尿液分析 對腎臟病的診斷

尿液分析 許多腎臟病人在臨床上並没有任何症狀只能由血中 creatinine異常或尿液分析異常才能發現

檢體採集 應於收集尿液後30 to 60 minutes內檢查 Clean catch 男性病人可採中段尿送檢 女性病人則需必免外陰部污染並避開月經週期

尿液分析 小便收集後先經2000 rpm for 3 to 5 minutes 離心 上清液倒入另一支試管 將少量沈澱物置於在載玻片上以備鏡檢

尿液分析 上清液用於物理及化學特性檢查 沈澱物則對成形物(cells, casts, crystals, and bacteria)做顯微鏡檢

尿液分析 物理特性:直接觀察 化學特性:試紙 沈澱物:顯微鏡檢

物理特性 外觀 氣味

化學特性 酸鹼度pH 蛋白質Protein 血液Blood 比重Specific gravity 葡萄糖Glucose 酮體Ketones Urobilirubin 胆紅素Bilirubin Nitrite 白血球Leucocyte

蛋白尿 試紙對於白蛋白albumin 有高度敏感性,但對於globulin, Hb, or light chain則較不敏感. sulfosalicylic acid (SSA)可偵測所有的蛋白質

蛋白尿 There are three basic types of proteinuria: glomerular, tubular, and overflow. Only glomerular proteinuria (ie, albuminuria) is identified on a urine dipstick.

血液 當尿液為紅色時首先需將尿液離心,區分紅色部分為上清液或沈澱物. 血尿(Hematuria):只有沈澱物是紅色.

血尿 若上清液為紅色則需用試紙檢查是否含血色素. 含血色素之紅色上清液需區分myoglobinuria or hemoglobinuria.

比重 與同體積水的重量. A convenient but inaccurate surrogate of osmolality.

血糖 高血糖或腎性尿糖Hyperglycemia or renal glycosuria

Urobilinogen A colorless pigment produced in the gut from metabolism of bilirubin. Some is excreted in feces and the rest reabsorbed and excreted in the urine. In obstructive jaundice, bilirubin does not reach the bowel and urine excretion of urobilinogen is diminished. In other types of jaundice, urobilinogen is increased.

Nitrite The screening test for bacteriuria relies on the ability of G(-) bacteria to convert urinary nitrate to nitrite.

白血球 尿液中有過量白血球代表: 1.泌尿系統發炎: including: glomerulonephritis, interstitial nephritis, 2.泌尿道感染 3.輸尿管旁發炎: such as regional ileitis, acute appendicitis

顯微鏡檢

顯微鏡檢 細胞: 紅血球 白血球 腎小管上皮細胞 扁平上皮細胞 圓柱體 細菌,黴菌及其它 晶體

血尿 紅血球可由腎小球至尿道口之間任何一點進入泌尿系統 肉眼可見 vs.顯微血尿

Gross hematuria Gross hematuria is suspected because of red or brown urine. Hematuria is responsible if the red color is seen only in the urine sediment, with the supernatant being clear.

顯微血尿 The urine sediment is the gold standard for the detection of microscopic hematuria.

血尿: Glomerular vs. extraglomerular bleeding 紅血球型態: 腎小球外出血時紅血型狀正常;腎小球出血則為變形紅血球 Dysmorphic: marked variability in red cell shape and a reduction in mean red cell size

血尿: Glomerular vs. extraglomerular bleeding Red cell injury in this setting may be due both to mechanical trauma as the cells pass through rents in the glomerular basement membrane and osmotic trauma as the cells flow through the different nephron segments.

血尿: Glomerular vs. extraglomerular bleeding 血塊(blood clot), if present, are almost indicative of extraglomerular bleeding. Clots are not seen with glomerular lesions

血尿: Glomerular vs. extraglomerular bleeding 腎小球出血的特徵有 1.紅血球圓柱體 (essentially pathognomonic for glomerular disease), 2. 蛋白質的排出量超過500 mg/day at a time when there is no gross bleeding,

血尿: Glomerular vs. extraglomerular bleeding 3.變形紅血球 4. 可樂色尿液 Although helpful if present, the absence of these findings does not exclude glomerular disease.

白血球 尿液中有過量白血球代表: 1.泌尿系統發炎: glomerulonephritis, interstitial nephritis, 2. 泌尿道感染 3.輸尿管旁發炎: regional ileitis, acute appendicitis

腎小管上皮細胞 Size varies in different segments and with urine osmolality. A few tubular cells may be seen in a normal urine, but more commonly imply tubular damage or inflammation.

圓柱體 圓柱體是以Tamm-horsfall mucoprotein為基質有明的外緣 with straight margin with or without cellular components embedded

圓柱體 玻璃狀圓柱體. 顆粒狀圓柱體 Waxy casts (broad casts) 紅血球圓柱體 白血球圓柱體

脂質尿 發生於腎病症候群 脂肪圓柱體: lipid laden tubular cells or free lipid droplet Oval fat body: sloughed tubular cells containing fat droplets 脂肪圓柱體: lipid laden tubular cells or free lipid droplet 脂質小滴Lipid droplet showed Maltese cross under polarized light

晶體 3 most distinctive crystal forms: Cystine: hexagonal plate resembling benzene ring Calcium oxalate: classically as envelop shapes or bipyramidal magnesium ammonium phosphate: rectangular with beveled ends as coffin-lid