INTERPRETATION OF URINALYSIS BY DR. ONUORAH PRINCESS .pptx

Physical, microscopic and chemical examination of urine explained in this well detailed slide. Urine analysis also referred to by some people as a poor man’s kidney biopsy.

1. INTERPRETATION OF URINALYSIS BY DR. ONUORAH PRINCESS CHINENYE CARDIOLOGY 2 UNIT DEPARTMENT OF INTERNAL MEDICINE Federal MEDICAL CENTRE,UMUAHIA. 5 TH JUNE, 2024.

2. OUTLINE Introduction/Definition. How Is Urinalysis Done? Brief Anatomy And Function Of The Urinary System. Urine Formation. Composition Of Normal Urine In Adults. Indications For Urinalysis. Collection Of Urine: Methods Of Urine Collection .

3. OUTLINE CONT’D Changes That Occur In Room Temperature After Prolonged Standing. Preservation Of Urine Sample. Urinalysis Interpretation Proper. Physical Examination Of Urine. Chemical Examination Of Urine. Microscopic Examination Of Urine. Conclusion. References.

4. INTRODUCTION The Clinical and Laboratory Standards Institute[CLSI] defines urinalysis as “the testing of urine with procedures commonly performed in an expeditious, reliable, accurate, safe, and cost-effective manner ”. Urinalysis (UA) is a simple, non-invasive diagnostic tool that examines the visual, chemical, and microscopic properties of one’s urine.

5. INTRODUCTION CONT’D A very common test that can be performed in many health care settings. Some physicians refer to urinalysis as ‘a poor man’s kidney biopsy’ because of the plethora of information that can be obtained about the health of the kidney or other internal diseases by this simple test. It is a renal function test. In general, urinalysis is easily available and relatively inexpensive.

6. HOW IS URINALYSIS DONE? During a urinalysis, a urine sample is collected into a specimen cup and analyzed. The first part of a urinalysis involves direct observation to assess the volume, color, clarity and odo u r of the urine .

7. CONT’D Next, the urine is analyzed using chemical tests to detect certain substances like glucose, protein ,ketone bodies etc. The final step of a urinalysis is microscopic exam, which is traditionally performed manually on a sediment from a centrifuged urine sample.

8. BRIEF ANATOMY AND FUNCTION OF THE URINARY SYSTEM The urinary system is composed of a pair of kidneys, a pair of ureters, a bladder, and a urethra . These components together carry out the urinary system’s function of regulating the volume and composition of body fluids, removing waste products from the blood, and expelling the waste and excess water from the body in the form of urine.

9. CONT’D The kidneys are located behind the peritoneum, and so are called retroperitoneal organs. They sit in the back of the abdomen between the levels of the T12 and L3 vertebrae. The right kidney is slightly lower than the left kidney to accommodate the liver.

10. CONT’D Both kidneys are bean shaped and about the size of an adult fist. The kidneys contain microscopic filtering units that remove waste, unwanted minerals, and excess water from the blood as urine. Each kidney is connected to the bladder by a tube called a ureter, which transports urine away.

11. URINE FORMATION The nephron is the functional unit of the kidney. Each nephron has a glomerulus, the site of blood filtration. The glomerulus is a network of capillaries surrounded by a cuplike structure, the glomerular capsule (or Bowman’s capsule).

12. CONT’D As blood flows through the glomerulus, blood pressure pushes water and solutes from the capillaries into the capsule through a filtration membrane. This glomerular filtration begins the urine formation process.

13. URINE FORMATION

14. COMPOSITION OF NORMAL URINE IN ADULTS PARAMETERS VALUES 1 Volume 600-2000ml 2 Specific gravity 1.005-1.030 3 Osmolality 300-900mOsm/kg 4 pH 4.6-8.0 5 Glucose <0.5gm 6 Proteins <150mg 7 Urobilinogen 0.5-4.0gm 8 Porphobilinogen 0.2mg

15. PARAMETERS VALUES 9 Creatinine M; 14-26mg/kg F; 11-20mg/kg 10 Urea Nitrogen 12-20gm 11 Uric Acid 250-750mg 12 Sodium 40-200mEq 13 Potassium 25-125mEq 14 Chloride 110-250mEq 15 Calcium[low calcium diet] 50-150mg 16 Formiminoglutamic acid [ FlGlu ] <3mg 17 Red cells, epithelial cells and white blood cells </ 1-2 per high power field

16. INDICATIONS FOR URINALYSIS Suspected renal diseases Glomerulonephritis Nephrotic Syndrome Pyelonephritis Renal Failure Diagnosis of urinary tract infection

17. CONT’D Monitoring metabolic disorders ie Diabetes mellitus As part of routine physical examination Detection of plasma dyscrasias Diagnosis of pregnancy related complications- Pre- eclampsia, Eclampsia To assess the complications of hypertension To diagnose liver diseases

18. COLLECTION OF URINE: METHODS OF COLLECTION Preanalytical Assessment First Morning Voiding Most Concentrated Acidic pH Formed elements preserved like casts, cells

19. CONT’D Used for: Routine examinations Fasting glucose Protein Nitrite Pregnancy test Microscopic analysis of cellular elements

20. CONT’D Random Specimen Can be collected at any point in time Routine examinations Post Prandial Specimen Collected 2 hours after a meal in the afternoon

21. CONT’D Insulin monitoring therapy in diabetes mellitus Urobilinogen Midstream specimen Used for all types of examination Collected after voiding initial half of urine

22. 24 HOUR SPECIMEN First urine discarded in the morning Clean 2 liters bottle with cap Whole day and night urine collected Next day first urine in the morning also collected

23. CONT’D Preserved at 4-6 degrees during collection After collection immediate transportation to the lab Thoroughly mixed and a part of the whole sample used for quantitative estimation of :Proteins, Hormones

24. CLEAN-CATCH URINE Used for bacteriological culture Urethral opening cleaned with soap and water Collected after voiding initial half of urine

25. CATHETER SPECIMEN Used for bacteriological culture For bed ridden and obstructed urinary tract patients

26. SUPRAPUBIC ASPIRATION Used to obtain sterile urine. Example in infants. Plastic bags are also used

27. CHANGES THAT OCCUR IN ROOM TEMPERATURE AFTER PROLONGED STANDING Increase in pH – production of ammonia Formation of crystal – calcium and phosphate precipitation Loss of ketone bodies – volatile Decrease of glucose – glycolysis by bacteria and cells

28. CONT’D Oxidation of bilirubin to biliverdin Oxidation of urobilinogen to urobilin Bacterial proliferation Disintegration of cellular elements

29. PRESERVATION OF URINE SAMPLE Test to be done within 2 hours Can be kept at 4-6 degrees for maximum of 8 hours Preservatives used in 24 hours sample: Hydrochloric acid- Used when detecting Adrenaline, Nor-adrenaline, vanillylmandelic acid, steroids.

30. CONT’D Toluene- measurement of chemicals Boric acid- general preservative Thymol- inhibits bacteria and fungi Formalin- formed elements

31. URINALYSIS INTERPRETATION PROPER

32. PHYSICAL EXAMINATION :APPEARANCE/ CLARITY Urine degree of clarity (cloudiness) Criteria Clear No visible particulate material is seen. Hazy Can see visible particulate material Can read the newspaper Cloudy Can see the newspaper But the words are distorted or not clear. Turbid Can not see the newspaper through the urine tube Urine degree of clarity (cloudiness) Criteria Clear No visible particulate material is seen. Hazy Can see visible particulate material Can read the newspaper Cloudy Can see the newspaper But the words are distorted or not clear. Turbid Can not see the newspaper through the urine tube

33. URINE COLOUR VARIATIONS Urine color Etiology for the color Pale yellow to light   Normal color Orange Concentrated urine Pale yellow Polyuria, Diabetes insipidus, and Mellitus Deep yellow Riboflavin Dark  yellow and dark color Concentrated urine Bilirubin. Urobilin, Biliverdin Yellow to amber Urobilin, Bilirubin, Biliverdin

34. Yellow-brown or yellow-green Bilirubin oxidized to biliverdin. Yellowish-brown to green Bile pigments Bacteria (pseudomonas) Red and brown after keeping the urine Porphyrins Reddish brown in fresh urine Hemoglobin, Red blood cells, Myoglobin Porphobilinogen Porphyrins Pink to red RBCs ,Hemoglobin, Myoglobin Beet root Rifampicin Menstrual contamination

35. Brownish-black color Alkaptonuria Green Pseudomonas infection Biliverdin Green-yellow Flavones in some vitamins Green or blue Methylene blue Brown-black RBCs oxidized to methemoglobin. Homogentisic acid Metronidazole Methyldopa

36. DRUGS THAT CAN CHANGE URINE COLOUR Drugs Effect of the Drug on the Body Change in the urine color Chloroquine Antimalarial drug Rusty yellow or brown Iron preparation Treat the anemia Drak brown and becomes black on standing Nitrofurantoin Antibacterial for UTI Brown Pyridium (Phenazopyridine) Urinary tract analgesic orange to red Dilantin Anticonvulsant for epilepsy Pink, red, or red-brown Vitamin B 2 (Riboflavin) Vitamin supplement Dark yellow Levodopa Treat Parkinson’s disease Dark-brown on standing

37. Rifampicin Antibacterial for TB Red-orange Dyrenium ( Triamterene) Diuretic Pale-blue Cascara sagrada Laxative Red in alkaline urine and yellow-brown in acidic urine Doxidan (Docusate calcium) Laxative Pink to red to red-brown Phenolphthalein Laxative Red or purplish-pink in alkaline urine Phenothiazine Antiemetic, antipsychotic, neuroleptic Red-brown Sulfasalazine Antibacterial Orange-yellow in alkaline urine

38. ODOUR Odour The reason for that odor Faint aromatic (fresh urine) Due to ammonia Strong, unpleasant odor Bacterial infection Sweety or fruity odor Diabetes mellitus ketone bodies Maple syrup odor Maple syrup disease Unusual pungent odor Ingestion of onions, garlic, and asparagus Mousy odor Phenylketonuria Sweet smell Malnutrition, vomiting, and diarrhea

39. VOLUME The urine volume depends on the amount of water excreted by the kidneys. The volume of the urine  depends upon the following: The fluid  (water) intake. Fluid (water) loss from nonrenal sources.

40. CONT’D The amount of ADH secretion. Excretion of dissolved solids such as glucose or salts. Normal urine volume: 1200 to 1500 mL/24 hours. The range of 600 to 2000 mL/24 hours may be considered normal.

41. Nocturnal polyuria: There is increased urine at night. This may be seen in diabetes mellitus and diabetes insipidus, intake of diuretics or intake of tea, coffee, or alcohol. These will suppress the ADH. Polyuria : More than 2000ml per day . Seen in Diabetes mellitus Diabetes insipidus , Chronic renal failure, diuretic therapy .

42. CONT’D Oliguria: There is a decrease in the normal daily urine volume where urine volume is <400 mL/day. This is seen in dehydration due to vomiting, diarrhea, perspiration, or severe burn, acute glomerulonephritis, congestive cardiac failure . Anuria : less than 100ml per day. Seen in Acute tubular necrosis , acute glomerulonephritis, complete urinary obstruction.

43. CHEMICAL EXAMINATION OF URINE PROTEINURIA The presence of detectable protein in the urine i.e. >150mg/day . It indicates glomerular injury. Normally, urine is free of protein or has only trace. While both albumin and globulin may be excreted in the urine, albumin filters more readily than globulin ,so protein in the urine is primarily albumin .

44. TESTS FOR PROTEIN Heat and acetic acid test Sulfosalicylic acid test Heller’s test Dipstick method

45. HEAT AND ACETIC ACID TEST

46. SULFOSALICYLIC ACID TEST

47. DIPSTICK METHOD

48. pH The lungs and the kidneys are major regulators of the acid-base balance of the body. These two organs control the pH by the secretion of hydrogen ions in the form of ammonium ions, hydrogen phosphate, and weak organic acids. These organs maintain the pH by reabsorption of HCO3 –  from the filtrate in the convoluted tubules.

49. pH CONT’D Alkaline Urine {pH is alkaline} Acidic Urine {pH is acidic } 1. Vomiting 1. Starvation 2. Vegetable diet 2. Dehydration 3. Low carbohydrate diet 3. Diarrhea 4. Chronic renal failure 4. Protein diet 5. Renal tubular acidosis 5. Metabolism of fats 6. Bacteria {ammonia producing and urea splitting bacteria } 6. Acid producing bacteria 7. Respiratory and metabolic alkalosis 7. Respiratory and metabolic acidosis 8. Acetazolamide therapy 8. Diabetic Ketoacidosis

50. Normal range: 4.6-8 Tested by: Litmus paper PH meter Reagent strip method

51. SPECIFIC GRAVITY This is the weight of 1 mL of urine in grams divided by 1 mL of water. This helps to give the state of hydration and dehydration. This indicates the concentrating ability of the kidney.

52. CONT’D The specific gravity of the urine can be measured by: Urinometer (hydrometer) Refractometer Chemical reagents strips

53. Low specific gravity of urine (hyposthenuria) is seen in: Diabetes insipidus . ADH hormone is lacking. Pyelonephritis Glomerulonephritis The consistently low specific gravity is known as isosthenuria. It is seen in chronic renal disease, where the capacity to concentrate urine is lost.

54. CONT’D High specific gravity of urine (hypersthenuria) is seen in : Diabetes mellitus. Congestive heart failure. Dehydration due to sweating, fever, vomiting, or diarrhea. Adrenal insufficiency. Liver disease. Nephrosis

55. REDUCING SUBSTANCES IN URINE Reducing substances are those compounds which reduce cupric ions{from copper sulphate in Benedict’s reagent} in an alkaline solution to cuprous ions {cuprous oxide }. Such substances may be sugar or non sugar .

56. TESTS FOR REDUCING SUBSTANCES Benedict’s qualitative test Dipstick method

57. BENEDICT’S QUALITATIVE TEST

58. Glucose in urine is called glycosuria. Causes include : Diabetes mellitus Pregnancy Renal glycosuria Endocrine disorders – Acromegaly, cushing’s syndrome, hyperthyroidism, pheochromocytoma.

59. KETONE BODIES Ketone bodies are three water soluble molecules{Acetoacetic acid , beta-hydroxybutyric acid and acetone} that are produced by the liver from fatty acids during low food intake, carbohydrate restrictive diets, starvation.

60. TESTS FOR KETONE BODIES Rothera’s test Ferric chloride Hart’s test Dipstick test

61. ROTHERA’S TEST Principle: Acetoacetic acid and acetone reacts with sodium nitroprusside in the presence of an alkali to form a purple colored compound .

62. CAUSES OF KETONURIA Diabetic ketoacidosis Starvation Prolonged vomiting or diarrhea Prolonged febrile illness Von Gierke’s disease Eclampsia

63. BILIRUBIN {BILE PIGMENT } Tests for bilirubin in urine provides information concerning metabolic or systemic disorders especially liver function . Bilirubin is a breakdown product of hemoglobin and is normally not present in urine . Causes include: Hepatitis, liver cirrhosis, hepatocellular carcinoma, etc.

64. TESTS FOR BILIRUBIN Fouchet’s test Dipstick method

65. UROBILINOGEN Urobilinogen is a colorless by-product of bilirubin reduction. It is formed in the intestines by bacterial action on bilirubin . Urobilinogen is normally present in urine in trace amount and is insufficient to cause a significant positive reaction.

66. CONT’D Whenever the liver is unable to efficiently remove the reabsorbed urobilinogen from the portal circulation more urobilinogen than normal is routed through the kidney and hence excreted in the urine .

67. TESTS FOR UROBILINOGEN Ehrlich’s test Dipstick method

68. BILE SALTS Bile salts are composed of mixture of bile acids and glycine or taurine. Important bile salts are sodium and potassium salts of glycocholates and taurocholates. Normally, bile salts are not present in urine

69. CONT’D Causes : Obstructive and hepatocellular jaundice TEST FOR BILE SALTS Hay’s sulfur test Nitrite and Leucocyte esterase

70. TESTS FOR BLOOD IN URINE These tests detects: Hematuria, Hemoglobinuria, Myoglobinuria. They include : Benzidine test Orthotoludine test Dipstick method

71. COMBI 10 & 11 IN FMC LAB, UMUAHIA

72. COMBI 10 IN NUDC, UMUAHIA

73. MICROSCOPIC EXAMINATION OF URINE

74. Most time consuming part of the routine urinalysis To detect and identify insoluble materials present in the urine These include RBCs, WBCs, epithelial cells, casts, bacteria, yeast, parasites, mucus, spermatozoa, crystals and artifacts . Some of these components are of no clinical significance and others are considered normal unless they are present in increased amounts.

75. CLASSIFICATION OF URINARY SEDIMENTS Urine sediments can be grossly categorized into 2 based on the substances they are composed of : Organized Non-organized sediments

76. ORGANIZED {FORMED} ELEMENTS RBCs/HPF WBCs/HPF Epithelial cells/LPF Casts/LPF Parasites/LPF Bacteria/HPF Yeast Cells/HPF Spermatozoa

77. NON-ORGANIZED {NON-LIVING MATERIALS } Triple phosphates Amorphous urates Calcium carbonate Calcium phosphate Calcium oxalate crystals

78. RED BLOOD CELL MICROSCOPY

79. WHITE BLOOD CELL MICROSCOPY

80. EPITHELIAL CELLS

81. MUDDY BROWN CASTS

82. EPITHELIAL CELL CASTS

83. WAXY/RENAL FAILURE CASTS

84. FATTY CASTS

85. PARASITES IN URINE

86. BACTERIA IN URINE

87. YEAST CELLS

88. CRYSTALS IN SEDIMENT Microscopic solids usually composed of a small number of different ions/molecules. Formed by precipitation of urine solutes including : Inorganic salts, Organic compounds and Medications {iatrogenic compounds}.

89. CONT’D Small amount of most type of crystals are not necessarily pathologic Formation of crystals is most dependent on: Concentration of ions and molecules Urine PH Decreased flow of urine through tubules

90. CONCLUSION The interpretation of urinalysis is a fundamental aspect of medical diagnosis and monitoring, providing valuable insights into the health status of an individual. By analyzing various components such as pH, specific gravity, presence of proteins, glucose, ketones, and other substances, healthcare professionals can assess kidney function, detect urinary tract infections, identify metabolic disorders, and screen for conditions like diabetes .

91. REFERENCES WHO. (2019 ). Urinalysis and body fluid: A review . Retrieved from WHO website. Levey, A. S., et al. (2020). KDIGO 2020 Clinical Practice Guideline for Glomerular Diseases. Kidney International Supplements, 10(2), e38-e39. Florkowski, C. (2018). Urinalysis: Routine and Automated. Critical Reviews in Clinical Laboratory Sciences, 55(8), 510-522 .

92. REFERENCES CONT’D Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. (2020). KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. Kidney International Supplements, 10(1), e33-e34. Ahmad, A. (2021). Ketone Bodies and Cardiovascular Health. Journal of Cardiovascular Development and Disease, 4(2), 21. Matsha, T. E., et al. (2020). Urinary Biomarkers for the Diagnosis of Renal Disease: A Systematic Review. The International Journal of Tuberculosis and Lung Disease, 22(7), 792-793. Wong, S. N., et al. (2022). Urine Crystals in Nonpregnant Women. American Family Physician, 96(2), 132-133.

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