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Urine Analysis

DJOKO HADIWIDODO
BAGIAN PATOLOGI KLINIK
FAKULTAS KEDOKTERAN UNS
SURAKARTA

Surakarta, 19 April 2010


TUJUAN PEMERIKSAAN URINE

UMUM :
1. Membantu / menegakkan diagnosis
2. Follow up & prognosis
3. Fungsi organ

KHUSUS :
1. Kelainan Traktus Urinarius / Urogenital
2. Penyakit ginjal
3. Penyakit diluar ginjal
Specimen
Collection
– Pertama - pagi

– Tampung

– Type of specimen

– Analisis dalam 2 jam

– Bebas dari debris vaginal


Specimen Collection
Mengapa urine pagiurine rutin ?

o Asam  pengawet
o Kandungan tinggi
o Nilai Rujukan
o Perlakuan minimal
Types of Analysis
Macroscopic
Chemical Analysis (Urine Dipstick)
Microscopic
Culture
Cytological
Macroscopic
Bau :
− Ammonia-like: (Urea-splitting bacteria)
− Foul, offensive: Old specimen, pus or inflammation
− Sweet: Glucose
− Fruity: Ketones
− Maple syrup-like: Maple Syrup Urine Disease

Warna :
− Colorless Diluted urine
− Deep Yellow Concentrated Urine, Riboflavin
− Yellow-Green Bilirubin / Biliverdin
− Red Blood / Hemoglobin
− Brownish-red Acidified Blood (Actute GN)
− Brownish-black Homogentisic acid (Melanin)
Chemical Analysis
Urine Dipstick

Glucose
Bilirubin
Ketones
Specific Gravity
Blood
pH
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
Specific Gravity pH
Significance Significance
- Diabetes insipidus - Acidic (> 4.5):
high-protein diet
Limitations - Alkaline (> 8.0)
- Interference: alkaline
urine Limitations
- Interference: bacterial
overgrowth (alkaline or
acidic),

Other
- Acidic sepanjang hari  batu
asam urat
- Alkaline sepanjang hari 
infeksi
Glucose Ketones

Significance Significance
Diabetes mellitus. - Diabetic ketoacidosis
Renal glycosuria. - Prolonged fasting
Glukosuria fisiologis - Demam

Limitations
Interference: reducing agents
vit. C , buah2an, antibiotik
Causes of Proteinuria
Functional Renal
- Severe muscular exertion - Glomerulonephritis
- Pregnancy - Nephrotic syndrome
- Orthostatic proteinuria - Renal tumor or infection

Pre-Renal Post-Renal
- Fever - Cystitis
- Renal hypoxia - Urethritis or prostatitis
- Hypertension - Contamination with vaginal
secretions
Proteins in “Normal” Urine

Protein % of Total Daily Maximum

Albumin 40% 60 mg
Tamm-Horsfall 40% 60 mg
Immunoglobulins 12% 24 mg
Secretory IgA 3% 6 mg
Other 5% 10 mg

TOTAL 100% 150 mg


Nitrite
Significance Limitations
- Gram negative bacteriuria - Interference: bacterial
overgrowth
- Vitamin C  negativ palsu
Leukocyte Esterase
Significance
- UTI
- Infeksi sekitar Saluran kemih
- Sumbatan saluran kemih bagian bawah

Limitations
- Interference: menstrual contamination
Bilirubin
Significance
- Increased direct bilirubin (correlates with urobilinogen and
serum bilirubin)

Limitations
- Positif palsu : Obat2-an yang berwarna merah
- Negatif palsu : vit. C

Urobilinogen
Significance
- High: increased hepatic processing of bilirubin
- Low: bile obstruction

Limitations
- Positf palsu : Obat2-an yang berwarna merah
Blood
Significance
- Hematuria (nephritis, trauma, etc)
- Hemoglobinuria (hemolysis, etc)
- Myoglobinuria (rhabdomyolysis, etc)
- UTI, urolithiasis, hipertensi, terapi antikoagulan.

Limitations
- Interference:
reducing agents,
microbial peroxidases
Microscopic Examination
Abnormal
Per High Power Field (HPF) (400x)
– > 5 erythrocytes
– > 12 leukocytes
– > 2 renal tubular cells

– > 10 bacteria
Per Low Power Field (LPF) (100x)
– > 3 hyaline casts or > 1 granular cast
– > 10 squamous cells (indicative of contaminated specimen)
– Any other cast (RBCs, WBCs)
Presence of:
– Fungal hyphae or yeast, parasite, viral inclusions
– Pathological crystals (leucine, tyrosine, cystine)
– Large number of uric acid or calcium oxalate crystals
Significance of Cellular Casts

Erythrocyte Casts
Leukocyte Casts
Bacterial Casts

Individual Erythrocytes
Individual Leukocytes
Individual Bacteria
Casts
Erythrocyte Casts: Glomerular diseases

Leukocyte Casts: Pyuria, glomerular disease

Degenerating Casts:
- Granular casts Nonspecific (Tamm-Horsfall protein)
- Hyaline casts Nonspecific (Tamm-Horsfall protein)
- Waxy casts Nonspecific
- Fatty casts Nephrotic syndrome
(oval fat body casts)
Urine microscopy cast

Erythrocyte cast. Leukocyte cast Epithelial cast.

Hyaline – Granula cast


pH  unsur anorganik

Neutral Urine
Acid Urine pH Alkaline Urine pH
pH
Ammonium
Calcium Oxalate Triple Phosphates
Biurate
Calcium
Uric Acid Ammonium Biurate
Carbonate
Calcium Oxalate Calcium Carbonate
Triple Phosphate Calcium Phosphate
Amorphous Amorphous
urates Phosphates
KRISTAL URINE

1. Umum
- Asam urat, Ca Oxalat, Ca Phosphat
- Makanan, dehidrasi, perubahan pH & suhu
- Gagal ginjal akut :
- Asam urat  urat akut nephropaty
- Calsium oxalat  keracunan ethylen glycol

2. Patologi
- Cholestrol, cystine, leucine, tyrosine

3. Obat
- Overdosis, dehidrasi, pH, hypoalbuminemia
CRYSTAL PATOLOGI
1. Cholesterol
2. Leucine
3. Cystein
4. Tyrosine

Kristaluria yang berhubungan dengan Gagal


Ginjal Akut :
1.Uric acid
2.Calsium oxalate
KRISTAL PATOLOGI

tyrosine
leucine

Cystine hexagonal
MANIFESTASI KLINIK KRISTALURIA :
1.Tanpa gejala
2.Hematuria & / leukosituria
3.Obstruksi  batu
4.Presipitasi intratubular  gagal ginjal akut
pH alkalis  RBC lisis
Urine „syndromes”
Urinary tract infection Glomerulo- Nephrosis
nephritis (idiopathic)
Bacterial infection of Structural Increased permeability to
renal parenchyma glomerular damage albumine
Leucocytes Erythrocytes -
bacteria (dysmorphic)
(erythrocytes+/-) (leucocytes+/-) -

(Protein+/-) Protein ++ Protein ++++


(0.5-1-2 g/day) (>3.5 g/day)
Leucocyte casts Erythrocyte casts (Hyaline/waxy casts)
(=Pyelonephritis)