This presentation gives a detailed explanation of the routine Urine analysis and explanation of a simple Urine RE, Hep B serology and Hep C serology

1. BY DR.BLEWUSI
ROUTINE
INVESTIGATION
S

2.  URINE ANALYSIS
 HEP B SEROLOGY
 HEP C SEROLOGY

3. IMPORTANCE OF A URINE RE
 Helpful in the diagnosis of
 1.Kidney failure 5.Acid base disorders
 2.Urinary tract infection 6.Hydration status
 3.kidney/urethral stones 7.Rhabdomyolysis
 4.GU malignancy 8.Response to alkalination therapy

4.  COLOUR-Clear, Cloudy, colourless
 SPECIFIC GRAVITY
 pH
 GLUCOSE
 KETONES
 BLOOD
 PROTEINS
 NITRITES
 LEUKOCYTES
 BILIRUBIN + UROBILINOGEN
URINE RE

5. COLOUR
 May be cloudy-clear, colourless-amber.
 Cloudyness may be due to an infection, percipitated crystals
 Red-bleeding, porphyria, schistosomiasis, Meds-rifampin, phenytoin,
phenazopyridine, beef
 Orange-Hyperbilirubinemia, rifampic, excessive vit A and B complex
 Remember cola like urine in sickle cell haemolytic crisis
 Orange crystals seen in diapers of babies due to dehydrations

6. SPECIFIC GRAVITY
 It is the density of urine, compared to that of water
 Basically the osmolality in urine ie what substances are in the urine. The osmolality of water is
1 because water has nothing in it.
 Urine has a specific gravity between 1.003 and 1.035
 Hence if Specific gravity >1.03, it is an indication of dehydration
 Below 1.003 is an indication of hyperhydration
 Again If S.G>1.03 it might be due to glucosuria, SIADH, IV contrast
 Decreased SG is also an indication of diabetes insipidus(too much dilute urine)NOT
DIAGNOSTIC
 Patients with adanced kidney disease have a fixed Specific gravity, as kidney is unable to
concenterate urine

7.  pH
 pH varies between 4.5-8 usually (5.5-6.5)
 Helpful in diagnosing renal tubular acidosis
 Monitoring alkalinzation to prevent precipitation of myoglobin in rhabdomyolysis,
and to aid elimination of some drugs eg aspirin, metothrexate
 Differentiate types of kidney stones
 Ingestion of protein(amino acid), which is converted to urea, making urine
acidic.certain bacteria such as proteus and klebsiella produce urease which breaks
down urea making urine alkaline
 Urine pH is greatly influenced by diet and hence shoul not be used to comment on
the acid-base balance of a patiant in the absence of ABGs

8. Glucose
 Glucose passes through glomerular basement membrane but is reabsorbed by the
proximal convoluted tubes, back into blood
 If urine is signifcant of glucose, its an indication there is a an overwhelming
amount of glucose in blood hence not adequately filtered, this might be due to
Diabetes mellitus or increased intake of glucose
 Glucose has an osmotic effect ie pulling water to it hence its association with
polyuria
 Proximal tubular dysfunction


9. KETONES
 3 types – B-hydroxybutyrate, acetoacetate, acetone. The test for ketones via dipstick only
detects acetoacetate, tho the most predominant ketones formed in ketoacidosis is B-
Hydroxybutyrate
 Again, clearance of B-hydroxybutyrate requires it to be converted to acetoacetate hence
when a patient is improving , dipstick can give a wrong impression that he/she is rather
worsening
 Ketones may be seen in urine due to diabetic ketoacidosis, usually triggered by an
infection or, alcoholism or starvation, ketogenic diet,(the extreme diet used for kids with
epilepsy)
 Ketones mostly seen in type 1 dm, Ketones are an alternage energy source.
 Remember glucose is turned into energy by glycolysis glucose-pyruvate-kreb cycle-electron
transport chain-36 atp molecules. This can only happen in the presence of insulin, in its
absence the body finds an alternate way of producing insuline
 Fats and proteins are broken down to form glucose by an alternate route, which produces
ketones
 Ketones can be produced when someone is not taking in enough carbohydrate diet.

10. BLOOD
 Test actually measures peroxidase activty(an indicator of hemoglobin, myoglobin
and erythrocyte activity)
 Erythrocytes ideally do not pass through the glomerular basement filter as they
are too big, presence indicated a damage to the glomerular basement membrane,
the bladder/urethra
 Myoglobin and hemoglobin do get through the glomerular filter, increased in
exercise(should be transient) or may be due to a crash injury infection as well
 A false positive result can also be due to contamination with semen

11. PROTEIN
 If proteins are less than 20,000daltons in size, they can be easily filtered through
the glomerular basement membrane(albumin and globulin)
 The sensitivity of this test is highly dependent on the concenteration of urine that
is, the more concenterated the urine is, the more sensitive the test
 May transient heart failure, exercise, fever, stress or long term in glomerular
diseases eg glomerulonephritis,diabetic nephropathy and also in overflow
proteinuria eg multiple myeloma, rhabdomyolsis, intravascular hemolysis

12. LEUKOCYTE ESTERASE AND
NITRITES
 Leukocte esterase are enzymes released by white blood cells and are used as
qualitative measure of white blood cells in the urinary tract
 Nitrites detect the presence of enterobacteriacae, which converts nitrates to
nitrites.Notably, enterococcus sp do not have this ability
 There can be other reasons for negative nitrites test even tho bacteria is present,
an example is insufficient incubation time of urine, decreased secretion of nitrates,
and a low urine pH

13. LEUKOCYTE ESTERASE AND
NITRITES
 Nitrite is more specific for infection and leukocytes more indicative of an
inflammation
LEUKOCYTES
(1-4+)
NITRITES
+/-
Urinary Tract infection X X
Indwelling urinary catheter X X
Recent Instrumentation of Genito-urinary
tract
X
Urologic malignancy X
Chronic Interstitial nephritis X
Interstital cystitis X
Intrabadominal inflammatory process,
adjacent to the urinary tract
X

14. BILIRUBIN AND UROBILINOGEN
 Hepatocellular disease or biliary disease
BILIRUBIN UROBILINOGEN
HEMOLYSIS NEGATIVE ELEVATED
BILIARY
OBSTRUCTION
POSITVE NORMAL/
DECREASED

15. MICROSCOPIC EXAMINATION
 Cellular elements seen in urine include
 Red blood cells
 White blood cells
 Mucus
 Epithelial cells
 Various crystals
 Bacteria
 Casts

16. ABNORMAL FINDINGS
 Abnormal findings depene on magnification power of the microscope used
 PER HIGH POWER FIELD (HPF)(400x)
 >3 erythrocytes
 >5 leukocytes
 >2 renal tubular cells
 >10 bacteria
 PER LOW POWER FIELD(LPF)(200x)
 >3 hyaline casts or >1 granular cast
 >10 squamous cells(indicates contaminated specimen)
 Any other cast (RBCs, WBCS)
 Presence of
 Funga hyphae or Yeast, viral inclusion
 High number of uric acid or calcium oxalate crystals

17. Presence of RBCs
 Presence of dysmorphic RBCs is strongly suggstive of glomerular disease
 RBCS may be elevated in case of
 UTI
 Renal stone
 GU malignancy
 Coagulopathy
 Glomerulonephritis
 Sickle cell anemia
 Renal Tuberculosis
 Vigorous exercuse
 Contamination with menstural blood

18. ELEVATED LEUKOCYTES
 Urinary tract infection
 Indwellinng urinary catheter
 Recent instrumentation of GU tract
 Urologic malignancy
 Chronic Interstial nephritis
 Interstital cystitis
 Intra-abdominal inflammatory process adjacennt to the GU tract
 Contamination with vaginal secetions

19. BACTERIA
 Tho a common findinng and consitent with UTI, in the absence of symptoms and if
leukocyte esterase and nitrites are negative, bacteria in urine is most liely due to poor
collection technique of urine collection

20. CRYSTALS
 Crystals are are highly organized microscopic solids, usually composed of a small number
of diffeent ions and/or molecules
 Crystalization depends on:
 1.Concenteration of the said ions and molecules
 2.Uirne pH
 Small amounrs of most types of crystals are not necessarily pathologic

21. CRYSTAL CHARACTERISTICS DIAGNOSTIC UTILITY
Uric acid Formation promoted by acidic
urine
Seen in tumor lysis syndrome
Calcium Phosphate Formation promoted by
alkaline urine
Tho huge quantities can lead to formation of renal
stoles, their presence in urine microscopy is Not
suggestive of a specific systenic disease
Magnessium
ammonium phosphate
(struvite/triple
phosphate)
Formation promoted by
alkaline Urine
Seen in UTIs by urease-producing organisms(eg
Proteus, Klebsiella)
Calcium Oxalate
dihydrate
Formatiob is largely
independent of pH
Not suggestive of any specific disease
Calcium oxalate
monohydrate
Formatiob is largely
independent of pH
Seen in ehylene glycol ingestion
Cystine Formation promoted in acidic
urine
Diagnostic of Cystinuria

22. CASTS
 Long cylindrical structurs, formed in renal tubules due to Precipitation of Tamm-Horsfall
mucuprotein
 Promoteddd by acidic and/or concentrateddd urine
Casts are described based on elements embedded within the mucuprotein matrix.
Presence of casts provide impoertnat insight in the etiology of AKI

23. CASTS
May be cellular or acellular
Acellular
casts
Hyaline Non specific, seen in dehydration
Muddy brown Stongly suggestive of acute tubular necrosis
Waxy Non-specific :seen in both acute and chronid kidney disease
Pigment Contains one of several coloured compound(Hme, bilirubin etc)
Granular Believed to be degeneration of cellular casts

24.  Cellular
 RBC-stongly suggestive of glomerulonephritis
 WBC- Stongly suggestive of interstitial inflammation(either infectious or non
infectious)

25. Appearance Specific
gravity
Proteins Leukocyte
esterase
Nitrites RBCs WBCs Casts
UTI Cloudy,
Turbid
any +/- +/- +/- + None
Dehydration/
Decreased
renal
perfussion
Dark yellow Relatively
high
+/- - - - - Hyaline
casts
ATN Dark yellow
or amber
Relatively
high
+/- +/- - +/- +/- Mudddy
Brown
casts
Nephrotic
syndrome
foamy Relatively
high
Severe
elevation
- - - - Fatty
acids
Nephritic
Syndrome
Red or
brown
Relatively
high
Mild-mod
elevation
+/- - +
(dysmorphic
+/- RBC
casts
SUMMARY

26. SEROLOGY MARKER INDICATES EASY
HBsAg Hep B infection(Acute or
chronic)
S- Sick with hep B
HBeAg Replication/Transmissibility E-Easily spread
HBcAg ------------------------- ------------------
Anti-HBc Previous or ongoing infection
IgM-acute infection
IgG-chronic infection
C-Come across Hep B
Anti-Hbe Low transmissibility Anti-easily spread
Anti-HBs Immune from recovery or
vaccination
Anti-Sick
HEP B SEROLOGY

27.  Example 1
 Hbsag -negative
 Anti-HBc. -negative
 Anti HBS. Negative
 Example 2
 HBsAg -negative
 Anti-HBc -positive
 Anti-HBs. -Positive
 Example 3
 Hbsag -negative
 Anti-HBc. -negative
 Anti- HBs - positive
 Example 4
 HBsAg -
positive
 Anti-HBc -
positive
 IgM Anti-HBc. -
Positive
 anti-HBs -
 Example 5
 HBsAg -Positive
 Anti-HBc. -Positive
 Anti HBS. - Negative
 Anti-HBs -Negative

28.  HEP C
 First test for anti-HCV(Remains + for life after exposure), if negative it means
there is no detectable antibodies to HCV and patient is negative(unless special
cirumstances eg immunocompromised, recently exposed) patient is considered
never infected or suceptiple
 A reactive anti-HCV can mean patient is currently infected, has previously been
infected or a false positive
 It should be followed with HCV RNA test, if detected, it is indicative of current
HCV infection, if however negative, it is indicative of a past/resolved infection or
false positive anti-HCV

29. Thank you for your attention