1. URINALYSIS
Dr. Wongsakorn Boonkarn Medicine

2. A complete urinalysis should be performed in the following settings
In a patient with evidence of kidney disease, such as
albuminuria
acute or chronic reduction in the glomerular filtration rate.
In a patient with suspected kidney disease.
SLE, secondary HT
In a patient with known or suspected kidney stones.
Asymptomatic individuals who may have had the urine dipstick as part of a workup for another condition
hypertension, diabetes mellitus

3. A Complete urinalysis
(a) Physical characteristics : color, appearance, and specific gravity
(b) Chemical characteristics : pH, protein, glucose, ketones, blood, bilirubin, nitrite and urobilinogen
(c) Microscopic structures in the sediment.

4. OBTAINING urine FOR ANALYSIS
The specimen should be collected into a clean dry container.
Patients should be asked to clean the external genitalia and provide
a midstream specimen for analysis.
In patients with indwelling urinary catheters, a recently produced urine sample should be obtained
Samples collected for routine urinalysis should be at least 15 mL in volume.
The sample be analyzed within 2 to 4 hours from collection. otherwise, samples can be kept at a temperature of 2°C to 8°C

5. SPECIMEN PRESERVATION
The routine use of preservatives is not recommended.
The specimen should be examined at room temperature within two hours of retrieval.
refrigerated at 2 to 8 C
Urea-splitting bacteria produce ammonium, thereby causing
an increase in the pH of the urine.
casts present
a false-negative test for glycosuria

6. TIMING OF COLLECTION
A random sample is usually sufficient for the performance of most urinary screening tests
The first or second morning urine specimen is recommended

7. TIMING OF COLLECTION Must be avoided
Strenuous physical exercise (e.g., running, soccer match) in the 72 hours preceding the collection
to avoid exercise-induced proteinuria and hematuria or cylindruria.
In women, during menstruation
blood contamination can easily occur.

8. Turbidity Turbid urine
crystals, an abundance of cells, chyle, and infection
Foam : white stable foam that is formed upon agitating the specimen can be seen in urine containing a moderate or large amount of protein

9. ODOR A change in urine odor may be caused by
The ingestion of some foods, such as asparagus.
A pungent odor, due to the production of ammonia, is typical of most bacterial urinary tract infection.
A sweet or fruity odor with ketones in the urine.

10. COLOR
Urine color — The yellow color of urine is lighter when urine is dilute and darker when concentrated
The color of normal urine ranges from pale to dark yellow and amber, depending on the concentration of the urochrome. Abnormal changes in color can be due to pathologic conditions, drugs, or foods. The main pathologic conditions that can cause color changes of the urine are gross hematuria, hemoglobinuria, or myoglobin- uria (pink, red, brown, or black urine); jaundice (dark yellow to brown urine); chyluria (white milky urine)6; massive uric acid crystalluria (pink urine); urinary infection due to some types of Escherichia coli (velvet urine); and porphyrinuria and alkaptonuria (red urine turning black on standing). The main drugs responsible for abnormal urine color are rifampin (yellow-orange to red urine); phenytoin (red urine); chloroquine and nitrofurantoin (brown urine); triamterene, pro- pofol, and blue dyes of enteral feeds (green urine); methylene blue (blue urine); and metronidazole, methyldopa, and imipe- nem-cilastatin (darkening on standing). Among foods are beetroot (red urine), senna and rhubarb (yellow to brown or red urine), and carotene (brown urine).

11. Other causes of red urine
A red urine supernatant that is negative for heme can be seen in several conditions
Medications rifampin or phenytoin
Consumption of food dyes
Ingestion of beets (beeturia), rhubarb, or senna
Acute intermittent porphyria

12. Other urine colors
White urine : pyuria, phosphate crystals, chyluria, or propofol.
Green urine : administration of methylene blue , propofol, or amitriptyline
Black urine : hemoglobinuria/myoglobulinuria or to ochronosis(also called black urine disease)
Purple urine : bacteriuria in patients with urinary catheters

13. Green Urine

14. Specific gravity The number and size of the particles in the urine
The specific gravity is used to measure the concentrating and diluting ability of the kidney
The normal range of specific gravity for a random specimen is –1.035

15. Urine osmolality Normally the urinary osmolality and specific gravity
: approximately mOsm being equal to each unit of specific gravity
The number of particles in the urine (eg, urea, sodium, potassium)
The number of solute particles per unit volume
Hyponatremia, hypernatremia, polyuria, and AKI

16. Urine Osmolality
The normal kidney : produce urine as dilute as 40–80 mOsm/kg water during excessive hydration and as concentrated as 800–1400 mOsm/kg water during dehydration
In terminal renal failure the urine osmolality may stay around 285 mOsm/kg

17. Specific Gravity Versus Osmolality
Urine osmolality VS Specific gravity
Osmolality depends on the number of particles in the solution, whereas specific gravity depends on the number and weight of the solutes.
Osmolality is a better indicator of the concentrating and diluting abilities of the kidney

18. Chemical analysis of urine

19. URINARY pH
The pH of the urine may range from 4.6 to 8.0 but averages around 6.0, so it is usually slightly acidic.
There is no abnormal range as such, since the urine can normally vary from acid to alkaline.

20. URINARY pH A low pH is often observed with
Metabolic acidosis
High-protein meals
Volume depletion.
High pH is often observed with
ATN
Renal tubular acidosis (especially distal, type 1)
Vegetarian diets
Infection with urease-positive organisms (such as Proteus).

21. PROTEIN
The presence of increased amounts of protein in the urine can be an important indicator of renal disease.
There are, however, physiologic conditions such as exercise and fever that can lead to increased protein excretion in the urine in the absence of renal disease.

22. PROTEIN
This method is highly sensitive for albumin (detection limit of approximately 0.20 to 0.25 g/l), whereas it has a very low sensitivity to other proteins such as tubular proteins and light-chain immunoglobulins.
The protein that is normally excreted includes a mucoprotein called Tamm–Horsfall protein, which is not contained in the plasma but is secreted by the renal tubules.

23. PROTEIN False-Positive Results False-Negative Results
Contamination of the urine with vaginal discharge, semen, heavy mucus, pus, and blood.
False-Negative Results
A very dilute urine can give a false-negative reaction because the concentration of protein fluctuates with the urine flow.
Therefore, it is important to interpret the protein result by correlating it with the specific gravity.
A trace of protein in a dilute urine indicates a greater loss of protein than does a trace amount in a concentrated specimen

24. PROTEIN
After filtration, most of the protein is reabsorbed in the tubules with less than 150 mg/24 h (or 20 mg/dL) being excreted.

25. The 24-Hour Protein Excretion
This remains the reference (gold standard) method.
Quantify total protein rather than simply albumin, and hence this can result in detection of light chains in subjects with myeloma.

26. Protein-Creatinine Ratio on a Random Urine Sample
This is a practical alternative to the 24-hour urine collection.
There is a strong correlation between the protein-creatinine ratio in a random urine sample and the 24-hour protein excretion

27. GLUCOSE AND OTHER REDUCING SUBSTANCES
The presence of significant amounts of glucose in the urine is called glycosuria (or glucosuria)
The quantity of glucose that appears in the urine is dependent upon the blood glucose level
The blood level exceeds 160–180 mg/dL, which is the normal renal threshold for glucose.

28. Ketone Ketone bodies ประกอบด้วย Acetoacetic acid (diacetic acid): 20%
Β-hydroxybutyric acid: 78% (** ตรวจไม่พบ)
Acetone: 2%
Positive
Diabetic ketoacidosis
Starving
Vomiting
Strenuous exercise

29. Occult blood
Hematuria
Hemoglobinuria
Myoglobinuria

30. Hematuria Blood or intacted RBC in urine
Very low alkaline or Specific gravity < can cause RBC to lyse

31. Hematuria If positive…
microscopic
Numerous epithelial cell? (possible menstrual contamination)
RBC present?
Number of RBC agree with intensity of chemical test?
RBC cast or hemoglobin cast?
Ghost cell?

32. Red urine Sediment red Supernatant red HEMATURIA Dipstick heme
POSITIVE
NEGATIVE
Plasma color
RED Plasma +RED Urine  Hemoglobinuria
CLEAR Plasma +RED Urine  Myoglobinuria
Red
Clear
HEMOGLOBINURIA
MYOGLOBINURIA

34. Bilirubin
Only Conjugated (direct) bilirubin can filter through glomerulus
Screening test
- Early diagnosis of obstructive
and hepatic jaundice
- Differentiate obstructive (positive)
and hemolytic (negative) jaundice
False negative:
- Exposed to light (bilirubin  biliverdin)

35. Nitrite
Indirect detection for bacteria that have Nitrate reductase activity:
E.coli
Enterobacter
Klebsiella
Citrobacter
Proteus species
Except: Pseudomonas species, Enterococcus species and Staphylcoccus albus

36. nitrite Nitrite negative ≠ absence of bacterial infection
Urine must incubated in bladder > 4 hr (recommend first morning urine)

37. Reagent test strip False positive: Not fresh specimen False negative
pH < 6
High level of urobilinogen
Ascorbic acid

38. Microscopic examination of urinary sedimen

39. Erythrocytes
Isomorphic : regular shapes and contours, derived from the urinary excretory system
Dysmorphic : irregular shapes and contours, which are of glomerular origin
acanthocytes

40. Isomorphic
Dysmorphic

41. Erythrocytes

42. Dysmorphic RBCs

43. Glomerular hematuria
Acanthocytes (ring-shaped RBCs with blebs of membrane coming off--sometimes described as RBCs with "Mickey Mouse ears") were the best predictor of glomerular disease compared to all other dysmorphic RBC types.
At least 5% acanthocyturia was noted in 75 out of 143 GN patients (giving a sensitivity of 52%) and in 4 out of 187 patients with nonglomerular disease (giving a specificity of 98%).
40% or greater of erythrocytes are dysmorphic and/or 5% or greater of erythrocytes examined are acanthocytes
Acanthocyturia. Kidney Int Jul;40(1):

44. Leukocytes

45. Epithelial cells Transitional epithelial cells
neoplasia, stones, ureteral stents
urinary tract infections.
Renal tubular epithelial cells
Suggest tubular damage
AKI, acute interstitial nephritis, acute cellular rejection of a renal allograft
Squamous epithelial cells
contamination

46. Epithelial cells

48. Crystals

49. Acidic urine

50. Acidic urine

52. Uric acid crystals AKI due to acute urate nephropathy gout
high purine metabolism
acute febrile conditions
chronic nephritis

53. monohydrated calcium oxalate
Bihydrated calcium oxalate

54. Calcium oxalate crystal
oxalate calculi
ethylene glycol poisoning
diabetes mellitus
liver disease
severe chronic renal disease

55. marker of cystinuria

57. Leucine maple syrup urine disease
serious liver disease (cirrhosis of the liver, severe viral hepatitis)

59. Cholesterol marked proteinuria nephritis and nephritic conditions
chyluria
obstruction to the lymphatic flow

60. Alkaline urine

62. Triple phosphates urinary calculi chronic pyelitis
chronic cystitis,UTI (Ureaplasma urealyticum and Corynebacterium urealyticum)
when urine is retained in the bladder

63. Found in normal urine or calculi

64. Clinical Significance of Crystals
Uric acid crystals : AKI due to acute urate nephropathy
Monohydrated calcium oxalate crystals : AKI from ethylene glycol intoxication
Triple phosphate crystals : urinary tract infection (Ureaplasma urealyticum and Corynebacterium urealyticum)
Cholesterol : marked proteinuria
Cystine : marker of cystinuria

66. Casts

67. Hyaline casts

68. Hyaline casts
physical exercise
physiologic dehydration

69. Red blood cell casts

70. Red blood cell casts acute glomerulonephritis renal infarction
lupus nephritis
goodpasture syndrome
subacute bacterial endocarditis
renal trauma
renal infarction
severe pyelonephritis
right-sided congestive heart failure
renal vein thrombosis
periarteritis nodosa

71. White blood cell casts

72. White blood cell casts acute pyelonephritis interstitial nephritis
lupus nephritis

73. Granular casts

74. Granular casts result of the degeneration of cellular casts
indicate significant renal disease
following strenuous exercise

75. Epithelial cell casts

76. Epithelial cell casts typical finding in ATN
acute interstitial nephritis

77. Waxy casts

78. Waxy casts degeneration of granular casts
typical of patients with renal failure
also frequent in patients with rapidly progressive GN

79. Fatty casts

80. Fatty casts Degeneration of granular casts
typical of glomerular diseases associated with marked proteinuria
nephrotic syndrome

82. Oval fat bodies and lipid
Glomerular disease associated with marked proteinuria
nephrotic syndrome
diabetes mellitus
chronic glomerulonephritis
fat embolism
extensive superficial injuries with crushing of the subcutaneous fat
fractures of the major long bones or pelvis

83. Artifacts and contaminants

84. Starch crystal
Cloth fibers

90. Thank you