Professional Documents
Culture Documents
URINALYSIS
Nephron Basic structural unit of kidney
1M/kidney
Urethra F: 3-4 cm
M: 20 cm
Urine formation (order) Glomerulus Bowman’s capsule PCT Loop of Henle
DCT CD
PCT 65% of reabsorption
ADH Regulate H2O reabsorption in DCT and CD
Urine composition 95-97% H2O
3-5% solids
60g TS in 24 hrs
35g: Organic = Urea (major)
25g: Inorganic = Cl (#1) > Na+ > K+
Glomerular Filtration
Clearance tests Evaluate glomerular filtration
1. Urea clearance
2. Creatinine clearance = most common
3. Inulin clearance = gold standard
4. Beta2-microglobulin
5. Radioisotopes
Creatinine clearance Formula:
Cc = U x V x 1.73
P A
Normal values:
M = 107-139 mL/min
F = 87-107 mL/min
Tubular Reabsorption
st
Tubular Reabsorption 1 function to be affected in renal disease
Concentration tests Evaluate tubular reabsorption
Fishberg test (Old) Patient is deprived of fluid for 24hrs then measure urine
SG
(SG ≥ 1.026)
Mosenthal test (Old) Compare day and night urine in terms of volume and SG
Specific Gravity (New) Influenced by # and density of particles in a solution
Osmolarity Influenced by # of particles in a solution
Principle: Freezing point depression
- 1 Osm or 1000 mOsm/kg of H2O will lower the FP of H2O
(0’C) by 1.86’C
- FP = Osm
Example:
Determine Osm in mOsm/kg
Temp. = -0.90’C
Solution:
1000 mOsm/kg = _ _x____
-1.86’C -0.90’C
Specific Gravity
SG Density of solution compared w/ density of similar
volume of distilled H2O at a similar temperature
NV = 1.003-1.035 (random)
SG <1.003 = not a urine except DI
Refractometer Based on refractive index:
(TS meter) RI = _light velocity in air_
light velocity in soln
Compensated to temperature (15-38’C)
Corrections:
a. 1g/dL glucose: (-0.004)
lec.mt 04 |Page | 138
b. 1g/dL protein: (-0.003)
Calibrations:
a. Distilled H2O = 1.000
b. 5% NaCl = 1.022 ± 0.001
c. 9% Sucrose = 1.034 ± 0.001
Urinometer Requires temperature correction
a. 3’C calibration temperature (20’C) = (+0.001)
b. 3’C calibration temperature (20’C) = (-0.001)
Requires correction for glucose and protein (Rf/U)
Rf < U by 0.002 Refractometer reading is lower than the urinometer
reading by 0.002
Urinometer K2SO4 solution: 1L H2O + 20.29g K2SO4
calibration SG = 1.015
Isosthenuria SG = 1.010 (Glomerular filtrate)
Hyposthenuria SG < 1.010
Hypersthenuria SG > 1.010
Urine Odor
Aromatic/Odorles Normal
s
Ammoniacal Urea ---(Urease)---> NH3
Ex. UTI (Proteus: urease)
Fruity, sweet DM (Ketones)
Rotten Trimethylaminuria
fish/Galunggong
Sweaty feet Isovaleric acidemia
Mousy Phenylketonuria
Cabbage Methionine malabsorption
Caramelized MSUD
sugar, curry
Bleach Contamination
Sulfur Cystine disorder
False-positive False-negative
Blood Strong oxidizing agents High specific gravity/crenated
Bacterial peroxidases cells
Menstrual contamination Formalin
Captopril
High concentration of nitrite
Ascorbic acid >25 mg/dL
Unmixed specimens
Bilirubin Highly pigmented urines, Specimen exposure to light
phenazopyridine Ascorbic acid >25 mg/dL
Indican (intestinal disorders) High concentrations of nitrite
Metabolites of Lodine
Urobilin Porphobilinogen Old specimens
ogen Indican Preservation in formalin
p-aminosalicylic acid
Sulfonamides
Methyldopa
Procaine
Chlorpromazine
Highly pigmented urine
Nitrite Improperly preserved Nonreductase-containing
specimens bacteria
Highly pigmented urine Insufficient contact time
between bacteria and nitrate
Lack of urinary nitrate
lec.mt 04 |Page | 146
Large quantities of bacteria
converting nitrite to nitrogen
High concentrations of
ascorbic acid
High specific gravity
Leukocy Strong oxidizing agents High concentrations of
tes Highly pigmented urine, protein, glucose, oxalic acid,
nitrofurantoin ascorbic acid, gentamicin,
cephalosporins, tetracyclines
Sources of error:
-Yeasts
lec.mt 04 |Page | 147
-Oil droplets
-Air bubbles
-CaOx crystals
♫ Remedy: add 2% acetic acid
-RBCs: lysed
-Other cells: intact
WBCs NV = 0-5 or 0-8/hpf
Glitter cells (Hypotonic urine)
-Granules swell
-Brownian movement
>1% eosinophils: significant
- Drug-induced allergic reaction
- Inflammation of renal interstitium
Addis count Quantitative measure of formed elements of urine
using hemacytometer
Specimen: 12 hr urine
Preservative: Formalin
NV:
a. RBCs: 0-500,000/12 hr urine
b. WBCs: 0-1,800,000/12 hr urine
c. Hyaline Casts: 0-5000/ hr urine
Squamous Largest cell in the urine sediment
epithelial cells From linings of vagina, female urethra and lower
male urethra
♫ Variation: Clue cells:
-EC w/c are studded w/ bacteria (bacterial
vaginosis)
-Whiff/Sniff test: vaginal discharge + 10% KOH
Fishy amine-like odor
-Culture: G. vaginalis = HBT medium
Transitional Spherical, polyhedral, or caudate w/ centrally
epithelial cells located nucleus
(Urothelial cells) Derived from the linings of the renal pelvis, ureter,
urinary bladder, male urethra (upper portion)
Not clinically significant in small numbers
Renal tubular Rectangular, polyhedral, cuboidal or columnar w/ an
epithelial cells eccentriac nucleus, possibly bilirubin stained or
hemosiderin laden
From nephron:
-PCT: rectangular, columnar/convoluted
-DCT: round/oval
>2 RTE/hpf: tubular injury
Oval fat body Lipid containing RTE cells
Lipiduria (Ex. nephrotic syndrome)
Cholesterol: Maltese cross
Bubble cells RTE cells w/ nonlipid containing vacuoles
Acute tubular necrosis
Yeast C. albicans (DM, vaginal moniliasis)
lec.mt 04 |Page | 148
T. vaginalis Flagellate w/ jerky motility
Pingpong disease
S. haematobium “Hematuria”
Specimen: 24 hr unpreserved urine
E. vermicularis Most common fecal contaminant
Casts Formed in the DCT and CD
(Cylindruria) ♫ Tamm-Horsfall protein (Uromodulin)
-Major constituent
-Glycoprotein secreted by RTE cells of DCT and CD
Hyaline casts NV = 0-2/lpf
Beginning of all types of casts (prototype cast)
a. Physiologic:
- Strenuous exercise (HC, GC, RC)
- Heat
b. Pathologic:
- GN
- PN
- CHF
RBC casts Bleeding w/in the nephron
a. GN
b. Strenuous exercise (HC, GC, RC)
WBC casts Inflammation w/in the nephron
Differentiates upper UTI (pyelonephritis, w/ cast)
from lower UTI (cystitis, no cast)
To differentiate from EC cast:
1. Phase contrast microscopy
2. Supravital stain
Seen in:
-PN
-AIN
Bacterial casts Pyelonephritis
Epithelial cell Renal tubular damage
casts Advanced tubular destruction
Coarse/Fine Formed from the disintegration of cellular cast
granular casts GN
PN
Strenuous exercise (HC, GC, RC)
Fatty casts Nephrotic syndrome: lipiduria
Not stained by Sternheimer-Malbin
Waxy casts Final degenerative form of all types of casts
Stasis of renal flow
Chronic renal failure
Brittle, highly refractile, w/ jagged ends
Broad casts “Renal failure casts”
Extreme urine stasis
Widening and destruction of tubular walls
Any type of cast can be broad
Sediment Urine Centrifuge: 400 RCF for 5 mins Decant
lec.mt 04 |Page | 149
preparation Remaining: 0.5mL/1.0mL
Urine sediment: 20μL (0.02 mL)
-10 lpf
-10 hpf
-Reduced light
RCF 1.118 x 10-5 x radius (cm) x (rpm)2
Urine Crystals
Amorphous Yellow-brown granules
Urates Pink sediment (Uroerythrin)
(Normal) Mistaken as cystine crystals
(pH: acid) Rhombic, wedge, rosette, hexagonal, four-sided
plate (whetstone)
Lemon-shaped (Henry)
Lesch-Nyhan syndrome: orange sands in diaper
Gout
Chemotherapy
Calcium Oxalate 1. Weddelite = dihydrate
(Normal) -Envelope/pyramidal
(pH: 2. Whewellite = monohydrate
acid/alkaline/neut -Oval, dumbbell
ral) -Ethylene glycol poisoning (antifreeze agent)
Most renal stones consist of CaOx
Amorphous White precipitate
Phosphates Granular appearance
(Normal) After meal (alkaline tide)
(pH:
alkaline/neutral)
Ammonium Yellow-brown
Biurate Thorny apples
(Normal) Old specimen: due to the presence of urea-splitting
(pH: alkaline) bacteria
Triple Phosphate A.k.a. Magnesium ammonium phosphate
(Normal) Coffin lid, “Struvite”, staghorn appearance
(pH: alkaline) Presence of urea-splitting bacteria
Calcium Phosphate Colorless, flat rectangular plates or thin prisms
(Normal) often in rosette formation
(pH: Rosettes may resemble sulfonamides
alkaline/neutral) -To differentiate: CaPO4 dissolves in acetic acid
1. Calcium Phosphate = Apatite
2. Basic Calcium Phosphate = Hydroxyapatite
3. Calcium Hydrogen Phosphate = Brushite
Calcium Carbonate Small and colorless
(Normal) Dumbbell or spherical shapes
(pH: alkaline) Acetic acid: (+) Effervescence
Cystine Colorless hexagonal plates
(Abnormal) Cystinuria
(pH: acid)
Cholesterol Rectangular plate w/ notch in one or more corners
lec.mt 04 |Page | 150
(Abnormal) Staircase pattern
(pH: acid) Lipiduria (Nephrotic syndrome)
Resemble crystals of RCM, to differentiate
a. Patient history
b. Correlate w/ other UA results
c. RCM: SG by refractometer ≥1.040
Tyrosine Colorless to yellow needles
(Abnormal) Liver disease (more common)
(pH: acid/neutral) (+) Nitroso-naphthol
Leucine Yellow-brown spheres w/ concentric circles and
(Abnormal) radial striations
(pH: acid/neutral) Liver disease
Bilirubin Clumped needles or granules w/ yellow color
(Abnormal) (+) Diazo reaction
(pH: acid) Liver disease
Sulfonamide Colorless to yellow brown
(Abnormal) Deposits in nephrons
(pH: acid/neutral) Tubular damage
Needles, sheaves of wheat, rosette (res. CaPO4
rosette)
♫ Lignin test:
Newspaper = urine + 25% HCl (+) Yellow orange
color
Ampicillin Massive doses
(Abnormal) Colorless needles
(pH: acid/neutral)
Uric Acid Cystine
Color Yellow brown Colorless
Solubility in NH3 Soluble Soluble
Solubility in dilute HCl Insoluble Soluble
Birefringence (Polarizing
+ -
microscope)
Cyanide-Nitroprusside
- +
test
Urinary Sediment 1. Starch granules (gloves):
Artifacts -Most common
-Maltese cross (O, FC, S)
-Dimpled center
2. Oil droplets
3. Air bubbles
4. Pollen grains = spheres w/ concentric circles
5. Hair and fibers = (+) Birefringence (polarizing
microscope)
6. Fecal contaminants
Renal Diseases
Cystitis Inflammation of urinary bladder
Infection
lec.mt 04 |Page | 151
WBCs, RBCs, bacteria
NO CAST
Urethritis Inflammation of urethra
WBCs, RBCs
Usually NO BACTERIA on routine UA
a. Male: GS of urethral exudates [Gram (-)
diplococcic]
b. Female: pelvic exam for vaginitis and cervicitis
Glomerulonephriti Inflammation of the glomerulus
s Immune-mediated
RBCs, WBCs, RBC CASTS, WBC casts, hyaline and
granular casts
Pyelonephritis Infection of renal tubules
WBCs, RBCs, bacteria, RBC casts, WBC CASTS,
hyaline and granular casts
Acute Interstitial Infection of the renal interstitium
Nephritis RBCs, WBCs, WBC casts, NO BACTERIA
Renal carcinoma 1’ = RCC
2’ = Transitional CC
RBCs and WBCs
Nephrotic Massive proteinuria and lipiduria
syndrome a. Serum (Chemistry)
- Albumin, alpha1, beta and gamma globulins
- alpha2 (AMG)
b. Urine (CM)
- Albumin, alpha1, beta and gamma globulins
-(-) alpha2 (AMG)
-Oval fat bodies, fatty and waxy casts
Telescoped Simultaneous appearance of the elements of
sediments acute/chronic GN and nephrotic syndrome
Cells and Casts
a. Lupus nephritis
b. SBE
UTI E. coli = 90% cases of UTI
S. saprophyticus = UTI among sexually active young
females
G. vaginalis = bacterial vaginosis
S. pyogenes = AGN and ARF
Viridans Streptococci = SBE
Rapidly Deposition of immune complex from systemic
progressive immune disorders on the glomerular membrane
(Crescentic) GN
Goodpasture Attachment of cytotoxic antibody to glomerular and
syndrome alveolar basement membrane
Wegener’s Antineutrophilic cytoplasmic autoantibody
granulomatosis
Henoch-Schönlein Occurse in children following viral respiratory
purpura infection
lec.mt 04 |Page | 152
Decrease in platelets disrupts vascular integrity
Membranous GN Thickening of the glomerular membrane following
IgG immune complex deposition
Membranoprolifer Cellular proliferation affecting the capillary walls or
ative GN the glomerular basement membrane
Chronic GN Marked decrease in renal function resulting from
glomerular damage precipitated by other renal
disorders
IgA nephropathy Deposition of IgA on the glomerular membrane
(Berger’s disease)
Nephrotic Disruption of the electrical charges that produce
syndrome tightly fitting podocyte barrier
Minimal change Disruption of the podocytes occurring primarily in
disease (Lipoid children following allergic reaction and immunization
nephrosis)
FSGS Disruption of podocytes in certain areas of
glomeruli associated w/ heroin and analgesic abuse
and AIDS
Alport syndrome Lamellated and thinning of glomerular basement
membrane
Diabetic Most common cause of ESRD
Nephropathy Microalbuminuria
(Kimmelstiel-
Wilson disease)
Acute tubular Damage to the renal tubules caused by ischemia or
necrosis toxic agents
Fanconi syndrome Generalized defect in renal tubular reabsorption in
the PCT
Nephrogenic DI Inability of the renal tubules to respond to ADH
Neurogenic DI Inability of the hypothalamus to produce ADH
Renal glucosuria Inability of the renal tubules to reabsorb glucose
Cystitis Ascending bacterial infection of the bladder
Acute PN Infection of the renal tubules and interstitium
Chronic PN Recurrent infection of the renal tubules and
interstitium
Visicoureteral reflux: most common cause
-Reflux of urine from the bladder back into the
ureters
2. Renal type
N-AA in blood
Phenylalanine (-)
Tyrosine
Tyrosyluria:
Fumarylacetoacetic acid
CSF Glucose
CSF Glucose NV = 60-70% of the plasma glucose concentration
A plasma glucose must also be run for comparison
Diagnostic significance:
- values
- CSF glucose values = result of plasma glucose
CSF glucose Bacterial, TB, fungal meningitis
N-CSF glucose Viral meningitis
CSF Lactate
CSF Lactate Frequently used to monitor severe head injuries
False elevations: Xanthochromia/hemolysis (RBC
contains lactate)
10-22 mg/dL Normal lactate
>35 mg/dL Bacterial meningitis
>25 Fungal and TB meningitis
<25 mg/dL Viral meningitis
CSF Enzymes
LD Serum: LD 2 > 1 > 3 > 4 > 5 [MI: LD 1 > 2 > 3 > 4 > 5]
CSF (normal): LD 1 > 2 > 3 > 4 > 5
Neurologic abnormalities: LD 2 > 1
Bacterial meningitis: LD 5 > 4 > 3 > 2 > 1
Synovial Fluid
Synovial Latin: “Egg”
Fluid Diarthroses/joints
Arthrocentesis Method of collections
Synoviocytes Phagocytic cells
Secrete hyaluronic acid
Specimen Fluid Syringe (heparin)
collection Micro: 3-5 mL in sterile tube, add 25 U heparin/mL
fluid
Hema: 3-5 mL, add 25 U heparin/mL fluid
-Do not use crystalline EDTA but liquid EDTA may
be accepted
Chem: 3-5 mL in red top and observe for clotting
NaF: glucose analysis
Normal Values Volume = <3.5 mL
Color = pale yellow
Clarity = clear
lec.mt 04 |Page | 174
Viscosity = 4-6 cm long
Crystals = none present
Glucose = <10 mg/dL lower than the blood glucose
Lactate = <250 mg/dL
Total protein = <3 mg/dL
Uric acid = equal to blood value
Turbidity WBCs
Milky (+) Crystals
Rope’s/Mucin clot Hyaluronate polymerization test
test 2-5% acetic acid
Grading:
-Good = solid clot
-Fair = soft clot
-Low = friable clot
-Poor = no clot at all
Cells in Synovial Fluid
WBC Total WBC count: most frequently tested
STAT, otherwise, refrigerate
Neubauer counting chamber
Clear fluids = counted undiluted
Diluting fluid = NSS
If necessary to lyse RBCs:
-Hypotonic saline (0.3%)
-Saline w/ saponin
Do not use WBC diluting fluid
Differential count 65% = Monocytes & Macrophages
<25% = Neutrophils
<15% = Lymphocytes
Very viscous Add hyaluronidase 0.5 mL of fluid or
specimen 1 drop of 0.05% hyaluronidase in PO4 buffer/mL of
fluid
37’C for 5 mins
LE cell Neutrophil
Reiter cells Vacuolated macrophage w/ ingested neutrophils
Ragocyte Neutrophil w/ dark cytoplasmic granules
Cartilage cells Large multinucleated cells
Rice bodies Macroscopically resembles polished rice
Ground pepper Ochronotic shards = debris
appearance of Metal and plastic joint prosthetic
synovial fluid
Hemosiderin Pigmented villonodular synovitis
Cartilage cells Osteoarthritis
Crystals
Normal No crystals
Abnormal Hydroxyapatite crystals
Cholesterol
Corticosteroid