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URINALYSIS – The ‘cornerstone’ of Clinical Nephrology N.Gopalakrishnan, MD, MRCP, DM
‘ Sick Lady and Doctor’ <ul><li>16 th century painting by  Caspar Netscher </li></ul><ul><li>(AJKD,2007) </li></ul>
Urinalysis - Aims <ul><li>Physical characteristics </li></ul><ul><li>Chemical composition </li></ul><ul><li>Cellular eleme...
Abnormal Colour of urine <ul><li>White  Chyle,pus </li></ul><ul><li>Yellow  Bilirubin </li></ul><ul><li>Pink / reddish bro...
Dipstick  <ul><li>pH </li></ul><ul><li>Protein </li></ul><ul><li>Blood </li></ul><ul><li>Specific gravity </li></ul><ul><l...
pH <ul><li>pH </li></ul><ul><li>Dipstick – pH 4.5 to 8.5;  less accurate when pH is < 5 or >8 </li></ul><ul><li>For accura...
Specific gravity <ul><li>Denotes weight of solutes </li></ul><ul><li>Inaccurate surrogate of osmolality </li></ul><ul><li>...
Protein <ul><li>Heat coagulation </li></ul><ul><li>Sulphosalicylic acid </li></ul><ul><li>Dipstick </li></ul>
Dipstick  - protein <ul><li>Protein indicator strips – tetrabromophenol blue or bromocresol blue </li></ul><ul><li>Colour ...
Dipstick - protein <ul><li>Highly alkaline urine - false positive reaction  </li></ul><ul><li>Quantification – influenced ...
Henry Bence Jones <ul><li>Light chains </li></ul><ul><li>Myeloma </li></ul><ul><li>Precipitate  40- 60 C </li></ul><ul><li...
Preparation of sample for microscopy <ul><li>Second urine of the morning after  discarding initial few millilitres </li></...
Microscopy <ul><li>Phase contrast microscope – ideal </li></ul><ul><li>High sensitivity for hyaline casts & RBCs with low ...
Erythrocytes <ul><li>> 2 -3 / HPF --- Haematuria </li></ul><ul><li>Isomorphic haematuria – from collecting system </li></u...
Dysmorphic RBCS <ul><li>Glomerular origin </li></ul><ul><li>Acanthocytes – sensitive indicator  </li></ul>
Leucocytes <ul><li>Indicate urinary tract inflammation </li></ul><ul><li>‘ Glitter cells’ – swollen polymorphs with promin...
Sterile pyuria <ul><li>Tuberculosis </li></ul><ul><li>Partially treated UTI </li></ul><ul><li>Steroids </li></ul><ul><li>C...
Eosinophiluria <ul><li>Acute allergic interstitial nephritis </li></ul><ul><li>Atheroembolism </li></ul><ul><li>Rapidly pr...
Renal tubular epithelial cells (RTECs) <ul><li>Larger than WBCs </li></ul><ul><li>Few cells are normal </li></ul><ul><li>I...
Casts in the urine <ul><li>Tubular moulds </li></ul><ul><li>Tamm Horsfall protein </li></ul><ul><li>forms the matrix  </li...
RBC cast <ul><li>Hyaline cast </li></ul><ul><li>+ </li></ul><ul><li>RBC </li></ul><ul><li>Always pathological </li></ul>
RBC cast <ul><li>Hallmark of Nephritic sediment </li></ul>
WBC cast <ul><li>Pyelonephritis </li></ul><ul><li>Glomerulonephritis </li></ul>
‘ Dirty brown’ cast <ul><li>Acute Tubular Necrosis </li></ul>
Fine granular cast <ul><li>Derived from altered serum proteins </li></ul><ul><li>Usually, pathological </li></ul>
Coarse granular cast <ul><li>Result from degeneration of embedded cells </li></ul><ul><li>Usually pathological </li></ul>
Broad casts (Waxy cast) <ul><li>Form in dilated, atrophic tubules  </li></ul><ul><li>More refractile than hyaline casts </...
Telescoped urine sediment <ul><li>Plethora of findings </li></ul><ul><li>RBCs, RBC casts, WBCs, granular casts, broad cast...
Crystals in urine <ul><li>Common crystals </li></ul><ul><li>Pathological crystals </li></ul><ul><li>Crystals due to drugs ...
Pathological crystals <ul><li>Cystine  -  Cystinuria </li></ul><ul><li>Cholesterol –  massive proteinuria </li></ul><ul><l...
Drugs causing crystalluria <ul><li>Drug overdose </li></ul><ul><li>Dehydration </li></ul><ul><li>Hypoalbuminemia </li></ul...
Cystine crystals <ul><li>Always pathological </li></ul><ul><li>Pathognomonic of cystinuria </li></ul>
Uric acid crystals <ul><li>Rhomboid  </li></ul><ul><li>Hyperuricosuric conditions </li></ul><ul><li>Acute uric acid nephro...
Calcium Oxalate <ul><li>Monohydrate:’dumb bell’ </li></ul><ul><li>Byhydrate:  ‘envelope’ </li></ul>
Triple phosphate crystals <ul><li>‘ Coffin lid’shaped </li></ul><ul><li>Rectangular with beveled ends </li></ul>
Blood <ul><li>Depends on peroxidase activity of haemoglobin </li></ul><ul><li>Blood, haemoglobin & myoglobin test positive...
Microorganisms <ul><li>Bacteria </li></ul><ul><li>Yeasts </li></ul><ul><li>Trichomonas </li></ul>
Nitrite screening test <ul><li>For detection of bacteriuria </li></ul><ul><li>Bacteria convert urinary nitrate to nitrite ...
Oval fat bodies <ul><li>Macrophages filled with fat droplets </li></ul><ul><li>Proteinuric conditions </li></ul>
Microalbumin dipsticks  <ul><li>For screening for microalbuminuria </li></ul><ul><li>Colorimetric detection of albumin bou...
<ul><li>Let us uphold the ancient tradition! </li></ul><ul><li>THANK  YOU </li></ul>
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CME - Urinalysis

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  • Transcript of "CME - Urinalysis"

    1. 1. URINALYSIS – The ‘cornerstone’ of Clinical Nephrology N.Gopalakrishnan, MD, MRCP, DM
    2. 2. ‘ Sick Lady and Doctor’ <ul><li>16 th century painting by Caspar Netscher </li></ul><ul><li>(AJKD,2007) </li></ul>
    3. 3. Urinalysis - Aims <ul><li>Physical characteristics </li></ul><ul><li>Chemical composition </li></ul><ul><li>Cellular elements </li></ul><ul><li>Microorganisms </li></ul>
    4. 4. Abnormal Colour of urine <ul><li>White Chyle,pus </li></ul><ul><li>Yellow Bilirubin </li></ul><ul><li>Pink / reddish brown RBCs, haemoglobin,myoglobin </li></ul><ul><li>Brown / black Methaemoglobin, homogentisic acid </li></ul><ul><li>Green Pseudomonas </li></ul>
    5. 5. Dipstick <ul><li>pH </li></ul><ul><li>Protein </li></ul><ul><li>Blood </li></ul><ul><li>Specific gravity </li></ul><ul><li>Glucose </li></ul><ul><li>Leucocytes </li></ul><ul><li>Nitrite </li></ul><ul><li>Bilirubin </li></ul><ul><li>Urobilinogen </li></ul><ul><li>Ketones </li></ul>
    6. 6. pH <ul><li>pH </li></ul><ul><li>Dipstick – pH 4.5 to 8.5; less accurate when pH is < 5 or >8 </li></ul><ul><li>For accurate estimation, pH meter with glass electrode is mandatory </li></ul>
    7. 7. Specific gravity <ul><li>Denotes weight of solutes </li></ul><ul><li>Inaccurate surrogate of osmolality </li></ul><ul><li>Methods: Hydrometer </li></ul><ul><li>Refractometer </li></ul><ul><li>Dipstick </li></ul><ul><li>Range: 1.001 – 1.035 </li></ul><ul><li>Assesses concentrating ability </li></ul><ul><li>Differentiation between pre renal azotemia & ATN </li></ul>
    8. 8. Protein <ul><li>Heat coagulation </li></ul><ul><li>Sulphosalicylic acid </li></ul><ul><li>Dipstick </li></ul>
    9. 9. Dipstick - protein <ul><li>Protein indicator strips – tetrabromophenol blue or bromocresol blue </li></ul><ul><li>Colour change according to protein concentration </li></ul><ul><li>Trace to 4+ </li></ul><ul><li>trace 5 – 20 mg/dl </li></ul><ul><li>1+ - 30, 2+ - 100, </li></ul><ul><li>3+ - 300, 4+ - > 2000 mg/dl </li></ul>
    10. 10. Dipstick - protein <ul><li>Highly alkaline urine - false positive reaction </li></ul><ul><li>Quantification – influenced by urinary concentration </li></ul><ul><li>Less sensitive to globulin,haemoglobin & light chain </li></ul><ul><li>Urine negative by dipstick but positive with sulphosalicylic acid – highly suspicious for light chains </li></ul>
    11. 11. Henry Bence Jones <ul><li>Light chains </li></ul><ul><li>Myeloma </li></ul><ul><li>Precipitate 40- 60 C </li></ul><ul><li>Dissolves 100 C </li></ul><ul><li>Reappears on cooling </li></ul>
    12. 12. Preparation of sample for microscopy <ul><li>Second urine of the morning after discarding initial few millilitres </li></ul><ul><li>Analysis within 2 – 4 hrs </li></ul><ul><li>Centrifuge (10 ml) at 2000 rpm for 10 min </li></ul><ul><li>Remove 9.5 ml of supernatant </li></ul><ul><li>Resuspend sediment with pipette in the in remaining 0.5 ml </li></ul><ul><li>Transfer 50 ul with pipette on to a slide </li></ul>
    13. 13. Microscopy <ul><li>Phase contrast microscope – ideal </li></ul><ul><li>High sensitivity for hyaline casts & RBCs with low Hb content </li></ul><ul><li>For RBC morphology </li></ul><ul><li>Filters to polarize light – for lipids & unusual crystals </li></ul>
    14. 14. Erythrocytes <ul><li>> 2 -3 / HPF --- Haematuria </li></ul><ul><li>Isomorphic haematuria – from collecting system </li></ul><ul><li>Dysmorphic haematuria – from renal parenchyma </li></ul>
    15. 15. Dysmorphic RBCS <ul><li>Glomerular origin </li></ul><ul><li>Acanthocytes – sensitive indicator </li></ul>
    16. 16. Leucocytes <ul><li>Indicate urinary tract inflammation </li></ul><ul><li>‘ Glitter cells’ – swollen polymorphs with prominent granules </li></ul><ul><li>UTI, interstitial nephritis, glomerulonephritis </li></ul>
    17. 17. Sterile pyuria <ul><li>Tuberculosis </li></ul><ul><li>Partially treated UTI </li></ul><ul><li>Steroids </li></ul><ul><li>Calculi </li></ul><ul><li>Prostatitis </li></ul><ul><li>Bladder tumour </li></ul><ul><li>Papillary necrosis </li></ul>
    18. 18. Eosinophiluria <ul><li>Acute allergic interstitial nephritis </li></ul><ul><li>Atheroembolism </li></ul><ul><li>Rapidly progressive glomerulonephritis </li></ul><ul><li>Schistosomiasis </li></ul><ul><li>Hansel’s stain </li></ul>
    19. 19. Renal tubular epithelial cells (RTECs) <ul><li>Larger than WBCs </li></ul><ul><li>Few cells are normal </li></ul><ul><li>Indicate tubular damage or inflammation </li></ul><ul><li>ATN, interstitial nephritis </li></ul>
    20. 20. Casts in the urine <ul><li>Tubular moulds </li></ul><ul><li>Tamm Horsfall protein </li></ul><ul><li>forms the matrix </li></ul><ul><li>Hyaline casts – base for other casts </li></ul>
    21. 21. RBC cast <ul><li>Hyaline cast </li></ul><ul><li>+ </li></ul><ul><li>RBC </li></ul><ul><li>Always pathological </li></ul>
    22. 22. RBC cast <ul><li>Hallmark of Nephritic sediment </li></ul>
    23. 23. WBC cast <ul><li>Pyelonephritis </li></ul><ul><li>Glomerulonephritis </li></ul>
    24. 24. ‘ Dirty brown’ cast <ul><li>Acute Tubular Necrosis </li></ul>
    25. 25. Fine granular cast <ul><li>Derived from altered serum proteins </li></ul><ul><li>Usually, pathological </li></ul>
    26. 26. Coarse granular cast <ul><li>Result from degeneration of embedded cells </li></ul><ul><li>Usually pathological </li></ul>
    27. 27. Broad casts (Waxy cast) <ul><li>Form in dilated, atrophic tubules </li></ul><ul><li>More refractile than hyaline casts </li></ul><ul><li>Usual in chronic renal insufficiency </li></ul>
    28. 28. Telescoped urine sediment <ul><li>Plethora of findings </li></ul><ul><li>RBCs, RBC casts, WBCs, granular casts, broad casts,etc </li></ul><ul><li>Classically seen in SLE </li></ul>
    29. 29. Crystals in urine <ul><li>Common crystals </li></ul><ul><li>Pathological crystals </li></ul><ul><li>Crystals due to drugs </li></ul>
    30. 30. Pathological crystals <ul><li>Cystine - Cystinuria </li></ul><ul><li>Cholesterol – massive proteinuria </li></ul><ul><li>2,8 dihydroxyadenine – Adeninie phosphoribosyl transferase deficiency </li></ul>
    31. 31. Drugs causing crystalluria <ul><li>Drug overdose </li></ul><ul><li>Dehydration </li></ul><ul><li>Hypoalbuminemia </li></ul><ul><li>Urine pH </li></ul><ul><li>Acyclovir </li></ul><ul><li>Indinavir </li></ul><ul><li>Sulphadiazine </li></ul><ul><li>Amoxycillin </li></ul><ul><li>Vitamin C (oxalate) </li></ul>
    32. 32. Cystine crystals <ul><li>Always pathological </li></ul><ul><li>Pathognomonic of cystinuria </li></ul>
    33. 33. Uric acid crystals <ul><li>Rhomboid </li></ul><ul><li>Hyperuricosuric conditions </li></ul><ul><li>Acute uric acid nephropathy </li></ul>
    34. 34. Calcium Oxalate <ul><li>Monohydrate:’dumb bell’ </li></ul><ul><li>Byhydrate: ‘envelope’ </li></ul>
    35. 35. Triple phosphate crystals <ul><li>‘ Coffin lid’shaped </li></ul><ul><li>Rectangular with beveled ends </li></ul>
    36. 36. Blood <ul><li>Depends on peroxidase activity of haemoglobin </li></ul><ul><li>Blood, haemoglobin & myoglobin test positive </li></ul><ul><li>Dipstick positive for blood, but no RBCs in microscopy – haemoglobin or myoglobin </li></ul>
    37. 37. Microorganisms <ul><li>Bacteria </li></ul><ul><li>Yeasts </li></ul><ul><li>Trichomonas </li></ul>
    38. 38. Nitrite screening test <ul><li>For detection of bacteriuria </li></ul><ul><li>Bacteria convert urinary nitrate to nitrite which activates a chromogen </li></ul><ul><li>False negative – Enterococcus </li></ul>
    39. 39. Oval fat bodies <ul><li>Macrophages filled with fat droplets </li></ul><ul><li>Proteinuric conditions </li></ul>
    40. 40. Microalbumin dipsticks <ul><li>For screening for microalbuminuria </li></ul><ul><li>Colorimetric detection of albumin bound to gold – conjugated antibody </li></ul>
    41. 41. <ul><li>Let us uphold the ancient tradition! </li></ul><ul><li>THANK YOU </li></ul>
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