60 seconds RR: Negative Analytic Sensitivity: 10 RBCs +++ (strong)
  35. 35. Uses and Limitations of Urine Blood DetectionSignificance - Hematuria (nephritis, trauma, etc) - Hemoglobinuria (hemolysis, etc) - Myoglobinuria (rhabdomyolysis, etc)Limitations - Interference: reducing agents, microbial peroxidases - Cannot distinguish between the above disease processesOther Tests - Urine microscopic examination - Urine cytology
  36. 36. The UrineDipstick: pH 5.0 6.0 Chemical Principle H+ interacts with: 6.5 Methyl Red (at high concentration; low pH) and Bromthymol Blue (at low concentration; high 7.0 pH), to form a colored complexes (dual indicator system) 7.5 8.0 Read up to 2 minutes R.R.: 4.5-8.0 8.5
  37. 37. Uses and Limitations of Urine pH Detection Significance - Acidic (less than 4.5): metabolic acidosis, high-protein diet - Alkaline (greater than 8.0): renal tubular acidosis (>5.5) Limitations - Interference: bacterial overgrowth (alkaline or acidic), “run over effect” effect of protein pad on pH indicator pad Other Tests - Titrable acidity - Blood gases to determine acid-base status
  38. 38. pH Run Over Effect Glucose Bilirubin Ketones Specific Gravity Buffers from the protein area of the strip (pH 3.0) spill over to the Blood pH area of the strip and make the pH pH of the sample appear more acidic than it really is. Protein Urobilinogen Nitrite Leukocyte Esterase
  39. 39. The UrineDipstick: Protein Chemical Principle “Protein Error of Indicators Method” Negative Pr H Pr H Pr Trace H Pr Pr + (30 mg/dL) H H H Pr ++ (100 mg/dL) Tetrabromphenol Blue H+ H H + + (buffered to pH 3.0) H+ H H + + +++ (300 mg/dL) Pr Pr Pr Pr Pr ++++ (2000 mg/dL) Pr Read at 60 seconds RR: Negative
  40. 40. Causes ofProteinuriaFunctional Renal - Severe muscular exertion - Glomerulonephritis - Pregnancy - Nephrotic syndrome - Orthostatic proteinuria - Renal tumor or infectionPre-Renal Post-Renal - Fever - Cystitis - Renal hypoxia - Urethritis or prostatitis - Hypertension - Contamination with vaginal secretions
  41. 41. Nephrotic Syndrome (> 3.5 g/dL in 24h) Primary - Lipoid nephrosis (severe) - Membranous glomerulonephritis - Membranoproliferative glomerulonephritis Secondary - Diabetes mellitus (Kimmelsteil-Wilson lesions) - Systemic lupus erythematosus - Amyloidosis and other infiltrative diseases - Renal vein thrombosis
  42. 42. Uses and Limitations of Urine ProteinDetection Significance - Proteinuria and the nephrotic syndrome. Limitations - Interference: highly alkaline urine. - Much more sensitive to albumin than other proteins (e.g., immunoglobulin light chains). Other Tests - Sulfosalicylic acid (SSA) turbidity test. - Urine protein electrophoresis (UPEP) - Bence Jones protein
  43. 43. Proteins in “Normal” UrineProtein % of Total Daily MaximumAlbumin 40% 60 mgTamm-Horsfall 40% 60 mgImmunoglobulins 12% 24 mgSecretory IgA 3% 6 mgOther 5%
  44. 44. The UrineDipstick: Urobilinogen 0.2 mg/dL Chemical Principle 1 mg/dL Urobilinogen + Diethylaminobenzaldehyde (Ehrlich’s Reagent) 2 mg/dL -------> Colored Complex 4 mg/dL Read at 60 seconds 8 mg/dL RR: 0.02-1.0 mg/dL
  45. 45. Uses and Limitations of UrobilinogenDetection Significance - High: increased hepatic processing of bilirubin - Low: bile obstruction Limitations - Interference: prolonged exposure of specimen to oxygen (urobilinogen ---> urobilin) - Cannot detect low levels of urobilinogen Other Tests - Serum total and direct bilirubin
  46. 46. The UrineDipstick: Nitrite Chemical Principle Acidic Negative Nitrite + p-arsenilic acid -------> Diazo compound Diazo compound + Tetrahydrobenzoquinolinol Positive ----------> Colored Complex Read at 60 seconds RR: Negative
  47. 47. Uses and Limitations of Nitrite Detection Significance - Gram negative bacteriuria Limitations - Interference: bacterial overgrowth - Only able to detect bacteria that reduce nitrate to nitrite Other Tests - Correlate with leukocyte esterase and - Urine microscopic examination (bacteria) - Urine culture
  48. 48. The UrineDipstick: Leukocyte Esterase Chemical Principle Derivatized pyrrole amino acid ester Negative Esterases ------------> 3-hydroxy-5-phenyl pyrrole Trace + (weak) 3-hydroxy-5-phenyl pyrrole + diazo salt -------------> Colored Complex ++ (moderate) Read at 2 minutes +++ (strong) RR: Negative Analytic Sensitivity: 3-5 WBCs
  49. 49. Uses and Limitations of Leukocyte Esterase Detection Significance - Pyuria - Acute inflammation - Renal calculus Limitations - Interference: oxidizing agents, menstrual contamination Other Tests - Urine microscopic examination (WBCs and bacteria) - Urine culture
  50. 50. Microscopic Examination General AspectsPreservation - Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp. - Refrigeration for up to 48 hours (little loss of cells).Specimen concentration - Ten to twenty-fold concentration by centrifugation.Types of microscopy - Phase contrast microscopy - Polarized microscopy - Bright field microscopy with special staining (e.g., Sternheimer-Malbin stain)
  51. 51. Microscopic Examination Abnormal FindingsPer High Power Field (HPF) (400x) – > 3 erythrocytes – > 5 leukocytes – > 2 renal tubular cells – > 10 bacteriaPer Low Power Field (LPF) (200x) – > 3 hyaline casts or > 1 granular cast – > 10 squamous cells (indicative of contaminated specimen) – Any other cast (RBCs, WBCs)Presence of: – Fungal hyphae or yeast, parasite, viral inclusions – Pathological crystals (cystine, leucine, tyrosine) – Large number of uric acid or calcium oxalate crystals
  52. 52. Microscopic Examination CellsErythrocytes - “Dysmorphic” vs. “normal” (> 10 per HPF)Leukocytes - Neutrophils (glitter cells) More than 1 per 3 HPF - Eosinophils Hansel test (special stain)Epithelial Cells - Squamous cells Indicate level of contamination - Renal tubular epithelial cells Few are normal - Transitional epithelial cells Few are normal - Oval fat bodies Abnormal, indicate Nephrosis
  53. 53. Microscopic Examination RBCs
  54. 54. Microscopic Examination RBCs
  55. 55. Microscopic Examination WBCs
  56. 56. Microscopic Examination Squamous Cells
  57. 57. Microscopic Examination Tubular Epithelial Cells
  58. 58. Microscopic Examination Transitional Cells
  59. 59. Microscopic Examination Transitional Cells
  60. 60. Microscopic Examination Oval Fat Body
  61. 61. Microscopic Examination LE Cell
  62. 62. Microscopic Examination Bacteria & Yeasts Bacteria - Bacteriuria More than 10 per HPF Yeasts - Candidiasis Most likely a contaminant but should correlate with clinical picture. Viruses - CMV inclusions Probable viral cystitis.
  63. 63. Microscopic Examination Bacteria
  64. 64. Microscopic Examination Yeasts
  65. 65. Microscopic Examination Yeasts
  66. 66. Microscopic Examination Cytomegalovirus
  67. 67. Microscopic Examination CastsErythrocyte Casts: Glomerular diseasesLeukocyte Casts: Pyuria, glomerular diseaseDegenerating Casts: - Granular casts Nonspecific (Tamm-Horsfall protein) - Hyaline casts Nonspecific (Tamm-Horsfall protein) - Waxy casts Nonspecific - Fatty casts Nephrotic syndrome (oval fat body casts)
  68. 68. Microscopic Examination Casts
  69. 69. Microscopic Examination RBCs Cast - Histology
  70. 70. Microscopic Examination RBCs Cast
  71. 71. Microscopic Examination RBCs Cast - Histology
  72. 72. Microscopic Examination WBCs Cast
  73. 73. Microscopic Examination Tubular Epith. Cast
  74. 74. Microscopic Examination Tubular Epith. Cast
  75. 75. Microscopic Examination Granular Cast
  76. 76. Microscopic Examination Hyaline Cast
  77. 77. Microscopic Examination Waxy Cast
  78. 78. Microscopic Examination Fatty Cast
  79. 79. Significance of Cellular Casts Erythrocyte Casts Leukocyte Casts Bacterial CastsSingle Erythrocytes Single Leukocytes Single Bacteria Verrier-Jones & Asscher, 1991.
  80. 80. Microscopic Examination Crystals - Urate Ammonium biurate Uric acid - Triple Phosphate - Calcium Oxalate - Amino Acids Cystine Leucine Tyrosine - Sulfonamide
  81. 81. Microscopic Examination Calcium Oxalate Crystals
  82. 82. Microscopic Examination Calcium Oxalate Crystals Dumbbell Shape
  83. 83. Microscopic Examination Triple Phosphate Crystals
  84. 84. Microscopic Examination Urate Crystals
  85. 85. Microscopic Examination Leucine Crystals
  86. 86. Microscopic Examination Cystine Crystals
  87. 87. Microscopic Examination Ammonium Biurate Crystals
  88. 88. Microscopic Examination Cholesterol Crystals
  89. 89. Cytological ExaminationStaining: – Papanicolau – Wright’s – Immunoperoxidase – Immunofluorescence
  90. 90. Cytology: Normal
  91. 91. Cytology: Normal
  92. 92. Cytology: Reactive
  93. 93. Cytology: Reactive
  94. 94. Cytology: Polyoma (DecoyCell)
  95. 95. Cytology: Polyoma (DecoyCell)Immunoperoxidase to SV40 ag
  96. 96. Cytology: TCC Low Grade
  97. 97. Cytology: TCC Low Grade
  98. 98. Cytology: TCC HighGrade
  99. 99. Cytology: TCC HighGrade
  100. 100. Cytology: Squamous CellCa.
  101. 101. Cytology: Renal Cell Ca.
  102. 102. Cytology: ProstaticCarcinoma
  103. 103. Urinalysis Disease Diagnosis
  104. 104. Case Diluted urine, request a voided urine in the morning If persisting low SG, possible diabetes insipida 1 A microscopic may give negative results Glucose Negative Bilirubin Negative A 35-year old man undergoing routine pre employment drug screening. Ketones Negative Physical characteristics: Clear. S.G. 1.001 Microscopic: Not performed. Drugs Identified: None. Blood Negative pH 5.5 Questions: Protein Negative - What is your differential diagnosis? - What would you do next to confirm yourUrobilinogen 0.2 mg/dL suspicion? - Would you order a microscopic analysis Nitrite Negative on this sample? L.E. Negative
  105. 105. Case Possible gallbladder or hepatic disease. No hemolytic anemia. Perform bilirubins in serum 2 Microscopic unlikely to provide additional info Glucose Negative Bilirubin +++ A 42-year old woman presents with “dark urine” Ketones Negative Physical characteristics: Red-brown. S.G. 1.020 Microscopic: Not performed. Blood Negative Questions: pH 5.5 - What is your differential diagnosis? Protein Negative - Could this be a case of hemolytic anemia? - How would you rule it out?Urobilinogen 0.2 mg/dL - What tests would you order next? Why? Nitrite - Would you order a microscopic analysis? Negative L.E. Negative
  106. 106. Case Possible UTI, request culture and antibiotic sensitivity Negative Nitrite test: Gram positive bacteria 3 Lower SG may show less number of cells and bacteria Un-common diagnosis in this type of patient Glucose Negative A 42-year old man presents painful urination Bilirubin Negative Ketones Physical characteristics: dark red, turbid Negative Microscopic: leukocytes = 30 per HPF S.G. 1.030 RBCs = >100 per HPF Bacteria = >100 per HPF Blood +++ Questions: pH 6.5 - What is your suspected diagnosis? - What would you do next? Protein Trace - What do you make of the nitrite test?Urobilinogen 1.0 mg/dL - How would the microscopic exam differ if the S.G. were 1.003? Nitrite Negative - Is this a common diagnosis for this type of patient? L.E. +++
  107. 107. Case Diabetes May be decompensated and with ketoacidosis 4 Ketones should become negative after treatment Glucose ++ Bilirubin Negative Ketones Trace A 27-year old woman presents with severe abdominal pain. S.G. 1.015 Physical characteristics: clear-yellow. Blood Negative Microscopic: Not performed. pH 6.0 Questions: Protein Negative - What is the most likely diagnosis? - What do you make of the ketone result?Urobilinogen 1.0 mg/dL - What do you expect to happen to the ketone measurement when treatment begins? Nitrite Negative L.E. Negative
  108. 108. Case Glomerulonephritis RBC casts reveals renal cortex involvement 5 RBC cast are not always present in GN Glucose Negative 8-year old boy presents with discolored urine Bilirubin Negative Ketones Physical characteristics: Red, turbid. Negative Microscopic: erythrocytes = >100 per HPF S.G. 1.015 (almost all dysmorphic) Red cell casts present. Blood +++ Questions: pH 6.5 - What is the most likely diagnosis in this Protein case? + - Does the presence of red cell casts help youUrobilinogen 1.0 mg/dL in any way? - If the erythrocytes were not dysmorphic Nitrite Negative would that change your diagnosis? L.E. Negative
  109. 109. Case “Functional” proteinuria? Microscopic may reveal a few leukocytes 6 Request protein concentration in 24 h urine Glucose Negative 22-year old man presenting for a routine Bilirubin Negative physical required for admission to medical Ketones Negative school S.G. 1.010 Physical characteristics: Yellow Microscopic: Not performed Blood Negative Questions: pH 5.0 - What is your differential diagnosis? Protein + - Would you order a microscopic analysis on this sample?Urobilinogen 0.2 mg/dL - What would you do next to confirm the diagnosis? Nitrite Negative L.E. Negative
  110. 110. Common Findings in: Acute Tubular Necrosis Glucose Bilirubin Ketones S.G. Decreased Microscopic: Blood +/- • Renal tubular epithelial cells pH • Pathological casts Protein +/-Urobilinogen Nitrite L.E.
  111. 111. Common Findings in: Acute Glomerulonephritis Glucose Bilirubin Ketones Microscopic: S.G. Blood Increased • Erythrocytes (dysmorphic) pH • Erythrocyte casts • Mixed cellular casts Protein IncreasedUrobilinogen Nitrite L.E.
  112. 112. Common Findings in: Chronic Glomerulonephritis Glucose Bilirubin Ketones Decreased Microscopic: S.G. Blood Increased • Pathological casts pH (broad waxy casts, RBCs) Protein IncreasedUrobilinogen Nitrite L.E.
  113. 113. Common Findings in: Acute Pyelonephritis Glucose Bilirubin Ketones Microscopic: S.G. • Bacteria Blood • Leukocytes pH • Leukocyte, granular, and Protein Trace waxy casts • Renal tubular epithelialUrobilinogen cell casts Nitrite Positive L.E. Positive
  114. 114. Common Findings in: Nephrotic Syndrome Glucose Bilirubin Ketones S.G. Microscopic: Blood • Oval fat bodies pH • Fatty casts Protein ++++ • Waxy castsUrobilinogen Nitrite L.E.
  115. 115. Common Findings in: Eosinophilic Cystitis Glucose Bilirubin Ketones S.G. Microscopic: Blood + • Numerous eosinophils pH (Hansel’s stain) Protein • NO significant casts.Urobilinogen Nitrite L.E.
  116. 116. Common Findings in: Urothelial Carcinoma Glucose Bilirubin Ketones S.G. Microscopic: Blood + • Malignant cells on pH urine cytology (urine Protein sample should be submitted separately to cytology, voidUrobilinogen or 24 hrs.) Nitrite L.E.
  117. 117. Acknowledgment: Dr. Brad Brimhall
  118. 118. Questions ?

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