Urinalysis 3/27


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  • Urinalysis 3/27

    1. 1. Urinalysis Jennifer Lyon, M.S., M.L.I.S. [email_address] Joanna Karpinski, M.L.I.S. [email_address]
    2. 2. Urinalysis <ul><li>A complete urinalysis consists of three distinct testing phases: </li></ul><ul><li>Physical examination – </li></ul><ul><ul><li>Evaluates the urine's color, clarity, and concentration </li></ul></ul><ul><li>Chemical examination – </li></ul><ul><ul><li>Tests chemically for many substances that provide valuable information about health and disease </li></ul></ul><ul><ul><ul><li>only some of these are covered today </li></ul></ul></ul><ul><li>Microscopic examination </li></ul><ul><ul><li>Identifies and counts types of cells, casts, crystals, and other components (bacteria, mucous) that can be present in urine </li></ul></ul><ul><li>Additional testing: urine culture (check to see if a microorganism is growing in the urine – not covered today ) </li></ul>
    3. 3. Why Is It Important? <ul><li>Urine composition provides information about: </li></ul><ul><ul><li>The health and function of part of the body’s waste management system </li></ul></ul><ul><ul><li>State of kidney function </li></ul></ul><ul><ul><li>Possible blood abnormalities </li></ul></ul><ul><li>Urine analysis can help a clinician: </li></ul><ul><ul><li>Identify infections and other diseases </li></ul></ul><ul><ul><li>Gauge generally the body’s hydration level </li></ul></ul>
    4. 4. Sample Clinical Questions <ul><li>Is there a predictive value of acute kidney injury in ICU patients? </li></ul><ul><li>Is there a method for localizing the site of a urinary tract infection: upper (renal) vs. lower (bladder). </li></ul><ul><li>Which is the best procedure: rapid (quick-emptying) versus slow (periodically-clamped) voiding of urine through a catheter in patients with urinary retention? </li></ul><ul><li>What strategies to prevent urinary tract infection in the acutely ill adult population are supported by evidence </li></ul><ul><li>Is MRSA (methicillin-resistant staphylococcus aureus) a significant pathogen for urinary tract infections? </li></ul>
    5. 5. Physical Exam <ul><li>Color </li></ul><ul><li>Concentration </li></ul><ul><li>Clarity (Turbidity) </li></ul><ul><li>(rarely) Odor </li></ul>
    6. 6. Urine Color <ul><li>The depth of urine color is also a crude indicator of urine concentration: </li></ul><ul><ul><li>A dilute urine where lots of water is being excreted: pale yellow </li></ul></ul><ul><ul><li>Excretion of waste products in as little water as possible (eg., during a fever, or first morning urine): dark yellow </li></ul></ul><ul><li>Normal color range: yellow to dark amber </li></ul><ul><li>Some color changes may not indicate disease: </li></ul><ul><ul><li>Drugs and vitamins: chloroquine, iron supplements, levodopa, nitrofurantoin, phenazopyridine, phenothiazines, phenytoin, B vitamins, warfarin… </li></ul></ul><ul><ul><li>Food: beets… </li></ul></ul><ul><ul><li>Contamination: menses… </li></ul></ul><ul><li>Some can indicate disease or damage: </li></ul><ul><ul><li>Trauma – presence of red blood cells(RBCs)-(red) </li></ul></ul><ul><ul><li>Disease/disorder – presence of RBCs(red), chirrhosis(dark amber), melanin/melanoma(black), liver disease(neon yellow) </li></ul></ul>
    7. 7. Urine Concentration <ul><li>Accurate measurement of urine concentration can be done using chemical tests called specific gravity and osmolality </li></ul><ul><ul><li>Measures the amount of dissolved substances in the urine water </li></ul></ul><ul><li>The specific gravity and osmolality tests will be covered in the Chemical Exam section. </li></ul>
    8. 8. Urine Clarity <ul><li>Urine clarity refers to how clear the urine is </li></ul><ul><ul><li>Labs usually report clarity of the urine as </li></ul></ul><ul><ul><ul><li>clear </li></ul></ul></ul><ul><ul><ul><li>slightly cloudy </li></ul></ul></ul><ul><ul><ul><li>cloudy </li></ul></ul></ul><ul><ul><ul><li>turbid </li></ul></ul></ul><ul><li>“ Normal” urine can be clear or cloudy </li></ul><ul><ul><li>Clinically unimportant substances that cause cloudiness: </li></ul></ul><ul><ul><ul><li>mucous, sperm and prostatic fluid, cells from the skin, normal urine crystals, and contaminants (eg. body lotions/powders) </li></ul></ul></ul><ul><ul><li>Clinically important substances that cause cloudiness: </li></ul></ul><ul><ul><ul><li>Red blood cells, white blood cells, protein, and bacteria </li></ul></ul></ul>
    9. 9. Chemical Exam <ul><li>These tests are often done using a urine dipstick - a plastic stick that has patches of chemical indicators on it which is placed in the urine. The color changes of the patches provide the results. </li></ul><ul><li>specific gravity/osmolality </li></ul><ul><li>pH </li></ul><ul><li>protein </li></ul><ul><li>hematuria (see also RBCs under microscopic exam) </li></ul><ul><li>glucose </li></ul><ul><li>ketones </li></ul><ul><li>leukocyte esterase </li></ul><ul><li>nitrite </li></ul><ul><li>bilirubin and urobilinogen </li></ul>
    10. 10. Specific Gravity (urine density) <ul><li>Specific gravity measures the concentration of particles in a solution (grams/ml). </li></ul><ul><li>Normal values under specific conditions: </li></ul><ul><li>1.010 to 1.025 (normal specific gravity) </li></ul><ul><li>1.001 after water loading </li></ul><ul><li>More than 1.025 after water deprivation </li></ul><ul><li>Concentrated (increased specific gravity) after ADH administration </li></ul>
    11. 11. Specific Gravity - Abnormalities <ul><li>Increased urine specific gravity may indicate: </li></ul><ul><ul><li>Dehydration; Water restriction </li></ul></ul><ul><ul><li>Diarrhea; Vomiting; Excessive sweating </li></ul></ul><ul><ul><li>Glucosuria </li></ul></ul><ul><ul><li>Heart failure (related to decreased blood flow to the kidneys) </li></ul></ul><ul><ul><li>Renal arterial stenosis </li></ul></ul><ul><ul><li>Syndrome of inappropriate antidiuretic hormone secretion (SIADH) </li></ul></ul><ul><li>Decreased urine specific gravity may indicate: </li></ul><ul><ul><li>Excessive fluid intake </li></ul></ul><ul><ul><li>Diabetes insipidus – central or nephrogenic </li></ul></ul><ul><ul><li>Renal failure (loss of ability to reabsorb water) </li></ul></ul><ul><ul><li>Pyelonephritis </li></ul></ul>
    12. 12. Urine Osmolality <ul><li>Normal values are 50 to 1400 mOsm/kg 12 to 14 hour fluid restriction: greater than 850 mOsm/kg </li></ul><ul><li>Greater-than-normal measurements may indicate: </li></ul><ul><ul><li>Addison's disease (rare) </li></ul></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Syndrome of inappropriate ADH secretion </li></ul></ul><ul><li>Lower-than-normal measurements may indicate: </li></ul><ul><ul><li>Aldosteronism (very rare) </li></ul></ul><ul><ul><li>Diabetes insipidus (rare) </li></ul></ul><ul><ul><li>Excess fluid intake </li></ul></ul><ul><ul><li>Renal tubular necrosis </li></ul></ul><ul><ul><li>Severe pyelonephritis </li></ul></ul>
    13. 13. pH (acidity/alkalinity of the urine ) <ul><li>The normal values range from 4.6 to 8.0. </li></ul><ul><li>A high urine pH (alkaline urine) may indicate: </li></ul><ul><ul><li>Gastric suction </li></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><ul><li>Renal tubular acidosis </li></ul></ul><ul><ul><li>Urinary tract infection </li></ul></ul><ul><ul><li>Vomiting </li></ul></ul><ul><li>A low urine pH (acidic urine) may indicate: </li></ul><ul><ul><li>Chronic obstructive pulmonary disease </li></ul></ul><ul><ul><li>Diabetic ketoacidosis </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>Starvation </li></ul></ul><ul><li>The drugs acetazolamide, potassium citrate, or sodium bicarbonate can increase pH; Ammonium chloride, chlorothiazide diuretics, and methenamine mandelate can decrease urine pH </li></ul>
    14. 14. Proteinuria (protein in the urine) <ul><li>For a spot check by dipstick: the normal values are approximately 0 to 8 mg/dl. </li></ul><ul><li>For a 24-hour test: the normal value is less than 150mg per 24 hours. </li></ul><ul><li>An abnormal value (high value) usually indicates a kidney disorder/disease </li></ul><ul><li>Proteinuria: Mild(<0.5g/day), moderate (.05-4g/day), severe (>4g/day) </li></ul><ul><li>Other conditions that can also produce proteinuria include </li></ul><ul><ul><li>Blood diseases involving lysis (destruction) of red blood cells </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Injury of the urinary tract (bladder, prostate, or urethra) </li></ul></ul><ul><ul><li>Preeclampsia </li></ul></ul>
    15. 15. Glucosuria <ul><li>Glucose should not be detectable in the urine </li></ul><ul><li>Diabetes (via high blood sugar) is the most common cause of glucosuria </li></ul><ul><li>Other causes include renal glycosuria (decrease or absence of the kidneys’ ability to absorb glucose), hormonal disorders, liver disease, some medications, and pregnancy </li></ul>
    16. 16. Hematuria <ul><li>Normal: Only an occasional RBC (1-4/high power field; 1000 per millimeter of urine) </li></ul><ul><li>The urinary dipstick for blood measures intact RBCs, free hemoglobin, and myoglobin </li></ul><ul><li>False-positive results in women from contamination with menstrual blood </li></ul><ul><li>More detail provided in the microscopic exam portion of this presentation) </li></ul>
    17. 17. Ketones <ul><li>Ketones (beta-hydroxybutyric acid, acetoacetic acid, and acetone) are intermediate products of fat metabolism and are present in starvation and diabetes </li></ul><ul><li>Normal: negative test result </li></ul><ul><li>Classification of acetone presence in the urine </li></ul><ul><ul><li>Small - < 20 mg/dL </li></ul></ul><ul><ul><li>Moderate - 30-40 mg/dL </li></ul></ul><ul><ul><li>Large - > 80 mg/dL </li></ul></ul><ul><li>Ketonuria: presence of ketones in urine </li></ul>
    18. 18. Ketone Abnormalities <ul><li>A positive test may indicate: </li></ul><ul><ul><li>Metabolic abnormalities, including uncontrolled diabetes or glycogen storage disease </li></ul></ul><ul><ul><li>Abnormal nutritional conditions, including starvation, fasting, anorexia, high protein or low carbohydrate diets </li></ul></ul><ul><ul><li>Protracted vomiting, (eg. hyperemesis gravidarum) </li></ul></ul><ul><ul><li>Disorders of increased metabolism, including hyperthyroidism, fever, acute or severe illness, burns, pregnancy, lactation or post-surgical condition </li></ul></ul><ul><ul><li>Some drugs </li></ul></ul>
    19. 19. Leukocyte Esterase <ul><li>Leukocyte esterase is an enzyme present in most white blood cells (WBCs) </li></ul><ul><li>A few white blood cells is normal in urine (see microscopic examination) and this test is negative </li></ul><ul><li>When the number of WBCs in urine increases significantly, test will become positive </li></ul><ul><li>WBC count in urine is high = Inflammation/infection in the kidney or urinary tract </li></ul><ul><li>Common cause for WBCs in urine (leukocyturia): bacterial infection, eg. a bladder infection </li></ul><ul><li>Source of contamination: vaginal secretions </li></ul>
    20. 20. Nitrite <ul><li>Test is used to detect a bacterial urinary tract infections (UTI) because many bacteria convert nitrate to nitrite </li></ul><ul><li>Normally, the urinary tract and urine are sterile </li></ul><ul><ul><li>Thus, no nitrites would be found </li></ul></ul><ul><li>A negative test does not rule out a UTI </li></ul><ul><ul><li>Not all bacteria are capable of converting nitrate to nitrite </li></ul></ul>
    21. 21. Bilirubin <ul><li>Bilirubin (a degradation product of hemoglobin) is not present in the urine of normal, healthy individuals </li></ul><ul><li>Increased bilirubin in the urine means that the bile ducts are obstructed </li></ul><ul><li>Causes include </li></ul><ul><ul><li>biliary strictures </li></ul></ul><ul><ul><li>cirrhosis </li></ul></ul><ul><ul><li>gallstones in the biliary tract </li></ul></ul><ul><ul><li>hepatitis with associated biliary obstruction </li></ul></ul><ul><ul><li>surgical trauma affecting the biliary tract </li></ul></ul><ul><ul><li>tumors of the liver or gall bladder </li></ul></ul>
    22. 22. Urobilirubin <ul><li>Urobilinogen (a degradation product of bilirubin) is normally present in urine in low concentrations – source of color </li></ul><ul><li>High concentrations can be due to </li></ul><ul><ul><li>Hemolytic processes </li></ul></ul><ul><ul><li>Hepatocellular disease </li></ul></ul><ul><li>Absence may be due to </li></ul><ul><ul><li>Complete biliary obstruction </li></ul></ul><ul><ul><li>Broad-spectrum antibiotics </li></ul></ul><ul><li>Normal levels are usually too low (<0.4mg/dl) to be detectable with the urine dipstick method </li></ul>
    23. 23. Microscopic Exam <ul><li>Part of the urinalysis is the examination of some urine with a microscope </li></ul><ul><li>Cells, crystals, and other substances are counted and reported either as the number observed “per low power field” (LPF) or “per high power field” (HPF) </li></ul><ul><li>Some entities are estimated as “few,” “moderate,” or “many,” such as epitheial cells, bacteria, and crystals </li></ul>
    24. 24. Microscopic Exam <ul><li>Things found on microscopic exam can include: </li></ul><ul><li>Bacteria and other microorganisms </li></ul><ul><li>Casts </li></ul><ul><li>Crystals </li></ul><ul><li>Fat </li></ul><ul><li>Mucous </li></ul><ul><li>Red blood cells </li></ul><ul><li>Renal tubular cells </li></ul><ul><li>Transitional epithelial cells </li></ul><ul><li>White blood cells (Pyuria) </li></ul>
    25. 25. RBCs <ul><li>Only a few RBCs (erythrocytes) should be present in urine sediment </li></ul><ul><li>Normal values are less than, or equal to 4 RBC/HPF </li></ul><ul><li>Normal value ranges may vary slightly among different laboratories </li></ul><ul><li>Note: RBC/HPF = red blood cells per high power field (a microscopic exam) </li></ul>
    26. 26. RBCs - Abnormalities <ul><li>Hematuria – presence of RBCs in urine </li></ul><ul><li>Hemoglobinuria – hemoglobin in urine </li></ul><ul><li>Even small increases in the amount of RBCs in urine are significant. </li></ul><ul><li>Causes: </li></ul><ul><ul><li>Numerous diseases of the kidney and urinary tract </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Strenuous exercise </li></ul></ul><ul><li>All patients with hematuria (>5 RBC/HPF) require further diagnostic workup </li></ul>
    27. 27. WBCs (Pyuria) <ul><li>The number of WBCs in urine sediment is normally low (1-4 WBCs/HPF) </li></ul><ul><li>The presence of >5 WBC/HPF = significant pyuria </li></ul><ul><li>When the number is high, it indicates an infection, damage or inflammation somewhere in the urinary tract </li></ul><ul><li>Causes include calculous disease, strictures, neoplasm, glomerulonephropathy, or interstitial cystitis </li></ul>
    28. 28. Epithelial Cells <ul><li>Epithelial cells: cells that form sheets that cover the surface of the body and line internal organs </li></ul><ul><li>Healthy urine shows a few normal epithelial cells and is relatively free of debris </li></ul><ul><li>Epithelial cells are usually reported as “few,” “moderate,” or “many” present per low power field (LPF) </li></ul><ul><li>In urinary tract conditions such as infections, inflammation, and malignancies, more epithelial cells are present </li></ul>
    29. 29. Microorganisms <ul><li>Include bacteria, trichomonads, yeast </li></ul><ul><li>In health, the urinary tract is sterile: No microorganisms </li></ul><ul><li>Presence indicates infection </li></ul><ul><ul><li>Microorganisms are usually reported as “few,” “moderate,” or “many” present per high power field (HPF) </li></ul></ul><ul><li>Microorganisms found may be from specimen contamination: </li></ul><ul><ul><li>From bacteria that normally live on the skin or in vaginal secretions (most often women) </li></ul></ul><ul><li>Yeast can also be present in urine and are more common in women due to a vaginal yeast infection </li></ul>
    30. 30. Trichomonads <ul><li>Trichomonads are parasites that may be found in the urine of women or men (rarely) </li></ul><ul><li>Often infect the vaginal canal </li></ul><ul><li>Their presence in urine is due to contamination during urine collection </li></ul>
    31. 31. Urinary Casts <ul><li>Casts – renal tubule “imprints” – </li></ul><ul><li>Absent in normal people, except for a few (0–5) hyaline casts per LPF. </li></ul><ul><li>Abnormal results include: </li></ul><ul><ul><li>Hyaline casts – made of protein; caused by dehydration, exercise, diuretic meds </li></ul></ul><ul><ul><li>Granular casts -- include prominent granules; related to underlying kidney disease </li></ul></ul><ul><ul><li>Fatty casts –condition of lipiduria (lipids in urine); related to nephrotic syndrome </li></ul></ul><ul><ul><li>RBC casts – result of bleeding into tubule from the glomerulus; nephrotic syndrome </li></ul></ul><ul><ul><li>WBC casts – interstitial cell kidney disease (interstitial inflammation, pyelonephritis, and parenchymal infection) </li></ul></ul><ul><ul><li>Renal tubular epithelial cell casts -- damage to the tubules; ie.renal tubular necrosis </li></ul></ul>
    32. 32. Crystals <ul><li>Urine contains many chemicals dissolved in the urine for elimination from the body. </li></ul><ul><li>These solutes can form crystals based on the urine pH & temperature and their concentration. </li></ul><ul><li>Crystals are identified by their shape, color, and urine pH. </li></ul><ul><li>Crystals are considered “normal” if they are from solutes that should be in urine </li></ul><ul><li>If they are from solutes that are not supposed to be in the urine, they are considered “abnormal.” </li></ul><ul><ul><li>Acidic urine: uric acid, oxalate, cystine </li></ul></ul><ul><ul><li>Alkaline urine: phosphate </li></ul></ul>
    33. 33. Quick Summary: Normal Values <ul><li>Normal color varies from almost colorless to dark amber. </li></ul><ul><li>The urine specific gravity ranges between 1.003 and 1.030 (higher numbers mean a higher concentration). </li></ul><ul><li>The normal pH range is from 4.6 to 8.0, with an average of 6.0. </li></ul><ul><li>There is usually no detectable urine glucose, nitrites, ketones, or protein. </li></ul><ul><li>There are usually no red blood cells in urine (<4/HPF). </li></ul><ul><li>Hemoglobin is not normally found in the urine. </li></ul><ul><li>Bilirubin is normally not detected in the urine. There may be a trace of urobilinogen in the urine. </li></ul><ul><li>White blood cells (leukocytes) are not normally present in the urine (<4/HPF). </li></ul>
    34. 34. Resources <ul><li>http://www.labtestsonline.org/understanding/analytes/urinalysis/sample.html </li></ul><ul><li>http://kidshealth.org/parent/general/sick/labtest7_p2.html </li></ul><ul><li>http://www.nlm.nih.gov/medlineplus/ency/article/003579.htm </li></ul><ul><li>Corbett JV. Laboratory Tests and Diagnostic Procedures. 5 th ed. New Jersey: Prentice-Hall, Inc., 2000. </li></ul><ul><li>Current Medical Diagnosis & Treatment - 44th Ed. (2005) online via Stat!-Ref </li></ul>