USES OF URINALYSIS IN CLINICAL CHEMISTRY

BY

AdENIjI N. AdEKOGA

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OUTLINE• INTRODUCTION• HISTORY OF URINALYSIS• URINE FORMATION• URINE SPECIMEN COLLECTION• USES OF URINE• SUMMARY• REFERENCES

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INTROdUCTION Urinalysis may be defined as the practice of examining

urine as an aid in diagnosis and in following the course of treatment of a disease.

Specimens for studies are easily obtained, tests are sensitive early detectors of disease, methodology is relatively convenient.

In general, the concentration of most substances normally found in urine reflects the plasma level of the substances (Cavanaugh, 2003)

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HISTORY OF URINALYSIS

Figure 1: A chart used to categorize urine.

Laboratory medicine began 6000 years ago with the analysis of human urine (Armstrong, 2007).

Basic observations as color, turbidity, odor, volume, viscosity, and even sweetness (by noting that certain specimens attracted ants or tasted sweet).

In 5th century BCE, Hippocrates wrote a book on Uroscopy.

By 1140 CE, color charts had been developed (Fig. 1)

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HISTORY OF URINALYSIS CONTd

In 1694, Frederik Dekkers’ discovered albuminuria by boiling urine.

In the 17th century, invention of microscope led to examination of urinary sediments.

In 1827, Richard Bright introduced the concept of urinalysis as part of a doctor’s routine patient examination.

BY 1930s, the number and complexity of the tests performed in a urinalysis had reached a point of impracticality. Fortunately, development of modern testing techniques rescued.

(Strasinger and Di Lorenzo, 2014)5

URINE FORMATION Urine is a unique body fluid

formed by a process of glomerular filtration, selective tubular secretion and reabsorption of constituents by the kidneys (Agbedana and Anetor, 2006).

25% of cardiac output perfuses the kidney each minute.

6Fig. 2: Urine formation

URINE FORMATION CONTd

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Fig. 3: Composition of Human Urine Fig 4: Composition of Human Urine: “Other Ingredients”

URINE SPECIMEN COLLECTIONTYPES OF URINE SPECIMEN COLLECTION:

•SPOT – FIRST MORNING SPECIMEN– RANDOM SPECIMEN– SECOND VOIDED SPECIMEN

•TIMED– POST PRANDIAL– 2-HOURS VOLUME– 24-HOUR VOLUME

•CATHETERIZED (Agbedana and Anetor, 2006; Sanford and McPherson, 2011)8

USES OF URINALYSISURINARY TRACT INFECTIONS

• APPEARANCE (TURBID)• ODOUR (PURGENT )• pH • NITRITE• LEUKOCYTE ESTERASE• BLOOD

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RENAL DISEASEExamination of urine is invaluable in identifying urological and kidney diseases. Protein: Presence of protein in urine is commonly associated with renal disease. This includes Glomerular disorders, immune complex disorders, amyloidosis, toxic agents, diabetic nephropathy, hypertension, pre-eclampsiapH: – reflects the kidney’s ability to regulate the acid–base

balance of the body.– Defects in secretion and reabsorption of acids and

bases.

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RENAL DISEASE coNtD• Specific Gravity• Glucose• Blood• Electrolyte • Clearance test• Kidney markers : N-acetyl-β-D-glucosaminidase

(NAG), Urinary Glutathione-S-Transferase (GST), Urinary liver-type fatty acid-binding protein (L-FABP),Urinary cystatin C, Urinary kidney injury molecule (KIM-1), Urinary interleukin-18 (IL-18).

(Levenson, 2014) 11

LIVER DISEASE• Urinalysis helps to narrow the diagnosis in liver disease.• Bilirubinuria is always pathological- once bilirubin is

found in urine, it excludes pre-hepatic or haemolytic jaundice.

• Urobilinogen

Table 1: urinalysis in the Classification of jaundice

• Porphyria (acquired) (Agbedana and Anetor, 2006)12

DIAbEtES mELLItuS AND DIAbEtES INSIpIDuS

• Urine volume

• Specific gravity

• Osmolality

• Glucose

• Microalbumin 13

DISoRDERS oF cHo mEtAboLISm

(a) Lactose—pregnancy, lactation, lactose intolerance.

(b) Galactose—hereditary galactosuria (severe enzyme [Gal-1-PUT] deficiency in infants; must be treated promptly).

(c) Xylose—excessive ingestion of fruits.

(d) Fructose—hereditary fructose intolerance, hepatic disorders.

(e) Pentose—certain drug therapies and rare hereditary conditions.

(f) Glucose14

INHERItED mEtAboLIc DISoRDERS (IbEm)

• Inherited metabolic disorders or inborn errors of metabolism (IBEM) first recognized from urine appearance and odour.

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Table 2: Inborn Errors of Metabolism and Enzyme Defects

Disease Deficient Enzyme 1. Alkaptonuria Homogentisate Oxygenase2. Argininosuccinic aciduria Argininosuccinase3. Cystathioninuria Cystathionine cleavage enzyme4. Histidinemia Histidine alpha-deaminase5. Homocystinuria Cystathionine syntherase6. Maple syrup urine disease Ketoacid CoA isomerase7. Phenylketonuria Phenylalanine hydroxylase8. Galactosemia Galactose-1-phosphate uridyl transferase9. Hartnup’s disease Tryptophan pyrrolase10. Glycogen storage disease Glucosidase11. Histidinemia Histidine alpha-deaminase

(Agbedana and Anetor, 2006)

NutRItIoNAL DISoRDERSMany nutritional disorders can be investigated by urine analysis:•Formino glutamate (FIGLU) screening test for folate deficiency.•Urinary thiamine used to assess B1 deficiency.•Xanthurenic acid in urine for pyridoxine (B6) deficiency.•Ascorbate saturation test for vitamin C deficiency.•Methyl malonic acid (MMA) for vitamin B12 deficiency.•Some of the measured minerals include iron (found in hemosiderin), copper, magnesium, iodine and oxalate.

(Agbedana and Anetor, 2006)17

DIEtARY coNDItIoN

• Ketosis may also be used in the assessment of:– Starvation– High-fat diets– Prolonged vomiting – diarrhoea– Anorexia– Low-carbohydrate diet

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pancreatitis

• Measurement of amylase in urine may help in the diagnosis of pancreatitis.

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enDOcrinOpatHY• Most urinary measures focus on the hormones secreted

by the adrenal cortex, the adrenal medulla, the gonads, and the placenta.

• Either the hormone itself or the metabolites thereof can be measured.

• Cortisol – Diagnostic evaluation of signs of Cushing’s syndrome

without elevation of plasma cortisol levels.– Diagnostic evaluation of obesity of undetermined etiology.

• Aldosterone– Suspected hyperaldosteronism, especially when serum

aldosterone levels are not definitive for diagnosis.20

enDOcrinOpatHY cOntD• 17-Hydroxycorticosteroids (17-OHCS)

• Signs and symptoms of adrenocortical hypofunctioning or hyperfunctioning

• Suspected Cushing’s syndrome as indicated by elevated levels• Suspected Addison’s disease as indicated by decreased levels

• 17-Ketosteroids • Suspected adrenocortical dysfunction, especially if urinary levels of 17-

OHCS are normal

• Catecholamines/Vanillylmandelic Acid– Hypertension of unknown etiology.

– Suspected pheochromocytoma as indicated by elevated levels.– Acute hypertensive episode (A random sample is collected in such cases).– Suspected neuroblastoma or ganglioneuroma as indicated by elevated levels.

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enDOcrinOpatHY cOntD• 5-HYDROXYINDOLEACETIC ACID– Detection of early carcinoid tumors (argentaffinomas) of

the intestine• Homovanillic Acid – Suspected neuroblastoma or ganglioneuroma as

indicated by elevated levels– Diagnosis of benign/malignant pheochromocytoma as

indicated by normal HVA levels with elevated VMA levels.

• Estrogens and Estrogen Fractions – Suspected tumor of the ovary, testicle, or adrenal gland

as indicated by elevated total estrogens and fractions – Suspected ovarian failure – Detection of placental and fetal problems 22

enDOcrinOpatHY cOntD

• Pregnanediol – Verification of ovulation in planning a pregnancy or

in determining the cause of infertility. – Diagnosis of placental dysfunction – Detection of fetal demise

• Human Chorionic Gonadotropin – Confirmation of pregnancy – Suspected hydatidiform mole as indicated by

elevated levels – Suspected choriocarcinoma or testicular tumor

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antiOxiDant/ OxiDative stress

• Ascorbate saturation test for vitamin C deficiency.

• 8-OHdG- of the DNA derived biomarker of oxidative stress, urinary 8-oxo-7,8-dihydro-2’-deoxyguanosine (8-OHdG ,8-oxodG) is the most frequently measured. It is a marker of oxidative DNA damage.

(Kasai et al., 2005 ; Agbedana and Anetor, 2006; Fasola et al., 2015 )

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tOxic state

• ARSENIC• MERCURY• CADMIUM• LEAD• ALUMINIUM

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DrUG screeninG• Toxicological analysis of urine is performed to identify drugs

that have been used and abused.• Urine is preferred because most drugs are detectable in urine

but not in blood.• The followings are commonly screened:– Sedatives: benzodiazepines, methaqualone – Depressants: alcohol, barbiturates, opiates (codeine,

morphine, methadone) – Stimulants: amphetamines, cocaine, “crack,”

methylphenidate – Hallucinogens: cannabinoids (marijuana, hashish),

phencyclidine (PCP), lysergic acid diethylamide (LSD), mescaline

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cancer DetectiOn• NANO PARTICLES (Matrix metalloproteinases)

(Warrena, 2014)

• Urinary 8-oxo-7,8-dihydro-2’-deoxyguanosine (8-OHdG ,8-oxodG).

• RENAL: Aquaporin-1 (AQP1), Perlipin-2 (PLIN2) (Morrissey, 2015)

• Blood27

CANCER DETCTION CONTD• Multiple Myeloma: Bence Jones proteins• Leukaemia: Lysozyme (Muramidase), Arylsulfatase

A.• Bladder: – Bladder tumour associated antigen (BTA), – NMP22– (ODOREADER ®): The device is constructed in the

laboratories at UWE Bristol's Institute of Biosensor Technology, analyses urine gas and produces a 'profile' of the chemicals in urine that can be read by scientists to diagnose the presence of cancer cells in the bladder (Tanzele, et al., 2013).

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CANCER DETCTION CONTD

• PROSTATE CANCER: A Belgian Malinois shepherd (dog) was trained by the clicker training method (operant conditioning) to scent and recognize urine of people having prostate cancer (Jean-Nicolas, et al., 2011).

•  THYROID CANCER: A trained scent dog accurately identified whether patients’ urine samples had thyroid cancer or were benign (noncancerous) 88.2 percent of the time, according to a new study (Endocrine society, 2015).

• CERVICAL CANCER: HPV DNA can be detected in urine (Pathak, et al., 2014).

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SUMMARY

• Analysis of urine is a vital tool that provides useful information about organ and systemic functions as well as their derangements. Also, disease progressions and therapeutic monitoring are well captured by an extensive urinalysis procedure.

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REFERENCESAgbedana E. O. and Anetor, J. I. (2006): Urinalysis in clinical and laboratory medicine. Ibadan: John Archers, 9-102.

Armstrong J. A. (2007): Urinalysis in western culture: A brief history. Kidney International. 71; 384-387.

Cooper, C. (1990): What is the colour of urine specimen. Am J Nurs. 93(8):37.

Endocrine society (2015): scent- Scent-trained dog detects thyroid cancer in human urine samples. Available at: https://www.endocrine.org/news-room/current-press-releases/scent-trained-dog-detects-thyroid-cancer-in-human-urine-samples

Fasola F. A.; Anetor J. I.; Ajenifuja K.O., et al. (2015) : Iron Indices and Urinary 8-Oxo-7, 8-Dihydro-2’- Deoxyguanosine (8-Oxodg) in Patients with Cervical Intraepithelial Neoplasia. BJMMR, 7(8): 678-687.

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Fischbach F. (2003): A manual of laboratory and diagnostic tests. 7th edition. Lippincott willians and Wilkins, 113-177.

Gerber G. S. and Brendler C. B. (2011): Evaluation of the urologicpatient: history, physical examination, and urinalysis. In:Wein, A.J.; Kavoussi, L.R.; Novick, A.C.; et al., eds. Campbell-Walsh Urology . 10th edition. Philadelphia: Elsevier Saunders, chap 3.

Kasai H.; Svoboda P.; Yamasaki S. and Kawai K. (2005): Simultaneous determination of 8-hydroxydeoxyguanosine, a marker of oxidative stress, and creatinine, a standardization compound, in urine. Industrial Health 43, 333-336.

Levenson, D. (2014): The search for improved markers of acute kidney injury. Available at: https://www.aacc.org/publications/cln/articles/2014/january/kidney-injury

Mc Pherson, R.A. and Ben-Ezra, J. (2011): Basic examination of urine. In: Mc Pherson, R.A. and Pincus, M.R (eds) Henry’s clinical diagnosis and management by laboratory methods. 22nd edition. Philadelphia: Elsevier Sanders, ch 28.

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Morrissey J. J.; Mellinick V. M.; Luo J. et al., (2015): Evaluation of urine aquaporin 1 and perlipin 2 concentrations as biomarker to screen for renal cell carcinoma. JAMA Oncol. doi:10.1001/jamaoncol.2015.0213

Pathak N.; Dodds J.; Zamora J. and Khalid K. (2014): Accuracy pf urinary human papilomaviru testing for cervical HPV: systematic review and meta-analysis. BMJ. 349:g5264.

Strasinger S. K. and Di Lorenzo, M. S. (2014): Urinalysis and body fluids. 6th edition. Philadelphia: F.A. Davis, 59-98.

Tanzeela Khalid, Paul White, Ben De Lacy Costello, Raj Persad, Richard Ewen, Emmanuel Johnson, Chris S. Probert, Norman Ratcliffe (2013): A Pilot Study Combining a GC-Sensor Device with a Statistical Model for the Identification of Bladder Cancer from Urine Headspace. PLoS ONE, 8 (7): e69602.

Warrena, A.D.; Kwonga, G.A.; Woodc, D.K.; et al. (2014): Point-of-care diagnostics for noncommunicable diseases using synthetic urinary biomarkers and paper microfluidics. PNAS, 111(10) 3671-3676.

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THANK YOU FOR YOUR DEvOTION.