Urine Interpretation / Test / Analysis

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Urine analysis, Interpretation of abnormal urine
Nephrology, kidney

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  • Urine Interpretation / Test / Analysis

    1. 1. INTERPRETATION OF ABNORMAL URINE ANALYSIS “Urine may be a waste material for man but is an important guide for a physician” PRESENTOR: Dr. Anshul Varshney MODERATOR: Dr. GK Mukhiya
    2. 2.  Urine should be analysed as rapidly as possible. ideally  If within 30 minutes. not possible: ◦ it should be refrigerated immediately and stored for preferably no more than 6–12 hours after collection. ◦ Refrigerated urine should be brought to room temperature and thoroughly mixed before analysis ◦ Urine should not be frozen if sediment analysis is to be performed. Casts are particularly vulnerable to disintegration and will only be detected if fresh urine is examined very soon after collection.
    3. 3. URINALYSIS . C. Microscopic Tests Include: 1. Cells. 2. Crystals. 3. Casts. 4. Microorganism 5. Parasites. 6.Contamination B. Biochemical Examination Includes: 1. Proteins. 2. Sugers. 3. Ketone bodies. 4. Bile salts. 5. Bile Pigments. 6. Blood. A. Physical Examination Includes: 1. Volume. 2. Color. 3. Odor. 4. Reaction (pH). 5. Specif ic gravity.
    4. 4. COLLECTION OF URINE SPECIMENS First morning sample –concentrated urine --biochemical analysis, casts and crystals. Random specimen - chemical screening, microscopic examinations. 24 sample urine sample - quantitative estimation of proteins, sugars, electrolytes, and hormones Mid stream urine specimen Clean catch urine
    5. 5. Clean Catch
    6. 6. Specimen Collection Supra-pubic Needle Aspiration
    7. 7. PHYSICAL EXAMINATION Volume – Normal -- 1.2-2 L /day. The day is 3-4 times > night. Night is < 400 ml. Polyuria >3000ml / day. Oliguria <400ml / day. Anuria <100 ml per day.
    8. 8. APPEARANCE COLOUR Normal - amber yellow (due to the presence of urobilin, uroerythrin and urochromes ). Colorless - Very dilute urine (Diabetes, Polyuria). Yellow orange (high colored) - Concentrated urine, Excess urobilin, Bile pigments, Intake of carrots.
    9. 9.  Red/ smoky - RBC, Myoglobin, Beetroot , Aniline dyes, Menstrual contamination.  Cloudy - Phosphates & Carbonates, Urates & Uric acid, Pus cells, Bacteria, Spermatozoabacteria,Yeast, Spermatozoa.  Milky - Pyuria, Fat, Chyluria.  Brown black – Methemoglobin, Homogenestic acid ( alkaptonuria ),Melanin.  Orange- Bile pigments, Drugs like Rifampicin- orange red Nitrofurantoin-dark yellow to brown Levodopa -brown to black; Amitryptyline- green or blue-green. Imipenem–cilastatin -brown urine
    10. 10. TURBIDITY Freshly Pus voided: Clear and transparent cells : form white precipitate Bacteria Mucus Red growth : gives uniform cloudiness. : it forms bulky deposits cells : gives turbid smoky urine Chyluria : gives turbid milky urine
    11. 11. ODOUR OF URINE Normal odour Fresh urine has aromatic odor Abnormal odors a. Ammonia smell: after prolonged standing b. Fecal smell: due to urinary infection. c. Fruity smell: ketosis d. Mousy order : phenylketonuria. e. Rancid : Tyrosinaemia. f. Maple syrup odour : MSUD
    12. 12. pH Normal A pH for urine ranges from 4.5 – 8.0. pH < 7 indicates acid urine and a pH > 7 alkaline urine. Some foods (such as citrus fruits and dairy products) and medications (such as antacids) can affect urine pH. In a diet high in protein the urine is more acidic, while a diet high in vegetable material yields a urine that is more alkaline.
    13. 13. CAUSES OF ACIDIC URINE Acidosis Uncontrolled diabetes Diarrhea Starvation and dehydration Respiratory Acidosis
    14. 14. CAUSES OF ALKALINE  UTI with urease producing org  Feeding  Salicylate intoxication  Urinary retention due to obstruction  Chronic renal failure  Respiratory  Renal alkalosis tubular acidosis URINE
    15. 15. SPECIFIC GRAVITY The specific gravity (SG) of urine is a useful indicator of renal concentrating ability. This can be readily obtained by measuring the refractive index (RI) in specially calibrated refractometer. 
    16. 16. The specific gravity of a solution refers to the ratio of its weight to that of an equal volume of water at the same temperature.  For urine, the specific gravity is a function of the number and weight of the dissolved solute particles. Specific gravity measures the concentrating and diluting abilities of the kidney.
    17. 17. Urine always has SG greater than that of distilled water, which has an SG of 1.000. Normal adults with adequate fluid intake: 1.016 and 1.022 (in a 24 hours specimen). The SG of urine is increased by large amounts of glucose, protein, lipid and contrast material.
    18. 18. LOW SPECIFIC GRAVITY  HYPOSTHENURIA :indicates dilute urine, which may be caused by: - Diabetes insipidus ( can be as low as 1.001). - Drinking excessive amounts of liquid. - Pyelonephritis, glomerulonephritis. - Use of diuretics.
    19. 19. HIGH SPECIFIC GRAVITY  HYPERSTHENURIA : indicates very concentrated urine, which may be caused by: - Dehydration - Diabetes mellitus. - Adrenal insufficiency. - Toximea of pregnancy (protein in the urine).
    20. 20. ISOSTHENURIC There is little or no variability between several specimens from a patient , and SG is fixed at about 1.010. It indicates : severe renal damage in which there is disruption of both concentrating and diluting abilities.
    21. 21. SPECIFIC GRAVITIY MEASUREMENT 1.Refractometer (total solids meter ): It measures the ratio of the velocity of light in air to the velocity of light in urine. 2. Urinometer : is a weighted float marked with a scale for specific gravities from 1.000 to 1.060. The urinometer is simple and quick to use. 3. Multiple test dipstick : an indicator changes color in relation to ionic concentration.
    22. 22. BIOCHEMICAL EXAMINATION GLUCOSURIA  Under normal circumstances glucose in not excreted in urine.  Glucose is freely filtered then reabsorbed in the proximal tubule, but resorptive capacity is limited.  Glucosuria occurs when : blood glucose exceeds this renal threshold, for example Diabetes mellitus  Glucosuria in the absence of hyperglycaemia reflects: - a tubular resorption defect eg: Fanconi syndrome
    23. 23. GLUCOSE
    24. 24. KETONURIA  Ketonuria is usually associated with diabetic ketoacidosis and starvation.  Dipsticks detect acetoacetate and to a lesser extent, acetone but do not detect betahydroxybutyrate (BHB).  TESTS 1.Dipstick test 2.Rothera’s test
    25. 25. KETONES  Ketones are excreted when the body metabolizes fats incompletely (ketonuria).
    26. 26. BILE IN URINE The constituents are : 1. Bilirubin (bile pigments), 2. Bile salts, 3. Urobilin and Urobilinogen. • Bilirubin appears IN JAUNDICE. • Increased bilirubinuria may be caused by liver diseses, cholestasis or haemolytic anaemia. • Bilirubin in urine is in the form of conjugated bilirubin
    27. 27. BLOOD IN URINE Red blood cells or Haemoglobin in urine. When hemolysis occurs in circulation or urine. Normally an occasional red cell may be found on microscopic examination of the urine sediment. In women during menstruation, the urine may get contaminated with menstrual blood
    28. 28.  HAEMATURIA: Denotes the presence of red blood cells in urine. - Renal disorders, Infections or Neoplasm or Trauma related to any part of urinary tract. HEMOGLOBINURIA: is the presence of blood pigments in the urine without the presence of red blood cells. - Hemolytic anemia, Transfusion reactions, Malaria, Paroxysmal Nocturnal Hemoglobinuria.
    29. 29. MICROSCOPY In this test, urine is spun in a centrifuge so the solid materials (sediment) settle out. The sediment is spread on a slide and examined under a microscope. Types of materials that may be found include: ◦ Red blood cells ◦ White blood cells ◦ Casts ◦ Epithelial cells ◦ Bacteria ◦ Crystals
    30. 30. CELLS Several types of cells can be found in the urine, some of which come from the blood and others from the different types of epithelium that line the urinary tract. TYPE 1.Erythrocytes 2. Leucocytes 3.Tubular cells 4. Uroepithelial cells 5. Squamous cells
    31. 31. ERYTHROCYTES (RBC’S) Hematuria is the presence of abnormal numbers of red blood cells in urine Due to glomerular damage, kidney trauma, urinary tract stones, urinary tract infections, blood toxins, and physical stress. Contaminate Some from the vagina in menstruating women. RBC may be present even in healthy individuals.
    32. 32. HAEMATURIA CAN BE Non-glomerular : 80 % of the erythrocytes show a regular (or isomorphic) appearance. Glomerular : when a similar proportion of erythrocytes are changed (or dysmorphic). Mixed : when the two types of cells are approximately in the same proportion.
    33. 33. (a) Isomorphic erythrocytes (dark cells have lost their hemoglobin content) (b) Dysmorphic erythrocytes.
    34. 34. LEUCOCYTES (WBC) Pyuria refers to the presence of abnormal numbers of WBC that may appear with infection in the urinary tract. WBC from the vagina, especially in the presence of vaginal and cervical infections, or the urethra in men and women may contaminate the urine.
    35. 35. NEUTROPHILS  Appear as cells with an average diameter of about 10 μm and a granular cytoplasm surrounding a lobulated nucleus.
    36. 36. Found in UTI , active proliferative glomerulonephritis, acute or chronic interstitial nephritis, and urological disorders. In women, consequence of urine contamination from genital secretions.  In such cases, they are associated with large amounts of squamous epithelial cells and bacteria.
    37. 37. LYMPHOCYTES Indicates Chronic inflmmatory conditions , viral diseases, renal transplant rejection The gradual or abrupt appearance of lymphocyturia in renal graft recipients is an early and sensitive marker of acute cellular rejection.
    38. 38. EOSINOPHILS  Marker of Acute interstitial nephritis caused by: - Drugs such as methycillin. - Extracapillary glomerulonephritis. - Atheroembolic renal disease. - Urinary tract infection, - Prostatitis. - Urinary schistosomiasis.
    39. 39. RENAL TUBULAR CELLS Round to ovoid mononucleated cells, 13um. Few tubular cells are rectangular, polygonal or even columnar. Tubular cells are a found in: - acute tubular necrosis - acute interstitial nephritis - acute cellular allograft rejection and - acute nephritic or nephrotic syndrome.
    40. 40. UROTHELIAL CELLS These come from the urothelium, a multilayered epithelium lining the urinary excretory tract from the calyces to the bladder in the female and to the proximal urethra in the male. Two main types of urothelial cells are found.
    41. 41. 1. Deriving from the deep layers : . have club-like or ovoid appearance, a thin cytoplasm, and a mean diameter of about 18 μm. . found in urolithiasis, bladder cancer, hydronephrosis, ureteric stents or prolonged bladder catheterization.
    42. 42. 2. Deriving from the superficial layers : . are round to oval and are much larger having a mean diameter of about 30 μm. . found in UTI.
    43. 43. SQUAMOUS CELLS Have abundant cytoplasm with few granules and a small, central nucleus. They are the largest cells found in the urine, with a mean diameter of about 55 μm. They are found routinely in small numbers, being exfoliated from the urethra. When found in large numbers, they indicate a contamination of urine from vaginal discharge.
    44. 44. LIPIDS Lipids are present in urine mainly as droplets. These can be either isolated or in aggregates —or within casts and cells. In casts or cells, they can form 'oval fat bodies', which are tubular cells or macrophages gorged with lipids. Under polarized light: when containing free cholesterol and cholesterol esters, they appear as 'Maltese crosses', which are bright particles cut by symmetrical crosses. CAUSES: Nephrotic PCKD In syndrome or heavy proteinuria. or with non-glomerular diseases. primary abnormalities of lipid metabolism, such as Fabry's disease.
    45. 45. (a) A large aggregate of lipid droplets. (b) A macrophage partly gorged with lipid droplets (a so-called 'oval fat body'). (c) Maltese crosses
    46. 46. CASTS Casts are elongated elements with a basic cylindrical shape that has some possible variation due to bending, wrinkling, and irregular edges. Kidney is the sole site of origin.
    47. 47. TAMM-HORSFALL PROTEIN A glycoprotein secreted by thick part of ascending loop of henle and early distal convoluted tubules. Constitutes Forms The 1/3 of total urinary protein. the matrix of all casts. protein forms a meshwork of fibrils that can trap any elements present in the tubular filtrate including cells, cell fragments or granular material.
    48. 48. CLASSIFICATION OF CASTS 1.MATRIX - Hyaline. - Waxy. 2.INCLUSIONS - Granules- proteins, cell debris. - Fat globules- triglycerides, cholestrol esters. - Hemosiderin granules. - Crystals- uncommon. - Melanin granules- rare.
    49. 49. 3.PIGMENTS - Haemoglobin. - Myoglobin. - Bilirubin . - Drugs. 4.CELLS - Erythocyte casts. - Leucocytes : neutrophils, lymphocytes, monocytes. - Renal tubular epithelial cells. - Mixed cells : erythrocytes, neutrophils and renal tubular cells. - Bacteria.
    50. 50. HYALINE CASTS Most frequently observed casts. Consists almost entirely of Tamm-Horsfall protein. Low refractive index so not easily visualized with brightfield microscopy.  Easily visualized with phase contrast microscopy.
    51. 51. Can be found normally and also seen in: 1.Exercise 2.Diuretics 3.Heat exposure 4.Dehydration 5.Fever
    52. 52. WAXY CASTS  In chronic renal diseases some casts become denser in appearance and known as waxy casts.  High refractive index so easily visualized with brightfield microscopy.  Commonly associated with tubular inflammation and degeneration.
    53. 53. SEEN IN:  Chronic  Acute renal failure. and chronic renal allogratft rejection. When unusually broad waxy casts are found known as renal failure casts. - They imply advanced tubular atrophy and/or dilatation , in turn reflecting ESRD and extreme stasis of urine flow.
    54. 54. HYALINE–GRANULAR CASTS These are hyaline casts containing variable amounts of fine granules. They are the most frequent casts seen in patients with glomerulonephritis.
    55. 55. GRANULAR CASTS These casts can contain either fine or coarse granules. Originate from plasma protein aggregates that pass into tubules from damaged glomeruli. Also from cellular remnants of WBC, RBC, damaged renal tubular cells.
    56. 56. APPEAR IN :  Glomerular and tubular diseases.  Tubulointerstitial  Renal disease. allogratft rejection.  Pyelonephritis, viral infection, chronic lead poisoning.  Coarse granular casts occur with Haematuria in renal papillary necrosis.
    57. 57. INCLUSION CASTS FATTY CASTS Fatty material is incorporated into the cast matrix from lipidladen renal tubular cells. Commonly seen with heavy proteinuria, so feature of nephrotic syndrome
    58. 58. INCLUSION CASTS CRYSTAL CAST  Casts containing urates, calcium oxalates and sulphonamides.   Occasionally seen. Indicate deposition of crystals in the tubule or collecting duct.  Hematuria related to tubular damage accompanies crystal casts.
    59. 59. PIGMENT CASTS HAEMOGLOBIN CASTS. MYOGLOBIN CASTS- red brown in colour and occur with myoglobinuria following acute muscle damage. May be associated with acute renal failure. BILIRUBIN CASTS- seen in obstructive jaundice as deep yellow brown colored. DRUGS- phenazopyridine cause a bright yellow to orange colour in acid urine and will color casts and cells.
    60. 60. HAEMOGLOBIN CASTS  Appear yellow to red or even pale.  Usually seen with erythrocyte casts and glomerular disease.  Rarely seen with tubular bleeding and hemoglobinuria.  When the erythrocytes embedded in the matrix of cast undergo degenerative processes haemoglobin casts are formed. An erythrocyte cast. Inset: a haemoglobin cast
    61. 61. CELLULAR CASTS 1. ERYTHROCYTE (RBC) CASTS  contain variable amounts of erythrocytes embedded in the matrix of the cast.  Indicator of bleeding with in nephron.  considered as a highly specific marker of glomerular bleeding.  Glomerular damage allows rbc to escape into tubule and if there is concomittant proteinuria and optimal conditions for cast formation , rbc casts form in distal nephron.
    62. 62. ERYTHROCYTE CASTS APPEAR IN: Acute IgA glomerulonephritis Nephropathy Lupus nephritis Renal infarction Severe Renal pyelonephritis relapse in patients with SLE
    63. 63. LEUCOCYTE (WBC) CASTS Contain variable amounts of neutrophils and indicate the renal origin of leucocytes. Value in patients with urinary tract infection, since their presence suggests the involvement of the renal parenchyma. May also be found in acute interstitial nephritis and proliferative active glomerulonephritis.
    64. 64. EPITHELIAL CASTS These contain tubular epithelial cells. found in all conditions associated with tubular damage such as:  acute tubular necrosis.  acute interstitial nephritis.  acute renal allograft cellular rejection.  acute nephritic syndrome.  nephrotic  Viral syndrome. diseases (CMV).  Heavy metal poisoning, ethylene glycol, salicylate intoxication.
    65. 65. CRYSTALS Formed by precipitation of urinary salts when alteration in multiple factors affect their solubility like pH, temperature, concentration. Urine can contain several types of crystals.  They are found in both acidic urine and alkaline urine. Some are birefringent under polarized light.
    66. 66. URIC ACID These crystals precipitate at a pH <5.4.  Wide range of shapes.  Appear mostly as lozenges which have a typical amber colour. Under polarized light show polychromatic birefringence. 1.Reflect increased nucleoprotein turnover eg chemotherapy for leukemia 2.Evidence of uric acid stones lodged in ureter. 3.Urate nephropathy of gout.
    67. 67. CALCIUM OXALATE Two 1. main types of calcium oxalate crystals: Monohydrated: dumb-bell or as biconcave/biconvex discs , birefringent. 2. Bihydrated: bipyramidal shape. can cause extensive tubular injury . Causes: .Chronic renal disease. .Ethylene glycol toxicity. . Increased absorption of oxalates from food following small bowel resection, crohns disease.
    68. 68. CYSTINE Are thin, hexagonal, birefringent plates with irregular sides. Can be isolated, heaped upon one another, or in clumps. Found mostly in acidic urine. Marker  of cystinuria. Also found in cystine calculi.
    69. 69. CRYSTALS DUE TO DRUGS Sulfadiazine Acyclovir and indinavir Triamterene Coronary dilator piridoxylate Barbiturate primidone, Vasodilator naftidrofuryl oxalate, Vitamin C Amoxycillin
    70. 70. CHOLESTEROL CRYSTALS  Appear as brownish, transparent thin plates, with sharp edges and corners.  Found with other lipid particles, in the urine of patients with nephrotic syndrome or heavy proteinuria.  A plate of cholesterol crystal (on its lowest corner, a few small lipid droplets; on the background, a hyaline cast)
    71. 71. MICROORGANISMS BACTERIA Seen as rods or cocci. May be found due to contamination rather than infection. The presence of leucocytes increases the probability of a real infection, especially in women, but leucocytes and bacteria may contaminate urine from genitalia. In patients with acute pyelonephritis, bacterial casts can be seen.
    72. 72. FUNGI • Candida - most frequently found yeast • Elongated, ovoid, or spherical. • Presence of buds. • Most frequent cause is contamination from the genitalia. • Grows in the urinary tract, mostly in patients with diabetes, structural abnormalities, indwelling catheters, prolonged antibiotic treatment or immunosuppression. • Candidal casts are found in urine of patients with renal candidiasis.
    73. 73. PARASITES SCHISTOSOMA HAEMATOBIUM The adult form lives and lays the eggs in the vesical plexus and veins draining the ureters. Endemic in Nile valley, West Africa, Arabia. Causes haematuria, chronic renal failure due to obstructive uropathy, glomerulonephritis, or bladder cancer. Eggs : spindle shaped, a rounded anterior and a conical posterior end tapering into a delicate terminal spine.

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