Value Of Urinalys

is In Clinical Medicin

e

Dr./ Sahar

HAMDY

Medical consultant el-

mataria teaching

hospital, cairo

Introduction Urine formed in the kidneys, is a product of ultrafiltration of plasma by the renal glomeruli.

Formation of Urine The nephron:

•allows for reabsorption of water and electrolytes

•plays a vital role in maintaining normal fluid balance

Three processes of urine formation :

glomerular filtration

tubular reabsorption

tubular secretion

Physical Composition and Chemical

Properties Urea, uric acid, ammonia, calcium, creatine, sodium, chloride, potassium, sulfates, phosphates, bicarbonates, hydrogen ions, urochrome, urobilinogen

Urine 95% water

5% waste productsOther dissolved chemicals

5

Apply Your Knowledge

Components of normal urine include:

A - urea, uric acid and ammonia.

B - chloride, potassium and sugar.

C - red blood cells, sperm and H2O2

D - hydrogen ions, urochrome, and uranium.

6

Apply Your Knowledge -Answer

Components of normal urine include:A - urea, uric acid and ammonia.

B - chloride, potassium and sugar.

C - red blood cells, sperm and H2O2

D - hydrogen ions, urochrome, and uranium.

Obtaining Specimens

General guidelines:Follow the procedureUse the type of specimen container

indicated by the labLabel the specimen container before

giving it to patientExplain the procedure to patient Wash your hands before and after

procedureComplete all necessary paperwork

Specimens Types It Varies in method used and in time frame in which to :collect specimenTypes of specimens:

RandomFirst morning

Clean catch midstreamTimed24 hour

Specimens Types (cont.)

Random – most common, taken anytime of day

First morning – has a greater concentration of substances, taken in morning

Clean catch midstream – genitalia is cleaned, urine is tested for microorganisms or presence of infection

Timed – specific time of day, always discard first specimen before timing

24 hour – used for quantitative and qualitative analysis of substances

UrinalysisEvaluation of urine to obtain information about body health and disease

Four types of testing: Physical Chemical Microscopic Culture and sensitivity( beyond the scope of

lecture)

Preservation and Storage

Refrigeration – most common method for storing and preserving urine

It prevents bacterial growth for 24 hours.

After 24 hours use chemical preservation

Changes that affect the chemical or microscopic properties of urine occur if urine is kept at room temperature for more than 1 hour

Normal Values of Urine Normal values of

various elements have been established

A routine vol. of 12 mL urine is analysed

Average adult daily urine output is 1250 mL/24 hours(>1mL/Kg/hour)

Intake and output should be approximately the same

I- Physical Examination of Urine

Visual examination of physical characteristics

Volume Color and turbidityOdorSpecific gravity/ Osmolality

Urinary volumeNormal = 600-1550mlPolyuria- >2000mlOliguria-<400mlAnuria-complete cessation of urine(<200ml)Nocturia-excretion of urine by a adult of >500ml with a specific gravity of <1.018 at night (characteristic of chronic glomerulonephritis)

Causes of polyuria Diabetes mellitus Diabetes insipidus Polycystic kidney Chronic renal failure Diuretics Intravenous saline/glucose

Causes of Oliguria

Acute renal failure: Pre-renal, renal and post-renal

Hypovolemia: Dehydration / vomiting, diarrhea, excessive sweating

Renal ischemia

Acute tubular necrosis

Obstructive Uropathy

Urinary Color and Appearance

Normally urine is amber yellow and clearColourless: D.I., D.M., diuretics..,

Milky: Pus, chyluriaOrange: Fever, excessive sweating,

metronidazole, rifampicin..,Red: Beet-root, hematuria, myoglobinuria ,

Brown: Porphyria, alkaptonuria

Turbidity means cellular elements and bacteria(which clear by centrifugation) and crystals(which clear by addition of acids or bases); it’s the microscopic examination which will

determine which type…

Odour of Urine

Normal: Urinefrous(aromatic volatile acids)Sweety: GlucoseFruity: KetonesFoul, offensive: old specimen, pus

Specific Gravity of Urine

Depends on the concentration of various solutes in the urine.

N.Sp.Gr. = 1.016 – 1.022Hyperosthenuria: dehydr., D.M..,.

Hyposthenuria: polyuria(except diabetes)Isosthenuria: Fixed at 1.010 in CRF

Measurement of Specific GravityIt’s measured by: -urinometer -refractometer -dipsticks Urinometer: Take 2/3 of urinometer container with urine Allow the urinometer to float into the urine Read the graduation at the lowest level of

urinary meniscus*Correction of temperature & albumin is a

must*.Urinometer is calibrated at 15 or 200cSo for every 3oc increase/decrease add/subtract 0.001For 1gm/dl of albumin add 0.001

23

Apply Your Knowledge

What is the specific gravity shown on this refractometer screen?

24

Apply Your Knowledge -Answer

The specific gravity shown here is 1.030

What is the specific gravity shown on this refractometer screen?

Urinary Dipsticks

Dipsticks Use The main

disadvantage :is that

1.Not very accurate (the test is time-sensitive).

2. It is a qualitative and not a quantitative test (no precise information about the severity of the abnormality).

•The main advantage of dipsticks is that they :are

1.  convenient ,

2.  easy to interpret ,

3.  and cost-effective

II- Chemical Examination of

Urine

Usually done with reagent strips or tablets

Used to determine body processes such as CHO metabolism, liver or kidney function or acid-base balance.

Used to determine presence of drug, toxic environmental substances or infections

Kidney involvement in multisystem

disease

Chemicals Found in Urine

pH – provides information about metabolic status, diet, medication or several conditionsGlucose –diabetesKetone bodies – Low carbohydrate diet, or starvationProtein –Intrinsic renal diseaseBlood (hemoglobinuria) –Menstruation, urinary tract infection or traumaBilirubin / urobilinogen –liver disease Nitrite –bacterial infectionLeukocyte esterase –InfectionPhenylketones / aminoacids –PKU, aminoaciduriaOthers: Ur. Calcium, microalbuminuria, ur. Magnesium, ur.Po4 ,

..

1 -Urinary pH/ reaction Reaction reflects ability of kidney to maintain normal hydrogen ion concentration in plasma & ECFNormal= 4.6-8Tested by :- 1.litmus paper

2 .pH paper 3 .dipsticks

Significance:Acidic PH <4.5= High ptn. Diet, metabolic acidosis, starvation,

E.coli.. ,Alkaline PH >8= RTA, vegeterians, metabolic alkalosis, proteus.. ,

Limitations: Interference: Bacterial overgrowth Run-Over Effect: Protein pad effect on PH padOther Tests: Titrable acidity Blood gases

Dipstick for pH

Buffers from the protein area of the strip (pH 3.0) spill over to the pH

area of the strip and make the pH of the sample appear more acidic than

it really is.

2 -Urinary Glucose detection

Detection of reducing sugars by:Benedict’s Test

Urinary dipsticksSemi-quantitative))Benedict:

•Principle-Benedict’s reagent contains cuso4.In the presence of reducing sugars cupric ions are converted to cuprous oxide which is hastened by heating, to give the color.

•Method- take 5ml of benedict’s reagent in a test tube, add 8drops of urine. Boil the mixture.

Blue-green = negative Yellow-green = +(<0.5%)

Greenish yellow = ++(0.5-1%) Yellow = +++(1-2%)

Brick red = ++++(>2%)N.B: Renal threshold must be passed in order for glucose to spill into urine

Urinary Dipsticks for Glucose

However, Benedict detects all reducing substances like glucose, fructose, & other reducing sustances such as:

N.B: Sucrose is not a reducing substance

To confirm it is glucose, dipsticks can be used (glucose oxidase)

Disease Sugar

Galactosemia Galactose

Lactase def. or intolerance

Lactose

Fructose intolerance

Fructose

Essential pentosuria

Pentose

Non-pathogenic Maltose

Causes of glycosuria

Glycosuria without hyperglycaemia -• Renal tubular

dysfunction• Renal Glycosuria• TTT with SGLT(sodium

glucose transport inhibitors used to treat DM)

Glycosuria with hyperglycaemia- • Diabetes,• Acromegaly, • Cushing’s disease,

Hyperthyroidism, • Drugs like

corticosteroids

3 -Urinary ketone detection

There are 3 types of ketone bodies: Acetone Acetoacetate Beta-hydroxy-butyrateDetection of ketones by: Rothera’s Test Dipsticks

•Rothera’s t. principle:Acetone & acetoacetic acid react with sodium nitroprusside in the presence of alkali to produce purple colour.

•Method- take 5ml of urine in a test tube & saturate it with ammonium sulphate. Then add one crystal of sodium nitroprusside. Then gently add 0.5ml of liquor ammonia along the sides of the test tube.

•Change in colour indicates a positive result

Ketonuria

Significance:DiabetesStarvationSevere vomiting/diarrheaHigh feverLimitations:

Measure only acetoacetate and not other ketones >>>Cannot detect alcoholic KA(with ↑BHB >AA)

Reagents can undergo degradation with exposure to moist of air

4 -Urinary protein detection

%of Total

Max. (mg/day)

Protein

40 60 Albumin

40 60 Tamm-Horsefall

12 24 Igs

3 6 Secretory IgA

5 10 Others

--Normally, up to 150 mg total proteins may be found in urine per 24 hours

--More than 300 mg per 24 hours is termed “ Frank Proteinuria “

N.BTest-thermal method:water-

bath))Proteins has an unusual and peculiar property of precipitation at 400 -600c & then dissolving when urine is brought to boiling at 1000c & then reappearing de novo on cooling of sample.

Tests for proteinsTest – heat & acetic acid testPrinciple-proteins are denatured & coagulated on heating to give white cloud precipitate.Method-take 2/3 of test tube with urine, heat only the upper part keeping lower part as control.Presence of phosphates, carbonates, proteins gives a white cloud formation. Add acetic acid 1-2 drops, if the cloud persists it indicates it is protein(acetic acid dissolves the carbonates/phosphates)Other Tests:

(SSA turbidity test-)Sulphosalicylic acid-Dipsticks

-Esbach-albuminometer- for quantitative estimation of proteinsUrine protein electrophoresis(UPEP)-

Albumin Excretion:

Alternative Methods for expressing the

normal range

Normal Value Sample

<30 mg / 24 hrs 24-h urine collection

<20 micro-g / min Timed sample from ambulant pt.

<10 micro-g / min Timed sample for recumbent pt.(or over-night sample)

in male) ) < 2.5 mg / mmol Albumin / creatinine ratio on a random urine sample

<3.5 mg / mmol (in female)

Dipsticks for proteinsLimitations:

Interference: Highly alkaline urine

-Almost all dipsticks detect proteins if present in an amount more than 300 mg / 24 Hs

-They cannot detect micro-albuminuria (30-150 mg) alb./24-h urinary sample

>>>>>… Esbach –albuminometer can be used

Bences- Jones proteins are light chain globulins present in multiple myeloma, macroglobulinemias and lymphomasThey are detected by: UPEP

Importance of micro-albuminuria

It is an early indicator of subclinical nephropathy either due to on intrinsic kidney disease or due to a cardiovascular disease..

It may be an important prognostic marker..? It is considered as a routine check-up in all

cases of diabetes mellitus or in hypertension (every 6 months)..

Serial rise in micro-albuminuria during the first 48 hours after admission to an intensive care unit can predict elevated risk for acute respiratory failure , multiple organ failure , and overall /CV mortality (as a bad prognostic criterion.. )

Causes Of Proteinuria

Functional

• Pregnancy• Orthostatic

(<1gm/24h)

• Severe Ms.exertion

Prerenal

• Fever• Hypoxia• HTN• Renal vein

thrombosis• Severe

exfoliative skin dis.(eg psoriasis)

Renal

• GN• NS• Diabetes• SLE• Amyloidosi

s• UTI• Tumours

Postrenal

• Cystitis/Urethritis

• Prostatitis• Obstructive

uropathy• Contaminat

ed vaginal secretions

45

Apply Your Knowledge

A urine analysis has detected that a patient has protein in

his urine. Why is this important?

46

Apply Your Knowledge -Answer

Protein in the urine usually indicates an intrinsic kidney disease

A urine analysis has detected that a patient has protein in his urine. Why is this important?

5-Urine blood detection

Test- BENZIDINE TEST

Principle-The peroxidase activity of hemoglobin decomposes hydrogen peroxide releasing nascent oxygen which in turn oxidizes benzidine to give blue color.

Method- mix 2ml of benzidine solution with 2ml of hydrogen peroxide in a test tube. Take 2ml of urine & add 2ml of above mixture. A blue color indicates + reaction.

:Significance -Hematuria: Nephritis, trauma..,

-Hemoglobinuria: Hemolysis (decr.haptoglobin)..,

-Myoglobinuria: Rhabdomyolysis (N.haptoglobin)..,

Limitations -Interference: reducing agents, microbial

peroxidases -Cannot distinguish between the above

disease processes

Other Tests -Urine microscopic examination

-Urine cytology

Causes of hematuria

Pre renal- bleeding diathesis, hemoglobinopathies, malignant hypertension.

Renal- Trauma, calculi, ac. & chr. glomerulonephritis, pyelonephritis, renal TB, renal tumours, Good-pasture syndrome and Henoch-shonlein purpura

Post renal – severe UTI, calculi, trauma, tumors of urinary tract

NegativeNegative

Trace (non-hemolyzed)Trace (non-hemolyzed)

Moderate (non-hemolyzed)Moderate (non-hemolyzed)

Trace (hemolyzed)Trace (hemolyzed)

( +weak) ( +weak)

( ++moderate) ( ++moderate)

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

The Urine Dipstick: Blood

Diisopropylbenzene dihydroperoxide+ Tetramethylbenzidine

>------------ Colored ComplexHeme

Chemical Principle

Lysing agent to lyse red blood cells

Read at 60 secondsRR: Negative

Analytic Sensitivity: 10 RBCs

6 -Urine bilirubin or UrobilinogenBilirubin Urobilinogen

Test- fouchet’s test.Causes• Liver diseases, injury, hepatitis• Obstruction to biliary tract

SignificanceIt correlates with D. serum bilirubin

Limitations- Interference: prolonged exposure

of sample to light- Only measures direct bilirubin--

will not pick up indirect bilirubin

Other Tests- Ictotest (more sensitive tablet

version of same assay)

Test- Ehrlich test

Causes- hemolytic anemia's and hepatocellular jaundice

Significance- High: increased hepatic processing of

bilirubin- Low: bile obstruction

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

Other Tests- Serum total and direct bilirubin

Dipsticks for bilirubin and

urobilinogenBilirubin Urobilinogen

7 -Urinary detection of nitritesSignificance:>>>>>>Gram negative bacteriuria

:Limitations -Interference: bacterial overgrowth

-Only able to detect bacteria that reduce nitrate to nitrite

:Other Tests -Correlate with leukocyte esterase and urine

microscopic examination (bacteria) -Urine culture

NegativeNegative

PositivePositive

The Urine Dipstick for nitrite:

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

Nitrite + p-arsenilic acid -------> Diazo compoundAcidic

Chemical Principle

Read at 60 secondsRR: Negative

8 -Urinary detection of leucocyte

esteraseSignificance

-Pyuria -Acute inflammation

-Renal calculus

Limitations -Interference: oxidizing agents, menstrual

contamination

Other Tests -Urine microscopic examination (WBCs and

bacteria) -Urine culture

NegativeNegative

TraceTrace

( +weak) ( +weak)

( ++moderate) ( ++moderate)

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

The Urine Dipstick: Leukocyte

Esterase

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

III- Microscopic Examination

of Urine

• Centrifuge the urine sample for a few minutes(10-20fold conc.)• Discard the supernatant.• The solid part left in the bottom of the test tube (the urine sediment) is

mixed with the remaining drop of urine in the test tube and one drop is analyzed under a microscope FOV:field of view:What is seen through the ocular lens)

A normal urine contains few epithelial cells, occasional RBC’s, few crystals. RBCs: N. Vs. Dysmorphic cells > 10 / Hpf

Leucocytes: PNLs(glitter cells) > 3 / HpfEosinophils, special stain

Epithelial cells: Squamous cells; indicating contamination

Renal tubular and transititional cells; few are N.Oval fat bodies; indicating IKD

Types of microscopy:1. Phase contrast2. Polarized3. Bight field with special stainingN.B:Cells and casts begin to disintegrate in 1 - 3 hrs. at room temp( refrigeration for up to 48 hours is a must to limit cell loss).

Presence of the following is considered “abnormal:”Fungal hyphae or yeast, parasite, viral inclusions

Sperms(post-vasectomy),starch, mucus, fibres

Pathological crystals (cystine, leucine, tyrosine)

Large number of uric acid or calcium oxalate crystals

Abnormal microscopic findingsPer high power

field(x40)Per low power

field(x10)

> 3 erythrocytes > 5 leukocytes > 2 renal tubular cells > 1 bacteria Yeast Trichomonas Crystals

> 3 hyaline casts > 1 granular cast > 10 squamous cells

(contaminated specimen) Any other cast (RBCs,

WBCs)

RBCS appear dysmorphic in glomerular

bleeding; whilst derived from LUT, they look

normal

WBCs(leucocytes) denote GN or IN

Squamous cellsTubular Epithelial

cells

Transitional Cells

Oval Fat Bodies

LE Cells

Bacteria

Yeasts

Cytomegalovirus

Crystals in urineCrystals are not a normal finding in a fresh urinary sampleCrystals in acidic urine Uric acid Calcium oxalate Cystine Leucine Tyrosine Cholesterol BilirubinCrystals in alkaline urine Amorphous phosphates Triple phosphates (NH4 Mg PO4) NH4 bi-urate Calcium carbonateOthersDrug-induced (sulfonamide and radiocontrast)

Bi-pyramidal or bi-concave ovals:Oxalate

Crystals

Triple Phosphate Crystals

Flat-square plates:Urate Crystals

Leucine crystals

Flat Hexagonal Plates:Cystine

Crystals

Ammonium bi-urate crystals

Cholesterol crystals

Urinary Casts Urinary casts are cylindrical

aggregations of particles that form in the distal nephron, dislodge, and pass into the urine.

In urinalysis they indicate kidney disease.

They form via precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells.

Cast formation is enhanced by:• PH of urine• Solute conc.• Presence of plasma

proteins(albumin, (globulin, hemoglobin, myoglobin,..

Types of casts

Acellular casts Cellular casts

• Hyaline casts• Granular casts• Waxy casts• Fatty casts• Pigment casts• Crystal casts• Broad casts

• Red cell casts• White cell casts• Epithelial cell cast

Casts and clinical significance

Clinical Significance Urinary Cast• Glomerulo-nephritis• Tubular bleeding

RBCs Cast

• Pyelo-nephritis, or interstitial nephritis(acute Allergic), ATN

• AGN(post-strept), nephrotic syndrome,..

WBCs Cast

• Normal(Tamm-Horsfall glycoprotein)• Fever, exercise, dehydration, emotional

stress,..

Hyaline Cast

• Acute tubular necrosis• Interstitial nephritis

Tubular Cast

Non-Specific(can result either from breakdown of cellular cast or from aggregation of pps)>>>indicate CKD

Granular Cast

• NS, DM, ATN, SLE Fatty Cast

Casts and clinical significance

Clinical Significance Urinary Cast

CRF Broad Cast(Formed in dilated remaining

tubules showing compensatory hypertrophy)

• Hemolytic anemia• Rhabdomyolysis• Liver disease

Pigment Cast(Formed by the adhesion of

metabolic breakdown products or drug pigments)

ATN, intoxication with mercury, salicylate or diethylene glycol

Epithelial Cast

Heavy crystal load Crystal Cast(Formed by incorporation of

crystallised urinary solutes with hyaline casts)

(Prolonged stasis (ESRD Waxy Cast

RBCS Cast

WBCs Cast

Hyaline Cast

Tubular Cast

Granular Cast

Fatty Cast

Waxy Cast

Cytological Examination

Staining:

o Papanicolaou staino Wright’s staino Hansel’s staino Immunoperoxidase sp. staino Immunofluorescence sp. stain

CytologyNormal Reactive

Transitional Cell CarcinomaLow Grade High Grade

Squamous Cell Carcinoma Prostatic Carcinoma

Common Microscopically Urinary Findings in various

DiseasesFINDINGS DISEASE

Dysmorphic RBCs – RBCs and mixed cellular Casts

1- Acute glomerulonephritis

RBCs and broad waxy Casts 2- Chronic glomerulonephritis

Bacteria – Leucocytes – Granular, leucocyte, waxy and renal tubular epithelial Casts

3- Acute pyelonephritis

Oval fat bodies – Fatty casts – Waxy casts

4- Nephrotic syndrome

Renal tubular epithelial cells – Pathological Casts

5- Acute tubular necrosis

No significant casts – Numerous eosinophils(Hansel’s stain)

6- Eosinophilic cystitis

UrinalysisDisease diagnosis

ANDCase study

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

Physical characteristics: Clear.Microscopic: Not performed .

Drugs Identified: None

Questions :

-What is your differential diagnosis? - What would you do next to confirm

your suspicion? - Would you order a microscopic

analysis on this sample?

A 35-year old man undergoing routinepre employment drug screening.

Physical characteristics: Clear.Microscopic: Not performed .

Drugs Identified: None

Questions :

-What is your differential diagnosis? -What would you do next to confirm

your suspicion? -Would you order a microscopic

analysis on this sample?

NegativeNegative

NegativeNegative

NegativeNegative

1.0011.001

NegativeNegative

5.55.5

NegativeNegative

0.2 mg/dL 0.2 mg/dL

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

UrobilinogenUrobilinogen

NitriteNitrite

L.E.L.E.

Case 1

Answer 1Diluted urine with a low Sp. Gr>>>>>.

Request a morning urine sample>>>>>If persisting low Sp.Gr>>>>>.

Possible diagnosis of diabetes insipidus

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

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

Questions

-What is your differential diagnosis? - Could this be a case of hemolytic

anemia? -How would you rule it out?

-What tests would you order next? Why? -Would you order a microscopic analysis?

A 42-year old woman presents with “darkurine”

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

Questions

-What is your differential diagnosis? -Could this be a case of hemolytic

anemia? -How would you rule it out?

-What tests would you order next? Why? -Would you order a microscopic analysis?

NegativeNegative

++++++

NegativeNegative

1.0201.020

NegativeNegative

5.55.5

NegativeNegative

0.2 mg/dL 0.2 mg/dL

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

UrobilinogenUrobilinogen

NitriteNitrite

L.E.L.E.

Case 2

Answer 2Possible gallbladder or hepatic disease.No hemolytic anemia .

Perform Serum assessment for total and direct bilirubinMicroscopic exam. is unlikely to provide additional information for diagnosis

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

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

Questions

-What is the most likely diagnosis? -What do you make of the ketone result?

- What do you expect to happen to the ketone measurement when treatment

begins?

A 27-year old woman presents with severeabdominal pain.

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

Questions

-What is the most likely diagnosis? -What do you make of the ketone result?

-What do you expect to happen to the ketone measurement when treatment begins?

++++

NegativeNegative

TraceTrace

1.0151.015

NegativeNegative

6.06.0

NegativeNegative

1.0 mg/dL 1.0 mg/dL

NegativeNegative

NegativeNegative

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.

UrobilinogenUrobilinogen

Case 3

Answer 3 Diabetes

May be associated with ketoacidosisKetones should become negative after treatment

NegativeNegative

NegativeNegative

NegativeNegative

1.0151.015

++++++

6.56.5

++

1.0 mg/dL 1.0 mg/dL

NegativeNegative

NegativeNegative

8- year old boy presents with discoloredurine

Physical characteristics: Red, turbid. Microscopic: erythrocytes = >100 per HPF(almost all dysmorphic)Red cell casts present.

Questions:

- What is the most likely diagnosis in thiscase?

- Does the presence of red cell casts helpyou in any way?

- If the erythrocytes were not dysmorphicwould that change your diagnosis?

8-year old boy presents with discolored urine

Physical characteristics: Red, turbid.Microscopic: erythrocytes = >100 per HPF (almost all dysmorphic)Red cell casts present.

Questions:

-What is the most likely diagnosis in this case?

-Does the presence of red cell casts help you in any way?

-If the erythrocytes were not dysmorphic would that change your diagnosis?

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.

UrobilinogenUrobilinogen

Case 4

Answer 4GlomerulonephritisRBC casts reveals renal cortex involvement

NegativeNegative

NegativeNegative

NegativeNegative

1.0101.010

NegativeNegative

5.05.0

++

0.2 mg/dL 0.2 mg/dL

NegativeNegative

NegativeNegative

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

Physical characteristics: YellowMicroscopic: Not performed

Questions:

-What is your differential diagnosis? - Would you order a microscopic analysis on

this sample? - What would you do next to confirm the

diagnosis?

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

Physical characteristics: YellowMicroscopic: Not performed

Questions:

-What is your differential diagnosis? -Would you order a microscopic analysis on

this sample? -What would you do next to confirm the

diagnosis?

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

S.G.S.G.

BloodBlood

pHpH

ProteinProtein

NitriteNitrite

L.E.L.E.

UrobilinogenUrobilinogen

Case 5

Answer 5“Functional” proteinuria ?

Microscopic may reveal a few leukocytesRequest protein concentration in 24 h urine