Review Topic: Renal Disease University of Nebraska Medical Center Review Topic: Renal Disease Ricki Otten MT(ASCP)SC uotten@unmc.edu

Case #1 A 3-year-old left unattended in the garage for 5 minutes is suspected of ingesting antifreeze (ethylene glycol). His parents brought him to the ER. STAT urinalysis results follow:

2. Based on the patient’s history and urinalysis results, select the most probable diagnosis: a. Acute glomerulonephritis b. Acute tubular necrosis c. Urinary tract infection 3. What type of crystals would you except to be present in this patient?

What are the two forms of crystal typically seen in this type of poisoning? The amorphous material present will be classified as: a. Amorphous phosphates b. Amorphous urates

Case #2 A urine specimen was sent to the laboratory from a patient being evaluated for kidney stones. Six hours earlier the patient was given radiographic contrast media by I.V.

2. Identify the discrepant test results 3. What is the most likely identity of this crystal? a. Uric acid, rare form b. Cystine c. Triple phosphate d. X-ray contrast media

4. State two results that support the crystal selection made in question #3

5. Which specific gravity result is the better indicator of this patient’s renal concentrating ability: a. Refractometer b. Reagent strip

Case #3 A 24-year-old female is seen in the outpatient clinic complaining of a painful burning sensation (dysuria) when urinating and feeling a constant urgency, like she ‘has to go’ all the time. A midstream clean catch urine specimen is collected for a routine urinalysis and culture.

2. Based on the patient’s symptoms and urinalysis results, select the most probable diagnosis: a. Acute glomerulonephritis b. Cystitis (bladder infection) c. Pyelonephritis d. Nephrotic syndrome

3. Suggest a cause for the increased number of transitional epithelial cells seen in this patient’s urine:

State three reasons why the nitrite test State three reasons why the nitrite test can be negative despite bacteriuria 5. Provide one reason why this patient’s diagnosis is not pyelonephritis:

Case #4 A 43-year-old man with a history of diabetes mellitus is seen in t he diabetes clinic complaining of decreased frequency of urination, having a constant ‘bloated’ feeling, and mild weight gain. Physical exam revealed mild edema of the ankles, abdomen and eyes. Urinalysis results follow:

2. Based on the patient’s symptoms and urinalysis results, select the most probable diagnosis: a. Acute glomerulonephritis b. Pyelonephritis c. Nephrotic syndrome d. Cystitis 3. The proteinuria in this patient should be classified as: a. Glomerular proteinuria b. Tubular proteinuria

4. What substance is responsible for the large amount of white foam: 5. What type of protein is predominantly present in the urine?

Explain why the glucose result is positive, yet the ketone result is negative 7. Decreased frequency of urination is called:

Case #5 A 43-year-old man is seen in the ER because his urine is red, he is having headaches and lacks an appetite. Careful questioning revealed he had a sore throat about 3 weeks ago that lasted 4-5 days, but went away without having to take medicine. Also, his daughter had strep throat about a month ago that was successfully treated with antibiotics. Urinalysis results follow:

2. The proteinuria in this patient would be classified as a. Glomerular proteinuria b. Tubular proteinuria c. Overflow proteinuria d. Transient proteinuria

What is the likely process by which the red blood cells are entering the urine:

4. Of the microscopic findings, which sediment entity specifically indicates adverse glomerular changes and the presence of a renal disorder

5. Based on the patient’s history and urinalysis test results, select the most probable diagnosis: a. Nephrotic syndrome b. Acute glomerulonephritis: post streptococcal infection c. Toxic tubular necrosis

6. Provide one reason why this patient’s diagnosis is not nephrotic syndrome: Does this patient have isosthenuria? Explain your answer

Case #6 A 53-year-old woman is seen by her physician complaining of vaginal itching, soreness and a white discharge. She also noted that she has been ‘thirsty all the time’ and seemed to be urinating more frequently. Urinalysis results follow:

2. What is the most likely cause of this patient’s vaginitis? Does this patient have a urinary tract infection?

3. What is the most likely origin or source of the white blood cells in this patient’s urine?

4. List two microscopic findings that suggest this urine is not a midstream clean catch:

5. Explain why the glucose and ketone results are positive:

Frequent urination at night is called: Explain why the nitrite test is negative in this patient:

Case #7 A 50-year-old male had an emergency appendectomy and received a unit of packed red blood cells following surgery. Two hours later he developed fever, chills and nausea. Two days following surgery, urine was submitted for urinalysis:

Explain the apparent discrepancy seen between the reagent strip blood result and the microscopic findings:

3. The positive blood reagent strip reaction would be classified as: a. Hematuria b. Hemoglobinuria c. Myoglobinuria

Explain why the urobilinogen is elevated in this patient:

5. Because of the intravascular hemolytic episode, her serum bilirubin is significantly increased. Explain why her urine bilirubin is negative.

6. Provide a possible explanation as to why the ictotest was performed despite a negative bilirubin reagent strip test:

Case #8 A 19-year-old female college basketball player is seen in student health clinic for a sports physical. She states she feels healthy and is taking no medications. A midstream clean catch urine is collected for urinalysis:

2. Identify any discrepant test results

3. The technologist checks the pH of the urinary sediment and rechecks that of the urine in the original specimen cup obtaining the following test results: Urine sediment: pH 5.0 Urine in specimen cup: pH 7.5 Suggest a cause for the discrepancies noted

Case #9 An 82-year-old woman was admitted to the hospital complaining of back and left rib pain. X-ray shows lytic lesions of the spine and ribs. A bone marrow evaluation showed >30% plasma cells in sheets. A diagnosis of multiple myeloma is made. Urinalysis results follow:

2. Identify the discrepant test results 3. Explain the most probable cause for the discrepancy between the protein results

4. Which protein(s) is most likely responsible for the proteinuria in this patient? a. Albumin b. Hemoglobin c. Uromodulin d. Globulins (immunoglobulins)

5. The proteinuria seen in this patient would be classified as a. Glomerular proteinuria b. Tubular proteinuria c. Overflow proteinuria d. Transient proteinuria

Case #10 A 25-year-old male is seen in the outpatient clinic complaining of extreme tiredness and nausea for the past 2 weeks. Physical examination revealed a tender liver and yellowish discoloration in the sclera of his eyes. Urinalysis results follow:

2. What substance most likely accounts for the urine color and foam color observations: 3. Explain why the reagent strip test for bilirubin is negative, yet the Ictotest is positive

4. Should the bilirubin result on this urine be reported as negative or positive? 5. Explain the physiologic process that accounts for the bilirubin result in this urine

6. Which form of bilirubin is present in this patient’s urine: a. Conjugated bilirubin b. Unconjugated bilirubin Explain why only this form of bilirubin is found in urine:

Case #11 A 43-year-old female is seen by her physician complaining of sudden weight loss and frequent urination, especially during the night. Urinalysis results follow:

2. Identify any discrepant test results 3. Explain why the glucose and ketone results are positive

4. The most likely diagnosis of this patient is: a. Diabetes mellitus b. Diabetes insipidus 5. What reagent strip test when positive, is an early sign of renal disease: 6. Is this patient showing signs of early renal disease:

7. Explain why the specific gravity results are different Which specific gravity result most accurately reflects the concentrating ability of the kidneys? 9. Excessive night time excretion of urine is called:

Case #12 A 9-day-old infant is seen by the pediatrician. His mother states that the baby cries all the time, cannot keep his formula down, has diarrhea and pulls his legs up as if he has gas. A catheterized urine specimen was obtained. Urinalysis results follow:

Identify any discrepant test results 3. What makes the reagent strip test specific for glucose?

4. The copper sulfate test reacts with what type of substance? 5. Explain the glucose reagent strip and Clinitest results:

6. Based on the clinical presentation of this patient and the urinalysis results, select the most likely diagnosis: a. Diabetes mellitus b. Diabetes insipidus c. Inborn error of metabolism such as galactosemia d. Renal glycosuria

7. Should the physician be concerned to see transitional epithelial cells? Explain

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