EXAMINATION OF THE URINE

EXAMINATION OF THE URINE

Urine analysis Dr. Mohamed Fouad Ahmad By MD. Internal medicine
1/25/2018

EXAMINATION OF THE URINE
1/25/2018

Value of urinalysis General evaluation of health
Diagnosis of disease or disorders of the kidneys or urinary tract Diagnosis of other systemic disease that affect kidney function Monitoring of patients with diabetes Screening for drug abuse 1/25/2018

Collection of urine specimens
The first voided morning urine (the most common) Random urine (for emergency) Clean-catch, midstream urine (for urine culture) Need to be examined within 1 hour 24 sample (proteinuria) 1/25/2018

Urine analysis PHYSICAL CHARACTERISTICS CHEMICAL CHARACTERISTICS
URINE MICROSCOPY 1/25/2018

PHYSICAL CHARACTERISTICS
Appearance Urine volume Specific gravity (SG)

Appearance Odor Color Clarity

Appearance Odor Ammonia-like: Urea-splitting bacteria
Foul, offensive: Old specimen, pus or inflammation Sweet: Glucose Fruity: Ketones Maple syrup-like: Maple Syrup Urine Disease 1/25/2018

Appearance Color Colorless Red urine Yellow-brown Green-brown
Normally , pale to dark yellow (urochrome) Colorless Diluted urine Red urine Hematuria ‘Glomerular or Urological origin’ Hemoglobinuria Myoglobinuria Bilirubin Obstructive jaundice Yellow-brown Green-brown

Appearance Clarity Turbidity Normally, clear
Typically cells or crystals. Cellular elements and bacteria will clear by centrifugation. Crystals dissolved by a variety of methods (acid or base). Microscopic examination will determine which is present.

PHYSICAL CHARACTERISTICS
Urine volume Polyuria Oliguria Anuria

Specific gravity (SG) Number and weight of the dissolved particles
1.000 1.005 1.010 1.015 1.020 1.025 1.030 Number and weight of the dissolved particles Influenced by urine temperature , proteins, glucose , and radiocontrast media. Underestimation occurs with urine ph > 6.5 Overestimation occurs with proteinuria >7.0 g/l. SG 1.000 to 1.003 Diabetes insipidus Water intoxication Marked urinary dilution Isosthenuric urine SG and osmolality = plasma Impaired urinary concentration SG 1.010 ATN CkD SG 1.040 Extrinsic osmotic agent Contrast material

Urine Osmolality Osmolality depends on the number of particles present
Measured by an osmometer It is not influenced by urine temperature and protein concentrations. However, high glucose concentrations significantly increase osmolality (10 g/l of glucose = 55.5 mOsm/l). 1/25/2018

CHEMICAL CHARACTERISTICS
Glucose Bilirubin Ketones Specific Gravity Blood pH Protein Urobilinogen Nitrite Leukocyte Esterase Urine dipstick

pH low pH >4.5 High pH>8 pH range 5.0 to 8.5
6.0 6.5 7.0 7.5 8.0 8.5 pH range 5.0 to 8.5 Urine pH reflects the presence of H ions, but this does not necessarily reflect the overall acid load in the urine as most of the acid is excreted as ammonia low pH >4.5 Metabolic acidosis (in which acid is secreted) High protein meals (which generate more acid & ammonia) Volume depletion (in which aldosterone is stimulated...…acid urine Indeed, low urine pH may help distinguish prerenal acute renal impairment from ATN (which is typically associated with a higher pH). High pH>8 Renal tubular acidosis ……………. especially distal, type 1 Vegetarian diets (due to minimal nitrogen and acid generation Infection with urease-positive organisms (such as proteus)

Hemoglobin False-negative results Green spots……intact erythrocytes
Trace (non-hemolyzed) Green spots……intact erythrocytes Moderate (non-hemolyzed) Homogeneous diffuse green pattern Trace (hemolyzed) Hemoglobinuria + (weak) Myoglobinuria ++ (moderate) +++ (strong) False-negative results Ascorbic acid, a strong reducing agent, which can cause low-grade microscopic hematuria to be completely missed 1/25/2018

Glucose Significance False-negative results *Ascorbic acid
Detects concentrations of 0.5 to 20 g/l. Negative Trace (100 mg/dL) + (250 mg/dL) ++ (500 mg/dL) +++ (1000 mg/dL) ++++ (2000+ mg/dL) Only measures glucose and not other sugars. Significance Diabetes mellitus. Renal glycosuria. False-negative results *Ascorbic acid *Bacteria. *Presence of oxidizing detergents and hydrochloric acid. 1/25/2018

Proteins in “Normal” Urine
150 mg Protein % of Total Daily Maximum Albumin 40% 60 mg Tamm-Horsfall 40% 60 mg Immunoglobulins 12% 24 mg Secretory IgA 3% 6 mg Other 5% 10 mg Total 100% 150 mg

Protein Physiologic proteinuria does not exceed 150 mg/24 h for adults
Negative Trace Physiologic proteinuria does not exceed 150 mg/24 h for adults 140 mg/m2 for children. + (30 mg/dL) ++ (100 mg/dL) +++ (300 mg/dL) ++++ (2000 mg/dL) Highly sensitive for albumin (detection limit of approximately 0.20 to 0.25 g/l) Very low sensitivity to other proteins as tubular proteins and light-chain immunoglobulins. 1/25/2018

Bence Jones proteinuria
The 24-Hour Protein Excretion This remains the reference (gold standard) method One advantage is that 24-hour urine protein is usually measured by methods that quantify total protein rather than simply albumin, Bence Jones proteinuria Suspected when the dipstick measurement for proteinuria is negative yet the 24-hour urine protein is elevated.

Albumin-creatinine Ratio on a Random Urine Sample(ACR)
This is a practical alternative to the 24-hour urine collection Albumin:creatinine ratio mg/mmol normal Albumin/creatinine ratio mg/mmol microalbuminuria Albumin/creatinine ratio ≥300 mg//mmol frank proteinuria 1/25/2018

Causes of Proteinuria Functional Renal Pre-Renal Post-Renal
- Severe muscular exertion - Glomerulonephritis - Pregnancy Nephrotic syndrome - Orthostatic proteinuria Renal tumor or infection Pre-Renal Post-Renal - Fever Cystitis - Renal hypoxia Urethritis or prostatitis - Hypertension Contamination with vaginal secretions

Nephrotic Syndrome (> 3.5 g/dL in 24 h)
Primary - Lipoid nephrosis (severe) - Membranous glomerulonephritis - Membranoproliferative glomerulonephritis Secondary - Diabetes mellitus (Kimmelsteil-Wilson lesions) - Systemic lupus erythematosus - Amyloidosis and other infiltrative diseases - Renal vein thrombosis

Leukocyte Leukocyte esterase may be positive when
Negative Trace + (weak) ++ (moderate) +++ (strong) Leukocyte esterase may be positive when Microscopy is negative when leukocytes are lysed because of Low density, alkaline ph, Delay in sample handling and examination. The detection limit of the dipstick is 20 × 106 WBc per liter. False-positive Formaldehyde is used as a urine preservative. False-negative High glucose or protein concentrations

Nitrites Negative Positive The dipstick nitrites test detects bacteria that reduce nitrates to nitrites by nitrate reductase activity. This includes most gram negative uropathogenic bacteria. But not Pseudomonas, Staphylococcus albus, and Enterococcus. 1/25/2018

Bile Pigments Measurements of urinary urobilinogen and bilirubin concentrations have lost their clinical value in the detection of liver disease after the introduction of serum tests of liver enzyme function. Negative + (weak) ++ (moderate) +++ (strong) Significance ; Increased direct bilirubin Hepatocellular &Obstructive jaundice Limitations Interference: prolonged exposure of sample to light 1/25/2018

Ketones This dipstick tests for the presence of acetoacetate and acetone (but not β-hydroxybutyrate) Negative Trace (5 mg/dL) + (15 mg/dL) ++ (40 mg/dL) +++ (80 mg/dL) ++++ (160+ mg/dL) Diabetic acidosis Fasting Vomiting Strenuous exercise 1/25/2018

1/25/2018

Microscopic Examination
General Aspects Preservation *Cells and casts begin to disintegrate in hrs. at room temp. *Refrigeration for up to 48 hours (little loss of cells). Specimen concentration *Ten to twenty-fold concentration by centrifugation. Types of microscopy * Phase contrast microscopy * Polarized microscopy * Bright field microscopy with special staining (e.g., Sternheimer-Malbin stain)

URINE MICROSCOPY The urine sediment can contain Cells Lipids Organisms
Casts Crystals Contaminants. 1/25/2018

Abnormal Findings Per High Power Field (HPF) (400x)
*> 3 erythrocytes *> 5 leukocytes *> 2 renal tubular cells *> 10 bacteria Per Low Power Field (LPF) (200x) *> 3 hyaline casts or > 1 granular cast *> 10 squamous cells (indicative of contaminated specimen) *Any other cast (RBCs, WBCs) Presence of: *Fungal hyphae or yeast, parasite, viral inclusions *Pathological crystals (cystine, leucine, tyrosine) *Large number of uric acid or calcium oxalate crystals

Cells Erythrocytes White blood cells. Epithelial Cells

Erythrocytes Types of urinary erythrocytes
The presence of one or more red cells per cubic millimetre in urine samples results in a positive Stix test for blood and is abnormal. Types of urinary erythrocytes Isomorphic, with regular shapes and contours, derived from the urinary excretory system Dysmorphic, with irregular shapes and contours, which are of glomerular origin Hematuria has been defined as non glomerular when isomorphic erythrocytes predominate (>80% of total erythrocytes) and as glomerular when dysmorphic erythrocytes prevail (>80% of total erythrocytes).

White blood cells. Indicates The presence of 10 or more WBCs
in fresh unspun mid-stream urine samples is abnormal Indicates Inflammatory reaction within the urinary tract UTI Stones Tubulointerstitial nephritis Papillary necrosis, Tuberculosis Interstitial cystitis.

Epithelial Cells Squamous Cells 1/25/2018

Tubular Epithelial Cells
1/25/2018

Transitional Cells 1/25/2018

LE Cell 1/25/2018

Lipids Oval Fat Body 1/25/2018

Organisms Bacteria 1/25/2018

Yeasts 1/25/2018

Cytomegalovirus 1/25/2018

Schistosomiasis (S. haematobium) 1/25/2018

Casts Casts are cylindrical and form in the lumen of distal renal tubules and collecting ducts. Their matrix is due to Tamm-Horsfall glycoprotein (also called uromodulin), which is secreted by the cells of the thick ascending Henle’s loop. Trapping of particles within the cast matrix results in casts with different appearances and clinical significance Coarse granular casts occur with pathological proteinuria in glomerular and tubular disease. White cell casts may be seen in acute pyelonephritis. Red-cell casts – even if only single – always indicate renal disease 1/25/2018

Hyaline casts Colorless Easily seen with phase contrast microscopy
Hyaline casts may occur in normal urine, (Tamm-Horsfall protein) In patients with renal disease, they are usually associated with other types of casts.

Hyaline-granular casts
Contain granules within the hyaline matrix Rare but possible in normal individuals, they are common in GN. 1/25/2018

Granular casts Either Finely granular Coarsely granular.
Both types are typical of renal disease but not more specific

Waxy casts Their name from their appearance, which is similar to that of melted wax The nature of waxy casts is still unknown. They are typical of patients with renal failure Frequently with rapidly progressive GN. 1/25/2018

Erythrocyte Red cell casts Contain a few erythrocytes
Indicates hematuria of glomerular origin. 1/25/2018

Hemoglobin casts Brownish hue
Granular appearance deriving from the degradation of erythrocytes entrapped within the casts 1/25/2018

Leukocyte casts Found in
Contain variable amounts of polymorphonuclear leukocytes Found in Acute pyelonephritis Acute interstitial nephritis 1/25/2018

Epithelial casts Epithelial casts contain variable numbers of renal tubular cells, which can be identified by their prominent nucleus Epithelial casts are a typical finding in ATN and acute interstitial nephritis. However, they are also frequent (even though in small numbers) in GN and in the nephrotic syndrome 1/25/2018

Tubular Epith. Cast 1/25/2018

Fatty casts Contain variable amounts of lipid droplets, isolated, in clumps, or packed. They are typical of glomerular diseases associated with marked proteinuria or the nephrotic syndrome 1/25/2018

1/25/2018

Crystals * Urate *Triple Phosphate * Calcium Oxalate * Amino Acids
Ammonium biurate Uric acid *Triple Phosphate * Calcium Oxalate * Amino Acids Cystine Leucine Tyrosine *Sulfonamide 1/25/2018

Crystals Correct identification of urine crystals requires knowledge of Crystal morphologies Urine ph Appearances under polarizing light. Informative in the assessment of patients with stone disease, with some rare inherited metabolic disorders, and with suspected drug nephrotoxicity.

Uric acid crystals Rhomboid shape is the most frequent 1/25/2018

Calcium Oxalate Crystals
Bihydrated calcium oxalate crystals with their typical appearance of a “letter envelope. 1/25/2018

Calcium Oxalate Crystals
Different types of monohydrated calcium oxalate crystals Dumb bell Shape 1/25/2018

Calcium phosphate crystal.
A star-like 1/25/2018

Triple phosphate crystal
Coffin lid crystals 1/25/2018

Cysteine crystals Hexagonal Heaped one on the other 1/25/2018

Leucine Crystals 1/25/2018

Cholesterol Crystals Clear, large, flat, rectangular plates with notched corners 1/25/2018

Cytological Examination
Staining: Papanicolau Wright’s Immunoperoxidase Immunofluorescence

Normal 1/25/2018

Reactive 1/25/2018

Polyoma (Decoy Cell) 1/25/2018

Polyoma (Decoy Cell) Immunoperoxidase to SV40 ag
1/25/2018

TCC Low Grade 1/25/2018

TCC High Grade 1/25/2018

Squamous Cell Ca. 1/25/2018

Renal Cell Ca. 1/25/2018

Prostatic Carcinoma 1/25/2018

1/25/2018

Common Urinary Findings
1/25/2018

Acute Tubular Necrosis
Glucose Bilirubin Ketones Microscopic: Renal tubular epithelial cells Pathological casts S.G. Decreased Blood + / - pH Protein + / - Urobilinogen Nitrite L.E. 1/25/2018

Acute Glomerulonephritis
Glucose Bilirubin Ketones Microscopic: Erythrocytes (dysmorphic) Erythrocyte casts Mixed cellular casts S.G. Blood Increased pH Protein Increased Urobilinogen Nitrite L.E. 1/25/2018

Chronic Glomerulonephritis
Glucose Bilirubin Ketones Microscopic: Pathological casts (broad waxy casts, RBCs) S.G. Decreased Blood Increased pH Protein Increased Urobilinogen Nitrite L.E.

Acute Pyelonephritis Microscopic: Bacteria Leukocytes
Glucose Bilirubin Microscopic: Bacteria Leukocytes Leukocyte, granular, and waxy casts Renal tubular epithelial cell casts Ketones S.G. Blood pH Protein Trace Urobilinogen Nitrite Positive L.E. Positive

Nephrotic Syndrome Microscopic: Oval fat bodies Fatty casts Waxy casts
Glucose Bilirubin Microscopic: Oval fat bodies Fatty casts Waxy casts Ketones S.G. Blood pH Protein ++++ Urobilinogen Nitrite L.E. 1/25/2018

Eosinophilic Cystitis
Glucose Bilirubin Ketones Microscopic: Numerous eosinophils (Hansel’s stain) NO significant casts. S.G. Blood + pH Protein Urobilinogen Nitrite 1/25/2018 L.E.

Urothelial Carcinoma Microscopic: Malignant cells on urine cytology
Glucose Bilirubin Ketones Microscopic: Malignant cells on urine cytology Urine sample should be submitted separately to cytology, void or 24 hrs S.G. Blood + pH Protein Urobilinogen Nitrite 1/25/2018 L.E.

Urinalysis Disease Diagnosis ? 1/25/2018

Case 1 A 35-year old man undergoing routine pre employment drug screening. Physical characteristics: Clear. Microscopic: Not performed. Drugs Identified: None. Questions: - What is your differential diagnosis? - What next to confirm your suspicion? - Would you order a microscopic analysis? Glucose Negative Bilirubin Negative Ketones Negative S.G. 1.001 Blood Negative pH 5.5 Protein Negative Urobilinogen 0.2 mg/dL Nitrite Negative L.E. Negative Diluted urine, request a voided urine in the morning If persisting low SG, possible diabetes insipides A microscopic may give negative results

Case 2 A 42-year old woman presents with “dark urine”
Physical characteristics: Red-brown. Microscopic: Not performed. Questions: - What is your differential diagnosis? - Could this be a case of hemolytic anemia? - How would you rule it out? - What tests would you order next? Why? - Would you order a microscopic analysis? Glucose Negative Bilirubin +++ Ketones Negative S.G. 1.020 Blood Negative pH 5.5 Protein Negative Urobilinogen 0.2 mg/dL Nitrite Negative 1/25/2018 L.E. Negative Possible gallbladder or hepatic disease. No hemolytic anemia. Perform bilirubins in serum Microscopic unlikely to provide additional info.

Case 3 A 42-year old man presents painful urination
Physical characteristics: dark red, turbid Microscopic: leukocytes = 30 per HPF RBCs = >100 per HPF Bacteria = >100 per HPF Questions: - What is your suspected diagnosis? - What would you do next? - What do you make of the nitrite test? - How would the microscopic exam differ if the S.G. were 1.003? - Is this a common diagnosis for this type of patient? Glucose Negative Bilirubin Negative Ketones Negative S.G. 1.030 Blood +++ pH 6.5 Protein Trace Urobilinogen 1.0 mg/dL Nitrite Negative L.E. +++ Possible UTI, request culture and antibiotic sensitivity Negative Nitrite test: Gram positive bacteria Lower SG may show less number of cells and bacteria Un-common diagnosis in this type of patient

Case 4 A 27-year old woman presents with severe abdominal pain.
Glucose ++ A 27-year old woman presents with severe abdominal pain. Physical characteristics: clear-yellow. Microscopic: Not performed. Questions: - What is the most likely diagnosis? - What do you make of the ketone result? - What do you expect to happen to the ketone measurement when treatment begins? Bilirubin Negative Ketones Trace S.G. 1.015 Blood Negative pH 6.0 Protein Negative Urobilinogen 1.0 mg/dL Nitrite Negative L.E. Negative Diabetes May be decompensated and with ketoacidosis Ketones should become negative after treatment

Case 5 Questions: 8-year old boy presents with discolored urine
Glucose Negative 8-year old boy presents with discolored urine Physical characteristics: Red, turbid. Microscopic: erythrocytes = >100 per HPF (almost all dysmorphic) &Red cell casts Questions: - What is the most likely diagnosis in this case? - Does the presence of red cell casts help you in any way? - If the erythrocytes were not dysmorphic would that change your diagnosis? Bilirubin Negative Ketones Negative S.G. 1.015 Blood +++ pH 6.5 Protein + Urobilinogen 1.0 mg/dL Nitrite Negative 1/25/2018 L.E. Negative Glomerulonephritis RBC casts reveals renal cortex involvement RBC cast are not always present in GN

Case 6 22-year old man presenting for a routine physical required for admission to medical school Physical characteristics: Yellow Microscopic: Not performed Questions: - What is your differential diagnosis? - Would you order a microscopic analysis on this sample? - What next to confirm the diagnosis? Glucose Negative Bilirubin Negative Ketones Negative S.G. 1.010 Blood Negative pH 5.0 Protein + Urobilinogen 0.2 mg/dL Nitrite Negative L.E. Negative “Functional” proteinuria? Microscopic may reveal a few leukocytes Request protein concentration in 24 h urine

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EXAMINATION OF THE URINE

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