LABORATORY LABORATORY INDICES IN THE INDICES IN THE

DIAGNOSTICS OF DIAGNOSTICS OF KIDNEY DISEASESKIDNEY DISEASES

Marushchak MariaMarushchak Maria

DefinitionDefinition

Examination of urine by chemical, physical, Examination of urine by chemical, physical, or microscopic means. Routine urinalysis or microscopic means. Routine urinalysis usually includes performing chemical screening usually includes performing chemical screening tests, determining specific gravity, observing tests, determining specific gravity, observing any unusual color or odor, screening for any unusual color or odor, screening for bacteriuria, and examining the sediment bacteriuria, and examining the sediment microscopically.microscopically.

Method Method

Multiple reagent test strip Multiple reagent test strip Urine Microscopic ExamUrine Microscopic Exam

Collection Collection First morning sample First morning sample Midstream, clean catch collection Midstream, clean catch collection Minimum volume of 3 ml (1 ml for children) Minimum volume of 3 ml (1 ml for children) Analyze within 1-2 hours or refrigerate Analyze within 1-2 hours or refrigerate

General Tests General Tests

Urine AppearanceUrine Appearance ( (Urine ColorUrine Color) ) Urine OdorUrine Odor Urine Specific GravityUrine Specific Gravity Urine pHUrine pH Urine Microscopic ExamUrine Microscopic Exam

Urine cells (RBCs, WBCs, epithelial cells) Urine cells (RBCs, WBCs, epithelial cells) Urine bacteria Urine bacteria Urine CastUrine Casts s Urine CrystalUrine Crystals s

Urine AppearanceUrine Appearance ( (Urine ColorUrine Color))

Cloudy urine causes Cloudy urine causes Urine with high phosphate, oxalate, lipids, Urine WBCs Urine with high phosphate, oxalate, lipids, Urine WBCs High purine food intake (increased High purine food intake (increased Uric AcidUric Acid) )

Brown urine causes Brown urine causes Bile pigment Bile pigment MyoglobinuriaMyoglobinuria Fava beans Fava beans Medications (Levodopa, Medications (Levodopa, FlagylFlagyl, , NitrofurantoinNitrofurantoin) )

Black urine causes Black urine causes MelaninMelanin Methemoglobinuria Methemoglobinuria CascaraCascara or senna or senna Methydopa Methydopa

Blue or green urine Blue or green urine Urinary Tract InfectionUrinary Tract Infection due to Pseudomonas due to Pseudomonas Bilverdin Bilverdin Medications Medications

AmitriptylineAmitriptyline, , TriamtereneTriamterene Intravenous mendications (Intravenous mendications (CimetidineCimetidine, , PhenerganPhenergan) )

Dyes Dyes Methylene blue Methylene blue Indigo carmine or indigo blue Indigo carmine or indigo blue

Orange to yellow urine Orange to yellow urine Increased urine concentration Increased urine concentration Bile pigments Bile pigments Phenothiazines Phenothiazines Pyridium Pyridium Carrots Carrots TetracyclineTetracycline Rhubarb (red in alkaline urine) Rhubarb (red in alkaline urine) SennaSenna (red in alkaline urine) (red in alkaline urine)

RED URINE CAUSES RED URINE CAUSES Red Urine Red Urine

Microscopic HematuriaMicroscopic Hematuria Urinary tract source Urinary tract source

Urethra or bladder Urethra or bladder Prostate Prostate Ureter or kidney Ureter or kidney

Non-Urinary tract source Non-Urinary tract source Vagina Vagina Anus or rectum Anus or rectum

Pseudohematuria (non-Pseudohematuria (non-HematuriaHematuria related red urine) related red urine) MyoglobinuriaMyoglobinuria HemoglobinuriaHemoglobinuria PhenolphthaleinPhenolphthalein LaxativeLaxatives s Phenothiazines Phenothiazines Porphyria Porphyria RifampinRifampin Pyridium Pyridium BilirubinBilirubinuria uria PhenytoinPhenytoin Pyridium Pyridium Red diaper syndrome Red diaper syndrome Foods (Beets, Blackberries, Rhubarb) Foods (Beets, Blackberries, Rhubarb)

Causes of Asymptomatic Gross Causes of Asymptomatic Gross Hematuria by Incidence Hematuria by Incidence

Acute CystitisAcute Cystitis (23%) (23%) Bladder CancerBladder Cancer (17%) (17%) Benign Prostatic HyperplasiaBenign Prostatic Hyperplasia (12%) (12%) NephrolithiasisNephrolithiasis (10%) (10%) Benign essential Benign essential HematuriaHematuria (10%) (10%) ProstatitisProstatitis (9%) (9%) Renal cancer (6%) Renal cancer (6%) PyelonephritisPyelonephritis (4%) (4%) Prostate CancerProstate Cancer (3%) (3%) Urethral stricture (2%) Urethral stricture (2%)

Medical Causes of abnormal urine Medical Causes of abnormal urine odor odor

Sweet or fruity odor Sweet or fruity odor Diabetic KetoacidosisDiabetic Ketoacidosis Maple syrup urine disease (infants, rare) Maple syrup urine disease (infants, rare)

Ammonia odor Ammonia odor Bladder retention Bladder retention Urine at room temperature for prolonged period Urine at room temperature for prolonged period

Fecal odor Fecal odor Bladder-Intestinal fistula Bladder-Intestinal fistula

Pungent odor Pungent odor Urinary Tract InfectionUrinary Tract Infection

Strong odor Strong odor Concentrated urine Concentrated urine

Musty odor Musty odor PhenylketonuriaPhenylketonuria

Sulfur odor Sulfur odor CystCystine decomposition ine decomposition

Food and medication causes of abnormal urine Food and medication causes of abnormal urine odor odor

Asparagus Asparagus Vitamin B6Vitamin B6 Supplementation Supplementation

Inborn Errors of Metabolism causing urine odorInborn Errors of Metabolism causing urine odor PhenylketonuriaPhenylketonuria Maple syrup urine disease (infants, rare) Maple syrup urine disease (infants, rare) Glutaric acidemia Glutaric acidemia Isovaleric acidemia Isovaleric acidemia Hawkinsinuria Hawkinsinuria Hypermethioninemia Hypermethioninemia Multiple carboxylase deficiency Multiple carboxylase deficiency Oasthouse urine disease Oasthouse urine disease Trimethylaminuria Trimethylaminuria Tyrosinemia Tyrosinemia

Specific Gravity: 1.005-1.030Specific Gravity: 1.005-1.030

Increased Increased Dehydration Dehydration FeverFever VomitingVomiting DiarrheaDiarrhea Diabetes MellitusDiabetes Mellitus and other causes of and other causes of GlycosuriaGlycosuria Congestive Heart FailureCongestive Heart Failure Syndrome Inappropriate ADH SecretionSyndrome Inappropriate ADH Secretion ( (SIADHSIADH) ) Adrenal InsufficiencyAdrenal Insufficiency X-Ray contrastX-Ray contrast

Decreased Decreased Diabetes InsipidusDiabetes Insipidus Excessive hydration Excessive hydration GlomerulonephritisGlomerulonephritis PyelonephritisPyelonephritis DiureticDiuretics s Adrenal InsufficiencyAdrenal Insufficiency AldosteronismAldosteronism Renal insufficiency Renal insufficiency

Falsely decreased specific gravity Falsely decreased specific gravity Alkaline urine Alkaline urine

Falsely increased specific gravity Falsely increased specific gravity Intravenous dextran or radiopague dye Intravenous dextran or radiopague dye ProteinuriaProteinuria

Urine pH Urine pH

Normal Normal 4.5-8.0 (usually 5.5 to 6.5) 4.5-8.0 (usually 5.5 to 6.5)

Background Background Urine pH reflects serum pH except with RTA Urine pH reflects serum pH except with RTA In In Renal Tubular AcidosisRenal Tubular Acidosis (RTA), urine pH >5.5 (RTA), urine pH >5.5

Urine cannot be acidified despite acid load Urine cannot be acidified despite acid load

Increased (Alkalotic urine) Increased (Alkalotic urine) Stale ammoniacal sample (Very high pH) Stale ammoniacal sample (Very high pH)

Void testing if old sample Void testing if old sample

Bacteriuria Bacteriuria Reflects urea splitting organisms Reflects urea splitting organisms Associated with magnesium-ammonium phosphate crystals Associated with magnesium-ammonium phosphate crystals

Vegetarian diet Vegetarian diet High citrate diet High citrate diet Renal FailureRenal Failure Drugs Drugs

Antibiotics Antibiotics Bicarbonate Bicarbonate AcetazolamideAcetazolamide

Decreased (Acidic urine) Decreased (Acidic urine)

Acidosis Acidosis Diabetes MellitusDiabetes Mellitus Starvation Starvation DiarrheaDiarrhea Uric Acid CalculiUric Acid Calculi Acidic fruits (Cranberry) Acidic fruits (Cranberry) Drugs Drugs

Ammonium chloride Ammonium chloride

Urine Microscopic ExamUrine Microscopic Exam

Sample preparation Sample preparation Obtain fresh urine sample Obtain fresh urine sample Centrifuge 10-15 ml at 1500 to 3000 rpm for 5 minutes Centrifuge 10-15 ml at 1500 to 3000 rpm for 5 minutes Decant supernatant and resuspend remainder of urine Decant supernatant and resuspend remainder of urine Place 1 drop of urine on slide and apply cover slip Place 1 drop of urine on slide and apply cover slip

Examination Examination Urine Cells Urine Cells

Urine Urine White Blood CellWhite Blood Cells s Normal <2/hpf in men and <5/hpf in women Normal <2/hpf in men and <5/hpf in women

Urine Urine Red Blood CellRed Blood Cells s Normal <3/hpf Normal <3/hpf Dysmorphic RBCs suggest glomerular disease Dysmorphic RBCs suggest glomerular disease

Epithelial cells Epithelial cells Transitional epithelial cells are normally present Transitional epithelial cells are normally present Squamous epithelial cells suggest contamination Squamous epithelial cells suggest contamination Renal tubule epithelial cells suggest renal disease Renal tubule epithelial cells suggest renal disease

Bacteria Bacteria Five bacteria per hpf represents 100,000 CFU/ml Five bacteria per hpf represents 100,000 CFU/ml Diagnostic for Diagnostic for Urinary Tract InfectionUrinary Tract Infection

Men: Any bacteria Men: Any bacteria Women: 5 or more bacteria per hpf Women: 5 or more bacteria per hpf

White White bblood lood ccellell in urine in urine

Urine Urine Red BloodRed Blood Cell Cell

ss

Epithelial Epithelial cellscells

Transitional Transitional epithelial epithelial cells are cells are normally normally presentpresent

Urine CrystalUrine Crystals s Types Types

Calcium oxalate crystals (square envelope shape) Calcium oxalate crystals (square envelope shape) Triple phosphate crystals (coffin lid shape) Triple phosphate crystals (coffin lid shape)

Associated with increased Associated with increased Urine pHUrine pH (alkaline) (alkaline) Associated with Associated with ProteusProteus Urinary Tract InfectionUrinary Tract Infection

Uric AcidUric Acid crystals (diamond shape) crystals (diamond shape) CystCystine crystals (hexagonal shape) ine crystals (hexagonal shape)

Urine CastUrine Casts s Cast Types Cast Types

Epithelial cell casts of renal tubule Epithelial cell casts of renal tubule Acute Tubular NecrosisAcute Tubular Necrosis Interstitial NephritisInterstitial Nephritis EclampsiaEclampsia Heavy metal poisoning Heavy metal poisoning Rejected transplant Rejected transplant

Red Blood CellRed Blood Cell casts casts Glomerulonephritis Glomerulonephritis May be normal in collision sport athletes May be normal in collision sport athletes

White Blood Cell casts White Blood Cell casts Pyelonephritis Pyelonephritis Glomerulonephritis Glomerulonephritis Interstitial Nephritis Interstitial Nephritis

Hyaline or mucoprotein casts Hyaline or mucoprotein casts Normal finding Normal finding Pyelonephritis Pyelonephritis Chronic renal disease Chronic renal disease

Granular casts Granular casts Severe renal disease Severe renal disease

Waxy casts Waxy casts Severe renal disease Severe renal disease

Fatty casts Fatty casts Nephrotic Syndrome Nephrotic Syndrome

Hypothyroidism Hypothyroidism

Hyaline Hyaline castscasts

Waxy castsWaxy casts

BacteriaBacteria castscasts