HIGH YIELD REVIEWER FOR CLINPATH PRAX URINALYSIS • SPECIMEN COLLECTION Voided Urethral catheterization Midstream sterile rubbing tubing Clean catch (unable to void) 20-30ml risk for infection Suprapubic aspiration anaerobic culture, critical bacterial quantification infants • Preservatives: o Ref 4-6 C upto 8 hours o Chemical (antimicrobial): Toluene, formalin, thymol, chloroform Boric acid (for hormonal assay: estriol, estrogen) Na Fluoride (ideal for glucose) o 50% alcohol (1:1) for tumor cell evaluation in urine PARAMETERS Color NORMAL Pale yellow – amber (urochrome) Transparency Clear – Slight Hazy Volume (24 hr) Odor SG (Refractometer) (Urinometer) Newborn: 20-350 mL/24 hr Children: 750-1500 mL/24 hr Adult: 1250-1500 mL/24 hr Aromatic 1.016-1.022 Newborn: 1.012 Infants: 1.002-1.006 GROSS EXAMINATION ABNORMAL Yellow-brown = nitrofurantoin, metronidazole, primaquine, sulfonamide, liver disorder Orange-yellow = rifampin, warfarin, dihydroergotamine, b complex, carotene, dehydration, liver disorder Red/pink = doxorubicin, ibuprofen, salicylate, heparin, methyldopa, blackberry, beet, hemoglobinuria Hazy/cloudy: UTI Turbid: amorphous phosphate/urate, bacteria, blood, pus, mucus, epithelial cells, fat globules Polyuria: 2000 mL/24 hr Oliguria: <30 mL/hr or 500 mL/24 hr (influenced by disease, diet, bacteria) Hyposthenuric: low SG < 1.007 (Diabetes insipidus) Isosthenuric: severe renal damage 1.010 Hypersthenuric: high SG > 1.010 Indicates concentration of solids (urea, phosphate, chlorides), kidney’s concentrating & excretory ability (Indirect) Refractometer = 1-2 drops, easy, (Indirect) Reagent strip = based on pKa changes (Direct) Urinometer = >15 mL urine (correction factor for temp, protein, glucose) PARAMETER pH NORMAL 5.5-8.0 Protein ---------- PROTEIN ERROR OF INDICATORS Scanty CHEMICAL ANALYSIS PRINCIPLE >7 = Alkaline <7 = Acidic Double indicator REAGENT STRIP (most widely used: albumin only) Fixed pH level ACID PPT (confirm) Protein denaturation Sulfosalicylic acid, Acetic acid, Nitric acid 2cc urine Negative, Trace, 1+ (Fine cloudy), 2+ (granular cloudy), 3+ (dense cloudy), 4+ (heavy ppt to solid coagulum) INTERPRETATION Influenced by diet, renal disease, metabolic disease, drugs Alkaline pH = Bacteria, UTI, Vegetarian, CRF, citrus fruit Acidic Ph = High Protein, uncontrolled DM, diarrhea, starvation, dehydration, metab/respi acidosis Proteinuria > 150 mg/24 hr = renal disease Plasma protein Urinary tract protein (Tamm horsfall glycoprotein, IgA, enzyme, desquamated WBC) Bence jones protein: mixture of abnormal serum protein of LMW Multiple myeloma, lymphoma, macroglobulinemia Electrophoresis & immunophoresis Heat & Acid test: Glomerular membrane damage, impaired renal tubular absorption, MM, Diabetic preeclampsia, orthostatic/postural proteinuria nephropathy, BJP Electrophoresis & immunophoresis Glucose -------130 mg/24 hr 0.01-0.03 mg/100 mL REAGENT STRIP Double sequential enzyme reaction: Glucose oxidase & peroxidase Glucose + O2 → Gluconic acid + H2O2 H2O2 + O-toluidine (peroxidase, chromogen) → Oxidized O-toluidine + H2O COPPER REDUCTION TEST Benedict’s & Clinitest (blue) CuSo4 + reduced glucose → (yellow red) Cu2O + Oxidized glucose 8 drops urine + 5ml benedict’s reagent Bilirubin -------- Sample must be protected from light OXIDATION TEST Bilirubin → biliverdin BaCl2 PPT phosphates → concentrate bile pigment DIAZOTIZATION TEST (DIAZO) More specific, reagent strip FOUCHET’S TEST 2 drop urine on filter paper + 1 drop 10% BaCl2 + 1 drop Fouchet Urobilinogen Ketone bodies 0.5 – 2.5 unit/ 24hr -------125 mg/24hr EHRLICH’S ALDEHYDE TEST 5 cc urine + 7 drops ehrlich aldehyde reagent = 5 min (colorless) → (red-purple) Fresh urine (ketosis) Acetoacetic acid > B-OHbutyric acid > acetone Standing: Metabolic end products of FA metabolism Acetone > acetoacetic acid & B-OHbutyric acid ROTHERA’S TEST 5 ml urine + ammonium sulfate crystal Saturate then add 2 drops Na nitroprusside Overly with ammonium hydroxide (+) Red-purple ring = acetone Nitrite reduction Nitrite Leukocyte esterase Blood Granulocyte esterase reduction Glycosuria > 180-200 mg/dL False (+): Strongly oxidizing cleaning agent (bleach, peroxide) False (-): NaF preservative False (-): large Qty of homogentistic acid & ascorbic acid Benedict’s test: DM, Impaired tubular reabsorption, CNS damage, thyroid disorder, GDM (-) Blue = none (Trace) Pale green 1+ Greenish ppt = traces of reducing sugar 2+ Yellow orange ppt 3+ orange red ppt = moderate 4+ Brick-red ppt = large amount of reducing sugar Bilirubinuria OXIDATION TEST (+) Green; interfered by salicylate, phenazopyridine (purple) DIAZOTIZATION TEST 2,4-Dichloroaniline = colored brown by bilirubin FOUCHET’S (HARRISON’S SPOT) (+) Blue green ppt Hepatic cirrhosis, biliary obstruction Liver disease, hemolytic disorder Don’t expose to light Acetoacetic acid, beta-hydroxybutyric acid, acetone Liver glycogen depletion → arrested oxidation of ketone compounds → ketosis In Glucose (+) urine, always test for ketone bodies ROTHERA’S TEST Diabetic ketoacidosis, starvation, excessive carbs loss Starvation UTI (+) = G(-) rods = E.coli, Klebsiella, Enterobacter, proteus UTI (+) = presence of WBC PSEUDOPEROXIDASE activity of Hb WBC • Normal : Male = 0-1/hpf Female = 1-5/hpf • INC WBC = PYURIA • Granular with visible nucleus MICROSCOPIC ANALYSIS RBC • Normal : Male = 0-2/hpf Female = 3-5/hpf • Highly refractive, round, yellowish, anucleated • Not fresh: faint, colorless circles/disc RBC Look-alike • Oil droplets: highly refractive, variable size • Yeast cells: budding Dilute acetic acid: dissolves RBC CASTS: Translucent cylindrical structure w/parallel sides & blunt round ends Formed in renal tubules (protein accumulation & precipitation) CELLULAR GRANULAR HYALINE (0-2 /LPO) WAXY • Contain RBC, WBC, epithelial cells in protein • Contain remnants of • Occasionally present • Rare, final phase of dissolution disintegrated cells in normal urine of granular casts RBC glomerular lesion/ renal casts parenchymal bleeding • Fine/ coarse granules • Mild renal damage • Blunted edges, cracks, chronic renal autograph rejection, tubular WBC renal parenchymal infection • Embedded in protein • Exercise, fever, CHF, inflammation, degeneration casts (tubule-interstitial disease) diuretic tx • Indicate serious damage • high refractive index = easily visualized PYELONEPHRITIS • Tamm horsfall • Glomerulonephritis • RENAL FAILURE CASTS Epithelial renal allograph rejection, • Pathologic > 2/LPF • Pyelonephritis • Advance tubular atrophy casts acute tubular necrosis, virus, • Hyaline matrix + granules heavy metal poisoning • Dilatation of ESRD EPITHELIAL CELLS: normal sloughing of aging cells TRANSITIONAL CELLS RENAL TUBULAR EPITHELIAL CELL Cells lining renal pelvis, bladder, upper male urethra Oblong/ egg shaped cells Round/pear shaped Coarsely granular cytoplasm Round & centrally located cytoplasm Most clinically significant epithelium Vacuole and irregular nuclei Oval fat bodies = renal tubular cells absorbing lipoprotein with cholesterol leaking from nephrotic glomeruli. (Lipiduria) Polarized light = maltese cross formation Rare, few, moderate per hpf. Abnormal crystals: averaged per lpf ACIDC URINE ALKALINE URINE Amorphous Yellow brown granules Amorphous Thorny apples (irregular spines) urate Clumps: resemble granular casts biurates Yellowish, opaque, spheroidal bodies Refrigerated specimen Old specimen Pink sediment +/- ammonia (urea splitting bacteria) Calcium Looks like envelopes with X intersection (envelope) Amorphous Colorless amorphous oxalate Most common: Dihydrate (Colorless, octahedral, referactive) phosphate Granular masses less common: monohydrate (dumbbell, oval) Cause white PPT high potential for renal stone formation Doesn’t dissolve on warming Post-refrigeration Uric acid Shapes: rhombic, whetstone (4-sided flat), wedges, rosettes INC purines & nucleic acids Calcium Small, colorless, dumbbell, spherical Leukemia receiving chemotherapy carbonate Clumps: resemble amorphous Lesch Nyhan syndrome Distinguished by adding acetic acid: Gout (+) gas formation Triple Colorless, highly refractile prisms phosphate Birefringent, alkaline urine (Ammonium Mg 3-6 sides phosphate) Urea splitting bacteria UTI Coffin lid crystals, rosette shape Calcium Pointing finger forms phosphate Not much significance SQUAMOUS CELLS Most common cell lining urethra Largest cell in normal urine, flat Distinct small nucleus, much cytoplasm OTHER CRYSTALS Bilirubin Hepatic disorder Sodium urates Sulfonamide Inadequate hydration UTI treatment Cholesterol Cystine Leucine Tyrosine PLEURAL ABNORMAL CRYSTALS Colorless, flat plate with notched corners Nephrotic syndrome Refrigerated specimen (lipids remain in droplet form) Colorless, refractile, flat hexagonal, Undequal sides Cystinuria Metabolic disorder: prevent reabsorption of cysteine by renal tubules Yellow-brown spheres: concentric circles & radial striation Less frequent than tyrosine crystal (should be accompanied by tyrosine) Liver disease Fine colorless to yellow needles Clumps/ rosette formation: sheaves In conjunction with leucine crystals and (+) bilirubin (chemically) Liver disease, inherited AA metabolism disorder SEROUS FLUID PERICARDIAL 10-50 mL Pale yellow, clear viral infection Light’s criteria applicable cell count, cytology glucose, LDH, G/S, culture PERITONEAL • 5-15 mL • • up to 50 mL • Light’s criteria (exudate): • • ascites > 50 mL o protein ratio > 0.5 • • CHF, Cirrhosis, hypoproteinemia, infection, neoplasm o LDH ratio > 0.6 • • ascites > 1.1 g/dL albumin gradient (transudate) o LDH >2/3 serum upper limit • • ascites < 1.1 g/dL albumin gradient (exudate) • Chemical analysis: protein, lactate, glucose, • • paracentesis, peritoneal dialysis lipid, pH, amylase, serology, tumor marker • • gross exam, wbc cytology & count, culture • Microbiological: G/S, AFB Transudate (clear, pale yellow-straw, odorless, unclotted) Exudate (cloudy, turbid, clotted if not heparinized) • • • • • • • • CSF (3rd major body fluid) supply nutrients, remove metabolic waste, mechanical barrier produced by choroid plexus & reabsorbed by arachnoid villi Adult 90-150 mL; Neonate 10-60 mL Collection: Fetal position L3-L5 (ICP 90-180 mmH2O; 20 mL can be removed) 2-4 mL = Tube 1 (chemical, serology), Tube 2 (microbio), Tube 3 (cell count) LP indication: infection, malignancy, SAH, demyelinating disease GROSS/MACROSCOPIC CHEMICAL MICROSCOPIC NV = clear and colorless • NV = • Turbid = similar to water Protein 15-45 mg/dL Pink/red = RBC > 6000 (Hemorrhage/traumatic tap) • Cloudy/turbid = WBC > 200; RBC > 400, protein > 150, microorganism, radiocontrast dye Xanthochromic: RBC lysis, Hb breakdown, hyperBIL, • INC protein = INC permeability in BBB, • lymphocyte : monocyte (70:30) hyperVIT A, melanoma meningitis, INC Ig Cloudy, milky, turbidity = lipid protein WBC • Pleocytosis: INC WBC in lymphocyte False (+) turbidity = long standing specimen/ detergent • Nephelometry • Normal wbc in adult = 0-5 (neonate 0-30) • CSF: serum albumin • normal rbc = 0 contamination ratio < 9 (intact BBB) Clot/pellicle = traumatic tap, froin’s syndrome, tb • Neutrophilia: bacterial meningitis, early infection (TB, fungal, viral meningitis), cerebral abscess, CNS • DEC protein = removal meningitis (web like) hemorrhage/ infarct, seizure, repeated LP, radiographic dye /leak of CSF Traumatic = uneven blood distribution, clot formation • Lymphocytosis: TB, fungal, viral meningitis, MS, GBS, Hemorrhage = even distribution, hemosiderin laden • DEC Glucose = bacteria macrophages, erythrophagocytosis, xanthochromic supernatant SSPE, Eosinophilia