Urinalysis

The First Affiliatied

Hospital, Zhengzhou
University
Dr.Liu
 Urine sample
► Urine Routine
► Visual inspection
► Dip-testing
► Microscopy
► Gram-stained
► Culture
► Biochemisry( protein,Cr.,Bun…..etc)
 Urinanalysis - Appearance
► Normal, fresh urine is pale to dark yellow or
amber in color and clear
► Turbidity or cloudiness :
► excessive cellular material or protein
► crystallization or precipitation of salts upon
standing at room temperature or in the
refrigerator.
► A red or red-brown (abnormal) color : food
dye, eating fresh beets, a drug, or the
presence of either hemoglobin or myoglobin.
 Urine colour/appearance

Urine may also be clear, bloody,

cloudy or flocculent (big bits in it).
Increasing concentration of urine
Acute Intermittent Porphyria
(AIP)
 Urinanalysis - Volume
► Temperate climates: output of 800-2500
ml urine per day is usual.
► Dependent upon subject’s activity,
hydration status, diet and body size.
► Always need to urinate to get rid of
metabolic wastes, even if not drinking.
Remember that you can urinate to death if
you are shipwrecked either through lack of
water, or by ingestion of salt water!
► Sudden changes in volume of urine can
indicate problems with ability to
concentrate urine, or in feedback
mechanisms that help you control ECF
volume/osmolality.
 Urinanalysis
► Oligouria – excrete < 300 ml/day.
 Might be “physiological” as in hypotension or hypovolaemia
where we compensate, but more often due to renal disease or
obstructive nephropathy.
► Polyuria – persistent, large increase in urine output
associated with nocturia.
 Must distinguish from higher frequency of small volumes of
urine.
 Usually due to hysterical intake of water, increased excretion
of solute (e.g. hyperglycaemia/glycosuria), defect in
concentrating ability or ADH failure).
► Osmolality – useful for determining whether ionic
imbalances exist in subject.
 May indicate renal failure (e.g. excess urea) or problems with
ADH.
► Urinary pH – mainly for acidosis/alkalosis determination –
important when studying metabolism of various nutrients
e.g. glucose during exercise
 Urine pH

► The glomerular filtrate of blood plasma is usually

acidified by renal tubules and collecting ducts from a
pH of 7.4 to about 6 in the final urine.
► Urine pH should be measured with a pH meter on a
freshly voided urine sample as on standing diffused loss
of CO2 or bacterial contamination may occur changing
the pH value.
► Urine pH is important for diagnosis of renal tubular
acidosis( RTA).
► Newborn/neonate: pH 5-7
► Thereafter: pH 4.5-8( average 6 )
 Specific Gravity (sp gr)
► Specific gravity (which is directly proportional to urine
osmolality which measures solute concentration)
measures urine density, or the ability of the kidney to
concentrate or dilute the urine over that of plasma.
► Normally, Osmolality of urine is between 40 to 1200mosm/kg.
Osmolality = ( Specific gravity -1.000) x 40,000
► Specific gravity between 1.002 and 1.030 on a random
sample should be considered normal if kidney function
is normal
► Since the sp gr of the glomerular filtrate in Bowman's
space ranges from 1.007 to 1.010. Hydration or relative
dehydration?
 Specific Gravity (sp gr)
► If sp gr is not > 1.022 after a 12 hour period
without food or water, renal concentrating
ability is impaired ( generalized renal
impairment or nephrogenic diabetes insipidus).
► In end-stage renal disease, sp gr tends to become
1.007 to 1.010.
► Any urine having a specific gravity over 1.035
contaminated, contains very high levels of
glucose, recently received high density
radiopaque dyes intravenously for radiographic
studies or low molecular weight dextran
solutions.
 Hematuria
► Hematuria is presence of occult blood in urine due to
glomerular damage, tumors, kidney trauma, urinary stones,
acute tubular necrosis, UTI and nephrotoxins.
► Dipsticks to detect occult blood are sensitive to any heme
group and may suggest presence of either intact RBCs,
hemoglobin or myoglobin.
► An urine examination positive by hemostix should be
examined microscopically to confirm the presence of RBCs.
► If no RBCs are seen, hemoglobinuria can be differentiated
from myoglobin by immunodiffusion techniques.
 Protein
► Normally, only small plasma proteins filtered at
the glomerulus are reabsorbed by the renal tubule.
However, a small amount of filtered plasma
proteins and protein secreted by the nephron
(Tamm-Horsfall protein) can be found in normal
urine.
► Normal total protein excretion: < 150 mg/24 hours
or 10 mg/100 ml in any single specimen.
► Proteinuria > 3.5 g/24 hours : nephrotic syndrome.
 Protein
► Dipsticks is most sensitive to albumin but detects
globulins and Bence-Jones protein poorly.
1. In rough terms, trace positive results (which represent a
slightly hazy appearance in urine) are equivalent to 10
mg/100 ml or about 150 mg/24 hours (the upper limit of
normal).
2. 1+ corresponds to about 200-500 mg/24 hours,300mg/L
3. 2+ to 0.5-1.5 g/24 hours, 1g/L
4. 3+ to 2-5 g/24 hours, 3g/L
5. 4+ represents 7 g/24 hours ,10g/L, or greater.
 Glucose
► Less than 0.1% of glucose normally filtered by the
glomerulus appears in urine (< 130 mg/24 hr).
► Glycosuria (excess sugar in urine) generally means diabetes
mellitus.
► False negative glycosuria may be seen with Vitamin C,
tetracyclines or homogentistic acid.

► Dipsticks employing the glucose oxidase reaction for

screening are specific for glucose but can miss other
reducing sugars such as galactose and fructose.
► For this reason, most newborn and infant urines are
routinely screened for reducing sugars by methods other
than glucose oxidase (such as the Clinitest, a modified
Benedict's copper reduction test).
 Ketones
► Ketones (acetone, aceotacetic acid, beta-
hydroxybutyric acid) resulting from either
diabetic ketosis or some other form of calorie
deprivation (starvation), are easily detected
using either dipsticks or test tablets containing
sodium nitroprusside.
 Nitrite
► A positive nitrite test indicates that bacteria may
be present in significant numbers in urine when
bacteria change nitrate in the urine to nitrite
► More than 90% of common urinary pathogens
(Gram negative rods) are nitrite-producing
bacteria.
 Leukocyte Esterase
► A positive leukocyte esterase test : presence of white
blood cells either as whole cells or as lysed cells.
► Pyuria can be detected even if the urine sample contains
damaged or lysed WBC's.
► A negative leukocyte esterase test means that an infection
is unlikely and that, without additional evidence of
urinary tract infection, microscopic exam and/or urine
culture need not be done to rule out significant
bacteriuria.
 Microscopic Urinnalysis
► The sediment is first examined under low power to identify
most crystals, casts, squamous cells, and WBC,RBC.
► The numbers of casts seen are usually reported as number of
each type found per low power field (LPF). Example: 5-10
hyaline casts/LPF.
► Next, examination is carried out at high power to identify
crystals, cells, and bacteria. The various types of cells are
usually described as the number of each type found per
average high power field (HPF). Example: 1-5 WBC/HPF.
► If microscopy is delayed, the specimen should be
refrigerated at + 40C to prevent bacterial overgrowth and
dissolution of cells and casts.
 Red Blood Cells
► >5 RBC in a HPF in 10ml of centrifuged sample is
considered abnormal.
► Once hematuria is established, it is important to
determine the source of bleeding.
► RBC casts, dysmorphic crenated RBCs suggest
glomerular bleed whereas normal RBC morphology
suggests lower urinary tract bleed.
 White Blood Cells
► > 10 WBC/cumm for boy and >50 WBC/cumm
for girls is abnormal and suggestive of pyuria
that is seen in UTI or with acute
glomerulonephritis
► Usually, the WBC's are granulocytes
Sternheimer-Malbin stain
 Epithelial Cells
► They arise from renal tubules and transitional cells arise
from renal pelvis, ureter or bladder & squamous epithelial
cells arise from outer urethra or skin surface.
► Increased renal tubular epithelial cells are seen in nephrotic
syndrome and tubular degeneration.
► When lipiduria occurs, these cells contain endogenous fats.
When filled with numerous fat droplets, such cells are
called oval fat bodies. Oval fat bodies exhibit a "Maltese
cross" configuration by polarized light microscopy
 Epithelial Cells
► Renal tubular epithelial cells, usually larger than
granulocytes, contain a large round or oval nucleus
and normally slough into the urine in small
numbers.
► Transitional epithelial cells have more regular cell
borders, larger nuclei, and smaller overall size than
squamous epithelium.
 Casts
► They are solid and cylindrical structures formed by
precipitation of debris in the renal tubules.
► Urinary casts are formed only in the distal convoluted
tubule or the collecting duct.
► Hyaline casts are composed primarily of Tamm-
Horsfall proteins. Hyaline casts are seen in healthy
individuals.
 Casts
► RBC casts are formed when RBCs stick together and are
seen in glomerular disease.
► WBC casts are seen in acute pyelonephritis and
glomerulonephritis & denote inflammation of the kidneys.
 Casts
► When cellular casts remain in the nephron for
some time before they are flushed into the bladder
urine, the cells may degenerate to become a
coarsely granular cast, later a finely granular cast,
and ultimately, a waxy cast.
► Granular and waxy casts are derived from renal
tubular cell casts and are seen in nephrotic
syndrome and tubular damage.
 Mucus

renal tubular cell cast

 Bacteria
► Bacteria are common in urine specimens because
of the abundant normal microbial flora of the
vagina or external urethral meatus and because of
their ability to rapidly multiply in urine standing at
room temperature.
► Diagnosis of bacteriuria in a case of suspected
urinary tract infection requires culture.
► Multiple organisms reflect contamination.
Upper panel: low magnification view
showing increased numbers of leukocytes
and several struvite crystals (unstained
wet prep). The leukocytes provide clear
evidence of an inflammatory process; the
background appears "busy", but bacteria
are not reliably identifiable at this
magnification.

Middle panel: high magnification view of

unstained wet prep showing leukocytes
and clumps and chains of bacteria
(arrows).

Lower panel: high magnification view of a

gram-stained slide. A neutrophil and
gram positive cocci arranged in clusters
and short chains are shown (arrows:
some organisms have partially or
completely decolorized). It can be
concluded that the inflammatory process
is caused or complicated by bacterial
 Yeast
► It may be a contaminant or represent a true yeast
infection.
► They are often difficult to distinguish from red
cells and amorphous crystals but are distinguished
by their tendency to bud.
► Most often they are Candida, which may colonize
bladder, urethra, or vagina.
 Crystals
► Common crystals seen even in healthy patients include
calcium oxalate, triple phosphate crystals and amorphous
phosphates.
► Very uncommon crystals include:
1. cystine crystals in urine of neonates with congenital
cystinuria or severe liver disease,
2. tyrosine crystals with congenital tyrosinosis or marked
liver impairment,
3. leucine crystals in patients with severe liver disease or
with maple syrup urine disease.
Leucine TYROSINE

"coffin-lid" struvite crystals associated with urea-splitting bacteria

 Notice
► Changes which occur with time after collection
include: 1) decreased clarity due to crystallization
of solutes, 2) rising pH, 3) loss of ketone bodies,
4) loss of bilirubin, 5) dissolution of cells and
casts, and 6) overgrowth of contaminating
microorganisms.
► Generally, urinalysis may not reflect the findings
of absolutely fresh urine if the sample is > 1 hour
old. Therefore, get the urine to the laboratory as
quickly as possible.
1
Colour Yellow
Appearance Turbid
Leukocyte Esterase 3+
Nitrite +
WBC/hpf >50/hpf
RBC/hpf 5-10/hpf
Casts WBC casts
Urine culture >105 bacteria/ml
2
Colour Cola Coloured
Blood ++++
Proteins ++
WBC/hpf 3-4/hpf
RBC/hpf 150-200/hpf
Casts RBC casts
3
Colour Yellow
Appearance Cloudy
Proteins 4+
Blood -
WBC -
Casts Waxy casts
Other Oval fat bodies occasional
24 hours urine albumin >40mg/kg/day.
THANKS FOR YOUR ATTENTION