urin analysis

Course: IDPT 5005Course: IDPT 5005School of Medicine, School of Medicine, UCDHSCUCDHSC

Francisco G. La Rosa, MDFrancisco G. La Rosa, MD

[email protected] Assistant Professor, Department of PathologyAssistant Professor, Department of Pathology

University of Colorado at Denver Health Science Center, Denver, University of Colorado at Denver Health Science Center, Denver, ColoradoColorado

UrinalysiUrinalysiss

Specimen Specimen CollectionCollection

– First morning voiding First morning voiding (most (most concentrated)concentrated)

– Record collection timeRecord collection time– Type of specimen (e.g. “clean Type of specimen (e.g. “clean

catch”) catch”) – Analyzed within 2 hours of collectionAnalyzed within 2 hours of collection– Free of debris or vaginal secretionsFree of debris or vaginal secretions

Clean CatchClean Catch

Specimen Specimen CollectionCollection

Supra-pubic Needle AspirationSupra-pubic Needle Aspiration

− Macroscopic ExaminationMacroscopic Examination− Chemical Analysis (Urine Chemical Analysis (Urine

Dipstick)Dipstick)− Microscopic ExaminationMicroscopic Examination− Culture Culture (not covered in this lecture)(not covered in this lecture)

− Cytological ExaminationCytological Examination

Types of AnalysisTypes of Analysis

Macroscopic Macroscopic ExaminationExaminationOdor:Odor:− Ammonia-like:Ammonia-like: (Urea-splitting bacteria)(Urea-splitting bacteria)− Foul, offensive:Foul, offensive: Old specimen, pus or Old specimen, pus or

inflammationinflammation− Sweet: Sweet: GlucoseGlucose− Fruity: Fruity: KetonesKetones− Maple syrup-like: Maple syrup-like: Maple Syrup Urine DiseaseMaple Syrup Urine DiseaseColor:Color:− Colorless Colorless Diluted urineDiluted urine− Deep YellowDeep Yellow Concentrated Urine, RiboflavinConcentrated Urine, Riboflavin− Yellow-GreenYellow-Green Bilirubin / BiliverdinBilirubin / Biliverdin− RedRed Blood / HemoglobinBlood / Hemoglobin− Brownish-redBrownish-red Acidified Blood (Actute GN)Acidified Blood (Actute GN)− Brownish-blackBrownish-black Homogentisic acid (Melanin)Homogentisic acid (Melanin)

Turbidity:Turbidity:− Typically cells or crystals.Typically cells or crystals.− Cellular elements and bacteria will clear by Cellular elements and bacteria will clear by

centrifugation.centrifugation.− Crystals dissolved by a variety of methods (acid or Crystals dissolved by a variety of methods (acid or

base).base).− Microscopic examination will determine which is Microscopic examination will determine which is

present.present.

Macroscopic Macroscopic ExaminationExamination

Chemical AnalysisChemical Analysis

Chemical AnalysisChemical AnalysisUrine Urine

DipstickDipstickGlucoseGlucose

BilirubinBilirubin

KetonesKetones

Specific GravitySpecific Gravity

BloodBlood

pHpH

ProteinProtein

UrobilinogenUrobilinogen

NitriteNitrite

Leukocyte EsteraseLeukocyte Esterase

NegativeNegativeNegativeNegative

Trace (100 mg/dL)Trace (100 mg/dL)Trace (100 mg/dL)Trace (100 mg/dL)

+ (250 mg/dL)+ (250 mg/dL)+ (250 mg/dL)+ (250 mg/dL)

++ (500 mg/dL)++ (500 mg/dL)++ (500 mg/dL)++ (500 mg/dL)

+++ (1000 mg/dL)+++ (1000 mg/dL)+++ (1000 mg/dL)+++ (1000 mg/dL)

++++ (2000+ mg/dL)++++ (2000+ mg/dL)++++ (2000+ mg/dL)++++ (2000+ mg/dL)

The Urine The Urine Dipstick:Dipstick: GlucosGlucos

ee

Glucose + 2 HGlucose + 2 H22OO + O+ O22 --->--->Gluconic Acid + 2 HGluconic Acid + 2 H22OO22

Glucose OxidaseGlucose Oxidase

3 H3 H22OO22 + KI + KI --->---> KIO KIO3 3 + 3 H+ 3 H22OO

Horseradish PeroxidaseHorseradish Peroxidase

Chemical PrincipleChemical Principle

Read at 30 secondsRead at 30 secondsRR: NegativeRR: Negative

SignificanceSignificance– Diabetes mellitus.Diabetes mellitus.– Renal glycosuria.Renal glycosuria.

LimitationsLimitations– Interference: reducing agents, ketones.Interference: reducing agents, ketones.– Only measures glucose and not other sugars.Only measures glucose and not other sugars.– Renal threshold must be passed in order for glucose to spill Renal threshold must be passed in order for glucose to spill

into the urine.into the urine.

Other TestsOther Tests– CuSOCuSO44 test for reducing sugars. test for reducing sugars.

Uses and Limitations of Urine Glucose Uses and Limitations of Urine Glucose DetectionDetection

SugarSugar DiseaseDisease(s)(s)

- Galactose- Galactose GalactosemiasGalactosemias- Fructose- Fructose Fructosuria, Fructose Intolerance, etc.Fructosuria, Fructose Intolerance, etc.- Lactose- Lactose Lactase DeficiencyLactase Deficiency- Pentoses- Pentoses Essential PentosuriaEssential Pentosuria- Maltose- Maltose Non-pathogenicNon-pathogenic

* NOT Sucrose because it is not a reducing sugar* NOT Sucrose because it is not a reducing sugar

Detection of Reducing Sugars* Detection of Reducing Sugars* by by CuSOCuSO44

++++

++

tracetrace

400400 600600 800800 10001000200200

Uri

naly

sis

Glu

cose R

esu

ltU

rin

aly

sis

Glu

cose R

esu

ltU

rin

aly

sis

Glu

cose R

esu

ltU

rin

aly

sis

Glu

cose R

esu

lt

Blood Glucose (mg/dL)Blood Glucose (mg/dL)Blood Glucose (mg/dL)Blood Glucose (mg/dL)

Urine versus Blood GlucoseUrine versus Blood Glucose

NegativeNegative


+ (weak)+ (weak)+ (weak)+ (weak)

++ (moderate)++ (moderate)++ (moderate)++ (moderate)

+++ (strong)+++ (strong)+++ (strong)+++ (strong)

The Urine The Urine Dipstick:Dipstick: BilirrubiBilirrubi

nn

Bilirubin + Diazo salt Bilirubin + Diazo salt --------->---------> Azobilirubin AzobilirubinAcidicAcidic



SignificanceSignificance- Increased direct bilirubin (correlates with urobilinogen and serum bilirubin)

LimitationsLimitations- Interference: prolonged exposure of sample to light- Only measures direct bilirubin--will not pick up indirect bilirubin

Other TestsOther Tests- Ictotest (more sensitive tablet version of same assay)- Serum test for total and direct bilirubin is more informative

Uses and Limitations of Urine Bilirrubin Uses and Limitations of Urine Bilirrubin DetectionDetection


Trace (5 mg/dL)Trace (5 mg/dL)Trace (5 mg/dL)Trace (5 mg/dL)




++++ (160+ mg/dL)++++ (160+ mg/dL)++++ (160+ mg/dL)++++ (160+ mg/dL)

The Urine The Urine Dipstick:Dipstick: KetonesKetones

Acetoacetic Acid + NitroprussideAcetoacetic Acid + Nitroprusside------> ------> Colored ComplexColored Complex



SignificanceSignificance- Diabetic ketoacidosis- Diabetic ketoacidosis- Prolonged fasting- Prolonged fasting

LimitationsLimitations- Interference: expired reagents (degradation with exposure to - Interference: expired reagents (degradation with exposure to moisture in air)moisture in air)- Only measures acetoacetate not other ketone bodies (such as in - Only measures acetoacetate not other ketone bodies (such as in rebound ketosis).rebound ketosis).

Other TestsOther Tests- Ketostix (more sensitive tablet version of same assay)- Ketostix (more sensitive tablet version of same assay)- Serum glucose measurement to confirm DKA- Serum glucose measurement to confirm DKA

Uses and Limitations of Urine Ketone Uses and Limitations of Urine Ketone DetectionDetection

1.0001.0001.0001.000

1.0051.0051.0051.005

1.0101.0101.0101.010

1.0151.0151.0151.015

1.0201.0201.0201.020

1.0251.0251.0251.025

1.0301.0301.0301.030

XX++ + Polymethyl vinyl ether / maleic anhydride + Polymethyl vinyl ether / maleic anhydride---------------> --------------->

XX++-Polymethyl vinyl ether / maleic anhydride + H-Polymethyl vinyl ether / maleic anhydride + H++

HH++ interacts with a Bromthymol Blue indicator to interacts with a Bromthymol Blue indicator toform a colored complex.form a colored complex.


Read up to 2 minutesRead up to 2 minutesRR: 1.003-1.035RR: 1.003-1.035

The Urine The Urine Dipstick:Dipstick: Specific Specific

GravityGravity

SignificanceSignificance- Diabetes insipidus

LimitationsLimitations- Interference: alkaline urine

- Does not measure non-ionized solutes (e.g. glucose)

Other TestsOther Tests- Refractometry

- Hydrometer

- Osmolality measurement (typically used with water deprivation test)

Uses and Limitations of Urine Specific Uses and Limitations of Urine Specific GravityGravity


TraceTrace (non-hemolyzed) (non-hemolyzed)TraceTrace (non-hemolyzed) (non-hemolyzed)

ModerateModerate (non-hemolyzed) (non-hemolyzed)ModerateModerate (non-hemolyzed) (non-hemolyzed)

TraceTrace (hemolyzed) (hemolyzed)TraceTrace (hemolyzed) (hemolyzed)

+ (weak)+ (weak)+ (weak)+ (weak)

++ (moderate)++ (moderate)++ (moderate)++ (moderate)

+++ (strong)+++ (strong)+++ (strong)+++ (strong)

The Urine The Urine Dipstick:Dipstick: BloodBlood

Diisopropylbenzene dihydroperoxide +Diisopropylbenzene dihydroperoxide +Tetramethylbenzidine Tetramethylbenzidine

------------>------------> Colored Complex Colored ComplexHemeHeme


Lysing agent to lyse red blood cellsLysing agent to lyse red blood cells


Analytic Sensitivity: 10 RBCsAnalytic Sensitivity: 10 RBCs

SignificanceSignificance- Hematuria (nephritis, trauma, etc)- Hematuria (nephritis, trauma, etc)- Hemoglobinuria (hemolysis, etc)- Hemoglobinuria (hemolysis, etc)- Myoglobinuria (rhabdomyolysis, etc)- Myoglobinuria (rhabdomyolysis, etc)

LimitationsLimitations- Interference: reducing agents, microbial peroxidases- Interference: reducing agents, microbial peroxidases- Cannot distinguish between the above disease processes- Cannot distinguish between the above disease processes

Other TestsOther Tests- Urine microscopic examination- Urine microscopic examination- Urine cytology- Urine cytology

Uses and Limitations of Urine Blood Uses and Limitations of Urine Blood DetectionDetection

5.05.05.05.0

6.06.06.06.0

6.56.56.56.5

7.07.07.07.0

7.57.57.57.5

8.08.08.08.0

8.58.58.58.5

The Urine The Urine Dipstick:Dipstick: pHpH

HH++ interacts with: interacts with:Methyl Red (at high concentration; low pH) andMethyl Red (at high concentration; low pH) andBromthymol Blue (at low concentration; high Bromthymol Blue (at low concentration; high

pH), to form a colored complexespH), to form a colored complexes(dual indicator system)(dual indicator system)


Read up to 2 minutesRead up to 2 minutesR.R.: 4.5-8.0R.R.: 4.5-8.0

SignificanceSignificance- Acidic (less than 4.5): metabolic acidosis, high-protein diet- Acidic (less than 4.5): metabolic acidosis, high-protein diet

- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)

LimitationsLimitations- Interference: bacterial overgrowth (alkaline or acidic),- Interference: bacterial overgrowth (alkaline or acidic),

“ “run over effect” effect of protein pad on pH indicator padrun over effect” effect of protein pad on pH indicator pad

Other TestsOther Tests- Titrable acidity- Titrable acidity

- Blood gases to determine acid-base status- Blood gases to determine acid-base status

Uses and Limitations of Urine pH Uses and Limitations of Urine pH DetectionDetection

GlucoseGlucoseGlucoseGlucose

BilirubinBilirubinBilirubinBilirubin

KetonesKetonesKetonesKetones

Specific GravitySpecific GravitySpecific GravitySpecific Gravity

BloodBloodBloodBlood

pHpHpHpH

ProteinProteinProteinProtein

UrobilinogenUrobilinogenUrobilinogenUrobilinogen

NitriteNitriteNitriteNitrite

Leukocyte EsteraseLeukocyte EsteraseLeukocyte EsteraseLeukocyte Esterase

Buffers from the protein area of Buffers from the protein area of the strip (pH 3.0) spill over to the the strip (pH 3.0) spill over to the pH area of the strip and make the pH area of the strip and make the pH of the sample appear more pH of the sample appear more acidic than it really is.acidic than it really is.

Buffers from the protein area of Buffers from the protein area of the strip (pH 3.0) spill over to the the strip (pH 3.0) spill over to the pH area of the strip and make the pH area of the strip and make the pH of the sample appear more pH of the sample appear more acidic than it really is.acidic than it really is.

pH Run Over EffectpH Run Over Effect


TraceTraceTraceTrace




++++ (2000 mg/dL)++++ (2000 mg/dL)++++ (2000 mg/dL)++++ (2000 mg/dL)

The Urine The Urine Dipstick:Dipstick: ProteinProtein


HHHH

HH

HH

HHHH

PrPrPrPr

PrPr

PrPr

PrPrPrPr

““Protein Error of Indicators Method”Protein Error of Indicators Method”

PrPr PrPr

PrPr

PrPrPrPr

PrPr

Tetrabromphenol BlueTetrabromphenol Blue(buffered to pH 3.0)(buffered to pH 3.0)

HH++

HH++

HH++HH++

HH++ HH++


FunctionalFunctional RenalRenal- Severe muscular exertion- Severe muscular exertion - Glomerulonephritis- Glomerulonephritis

- Pregnancy- Pregnancy - Nephrotic syndrome- Nephrotic syndrome

- Orthostatic proteinuria- Orthostatic proteinuria - Renal tumor or infection- Renal tumor or infection

Pre-RenalPre-Renal Post-RenalPost-Renal- Fever- Fever - Cystitis- Cystitis

- Renal hypoxia- Renal hypoxia - Urethritis or prostatitis- Urethritis or prostatitis

- Hypertension- Hypertension - Contamination with - Contamination with vaginal vaginal secretions secretions

Causes of Causes of ProteinuriaProteinuria

PrimaryPrimary- Lipoid nephrosis (severe)- Lipoid nephrosis (severe)

- Membranous glomerulonephritis- Membranous glomerulonephritis

- Membranoproliferative glomerulonephritis- Membranoproliferative glomerulonephritis

SecondarySecondary- Diabetes mellitus (Kimmelsteil-Wilson lesions)- Diabetes mellitus (Kimmelsteil-Wilson lesions)

- Systemic lupus erythematosus- Systemic lupus erythematosus

- Amyloidosis and other infiltrative diseases- Amyloidosis and other infiltrative diseases

- Renal vein thrombosis- Renal vein thrombosis

Nephrotic Syndrome (> 3.5 g/dL in Nephrotic Syndrome (> 3.5 g/dL in 24 h)24 h)

SignificanceSignificance- Proteinuria and the nephrotic syndrome.- Proteinuria and the nephrotic syndrome.

LimitationsLimitations- Interference: highly alkaline urine.- Interference: highly alkaline urine.- Much more sensitive to albumin than other proteins- Much more sensitive to albumin than other proteins

(e.g., immunoglobulin light chains).(e.g., immunoglobulin light chains).

Other TestsOther Tests- Sulfosalicylic acid (SSA) turbidity test.- Sulfosalicylic acid (SSA) turbidity test.- Urine protein electrophoresis (UPEP)- Urine protein electrophoresis (UPEP)- Bence Jones protein- Bence Jones protein

Uses and Limitations of Urine Protein Uses and Limitations of Urine Protein DetectionDetection

ProteinProtein % of Total% of Total Daily MaximumDaily Maximum

AlbuminAlbumin 40%40% 60 mg60 mg

Tamm-HorsfallTamm-Horsfall 40%40% 60 mg60 mg

ImmunoglobulinsImmunoglobulins 12%12% 24 mg24 mg

Secretory IgASecretory IgA 3%3% 6 mg6 mg

OtherOther 5%5% 10 mg10 mg

TOTALTOTAL 100%100% 150 mg150 mg

Proteins in “Normal” UrineProteins in “Normal” Urine

0.2 mg/dL0.2 mg/dL0.2 mg/dL0.2 mg/dL

1 mg/dL1 mg/dL1 mg/dL1 mg/dL




The Urine The Urine Dipstick:Dipstick: UrobilinogenUrobilinogen

Urobilinogen + DiethylaminobenzaldehydeUrobilinogen + Diethylaminobenzaldehyde

------->-------> Colored Complex Colored Complex(Ehrlich’s Reagent)(Ehrlich’s Reagent)


Read at 60 secondsRead at 60 secondsRR: 0.02-1.0 mg/dLRR: 0.02-1.0 mg/dL

SignificanceSignificance- High: increased hepatic processing of bilirubin- High: increased hepatic processing of bilirubin- Low: bile obstruction- Low: bile obstruction

LimitationsLimitations- Interference: prolonged exposure of specimen to oxygen - Interference: prolonged exposure of specimen to oxygen (urobilinogen (urobilinogen --->---> urobilin) urobilin)- Cannot detect low levels of urobilinogen- Cannot detect low levels of urobilinogen

Other TestsOther Tests- Serum total and direct bilirubin- Serum total and direct bilirubin

Uses and Limitations of Urobilinogen Uses and Limitations of Urobilinogen DetectionDetection


PositivePositivePositivePositive

The Urine The Urine Dipstick:Dipstick: NitriteNitrite

Diazo compound + TetrahydrobenzoquinolinolDiazo compound + Tetrahydrobenzoquinolinol---------->----------> Colored Complex Colored Complex

Nitrite + p-arsenilic acid Nitrite + p-arsenilic acid ------->-------> Diazo compound Diazo compoundAcidicAcidic



SignificanceSignificance- Gram negative bacteriuria- Gram negative bacteriuria

LimitationsLimitations- Interference: bacterial overgrowth- Interference: bacterial overgrowth

- Only able to detect bacteria that reduce nitrate to nitrite- Only able to detect bacteria that reduce nitrate to nitrite

Other TestsOther Tests- Correlate with leukocyte esterase and- Correlate with leukocyte esterase and

- Urine microscopic examination (bacteria)- Urine microscopic examination (bacteria)

- Urine culture- Urine culture

Uses and Limitations of Nitrite DetectionUses and Limitations of Nitrite Detection

NegativeNegative

TraceTrace

+ (weak)+ (weak)

++ (moderate)++ (moderate)

+++ (strong)+++ (strong)

The Urine The Urine Dipstick:Dipstick: Leukocyte Leukocyte

EsteraseEsterase

Derivatized pyrrole amino acid ester

------------> 3-hydroxy-5-phenyl pyrroleEsterases

3-hydroxy-5-phenyl pyrrole + diazo salt-------------> Colored Complex

Read at 2 minutesRR: Negative

Analytic Sensitivity: 3-5 WBCs

Chemical Principle

SignificanceSignificance- Pyuria- Pyuria- Acute inflammation- Acute inflammation- Renal calculus- Renal calculus

LimitationsLimitations- Interference: oxidizing agents, menstrual contamination- Interference: oxidizing agents, menstrual contamination

Other TestsOther Tests- Urine microscopic examination (WBCs and bacteria)- Urine microscopic examination (WBCs and bacteria)- Urine culture- Urine culture

Uses and Limitations of Leukocyte Esterase Uses and Limitations of Leukocyte Esterase DetectionDetection

PreservationPreservation- Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp.- Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp.- Refrigeration for up to 48 hours (little loss of cells).- Refrigeration for up to 48 hours (little loss of cells).

Specimen concentrationSpecimen concentration- Ten to twenty-fold concentration by centrifugation.- Ten to twenty-fold concentration by centrifugation.

Types of microscopyTypes of microscopy- Phase contrast microscopy- Phase contrast microscopy- Polarized microscopy- Polarized microscopy- Bright field microscopy with special staining- Bright field microscopy with special staining (e.g., Sternheimer-Malbin stain)(e.g., Sternheimer-Malbin stain)

Microscopic Microscopic ExaminationExamination General AspectsGeneral Aspects

Microscopic Microscopic ExaminationExamination

Per High Power Field (HPF) (400x)Per High Power Field (HPF) (400x)– > 3 erythrocytes> 3 erythrocytes

– > 5 leukocytes> 5 leukocytes

– > 2 renal tubular cells> 2 renal tubular cells

– > 10 bacteria> 10 bacteria

Per Low Power Field (LPF) (200x)Per Low Power Field (LPF) (200x)– > 3 hyaline casts or > 1 granular cast> 3 hyaline casts or > 1 granular cast

– > 10 squamous cells (indicative of contaminated specimen)> 10 squamous cells (indicative of contaminated specimen)

– Any other cast (RBCs, WBCs)Any other cast (RBCs, WBCs)

Presence of:Presence of:– Fungal hyphae or yeast, parasite, viral inclusionsFungal hyphae or yeast, parasite, viral inclusions

– Pathological crystals (cystine, leucine, tyrosine)Pathological crystals (cystine, leucine, tyrosine)

– Large number of uric acid or calcium oxalate crystalsLarge number of uric acid or calcium oxalate crystals

Abnormal Abnormal FindingsFindings

ErythrocytesErythrocytes- “Dysmorphic” vs. “normal”- “Dysmorphic” vs. “normal” (> 10 per HPF)(> 10 per HPF)

LeukocytesLeukocytes- Neutrophils (glitter cells)- Neutrophils (glitter cells) More than 1 per 3 HPFMore than 1 per 3 HPF- Eosinophils- Eosinophils Hansel test (special stain)Hansel test (special stain)

Epithelial CellsEpithelial Cells- Squamous cells- Squamous cells Indicate level of contaminationIndicate level of contamination- Renal tubular epithelial cells- Renal tubular epithelial cells Few are normalFew are normal- Transitional epithelial cells- Transitional epithelial cells Few are normalFew are normal

- Oval fat bodies- Oval fat bodies Abnormal, indicate NephrosisAbnormal, indicate Nephrosis

Microscopic Microscopic ExaminationExamination CellsCells

Microscopic Microscopic ExaminationExamination RBCsRBCs

Microscopic Microscopic ExaminationExamination WBCsWBCs

Microscopic Microscopic ExaminationExamination Squamous CellsSquamous Cells

Microscopic Microscopic ExaminationExamination Tubular Epithelial Tubular Epithelial

CellsCells

Microscopic Microscopic ExaminationExamination Transitional CellsTransitional Cells

Microscopic Microscopic ExaminationExamination Oval Fat BodyOval Fat Body

Microscopic Microscopic ExaminationExamination LE CellLE Cell

BacteriaBacteria-- BacteriuriaBacteriuria More than 10 per HPFMore than 10 per HPF

YeastsYeasts- Candidiasis- Candidiasis Most likely a Most likely a contaminantcontaminantbut should correlate withbut should correlate withclinical picture.clinical picture.

VirusesViruses-- CMV inclusionsCMV inclusions Probable viral cystitis.Probable viral cystitis.

Microscopic Microscopic ExaminationExamination Bacteria & YeastsBacteria & Yeasts

Microscopic Microscopic ExaminationExamination BacteriaBacteria

Microscopic Microscopic ExaminationExamination YeastsYeasts

Microscopic Microscopic ExaminationExamination CytomegalovirusCytomegalovirus

Erythrocyte Casts:Erythrocyte Casts: Glomerular diseasesGlomerular diseases

Leukocyte Casts:Leukocyte Casts: Pyuria, glomerular diseasePyuria, glomerular disease

Degenerating Casts:Degenerating Casts:- Granular casts- Granular casts Nonspecific (Tamm-Horsfall Nonspecific (Tamm-Horsfall protein)protein)- Hyaline casts- Hyaline casts Nonspecific (Tamm-Horsfall Nonspecific (Tamm-Horsfall protein)protein)- Waxy casts- Waxy casts NonspecificNonspecific- Fatty casts- Fatty casts Nephrotic syndromeNephrotic syndrome (oval fat body casts)(oval fat body casts)

Microscopic Microscopic ExaminationExamination CastsCasts

Microscopic Microscopic ExaminationExamination CastsCasts

Microscopic Microscopic ExaminationExamination RBCs Cast - RBCs Cast -

HistologyHistology

Microscopic Microscopic ExaminationExamination RBCs CastRBCs Cast

Microscopic Microscopic ExaminationExamination RBCs Cast - RBCs Cast -

HistologyHistology

Microscopic Microscopic ExaminationExamination WBCs CastWBCs Cast

Microscopic Microscopic ExaminationExamination Tubular Epith. CastTubular Epith. Cast

Microscopic Microscopic ExaminationExamination Granular CastGranular Cast

Microscopic Microscopic ExaminationExamination Hyaline CastHyaline Cast

Microscopic Microscopic ExaminationExamination Waxy CastWaxy Cast

Microscopic Microscopic ExaminationExamination Fatty CastFatty Cast

Bacterial CastsBacterial CastsBacterial CastsBacterial Casts

Single LeukocytesSingle LeukocytesSingle LeukocytesSingle Leukocytes

Leukocyte CastsLeukocyte CastsLeukocyte CastsLeukocyte Casts

Verrier-Jones & Asscher, 1991.Verrier-Jones & Asscher, 1991.

Single ErythrocytesSingle ErythrocytesSingle ErythrocytesSingle Erythrocytes

Erythrocyte CastsErythrocyte CastsErythrocyte CastsErythrocyte Casts

Single BacteriaSingle BacteriaSingle BacteriaSingle Bacteria

Significance of Cellular Significance of Cellular CastsCasts

- Urate- UrateAmmonium biurateAmmonium biurateUric acidUric acid

- Triple Phosphate- Triple Phosphate- Calcium Oxalate- Calcium Oxalate- - Amino AcidsAmino Acids

CystineCystineLeucineLeucineTyrosineTyrosine

- Sulfonamide- Sulfonamide

Microscopic Microscopic ExaminationExamination CrystalsCrystals

Microscopic Microscopic ExaminationExaminationCalcium Oxalate CrystalsCalcium Oxalate Crystals

Microscopic Microscopic ExaminationExaminationCalcium Oxalate CrystalsCalcium Oxalate Crystals

Dumbbell Dumbbell Shape Shape

Microscopic Microscopic ExaminationExaminationTriple Phosphate CrystalsTriple Phosphate Crystals

Microscopic Microscopic ExaminationExamination Urate CrystalsUrate Crystals

Microscopic Microscopic ExaminationExamination Leucine CrystalsLeucine Crystals

Microscopic Microscopic ExaminationExamination Cystine CrystalsCystine Crystals

Microscopic Microscopic ExaminationExamination Ammonium Biurate Ammonium Biurate

CrystalsCrystals

Microscopic Microscopic ExaminationExamination Cholesterol CrystalsCholesterol Crystals

Cytological ExaminationCytological Examination

Staining:Staining:

– PapanicolauPapanicolau– Wright’sWright’s– ImmunoperoxidaseImmunoperoxidase– ImmunofluorescenceImmunofluorescence

Cytology: NormalCytology: Normal

Cytology: ReactiveCytology: Reactive

Cytology: PolyomaCytology: Polyoma (Decoy (Decoy Cell)Cell)

Cytology: PolyomaCytology: Polyoma (Decoy (Decoy Cell)Cell)Immunoperoxidase to SV40 agImmunoperoxidase to SV40 ag

Cytology: TCC Low Cytology: TCC Low GradeGrade

Cytology: TCC High Cytology: TCC High GradeGrade

Cytology: Squamous Cell Cytology: Squamous Cell Ca.Ca.

Cytology: Renal Cell Ca.Cytology: Renal Cell Ca.

Cytology: Prostatic Cytology: Prostatic CarcinomaCarcinoma

Disease DiagnosisDisease Diagnosis

UrinalysiUrinalysiss

A 35-year old man undergoing routine pre A 35-year old man undergoing routine pre employment drug screening.employment drug screening.

Physical characteristics: Clear.Physical characteristics: Clear.Microscopic: Microscopic: Not performed.Not performed.Drugs Identified: Drugs Identified: None.None.

Questions:Questions:

- What is your differential diagnosis?- What is your differential diagnosis?- What would you do next to confirm your - What would you do next to confirm your suspicion?suspicion?- Would you order a microscopic analysis - Would you order a microscopic analysis on this sample?on this sample?

A 35-year old man undergoing routine pre A 35-year old man undergoing routine pre employment drug screening.employment drug screening.

Physical characteristics: Clear.Physical characteristics: Clear.Microscopic: Microscopic: Not performed.Not performed.Drugs Identified: Drugs Identified: None.None.


- What is your differential diagnosis?- What is your differential diagnosis?- What would you do next to confirm your - What would you do next to confirm your suspicion?suspicion?- Would you order a microscopic analysis - Would you order a microscopic analysis on this sample?on this sample?

NegativeNegative

NegativeNegative

NegativeNegative

1.0011.001

NegativeNegative

5.55.5

NegativeNegative

0.2 mg/dL0.2 mg/dL

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein


NitriteNitrite

L.E.L.E.

Diluted urine, request a voided urine in the morningDiluted urine, request a voided urine in the morningIf persisting low SG, possible diabetes insipidaIf persisting low SG, possible diabetes insipida

A microscopic may give negative resultsA microscopic may give negative results

Case Case 11

A 42-year old woman presents with “dark urine”A 42-year old woman presents with “dark urine”

Physical characteristics: Red-brown.Physical characteristics: Red-brown.Microscopic: Not performed.Microscopic: Not performed.


- What is your differential diagnosis?- What is your differential diagnosis?- Could this be a case of hemolytic anemia?- Could this be a case of hemolytic anemia?- How would you rule it out?- How would you rule it out?- What tests would you order next? Why?- What tests would you order next? Why?- Would you order a microscopic analysis?- Would you order a microscopic analysis?

A 42-year old woman presents with “dark urine”A 42-year old woman presents with “dark urine”

Physical characteristics: Red-brown.Physical characteristics: Red-brown.Microscopic: Not performed.Microscopic: Not performed.


- What is your differential diagnosis?- What is your differential diagnosis?- Could this be a case of hemolytic anemia?- Could this be a case of hemolytic anemia?- How would you rule it out?- How would you rule it out?- What tests would you order next? Why?- What tests would you order next? Why?- Would you order a microscopic analysis?- Would you order a microscopic analysis?

NegativeNegative

++++++

NegativeNegative

1.0201.020

NegativeNegative

5.55.5

NegativeNegative

0.2 mg/dL0.2 mg/dL

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein


NitriteNitrite

L.E.L.E.

Possible gallbladder or hepatic disease.Possible gallbladder or hepatic disease.No hemolytic anemia. Perform bilirubins in serumNo hemolytic anemia. Perform bilirubins in serum

Microscopic unlikely to provide additional infoMicroscopic unlikely to provide additional info

Case Case 22

A 42-year old man presents painful urinationA 42-year old man presents painful urination

Physical characteristics: dark red, turbidPhysical characteristics: dark red, turbidMicroscopic: leukocytes = 30 per HPFMicroscopic: leukocytes = 30 per HPFRBCs = >100 per HPFRBCs = >100 per HPFBacteria = >100 per HPFBacteria = >100 per HPF

Questions:Questions:- What is your suspected diagnosis?- What is your suspected diagnosis?- What would you do next?- What would you do next?- What do you make of the nitrite test?- What do you make of the nitrite test?- How would the microscopic exam differ if - How would the microscopic exam differ if

the S.G. were 1.003?the S.G. were 1.003?- Is this a common diagnosis for this type of - Is this a common diagnosis for this type of

patient?patient?

A 42-year old man presents painful urinationA 42-year old man presents painful urination

Physical characteristics: dark red, turbidPhysical characteristics: dark red, turbidMicroscopic: leukocytes = 30 per HPFMicroscopic: leukocytes = 30 per HPFRBCs = >100 per HPFRBCs = >100 per HPFBacteria = >100 per HPFBacteria = >100 per HPF

Questions:Questions:- What is your suspected diagnosis?- What is your suspected diagnosis?- What would you do next?- What would you do next?- What do you make of the nitrite test?- What do you make of the nitrite test?- How would the microscopic exam differ if - How would the microscopic exam differ if

the S.G. were 1.003?the S.G. were 1.003?- Is this a common diagnosis for this type of - Is this a common diagnosis for this type of

patient?patient?

NegativeNegative

NegativeNegative

NegativeNegative

1.0301.030

++++++

6.56.5

TraceTrace

1.0 mg/dL1.0 mg/dL

NegativeNegative

++++++

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein


NitriteNitrite

L.E.L.E.

Possible UTI, request culture and antibiotic sensitivityPossible UTI, request culture and antibiotic sensitivityNegative Nitrite test: Gram positive bacteriaNegative Nitrite test: Gram positive bacteria

Lower SG may show less number of cells and bacteriaLower SG may show less number of cells and bacteriaUn-common diagnosis in this type of patientUn-common diagnosis in this type of patient

Case Case 33

A 27-year old woman presents with severe A 27-year old woman presents with severe abdominal pain.abdominal pain.

Physical characteristics: clear-yellow.Physical characteristics: clear-yellow.Microscopic: Not performed.Microscopic: Not performed.

Questions:Questions:- What is the most likely diagnosis?- What is the most likely diagnosis?- What do you make of the ketone result?- What do you make of the ketone result?- What do you expect to happen to the ketone - What do you expect to happen to the ketone

measurement when treatment begins?measurement when treatment begins?

A 27-year old woman presents with severe A 27-year old woman presents with severe abdominal pain.abdominal pain.

Physical characteristics: clear-yellow.Physical characteristics: clear-yellow.Microscopic: Not performed.Microscopic: Not performed.

Questions:Questions:- What is the most likely diagnosis?- What is the most likely diagnosis?- What do you make of the ketone result?- What do you make of the ketone result?- What do you expect to happen to the ketone - What do you expect to happen to the ketone

measurement when treatment begins?measurement when treatment begins?

++++++++


TraceTraceTraceTrace

1.0151.0151.0151.015


6.06.06.06.0


1.0 mg/dL1.0 mg/dL1.0 mg/dL1.0 mg/dL



GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


DiabetesDiabetesMay be decompensated and with ketoacidosisMay be decompensated and with ketoacidosis

Ketones should become negative after treatmentKetones should become negative after treatment

Case Case 44

NegativeNegative

NegativeNegative

NegativeNegative

1.0151.015

++++++

6.56.5

++

1.0 mg/dL1.0 mg/dL

NegativeNegative

NegativeNegative

8-year old boy presents with discolored urine8-year old boy presents with discolored urine

Physical characteristics: Red, turbid.Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF Microscopic: erythrocytes = >100 per HPF

(almost all dysmorphic)(almost all dysmorphic)Red cell casts present.Red cell casts present.

Questions:Questions:- What is the most likely diagnosis in this - What is the most likely diagnosis in this

case?case?- Does the presence of red cell casts help you - Does the presence of red cell casts help you

in any way?in any way?- If the erythrocytes were not dysmorphic - If the erythrocytes were not dysmorphic

would that change your diagnosis?would that change your diagnosis?

8-year old boy presents with discolored urine8-year old boy presents with discolored urine

Physical characteristics: Red, turbid.Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF Microscopic: erythrocytes = >100 per HPF

(almost all dysmorphic)(almost all dysmorphic)Red cell casts present.Red cell casts present.

Questions:Questions:- What is the most likely diagnosis in this - What is the most likely diagnosis in this

case?case?- Does the presence of red cell casts help you - Does the presence of red cell casts help you

in any way?in any way?- If the erythrocytes were not dysmorphic - If the erythrocytes were not dysmorphic

would that change your diagnosis?would that change your diagnosis?

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


Case Case 55

GlomerulonephritisGlomerulonephritisRBC casts reveals renal cortex involvementRBC casts reveals renal cortex involvement

RBC cast are not always present in GNRBC cast are not always present in GN

NegativeNegative

NegativeNegative

NegativeNegative

1.0101.010

NegativeNegative

5.05.0

++

0.2 mg/dL0.2 mg/dL

NegativeNegative

NegativeNegative

22-year old man presenting for a routine 22-year old man presenting for a routine physical required for admission to medical physical required for admission to medical schoolschool

Physical characteristics: YellowPhysical characteristics: YellowMicroscopic: Not performedMicroscopic: Not performed

Questions:Questions:- What is your differential diagnosis?- What is your differential diagnosis?- Would you order a microscopic analysis on - Would you order a microscopic analysis on this sample?this sample?

- What would you do next to confirm the - What would you do next to confirm the diagnosis?diagnosis?

22-year old man presenting for a routine 22-year old man presenting for a routine physical required for admission to medical physical required for admission to medical schoolschool

Physical characteristics: YellowPhysical characteristics: YellowMicroscopic: Not performedMicroscopic: Not performed

Questions:Questions:- What is your differential diagnosis?- What is your differential diagnosis?- Would you order a microscopic analysis on - Would you order a microscopic analysis on this sample?this sample?

- What would you do next to confirm the - What would you do next to confirm the diagnosis?diagnosis?

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


Case Case 66

““Functional” proteinuria?Functional” proteinuria?Microscopic may reveal a few leukocytesMicroscopic may reveal a few leukocytes

Request protein concentration in 24 h urineRequest protein concentration in 24 h urine

Common Findings in:Common Findings in:Acute Tubular Acute Tubular NecrosisNecrosis

DecreasedDecreased

+ / -+ / -

+ / -+ / -

Microscopic:Microscopic:

• Renal tubular epithelial cellsRenal tubular epithelial cells• Pathological castsPathological casts


• Renal tubular epithelial cellsRenal tubular epithelial cells• Pathological castsPathological casts

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


IncreasedIncreased

IncreasedIncreased


• Erythrocytes (dysmorphic)Erythrocytes (dysmorphic)• Erythrocyte castsErythrocyte casts• Mixed cellular castsMixed cellular casts


• Erythrocytes (dysmorphic)Erythrocytes (dysmorphic)• Erythrocyte castsErythrocyte casts• Mixed cellular castsMixed cellular casts

Common Findings in:Common Findings in:Acute Acute GlomerulonephritisGlomerulonephritis

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


DecreasedDecreased

IncreasedIncreased

IncreasedIncreased

Common Findings in:Common Findings in:Chronic Chronic GlomerulonephritisGlomerulonephritis

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.



• Pathological castsPathological casts(broad waxy casts, RBCs)(broad waxy casts, RBCs)


• Pathological castsPathological casts(broad waxy casts, RBCs)(broad waxy casts, RBCs)

TraceTrace

PositivePositive

PositivePositive


• BacteriaBacteria• LeukocytesLeukocytes• Leukocyte, granular, andLeukocyte, granular, and

waxy castswaxy casts• Renal tubular epithelialRenal tubular epithelial

cell castscell casts


• BacteriaBacteria• LeukocytesLeukocytes• Leukocyte, granular, andLeukocyte, granular, and

waxy castswaxy casts• Renal tubular epithelialRenal tubular epithelial

cell castscell casts

Common Findings in:Common Findings in:Acute PyelonephritisAcute Pyelonephritis

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


++++++++


• Oval fat bodiesOval fat bodies• Fatty castsFatty casts• Waxy castsWaxy casts


• Oval fat bodiesOval fat bodies• Fatty castsFatty casts• Waxy castsWaxy casts

Common Findings in:Common Findings in:Nephrotic SyndromeNephrotic Syndrome

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


++

Common Findings in:Common Findings in:Eosinophilic CystitisEosinophilic Cystitis


• Numerous eosinophilsNumerous eosinophils(Hansel’s stain)(Hansel’s stain)

• NO significant casts.NO significant casts.


• Numerous eosinophilsNumerous eosinophils(Hansel’s stain)(Hansel’s stain)

• NO significant casts.NO significant casts.

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


Common Findings in:Common Findings in:Urothelial CarcinomaUrothelial Carcinoma


• Malignant cells on Malignant cells on urine cytology urine cytology (urine (urine sample should be submitted sample should be submitted separately to cytology, void separately to cytology, void or 24 hrs.)or 24 hrs.)


• Malignant cells on Malignant cells on urine cytology urine cytology (urine (urine sample should be submitted sample should be submitted separately to cytology, void separately to cytology, void or 24 hrs.)or 24 hrs.)

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.


++

Acknowledgment:Acknowledgment:

Dr. Brad BrimhallDr. Brad Brimhall

Questions ?Questions ?

urin analysis

Education