This document provides guidance on evaluating a patient presenting with abnormal urine findings. It outlines the important steps to take which include obtaining a thorough history, conducting a physical exam, and ordering key investigations such as a urine analysis. The urine analysis involves macroscopic, chemical, and microscopic evaluations to identify abnormalities that could indicate underlying renal or urinary tract conditions. Key things to examine include urine color, clarity, specific gravity, pH, presence of blood, protein, glucose, ketones, nitrites, and cells/casts under the microscope. Taking this systematic approach helps reach the correct diagnosis.

1. Approach To Patient With
Abnormal Urine Findings
Khaled El Zorkany, MD
Associate Professor
Internal Medicine & Nephrology
King Faisal University

2. Objectives
How to reach a diagnosis through
interpretation of urine analysis.

3. Introduction
Approach To Renal Patient
• History (symptoms of urinary system
disorders)
• Examination (signs of urinary system
disorders)
• Investigations

4. Symptoms Of Urinary
System Disorders
1- Urogenital Pain
2- Change in volume of urine
Polyuria
Urine output > 3 L/day
Oliguria
Urine output < 400 ml/day
Anuria
Urine output < 100 ml/day

5. 3- Change in color of urine
4- Dysuria, Frequency and Urgency
5- Hesitancy, Weak stream and Terminal
dribbling
6- Nocturia
7- Incontinence
8- Urethral discharge
9- Constitutional symptoms
10- Retention of urine
11- Puffiness of eyelids, lower limb edema,
Ascitis
12- Uremic manifestations

6. General Examination
General look: Looks pale, earthy
look (CKD), Dyspneic, Short stature
and underbuilt if renal failure since
childhood
Characteristic facies: SLE,
Scleroderma,…
Consciousness: Coma or uremic
Encephalopathy
Orthopnea in bed

7. General Examination
Vital signs
High BL P
Tachycardia (Anemia) or arrhythmia
(electrolyte and acid base disturbance)
Rapid deep breathing (Acidosis) ???
Fever

8. General Examination
Congested neck veins in volume
overload
Skin scratches due to uremic pruritis,
vasculitic rash
Uremic frost (White powder over the
skin represent urea of the sweat)
Spooning of nails due to anemia
Half and half nail in end stage renal
disease
Lower limb edema

10. Half and half nail
Preorbital edema
Lower limb edema

11. Half and half nails
Half and half nails (also known as "Lindsay's
nails") show the proximal portion of the nail white
and the distal half red, pink, or brown. It usually
shows a sharp demarcation line between the two
portions, which usually remains parallel to the
distal free margin of the nail. are a highly specific
nail abnormalities for chronic kidney disease
It can also be seen in yellow nail syndrome,
Crohn's disease, Kawasaki's disease, Behcet's
disease, cirrhosis, hyperthyroidism, zinc
deficiency, citrullinemia, pellagra, HIV infection,
and even in healthy persons

12. Half and half nails
 Leyden and Wood proposed that the discoloration
was secondary to melanin deposition, based on
the results from nail biopsy. They hypothesized
that renal failure led to acidosis and uremia that
stimulated nail matrix melanocytes to produce
melanin. The associated slow growth of the nail in
renal failure also exacerbated the resulting
discoloration. Others postulated that changes in
the nail bed rather than in the nail were
responsible for the discoloration and patterns.3
Specifically, they attributed the changes to an
increase in the number of capillaries and a
thickening of the capillary walls in the nail bed.

15. Local Examination
Inspection
Distended Abdomen with full flanks
(Ascitis in nephrotic syndrome)
Palpation
Bimanual palpation of kidney with
ballottement
Causes of palpable kidney
Hydronephrosis
Polycystic kidney
Kidney tumor

16. Local Examination
PR examination for enlarged prostate
Urinary bladder
Percussion
Ascites, Urinary bladder
Tender renal angle (Pyelonephritis)
Auscultation
Pleural and pericardial rub
Bruit over renal arteries (Renal
artery stenosis)

17. INVESTIGATIONS

18. Investigations
Urine analysis
Kidney functions
Imaging studies
Others

19. Urine Analysis-When?

20.  Morning sample
 Mid-stream sample
 Cleaning of external genetalia in women
 Avoid during menstruations
 Sample should be examined with 30 – 60
min
Precautions

21. Components of a complete urine
analysis
1) The Macroscopic (Physical) Examination
• Color
• Odor
• Turbidity
2) The Chemical Examination
• Dipstick testing
3) The Microscopic Examination
4) Others e.g. Protein/creatinine ratio, 24 hs
proteins,

22. Normal values are as follows:
 Color – Yellow (light/pale to dark/deep amber)
 Clarity/turbidity – Clear or cloudy
 PH – 4.5-6.5
 Specific gravity – 1.005-1.030
 Glucose - Negative
 Ketones – None
 Nitrites – Negative
 Leukocyte Esterase – Negative
 Bilirubin – Negative
 Urobilirubin – Small amount (0.5-1 mg/dL)

23.  Protein - ≤150 mg/d
 RBCs - 3 RBCs/HPF
 WBCs - ≤ 2-5 WBCs/HPF
 Squamous epithelial cells - ≤15-20 squamous
epithelial cells/hpf
 Casts – 0-5 hyaline casts/ HPF
 Crystals – Occasionally
 Bacteria – None
 Yeast - None

24. • Color
• Aspect (Transparency)
• Odor
• Amount
• Froth
• Foreign materials
I- Physical Examination

25. I- Physical Examination
1) Color and Aspect
Aspect is usually clear
Amber yellow due to the pigment
urobilin
It could be diluted or concentrated
according to the patient hydration status

26. Causes of colored urine
1. Red or Brown
Haematuria,
Haemoglobinuria, Myoglobinuria
Porphyria
Foods (beets, blackberries, rhubarb)
Drugs (rifampicin, desferroxamine,
laxatives containing senna)

27. Phenolphthalein's
Rifampicin powder
beets
blackberries
rhubarb

28. An elderly male patient with malpostioned Foley catheter.
The catheter balloon was found in the prostatic urethra.

31. Causes Of Colored Urine
2. Orange
Dehydration, bile duct
obstruction, Laxatives,
sulfasalazine
3. Green/Blue
Methylene blue ingestion
Promethazine, cimetidinet,
propofol

32. Causes Of Colored Urine
4. Black
Alkaptonuria (Black Urine Dis.)
Melanuria
Fava beans
Copper or phenol poisoning
Dyes
Para-Phenylenediamine

33. Causes Of Colored Urine
5. Cloudy /Turbid
Crystals, Bacteria or Pus
Chyluria, phosphaturia, lipiduria and hyperoxaluria

34. I- Physical Examination
2) Odor

35. I- Physical Examination
2) Aspect (Transparency)
Cloudy or murky
Urinary tract infection
Kidney stones crystals

36. • Specific gravity
• PH
• Blood
• Protein/Albumin
• Glucose
• Ketone
• Nitrite
• Leucocyte esterase
II- Dipstick Examination
Chemical examination

37. Chemical
examination
Dipstick performance
• Subjective how to read

38. The Urine Dipstick-SG
 RR: 1.005-1.030
Significance:
Hydration status
Capacity of the kidneys to dilute and concentrate the
urine.
Low : dilute urine; impaired urine concentration
(e.g. DI, sickle cell nephropathy, ATN)
High: volume depletion, renal hypoperfusion and
excretion of hypertonic solutes( glycosuria and
contrast dye)

39. The Urine Dipstick-PH
RR= 5- 6.5
Causes of alkaline urine
UTI with urease-splitting organism e.g proteus species,
E. coli, pseudomonas, klebsiella species
Type 1 Distal renal tubular acidosis
Metabolic alkalosis
Administration of NaHCO3
Increased risk of struvite and calcium phosphate stones

40. The Urine Dipstick-PH
RR= 5- 6.5
Causes of acidic urine
High protein intake
Type 4 RTA and some type 2 proximal RTA
Hyperaldosteronism
Metabolic acidosis
Iliostomy drainage
Diarrhea
Increased risk of uric acid and cysteine calculi

41. The Urine Dipstick-Blood
Read at 60 seconds
RR: Negative
 Dipstick detects peroxidase activity of RBCs and
free heme pigments (hemoglobin & myoglobin).
Significance:
Hematuria (Trauma, nephritis, etc)
Hemoglobinuria (hemolysis, etc)
Myoglobinuria (rhabdomyolysis, etc)

42. The Urine Dipstick-Blood
False positive tests ???
Red urine???

43. Clinical Evaluation of
Hematuria
Hematuria is defined as  3 erythrocytes/HPF
Macroscopic (grossly visible) or microscopic
(detectable only on urine testing).
Glomerular or non glomerular ?

44. AMH ≥ 3 erythrocytes/HPF on urine microscopy
• Assess kidney function, RBCs morphology and
protein/creatinine ratio to evaluate for a nephrologic cause

45. False hematuria or hematuria mimics may
be caused by contamination from menstrual
bleeding or from substances that produce
red-colored urine not due to erythrocytes or
hemoglobinuria, including medications
(rifmpin, phenytoin), food (rhubarb, beets),
acute porphyrias, and myoglobinuria.

46. The American Urological Association (AUA)
guidelines for the evaluation of asymptomatic
non glomerular hematuria recommend
evaluation for malignancy in all patients over
35 years of age or those with risk factors for
urologic malignancy, include CT urography.
The AUA guidelines also recommend
cystoscopy if imaging is negative.
The AUA guidelines do not recommend urine
cytology for routine or initial evaluation of
asymptomatic hematuria.

47. The Urine Dipstick-Protein
Read at 60 seconds
RR: Negative
Significance:
Albumin predominant protein detected on urine
dipstick, which detects albumin excretion graded
as trace (5-30 mg/dL), l+ (30 mg/dL), 2+ (100
mg/dL), 3+ (300 mg/dL), and 4+ (>1000
mg/dL).

48. False-positive results Highly alkaline urine or
concentrated urine.
Not sensitive for detection of moderately
increased albuminuria (microalbuminuria)
The Urine Dipstick-Protein

49. The Urine Dipstick-Glucose
Read at 30 seconds.
RR: negative
Glycosuria typically occurs when the plasma
glucose concentration is >180 mg/dL.
Significance:
DM
Renal glycosuria

50. The Urine Dipstick-Glucose
Renal glycosuria:
Renal threshold for glucose excretion is lower
than 180 mg/dl.
Glycosuria can present in absence of
hyperglycemia suggest proximal tubular
dysfunction (termed Fanconi syndrome) as seen
with myeloma or exposure to drugs such as SGLT-
2 inhibitors.
 Normal pregnancy with a change in threshold for
glucose.

51. The Urine Dipstick-Ketones
Read at 40 seconds
RR: Negative
Significance:
Diabetic ketoacidosis
Prolonged fasting (starvation)
Alcoholic ketoacidosis
Salicylate toxicity, isopropyl alcohol poisoning

52. The Urine Dipstick-Ketones
The urine dipstick detects acetoacetate and acetone
but not -hdroxybutyrate.
False-positive tests:
Drugs containing sulfydryl groups such as
captopril

53. The Urine Dipstick-Leukocyte Esterase
Read at 2 minutes
RR: Negative
Significance:
 UTI
 Acute Inflammation (e.g. AIN,….
 kidney stone

54. The Urine Dipstick-Nitrite
Read at 60 seconds
RR: Negative
Significance:
 UTI by Gram negative bacteria e.g including Escherichia coli,
Klebsiella pneumoniae, and
the Prteus, Citrobacter, Enterobacter and Pseudomonas
species.
 The presence of both leukocyte esterase and nitrites on
urine dipstick is highly suggestive of a UTI; the absence
of both has a high negative predictive value for a UTI

55. The Urine Dipstick-Bilirubin
Read at 30 seconds
RR: Negative
Significance:
Liver disease
Obstructive hepatobiliary disease

56. The Urine Dipstick-Urobilinogen
Read at 60 seconds
RR: 0.02-1.0 mg/dl
Significance:
High: hepatic diseases, hemolytic anemia
Low: severe cholestasis and obstructive disease

57. III- Microscopic examination
Abnormalities on urine dipstick,
AKI
Suspicion for glomerulonephritis
Newly diagnosed CKD.

58. • RBCs
• WBCs
• Epithelial cells
• Casts
• Crystals
• Bacteria, Yeasts and Ova
• Spermatozoa
III- Microscopic examination

59. III- Microscopic examination
1- Red blood cells:-
Normal 1-2 cells /HPF
Hematuria  3/HPF
Isomorphic erythrocytes (urologic process)
Dysmorphic cells (Glomerular process)
Acanthocytes

61. Urine microscopy demonstrating acanthocytes, indicated in the red circles. Acanthocytes, one
form of dysmorphic erythrocytes, are characterized by vesicle-shaped protrusions

63. III- Microscopic examination
2- White blood cells:-
3-4/HPF
Pyuria  5/HPF
Their presence denoting infection or inflammation

64. Sterile Pyuria
Patients who have already taken antimicrobials
(often due to self-medication).
AIN
Kidney stones
Prostatitis, vaginitis, cervicitis
Uroepithelial tumor
Kidney transplant rejection
Chemical cystitis (e.g. cyclophosphamide)
 Atypical organisms such as Chlamydia, Ureaplasma
urealyticum, or Tuberculosis.

65. Causes of Eosinophiluria:-

AIN (Drug hypersensitivity)

Reno-atheroembolic disease

Renal transplant rejection

Small-vessel vasculitis,

UTI, prostatic disease, or parasitic infections.

66. III- Microscopic examination
3- Epithelial Cells:-
Appears in urine after shedding from any where
of urinary tract
Renal tubular, Transitional and
Squamous epithelial cells.

67. III- Microscopic examination
4- Casts:-
The backbone of urine Casts is a matrix of
Tamm-Horsfll mucoprotein (also known as
uromodulin).
These cylindrical casts are formed in distal
tubular lumen.
 Any cells or debris in cast were present in tubules at
time of cast formation

68. Red blood cell casts:-
GN

69. White Blood Cell Cast
Their presence indicate pyelonephritis or AIN

70. Granular pigmented (muddy
brown) casts
Contain tubular cell debris and present in
AKI.
The severity of AKI correlate with the number
of casts and presence of renal tubular
epithelial cells.

71. Hyaline casts
formed in the absence of cells in the tubular
lumen. They have a smooth hyaline cast
texture and a refractive index very close to
that of the surrounding fluid.
 hyaline casts are not always indicative of
clinically significant renal disease.

72. Crystals
Result of the supersaturation of solutes in
concentrated urine.
Crystals formation depends on:-
 Degree of super-saturation of constituent
molecule
 Urine PH
 Presence of inhibitors of crystallization

73. Calcium Oxalate crystals
Look like little envelopes or dumbbell shaped
• Hypercalciuria, hyperoxaluria; ethylene glycol poisoning

75. • Diabetes mellitus; needle;
rosette obesity; gout;
hyperuricemia; tumor lysis
syndrome; urine pH <6.0

79. Magnesium ammonium phosphate (struvite): Coffin-lid in Chronic urinary
tract infection with urease-producing organisms

81. Measurement of Albumin and
Protein Excretion
 Protein detected by urine dipstick, spot (random)
urine protein-creatinine ratio or Albumin-Creatinine
ratio and a 24-hour urine collections.
 Urine albumin when present in high amount indicates
glomerular injury, conversely the absence of
albuminuria essentially exclude most glomerular
diseases.
 Smaller proteins are filtered at glomeruli but
reabsorbed by PCT; so their presence in urine
generally indicate tubulointerstitial disease.