F ACULTY OF ALLIED MEDICAL SCIENCES Clinical chemistry (MLCC-203) 1

2 Dr Eman El-Attar MLCC 203

3 ILOs 1- To understand the different types of urine samples 2- To be able to perform different tests of urine analysis 3- To be able to find abnormal findings in urine

COMPLETE URINE ANALYSIS 4  Simple, non-invasive diagnostic test that provides a window to the patient’s health (kidney diseases, DM,UTI…...) 1 st thing: you should learn about various types of urine specimens and how to properly instruct patients about sample collection.

5 S PECIMENS T YPES  Random  First morning  Midstream  Timed/ 24 hours

S PECIMENS T YPES ( CONT.)  Random – most common, taken anytime of day  First morning – higher concentration of substances, taken in morning  Midstream – genitalia is cleaned, urine is tested for microorganisms & presence of infection  Timed/ 24 hour – used for quantitative analysis of substances (Instructions??) 6

S PECIMEN COLLECTION  The specimen must be collected in a clean dry, disposable container.  The container must be properly labeled with the patient name, date, and time of collection. The labels should be applied to the container and not to the lid. 7

URINE CONTAINERS 8 The container should be labeled with: the patient name, date, and time of collection

The specimen must be delivered to the laboratory on time and tested within 1hr, OR it should be refrigerated or have an appropriate chemical preservative added. 9

CHANGES OCCUR IN NON PRESERVED SPECIMEN 10  Increase bacterial number.  Increase crystals deposition (amorphous)  Increase turbidity caused by bacteria & amorphous  Decrease glucose due to glycolysis and bacterial utilization.  Decrease ketones because of volatilization.  Decrease bilirubin from exposure to light.  Breakdown of RBCs  Transformation of urea to ammonia which increase pH.  Changes in color due to oxidation or reduction of metabolic

U RINE ANALYSIS Three types of testing should be learned:  Physical  Chemical  Microscopic 11

12 P HYSICAL E XAMINATION OF U RINE Visual examination:  Volume  Color  Aspect  pH (reagent strips, Acidic/Alkaline)  Specific gravity ( )  The refractometer or a reagent strip is used to measure specific gravity Reagent Strips Refractometer

13 Color: − Normal: Amber Yellow − Colorless Diluted urine − Deep YellowConcentrated Urine − Deep Yellow-GreenBilirubin − RedBlood (hematuria) / Hb (Hemoglobinuria) − Green Pseudomonas infection − Brownish-blackAlkaptonuria, Melaninuria − Diet (beet), drugs (rifampicin) Aspect: Normal aspect: Clear - Normal aspect: Clear − Turbidity indicates cells,crystals, bacteria, yeast. − Microscopic examination will determine which is present.

C HEMICAL E XAMINATION OF U RINE  Proteins  Glucose  Ketone bodies  Bilirubin  Urobilinogen 14

C HEMICAL E XAMINATION OF U RINE ( CONT.)  Proteins: Normal urine contains small quantity of proteins usually less than 20 mg/dL (150 mg/day). *Qualitative detection: Heat and acetic acid test. Urine reagent strips. 15

HEAT AND ACETIC ACID Boil the upper 1/3 of a test tube containing clear urine. If turbidity occurs, add few drops of 33% acetic acid. If turbidity disappears, it was phosphates. If turbidity persists, it was due to proteins (Trace,+,++,+++,++++). 16

U RINE REAGENTS STRIPS 17 Strips impregnated with indicator that changes its colour in presence of proteins. (Nil,Trace,+,++,+++,++++).

CHEMICAL EXAMINATION OF URINE (CONT.)  Glucose  Glucose – reagent strip Present in DM, renal glucosuria  Ketone bodies  Ketone bodies ( acetone ) –reagent strip Present in DKA/ starvation/vomiting 18

 Bilirubin: Seen in Seen in obstructive jauindice, liver diseases Detection: Urine reagent strips. Iodine test. - Carefully, layer diluted iodine in absolute ethanol on urine. - A green ring is formed at the interphase due to oxidation of bilirubin to biliverdin. 19

 Urobilinogen Normally, there is a normal trace of urobilinogen. Increased in hemolytic anemia *Detection:  Urine reagent strips.  Erlich test. 20

M ICROSCOPIC E XAMINATION OF U RINE  Microscopic examination used to view elements not visible without microscope  Centrifuge spins urine to cause heavier substances to settle to the bottom 21 Bacteria Yeast Cells Crystals Casts

MICROSCOPIC EXAMINATION OF URINE (CONT.) Cells: RBCs : (0-5/ HPF) Double wall, homogeneous,non- nucleated, 33%AA? Pus cells: (0-5/ HPF) Larger, grainy,colourless and nucleated. Epithelial cells: Larger, nucleated 22

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Crystals: According to urine pH  In acidic urine: Amorphous urates: granular dust powder (Pink). Uric acid: ellipses, triangles or rectangles. Ca oxalate: small envelops or octahedral.  In alkaline urine: Amorphous phosphates: granular dust powder (white). Triple phosphate: colourless prisms (coffin lid type). Ca oxalate : small envelops or octahedral. 30

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Casts: They are moulds of renal tubular endothelial lining which dislodge, and pass into the urine and indicate kidney disease.urinekidney They form via precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells.Tamm-Horsfall mucoproteinrenal tubule 37

Significance:Kidney damage Types: Hyaline casts. Blood and leucocyte casts. Epithelial casts. Granular casts. 38

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STUDY QUESTIONS What is iodine test? What is the findings in a urine sample of a diabetic patient ? 48

ASSIGNMENT Describe in full details how to perform blood sampling on a female patient who wants to do the following tests: CBC PT, PTT SGOT, SGPt Urea, Creatinine By: Aysha khedr 49

50 END OF IT’S TIME FOR PRACTICAL APPLICATION!