LABORATORY INDICES IN THE DIAGNOSTICS OF KIDNEY DISEASES Marushchak Maria

Definition Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically.

Method Multiple reagent test strip Multiple reagent test strip Urine Microscopic Exam Urine Microscopic ExamCollection First morning sample First morning sample Midstream, clean catch collection Midstream, clean catch collection Minimum volume of 3 ml (1 ml for children) Minimum volume of 3 ml (1 ml for children) Analyze within 1-2 hours or refrigerate Analyze within 1-2 hours or refrigerate

General Tests Urine Appearance (Urine Color) Urine Appearance (Urine Color) Urine AppearanceUrine Color Urine AppearanceUrine Color Urine Odor Urine Odor Urine Odor Urine Odor Urine Specific Gravity Urine Specific Gravity Urine Specific Gravity Urine Specific Gravity Urine pH Urine pH Urine pH Urine pH Urine Microscopic Exam Urine Microscopic Exam Urine Microscopic Exam Urine Microscopic Exam Urine cells (RBCs, WBCs, epithelial cells) Urine cells (RBCs, WBCs, epithelial cells) Urine bacteria Urine bacteria Urine Casts Urine Casts Urine Cast Urine Cast Urine Crystals Urine Crystals Urine Crystal Urine Crystal

Urine AppearanceUrine Appearance (Urine Color) Urine Color Urine AppearanceUrine Color Cloudy urine causes Cloudy urine causes Urine with high phosphate, oxalate, lipids, Urine WBCs Urine with high phosphate, oxalate, lipids, Urine WBCs High purine food intake (increased Uric Acid) High purine food intake (increased Uric Acid)Uric AcidUric Acid Brown urine causes Brown urine causes Bile pigment Bile pigment Myoglobinuria Myoglobinuria Myoglobinuria Fava beans Fava beans Medications (Levodopa, Flagyl, Nitrofurantoin) Medications (Levodopa, Flagyl, Nitrofurantoin)FlagylNitrofurantoinFlagylNitrofurantoin Black urine causes Black urine causes Melanin Melanin Melanin Methemoglobinuria Methemoglobinuria Cascara or senna Cascara or senna Cascara Methydopa Methydopa

Blue or green urine Blue or green urine Urinary Tract Infection due to Pseudomonas Urinary Tract Infection due to Pseudomonas Urinary Tract Infection Urinary Tract Infection Bilverdin Bilverdin Medications Medications Amitriptyline, Triamterene Amitriptyline, Triamterene AmitriptylineTriamterene AmitriptylineTriamterene Intravenous mendications (Cimetidine, Phenergan) Intravenous mendications (Cimetidine, Phenergan)CimetidinePhenerganCimetidinePhenergan Dyes Dyes Methylene blue Methylene blue Indigo carmine or indigo blue Indigo carmine or indigo blue Orange to yellow urine Orange to yellow urine Increased urine concentration Increased urine concentration Bile pigments Bile pigments Phenothiazines Phenothiazines Pyridium Pyridium Carrots Carrots Tetracycline Tetracycline Tetracycline Rhubarb (red in alkaline urine) Rhubarb (red in alkaline urine) Senna (red in alkaline urine) Senna (red in alkaline urine) Senna

RED URINE CAUSES Red Urine Red Urine Microscopic Hematuria Microscopic Hematuria Microscopic Hematuria Microscopic Hematuria Urinary tract source Urinary tract source Urethra or bladder Urethra or bladder Prostate Prostate Ureter or kidney Ureter or kidney Non-Urinary tract source Non-Urinary tract source Vagina Vagina Anus or rectum Anus or rectum Pseudohematuria (non-Hematuria related red urine) Pseudohematuria (non-Hematuria related red urine)Hematuria Myoglobinuria Myoglobinuria Myoglobinuria Hemoglobinuria Hemoglobinuria Hemoglobinuria Phenolphthalein Laxatives Phenolphthalein Laxatives PhenolphthaleinLaxative PhenolphthaleinLaxative Phenothiazines Phenothiazines Porphyria Porphyria Rifampin Rifampin Rifampin Pyridium Pyridium Bilirubinuria Bilirubinuria Bilirubin Phenytoin Phenytoin Phenytoin Pyridium Pyridium Red diaper syndrome Red diaper syndrome Foods (Beets, Blackberries, Rhubarb) Foods (Beets, Blackberries, Rhubarb)

Causes of Asymptomatic Gross Hematuria by Incidence Acute Cystitis (23%) Acute Cystitis (23%) Acute Cystitis Acute Cystitis Bladder Cancer (17%) Bladder Cancer (17%) Bladder Cancer Bladder Cancer Benign Prostatic Hyperplasia (12%) Benign Prostatic Hyperplasia (12%) Benign Prostatic Hyperplasia Benign Prostatic Hyperplasia Nephrolithiasis (10%) Nephrolithiasis (10%) Nephrolithiasis Benign essential Hematuria (10%) Benign essential Hematuria (10%)Hematuria Prostatitis (9%) Prostatitis (9%) Prostatitis Renal cancer (6%) Renal cancer (6%) Pyelonephritis (4%) Pyelonephritis (4%) Pyelonephritis Prostate Cancer (3%) Prostate Cancer (3%) Prostate Cancer Prostate Cancer Urethral stricture (2%) Urethral stricture (2%)

Medical Causes of abnormal urine odor Sweet or fruity odor Sweet or fruity odor Diabetic Ketoacidosis Diabetic Ketoacidosis Diabetic Ketoacidosis Diabetic Ketoacidosis Maple syrup urine disease (infants, rare) Maple syrup urine disease (infants, rare) Ammonia odor Ammonia odor Bladder retention Bladder retention Urine at room temperature for prolonged period Urine at room temperature for prolonged period Fecal odor Fecal odor Bladder-Intestinal fistula Bladder-Intestinal fistula Pungent odor Pungent odor Urinary Tract Infection Urinary Tract Infection Urinary Tract Infection Urinary Tract Infection Strong odor Strong odor Concentrated urine Concentrated urine Musty odor Musty odor Phenylketonuria Phenylketonuria Phenylketonuria Sulfur odor Sulfur odor Cystine decomposition Cystine decomposition Cyst

Food and medication causes of abnormal urine odor Asparagus Asparagus Vitamin B6 Supplementation Vitamin B6 Supplementation Vitamin B6 Vitamin B6 Inborn Errors of Metabolism causing urine odor Phenylketonuria Phenylketonuria Phenylketonuria Maple syrup urine disease (infants, rare) Maple syrup urine disease (infants, rare) Glutaric acidemia Glutaric acidemia Isovaleric acidemia Isovaleric acidemia Hawkinsinuria Hawkinsinuria Hypermethioninemia Hypermethioninemia Multiple carboxylase deficiency Multiple carboxylase deficiency Oasthouse urine disease Oasthouse urine disease Trimethylaminuria Trimethylaminuria Tyrosinemia Tyrosinemia

Specific Gravity: Increased Dehydration Dehydration Fever Fever Fever Vomiting Vomiting Vomiting Diarrhea Diarrhea Diarrhea Diabetes Mellitus and other causes of Glycosuria Diabetes Mellitus and other causes of Glycosuria Diabetes MellitusGlycosuria Diabetes MellitusGlycosuria Congestive Heart Failure Congestive Heart Failure Congestive Heart Failure Congestive Heart Failure Syndrome Inappropriate ADH Secretion (SIADH) Syndrome Inappropriate ADH Secretion (SIADH) Syndrome Inappropriate ADH SecretionSIADH Syndrome Inappropriate ADH SecretionSIADH Adrenal Insufficiency Adrenal Insufficiency Adrenal Insufficiency Adrenal Insufficiency X-Ray contrast X-Ray contrast

Decreased Diabetes Insipidus Diabetes Insipidus Diabetes Insipidus Diabetes Insipidus Excessive hydration Excessive hydration Glomerulonephritis Glomerulonephritis Glomerulonephritis Pyelonephritis Pyelonephritis Pyelonephritis Diuretics Diuretics Diuretic Adrenal Insufficiency Adrenal Insufficiency Adrenal Insufficiency Adrenal Insufficiency Aldosteronism Aldosteronism Aldosteronism Renal insufficiency Renal insufficiency

Falsely decreased specific gravity Falsely decreased specific gravity Alkaline urine Alkaline urine Falsely increased specific gravity Falsely increased specific gravity Intravenous dextran or radiopague dye Intravenous dextran or radiopague dye Proteinuria Proteinuria Proteinuria

Urine pH Normal Normal (usually 5.5 to 6.5) (usually 5.5 to 6.5) Background Background Urine pH reflects serum pH except with RTA Urine pH reflects serum pH except with RTA In Renal Tubular Acidosis (RTA), urine pH >5.5 In Renal Tubular Acidosis (RTA), urine pH >5.5Renal Tubular AcidosisRenal Tubular Acidosis Urine cannot be acidified despite acid load Urine cannot be acidified despite acid load

Increased (Alkalotic urine) Stale ammoniacal sample (Very high pH) Stale ammoniacal sample (Very high pH) Void testing if old sample Void testing if old sample Bacteriuria Bacteriuria Reflects urea splitting organisms Reflects urea splitting organisms Associated with magnesium-ammonium phosphate crystals Associated with magnesium-ammonium phosphate crystals Vegetarian diet Vegetarian diet High citrate diet High citrate diet Renal Failure Renal Failure Renal Failure Renal Failure Drugs Drugs Antibiotics Antibiotics Bicarbonate Bicarbonate Acetazolamide Acetazolamide Acetazolamide

Decreased (Acidic urine) Acidosis Acidosis Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Diabetes Mellitus Starvation Starvation Diarrhea Diarrhea Diarrhea Uric Acid Calculi Uric Acid Calculi Uric Acid Calculi Uric Acid Calculi Acidic fruits (Cranberry) Acidic fruits (Cranberry) Drugs Drugs Ammonium chloride Ammonium chloride

Urine Microscopic Exam Urine Microscopic Exam Sample preparation Obtain fresh urine sample Obtain fresh urine sample Centrifuge ml at 1500 to 3000 rpm for 5 minutes Centrifuge ml at 1500 to 3000 rpm for 5 minutes Decant supernatant and resuspend remainder of urine Decant supernatant and resuspend remainder of urine Place 1 drop of urine on slide and apply cover slip Place 1 drop of urine on slide and apply cover slipExamination Urine Cells Urine Cells Urine White Blood Cells Urine White Blood CellsWhite Blood CellWhite Blood Cell Normal <2/hpf in men and <5/hpf in women Normal <2/hpf in men and <5/hpf in women Urine Red Blood Cells Urine Red Blood CellsRed Blood CellRed Blood Cell Normal <3/hpf Normal <3/hpf Dysmorphic RBCs suggest glomerular disease Dysmorphic RBCs suggest glomerular disease Epithelial cells Epithelial cells Transitional epithelial cells are normally present Transitional epithelial cells are normally present Squamous epithelial cells suggest contamination Squamous epithelial cells suggest contamination Renal tubule epithelial cells suggest renal disease Renal tubule epithelial cells suggest renal disease Bacteria Bacteria Five bacteria per hpf represents 100,000 CFU/ml Five bacteria per hpf represents 100,000 CFU/ml Diagnostic for Urinary Tract Infection Diagnostic for Urinary Tract InfectionUrinary Tract InfectionUrinary Tract Infection Men: Any bacteria Men: Any bacteria Women: 5 or more bacteria per hpf Women: 5 or more bacteria per hpf

White blood cellWhite blood cell in urine White blood cell

Urine Red Blood Cells Red Blood CellRed Blood Cell

Epithelial cells

Transitional epithelial cells are normally present

Urine Crystals Urine Crystals Urine Crystal Urine Crystal Types Types Calcium oxalate crystals (square envelope shape) Calcium oxalate crystals (square envelope shape) Triple phosphate crystals (coffin lid shape) Triple phosphate crystals (coffin lid shape) Associated with increased Urine pH (alkaline) Associated with increased Urine pH (alkaline)Urine pHUrine pH Associated with Proteus Urinary Tract Infection Associated with Proteus Urinary Tract InfectionProteusUrinary Tract InfectionProteusUrinary Tract Infection Uric Acid crystals (diamond shape) Uric Acid crystals (diamond shape) Uric Acid Uric Acid Cystine crystals (hexagonal shape) Cystine crystals (hexagonal shape) Cyst

Urine Casts Urine Casts Urine Cast Urine Cast Cast Types Cast Types Epithelial cell casts of renal tubule Epithelial cell casts of renal tubule Acute Tubular Necrosis Acute Tubular Necrosis Acute Tubular Necrosis Acute Tubular Necrosis Interstitial Nephritis Interstitial Nephritis Interstitial Nephritis Interstitial Nephritis Eclampsia Eclampsia Eclampsia Heavy metal poisoning Heavy metal poisoning Rejected transplant Rejected transplant Red Blood Cell casts Red Blood Cell casts Red Blood Cell Red Blood Cell Glomerulonephritis Glomerulonephritis Glomerulonephritis May be normal in collision sport athletes May be normal in collision sport athletes White Blood Cell casts White Blood Cell casts White Blood Cell White Blood Cell Pyelonephritis Pyelonephritis Pyelonephritis Glomerulonephritis Glomerulonephritis Glomerulonephritis Interstitial Nephritis Interstitial Nephritis Interstitial Nephritis Interstitial Nephritis Hyaline or mucoprotein casts Hyaline or mucoprotein casts Normal finding Normal finding Pyelonephritis Pyelonephritis Pyelonephritis Chronic renal disease Chronic renal disease Granular casts Granular casts Severe renal disease Severe renal disease Waxy casts Waxy casts Severe renal disease Severe renal disease Fatty casts Fatty casts Nephrotic Syndrome Nephrotic Syndrome Nephrotic Syndrome Nephrotic Syndrome Hypothyroidism HypothyroidismHypothyroidism

Hyaline casts

Waxy casts

Bacteria casts