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Analysis of the urine

Down /undeR
The Poor man’s renal biopsy
The detailed report
How to catch…
• Males……catch the mid stream part as they go

• Females….ideally should be catheterized

• Otherwise cleans first front to back

• Adhesive bag for infants/neonates

• Analyze with in an hour

• Or store at 5ᵒC
Color
• Pale yellow to dark amber

• Urochrome the painter

• Product of heme
degradation

• Heme to bilirubin to
urobilinogen to
urobilin/urochrome
Rhubarb
Propofol Vitamin C
UTI Vitamin B UTI
Rifampicin
urolithiasis
Rhabdomyolisis

Methylene blue
Metronidazole
Amytriptaline Bacteriuria
Hepatobilliary disease
Blue diaper syndrome
Turbidity
• Usually due to phosphaturia…milk
intake

• Acidification clears the urine

• Pus can also make it turbid

• Rare causes chyluria, lipiduria,


crystals

• Sperm and vaginal secretions can


have effect
Specific gravity
• Comparison of the amount of solute in urine as
compared to water

• Usually reflects the hydration status

• Measure of the concentrating ability of the kidney

• Range 1.001-1.035

• Rough estimate of urine osmolality


The modifiers..
• Decreased fluid intake • Increased fluid intake

• Dehydration • Diuretics

• Fever, sweating, diarrhea • Decreased renal


concentrating ability
• Diabetes mellitus
• Diabetes insipidus
• SIADH
pH
• Usually acidic due to obligate net acid production

• Ranges from 4.5-8

• In general is a reflection of serum pH

• “RTA” the exception

• The alkaline tide

• Effect of animal protein


pH contd….

• Helps in diagnosing UTI


organism

• Helps ascertaining type


of stone

• pH monitoring for stone


management
The Dipstick
• Short plastic strip with marker pads

• Substances producing abnormal colors interfere with the


result

• Mostly oxidative reactions that produce the color change

• Immerse---Remove---hold Horizontal

• Ascorbic acid and alkaline urine interfere with results


Hematuria
• Normal < 3RBC’s per HPF

• Hematuria, Hemoglobinuria, Myoglobinuria

• Microscopy And Serum Exam For Differentiation

• Sensitivity 90%------false positive high


False Positive

• Dehydration—solute:solvent

• Exercise—number of filtered RBC’s increase

• Contamination
What it means..
• In asymptomatic individuals….

• At Mayo clinic….
– 0.8% had urologic malignancy
– 1.8% had serious urologic disease later on

• At Wisconsin….
– 26% had significant urologic issue in the ensuing years

• Confirm results with microscopy before proceeding


Hematuria
• Glomerular ---
• dysmorphic RBC’s
• Red cell casts
• Proteinuria
• Interstitial ---
• normal RBC’s
• Proteinuria
• Urologic ---
• normal RBC’s
• No proteinuria
Nephrological evaluation
Non glomerular
• Tubulo interstitial

• Renovascular
• Renal arteryembolus/vein thrombus
• AV fistuula
• aneurysm

• Systemic disorders
• Bleeding disorder
• Papillary necrosis
• Excessive anticoagulation
• Tumor
• Urolithiasis
• UTI
Exercise induced
• Usually seen in athlete – long runners

• Disappears with rest

• Cystoscopy reveals punctate hemorrhage

• Can be a first sign of IgA nephropathy


Proteinuria
• 80-150mg normal

• 30:30:40 --- A:G:T

• Concentration seldom exceeds 20mg/dl

• Represents leakage or overflow

• The dipstick more sensitive for albumin

• Sulfosalicylic acid test for other proteins


The dipstick scale
• Trace - Approx 10-30 mg/dL

• 1+ ---- Approximately 30 mg/dL

• 2+ ---- Approximately 100 mg/dL

• 3+ ---- Approximately 300 mg/dL

• 4+ ---- 1000 mg/dL or more


Pathophysiology
• Glomerular due to increased permeability
• Usually albumin

• Tubular due to failed absorption


• Usually low molecular weight proteins (immunoglobulins)

• Overflow due to systemic overproduction


• Multiple myeloma
• myoglobinuria
False negative…

• Alkaline urine

• Dilute urine

• Primary protein not albumin


Categories
• Transient
– Fever
– exercise
– emotional stress
– CCF
• Intermittent
– Postural
– More pressure on renal artery
• Persistent
– Mostly glomerular in origin
– >2gm /24 hour urine=glomerular disease
– If low molecular weight on salicylic acid test then do
immunoelctrophoresis
Glucose
• All that goes out comes back in-----almost

• Threshold of 180mg/dl to be crossed

• Dipstick specific for glucose

• Decreased sensitivity with increased specific


gravity and temperature
Ketones
• Acetoacetic acid, Acetone,β Hydroxybutyric Acid

• Dipstick identify acetoacetic acid


• Diabetic ketoacedosis
• Pregnancy
• Starvation
• Rapid weight loss

• False positive
• Acidic urine
• Abmormally colored
Billirubin—Urobilinogin
• Product of heme metabolism

• Direct and indirect

• Direct plus urobilinogen in urine if


• Increased production (hemolytic disorder)
• Obstructive jaundice

• Indirect never found in urine


Leukocyte Esterase
• Represents the presence of leukocytes

• Sensitivity decreases with time as WBC lyse

• False negative with


• Increased specific gravity
• Glycosuria
• Presence of urobilinogen

• False positive with contamination


Nitrite
• Not normally found in urine

• Bacterial species convert nitrate to nitrites

• Assessed along with leukocyte esterase

• High specificity >90%

Visual appearance with LE + Nitrite detects 95%


of infected urine samples
All urologist should be capable of performing and interpreting
the microscopic examination of urinary sediments
Campbell
Obtaining specimen

• 10-15ml of urine

• Centrifuged for 5mins

• At 3000rpm

• Supernatant discarded

• Sediments resuspended
What to see..
• Low power microscopy enough to see all

• High power to differentiate dysmorphic and normal


RBC’s

• Sediment examined for


• Cells
• Casts
• Crystals
• Bacteria yeast parasites
Normal RBC’s
Dysmorphic RBC’s
Old leukocytes
The budding yeast
Cast
• Protein coagulam that forms in the renal
tubule

• Tamm Horsfall protein basic matrix of all casts

• Only mucoprotein cast are usually normal


found in
• Heat exposure
• Exercise
Red cell cast
Cellular casts
Crystals
Bacteria
• Normal urine should have no bacteria

• Each bacterium per HPF=30,000/ml

• This is standard for diagnosing UTI in females

• Males should have no bacteria in a clean catch


specimen