1. CLINICAL INVESTIGATION OF URINE. CHANGES IN THE URINE IN PATHOLOGICAL PROCESSES OF INTERNAL ORGANS

2. 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.

3. 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

4. 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

5. 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

7. 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

8. 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)

9. 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%)

10. 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

11. 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

12. Specific Gravity: 1.005-1.030 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

13. 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

14. Urine pH Normal Normal 4.5-8.0 (usually 5.5 to 6.5) 4.5-8.0 (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

15. 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

17. Urine Microscopic Exam Urine Microscopic Exam Sample preparation Obtain fresh urine sample Obtain fresh urine sample Centrifuge 10-15 ml at 1500 to 3000 rpm for 5 minutes Centrifuge 10-15 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

18. 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

19. 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

20. Kidney and Urinary Tract Disease Tests Urine Protein Urine Protein Urine Protein Urine Protein Urine Blood Urine Blood Gross Hematuria Gross Hematuria Gross Hematuria Gross Hematuria Microscopic Hematuria Microscopic Hematuria Microscopic Hematuria Microscopic Hematuria

23. Urine Protein Normal Normal Dipstick with trace protein or less Dipstick with trace protein or less Technique Technique First morning void collected First morning void collected Detection Method Detection Method Initial: Dipstick urine protein Initial: Dipstick urine protein Confirmation: Sulfosalicylic acid Confirmation: Sulfosalicylic acidSulfosalicylic acidSulfosalicylic acid Dipstick turns from yellow to green for protein present Dipstick turns from yellow to green for protein present Negative: <10 mg/dl Negative: <10 mg/dl Trace: 10-20 mg/dl Trace: 10-20 mg/dl Protein 1+: 30 mg/dl Protein 1+: 30 mg/dl Protein 2+: 100 mg/dl Protein 2+: 100 mg/dl Protein 3+: 300 mg/dl Protein 3+: 300 mg/dl Protein 4+: 1000 mg/dl Protein 4+: 1000 mg/dl

24. False Positive Alkaline urine (Urine pH >7.5) Alkaline urine (Urine pH >7.5)Urine pHUrine pH Increased Urine Specific Gravity (concentrated) Increased Urine Specific Gravity (concentrated)Urine Specific GravityUrine Specific Gravity Specimen contaminated by chlorhexidine detergent Specimen contaminated by chlorhexidine detergent Dipstick immersed too long in urine Dipstick immersed too long in urine Medications Medications Penicillin Penicillin Penicillin Sulfonamide Sulfonamide Sulfonamide Tolbutamide Tolbutamide Tolbutamide Phenazopyridine Phenazopyridine Body fluid contamination Body fluid contamination Gross Hematuria present Gross Hematuria present Gross Hematuria Gross Hematuria Pus Pus Semen Semen Vaginal secretions Vaginal secretions

25. Urine Protein to Creatinine Ratio Indication Indication Monitor persistant Proteinuria Monitor persistant ProteinuriaProteinuria Efficacy Efficacy More accurate than 24 Hour Urine Protein collection More accurate than 24 Hour Urine Protein collection24 Hour Urine Protein24 Hour Urine Protein Most accurate if first morning void is used Most accurate if first morning void is used Technique: Random urine collection Technique: Random urine collection Urine Creatinine in mg Urine Creatinine in mg Urine Creatinine Urine Creatinine Urine Protein in mg Urine Protein in mg Urine Protein Urine Protein Calculate Urine Protein mg to Urine Creatinine mg Ratio Calculate Urine Protein mg to Urine Creatinine mg RatioUrine ProteinUrine CreatinineUrine ProteinUrine Creatinine

26. Interpretation of Urine Protein to Urine Creatinine Ratio Child under age 2 years Child under age 2 years Normal Ratio <0.5 Normal Ratio <0.5 Adults and children over age 2 years Adults and children over age 2 years Normal ratio <0.2 grams protein per gram Creatinine Normal ratio <0.2 grams protein per gram Creatinine Creatinine Correlates with 0.2 g protein/day Correlates with 0.2 g protein/day Nephrotic Ratio >3.5 (correlates with 3.5 g protein) Nephrotic Ratio >3.5 (correlates with 3.5 g protein)

27. Interpretation of Urine Albumin to Creatinine Ratio Normal Ratio (in general <30 mg/g is normal) Normal Ratio (in general <30 mg/g is normal) Men: < 0.017 (or 17 mg albumin to 1 gram Creatinine) Men: < 0.017 (or 17 mg albumin to 1 gram Creatinine)Creatinine Women: <0.025 (or 25 mg albumin to 1 gram Creatinine) Women: <0.025 (or 25 mg albumin to 1 gram Creatinine) Creatinine Microalbuminuria: 30-300 mg albumin/g Creatinine Microalbuminuria: 30-300 mg albumin/g Creatinine Creatinine Macroalbuminuria: >300 mg albumin/g Creatinine Macroalbuminuria: >300 mg albumin/g Creatinine Creatinine

28. Proteinuria in Adults Causes Glomerular Causes (Increased glomerulus permeability) Primary Glomerulonephropathy Primary Glomerulonephropathy Minimal Change Disease Minimal Change Disease IgA Nephropathy IgA Nephropathy Idiopathic membranous Glomerulonephritis Idiopathic membranous GlomerulonephritisGlomerulonephritis Focal segmental Glomerulonephritis Focal segmental GlomerulonephritisGlomerulonephritis Membranoproliferative Glomerulonephritis Membranoproliferative GlomerulonephritisGlomerulonephritis

29. Secondary Glomerulonephropathy Secondary Glomerulonephropathy Diabetes Mellitus (Diabetic Nephropathy) Diabetes Mellitus (Diabetic Nephropathy) Diabetes MellitusDiabetic Nephropathy Diabetes MellitusDiabetic Nephropathy Systemic Lupus Erythematosus (Lupus Nephritis) Systemic Lupus Erythematosus (Lupus Nephritis) Systemic Lupus ErythematosusLupus Systemic Lupus ErythematosusLupus Amyloidosis Amyloidosis Amyloidosis Preeclampsia (Pregnancy Induced Hypertension) Preeclampsia (Pregnancy Induced Hypertension) PreeclampsiaPregnancy Induced Hypertension PreeclampsiaPregnancy Induced Hypertension Infection Infection HIV Infection HIV Infection HIV Infection HIV Infection Hepatitis B Hepatitis B Hepatitis B Hepatitis B Hepatitis C Hepatitis C Hepatitis C Hepatitis C Poststreptococcal Glomerulonephritis Poststreptococcal Glomerulonephritis Poststreptococcal Glomerulonephritis Poststreptococcal Glomerulonephritis Syphilis Syphilis Syphilis Malaria Malaria Malaria Endocarditis Endocarditis Lung Cancer Lung Cancer Lung Cancer Lung Cancer Gastrointestinal Cancer Gastrointestinal Cancer Lymphoma Lymphoma Lymphoma Renal transplant rejection Renal transplant rejection

30. Microscopic UrinalysisMicroscopic Urinalysis findings of renal disease Microscopic Urinalysis Urine fats (Nephrotic Syndrome) Urine fats (Nephrotic Syndrome)Nephrotic SyndromeNephrotic Syndrome Urine WBCs without bacteruria (Renal Interstitial) Urine WBCs without bacteruria (Renal Interstitial) Dysmorphic erythrocytes (Glomerular disease) Dysmorphic erythrocytes (Glomerular disease) Cellular or granular casts (chronic renal disease) Cellular or granular casts (chronic renal disease) Urine Eosinophils Urine EosinophilsEosinophil

31. Urine Leukocyte Esterase Mechanism Mechanism Neutrophil Granulocytes contain esterases Neutrophil Granulocytes contain esterases NeutrophilGranulocyte NeutrophilGranulocyte Positive test suggests pyuria Positive test suggests pyuria Dipstick requires 5 minutes to change color Dipstick requires 5 minutes to change color Normal Normal Negative Negative Abnormal: Positive Abnormal: Positive Urinary Tract Infection Urinary Tract Infection Urinary Tract Infection Urinary Tract Infection Vaginal contaminant Vaginal contaminant

33. Causes of false negative Leukocyte esterase on Urinalysis Inadequate time allowed for dipstick reading Inadequate time allowed for dipstick reading Increased Urine Specific Gravity Increased Urine Specific GravityUrine Specific GravityUrine Specific Gravity Urine Glucose present (Glycosuria) Urine Glucose present (Glycosuria) Urine GlucoseGlycosuria Urine GlucoseGlycosuria Urine Ketones present (Ketonuria) Urine Ketones present (Ketonuria) Urine Ketone Urine Ketone Proteinuria Proteinuria Proteinuria Keflex Keflex Keflex Nitrofurantoin Nitrofurantoin Nitrofurantoin Tetracycline Tetracycline Tetracycline Gentamicin Gentamicin Gentamicin Vitamin C Vitamin C Vitamin C Vitamin C

35. Causes positive Leukocyte esterase and negative culture Chlamydia Chlamydia Chlamydia Ureaplasma urealyticum Ureaplasma urealyticum Ureaplasma Balanitis Balanitis Balanitis Bladder Cancer Bladder Cancer Bladder Cancer Bladder Cancer Nephrolithiasis Nephrolithiasis Nephrolithiasis Tuberculosis Tuberculosis Tuberculosis Urinary tract foreign body Urinary tract foreign body Glomerulonephritis Glomerulonephritis Glomerulonephritis Medications (Corticosteroid, Cytoxan) Medications (Corticosteroid, Cytoxan)Corticosteroid

38. Acute Glomerulonephritis Labs: Initial (characterize condition) Labs: Initial (characterize condition) Urine sediment examination Urine sediment examination Proteinuria Proteinuria Proteinuria Glomerular Hematuria Glomerular HematuriaHematuria Pigmented or Red Blood Cell casts Pigmented or Red Blood Cell castsRed Blood CellRed Blood Cell Dysmorphic Red Blood Cells Dysmorphic Red Blood CellsRed Blood CellRed Blood Cell Twenty-four hour urine collection Twenty-four hour urine collection 24 Hour Urine Protein 24 Hour Urine Protein 24 Hour Urine Protein 24 Hour Urine Protein Creatine Clearance Creatine Clearance Creatine Renal insufficiency Renal insufficiency

39. Acute Glomerulonephritis Routine blood testing Routine blood testing Serum chemistries Serum chemistries Albumin and Liver Function Tests Albumin and Liver Function TestsLiver Function TestLiver Function Test Total Cholesterol Total Cholesterol Total Cholesterol Total Cholesterol If over age 40 with Proteinuria >1 gram/24 hours If over age 40 with Proteinuria >1 gram/24 hoursProteinuria Serum Protein Electrophoresis (SPEP) Serum Protein Electrophoresis (SPEP) Serum Protein ElectrophoresisSPEP Serum Protein ElectrophoresisSPEP Urine Protein electrophoresis Urine Protein electrophoresis Urine Protein Urine Protein

40. Acute Glomerulonephritis Labs: Next (Screen for etiology) Labs: Next (Screen for etiology) Serum Complement (C3, C4, CH50) Serum Complement (C3, C4, CH50) Antinuclear Antibody (ANA) Antinuclear Antibody (ANA) Antinuclear Antibody Antinuclear Antibody Rheumatoid Factor (RF) Rheumatoid Factor (RF) Rheumatoid Factor Rheumatoid Factor Erythrocyte Sedimentation Rate (ESR) Erythrocyte Sedimentation Rate (ESR) Erythrocyte Sedimentation Rate Erythrocyte Sedimentation Rate Anti-Glomerular Basement Membrane Antibody titer Anti-Glomerular Basement Membrane Antibody titerGlomerular Basement Membrane AntibodyGlomerular Basement Membrane Antibody Hepatitis serology (HBsAg, xHBc IgM, HCV) Hepatitis serology (HBsAg, xHBc IgM, HCV)HBsAgxHBc IgMHBsAgxHBc IgM Anti-Neutrophilic cytoplasmic Antibody (ANCA) Anti-Neutrophilic cytoplasmic Antibody (ANCA)NeutrophilAntibodyANCANeutrophilAntibodyANCA Anti-streptolysin O titer (ASO Titer) Anti-streptolysin O titer (ASO Titer) Anti-streptolysin O titerASO Titer Anti-streptolysin O titerASO Titer Human Immunodeficiency Virus (HIV) Human Immunodeficiency Virus (HIV) Human Immunodeficiency Virus Human Immunodeficiency Virus

41. ACUTE PYELONEPHRITIS Labs Labs Urinalysis Urinalysis Urinalysis Leukocyte esterase or nitrite positive Leukocyte esterase or nitrite positive Leukocyte Hematuria may be present Hematuria may be present Hematuria Microscopic examination may show WBC casts Microscopic examination may show WBC casts Urine Culture (positive in 90% of pyelonephritis) Urine Culture (positive in 90% of pyelonephritis) Urine Culture Urine Culture Diagnosis requires at least 10,000 CFU/mm3 Diagnosis requires at least 10,000 CFU/mm3 Consider lower threshold in men and in pregnancy Consider lower threshold in men and in pregnancy Blood Culture indications (not indicated in most cases) Blood Culture indications (not indicated in most cases) Blood Culture Blood Culture Immunocompromised patient Immunocompromised patient Unclear diagnosis Unclear diagnosis Hematogenous source suspected Hematogenous source suspected

42. Acute Renal Failure Urinalysis with Urine sediment examination Urinalysis with Urine sediment examination Urinalysis Urine Specific Gravity Urine Specific Gravity Urine Specific Gravity Urine Specific Gravity Prerenal Failure: Specific Gravity >1.020 Prerenal Failure: Specific Gravity >1.020 Prerenal Failure Prerenal Failure Intrarenal Failure: Specific Gravity 1.010 - 1.020 Intrarenal Failure: Specific Gravity 1.010 - 1.020 Vascular disease Vascular disease Urine RBCs often present Urine RBCs often present Glomerulonephritis Glomerulonephritis Glomerulonephritis Urine RBCs Urine RBCs Granular casts Granular casts Proteinuria Proteinuria Proteinuria

43. Acute Renal Failure Interstitial Nephritis Interstitial Nephritis Interstitial Nephritis Interstitial Nephritis Pyuria Pyuria Eosinophils Eosinophils Eosinophil White Blood Cell and Eosinophil casts White Blood Cell and Eosinophil casts White Blood CellEosinophil White Blood CellEosinophil Drug hypersensitivity nephritis Drug hypersensitivity nephritis Eosinophils Eosinophils Eosinophil Tubular Necrosis Tubular Necrosis Pigmented granular casts Pigmented granular casts Tubular epithelial cells Tubular epithelial cells Granular casts Granular casts Prerenal Failure Prerenal Failure Prerenal Failure Prerenal Failure Hyaline Casts Hyaline Casts

44. Autoimmune Testing for Glomerular Disease Antinuclear Antibody (ANA) Antinuclear Antibody (ANA) Antinuclear Antibody Antinuclear Antibody Antineutrophil Cytoplasmic Antibody Antineutrophil Cytoplasmic Antibody Antineutrophil Cytoplasmic Antibody Antineutrophil Cytoplasmic Antibody Antiglomerular basement membrane Antibody Antiglomerular basement membrane Antibody Antibody

45. NKF Classification System Stage 1: GFR >90 ml/min despite kidney damage Microalbuminuria present Microalbuminuria present Stage 2: Mild reduction (GFR 60-89 min/min) GFR of 60 may represent 50% loss in function GFR of 60 may represent 50% loss in function Parathyroid Hormone starts to increase Parathyroid Hormone starts to increase Parathyroid Hormone Parathyroid Hormone Chronic Renal Failure

46. Stage 3: Moderate reduction (GFR 30-59 ml/min) Stage 3: Moderate reduction (GFR 30-59 ml/min) Calcium absorption decreases Calcium absorption decreases Malnutrition onset Malnutrition onset Anemia secondary to Erythropoietin deficiency Anemia secondary to Erythropoietin deficiency AnemiaErythropoietin AnemiaErythropoietin Left Ventricular Hypertrophy Left Ventricular Hypertrophy Left Ventricular Hypertrophy Left Ventricular Hypertrophy Stage 4: Severe reduction (GFR 15-29 ml/min) Stage 4: Severe reduction (GFR 15-29 ml/min) Serum Triglycerides increase Serum Triglycerides increaseTriglyceride Hyperphosphatemia Hyperphosphatemia Hyperphosphatemia Metabolic Acidosis Metabolic Acidosis Metabolic Acidosis Metabolic Acidosis Hyperkalemia Hyperkalemia Hyperkalemia Stage 5: Kidney Failure (GFR <15 ml/min) Stage 5: Kidney Failure (GFR <15 ml/min) Azotemia Azotemia Azotemia

47. Acute Interstitial Nephritis Urinalysis Urinalysis Urinalysis Eosinophiluria Eosinophiluria Eosinophil Proteinuria Proteinuria Proteinuria Fractional Excretion of Sodium >1% Fractional Excretion of Sodium >1% Fractional Excretion of Sodium Fractional Excretion of Sodium Renal Function tests with renal insufficiency Renal Function tests with renal insufficiency Renal Function Renal Function Serum Creatinine increased Serum Creatinine increased Serum Creatinine Serum Creatinine Blood Urea Nitrogen increased Blood Urea Nitrogen increased Blood Urea Nitrogen Blood Urea Nitrogen Miscellaneous Miscellaneous Hyperchloremic Metabolic Acidosis Hyperchloremic Metabolic AcidosisMetabolic AcidosisMetabolic Acidosis