PRINCIPLE OF URINALYSIS

Collection of urineCollection of urine Routine urinalysis Fresh First morning or random specimen Midstream Clean, dry & detergent free container Timed...

0 downloads 181 Views 593KB Size
PRINCIPLE OF URINALYSIS

Vanngarm Gonggetyai

Objective • Can explain : the abnormalities detected in urine • Can perform : routine urinalysis • Can interprete : the results of urinalysis

Examination of urine   

Screening Diagnosis and management Follow up and prognosis

Collection of urine 

Routine urinalysis

 

 



Timed specimen

 



Specimen for culture





Fresh First morning or random specimen Midstream Clean, dry & detergent free container Refrigerator Preservative

Clean-voided/clean-catch midstream Sterile container

Routine urinalysis   

Physical examination Chemical examination Microscopic examination

Routine urinalysis : Physical examination Normal 

Colour



Pale yellow

Abnormal   



Clarity





Volume



Clear 600-1,600 ml (adult)



  



Specific  1.003-1.035 gravity

 

Hematuria .. smoky urine Hemoglobinuria Etc. Turbid .. Cells, Organisms, etc. Polyuria .. >2,000 ml/day Oliguria .. <500 ml/day Anuria .. <100 ml/day

High .. Diabetes mellitus Low .. Diabetes insipidus

Routine urinalysis : Chemical examination     

    

Specific gravity pH Protein Sugar Blood, hemoglobin & myoglobin Bile (conjugated bilirubin) Urobilinogen Ketone Nitrite Leukocyte esterase

Conventional method vs Reagent strip

Routine urinalysis : Chemical examination Specific gravity o o o

Indirect method Depends on ionic concentration of urine Not affected by high amount of glucose and protein

Routine urinalysis : Chemical examination pH    

Fresh urine Normal .. 4.6 - 8.0 Acid urine Alkaline urine

Routine urinalysis : Chemical examination Protein 

Urine protein excretion > 150 mg/day = proteinuria



Most filtered protein = albumin



Reagent strip is sensitive to albumin

Proteinuria Functional proteinuria Organic proteinuria



Pre-renal proteinuria



Renal proteinuria



Post-renal proteinuria

Vaginal discharge contamination

Routine urinalysis : Chemical examination Glucose  

Reagent strip is specific for glucose Renal threshold = 160 mg/dl

Glucosuria 

Without hyperglycemia



With hyperglycemia

Routine urinalysis : Chemical examination Ketone 

Ketone bodies .. .. Beta hydroxybutyric acid acetoacetic acid acetone



Most reagent strips detect only acetoacetic acid

Ketonuria 

Diabetic ketonuria



Non-diabetic ketonuria

Routine urinalysis : Chemical examination Bile (conjugated bilirubin) 

Obstructive jaundice



Hepatocellular jaundice

Routine urinalysis : Chemical examination Urobilinogen 

Fresh urine



A small amount is excreted in urine

Increased urobilinogen 

Hemolytic jaundice



Hepatocellular disease

Routine urinalysis : Chemical examination Blood, Hemoglobin, Myoglobin



Hematuria



Intact erythrocyte



Hemoglobinuria



Hemoglobin from hemolysis



Myoglobinuria



Myoglobin from rhabdomyolysis

Routine urinalysis : Chemical examination Nitrite 

Nitrite-forming bacteria

Leukocyte esterase 

Detects both lysed and intact leukocyte equivalent to 5 - 15 cells/HPF

Routine urinalysis : Microscopic examination 

Fresh urine



No preservative



Midstream collection

Routine urinalysis : Microscopic examination

Preparation of urine sediments

Routine urinalysis : Microscopic examination Formed element of urine 

Cells



Casts



Crystals



Organisms



Contaminants and artifacts

Routine urinalysis : Microscopic examination Cells 

Erythrocyte



Leukocyte



Epithelial cell 

Tubular cell, Oval fat body



Transitional cell



Squamous cell

Routine urinalysis : Microscopic examination Erythrocyte (Red blood cell) 



Pale, biconcave disc, diameter ~ 7 micron Normal .. .. 0 - 2 cells/HPF

Increased erythrocyte     

Renal diseases Lower urinary tract disease Extrarenal diseases Toxic reaction Physiologic

Routine urinalysis : Microscopic examination Dysmorphic erythrocyte 

Red blood cell with cellular protrusions or fragmentation



Reflect glomerular origin



Detected by phase contrast microscope

Routine urinalysis : Microscopic examination Leukocyte (White blood cell) 



Granular spheres, diameter ~ 12 micron, multilobated nuclei Normal .. .. 0 - 5 cells/HPF

Increased leukocyte 

Infection, inflammation, fever, streneous exercise

Routine urinalysis : Microscopic examination Renal tubular cell  

 

Line the tubule Slightly larger than leukocyte Round or polygonal shape Large nucleus

Increased renal tubular cell 

Acute tubular damage

Routine urinalysis : Microscopic examination Oval fat body 

Tubular cell that absorbed lipoprotein with cholesterol and triglyceride leaked from nephrotic glomeruli



Characteristic of the nephrotic syndrome

Routine urinalysis : Microscopic examination Transitional epithelial cell 







Line the urinary tract from the renal pelvis to the proximal third of the urethra Round, oval, fusiform shape Round centrally located nucleus Increased : infection, CA

Routine urinalysis : Microscopic examination Squamous epithelial cell 





Line the distal third of the urethra Large and flat with abundant cytoplasm, fold margin Small round central nucleus

Vaginal discharge contamination

Routine urinalysis : Microscopic examination Casts Tamm-Horsfall protein .. the glycoprotein secreted by the ascending loop of Henle .. forming the matrix of all casts        

Hyaline casts Red blood cell casts White blood cell casts Renal tubular epithelial casts Granular casts Fatty casts Waxy casts Broad casts

Routine urinalysis : Microscopic examination Hyaline casts 



Transparent, homogenous and colourless Can be seen 0-2/LPF in normal

Increased in  

Various renal diseases Transiently in exercise, dehydration, fever, etc.

Routine urinalysis : Microscopic examination Erythrocyte (RBC) casts  

Prolonged stasis leading to hemoglobin (blood) cast Indication of bleeding in nephron : acute GN, lupus nephritis, nephrosclerosis, etc.

Erythrocyte (RBC) casts

Hemoglobin casts

Routine urinalysis : Microscopic examination Leukocyte (WBC) casts 

Tubular and/or tubulointerstitial diseases eg. acute & chronic pyelonephritis, interstitial nephritis, acute GN

Routine urinalysis : Microscopic examination Renal tubular epithelial casts 

Reflect tubular damage, e.g. acute tubular necrosis, acute allograft rejection, etc.

Routine urinalysis : Microscopic examination Granular casts 



Granules may originate from plasma protein aggregates as well as from cellular remnants Appear with both pathologic and nonpathologic conditions

Routine urinalysis : Microscopic examination Fatty casts 



Commonly seen with heavy proteinuria Feature of nephrotic syndrome

Routine urinalysis : Microscopic examination Waxy casts 





Homogeneously smooth with sharp margins, blunted ends and cracks along the lateral margins Extreme stasis of urine flow Advanced renal disease

Routine urinalysis : Microscopic examination Broad casts  



Diameter 2-6 times that of normal casts Indicate tubular dilatation and/or stasis in the distal collecting duct Found in chronic renal failure / Poor prognosis

Routine urinalysis : Microscopic examination Telescoped sediment 





Element of glomerulonephritis & nephrotic syndrome in the same urine specimen Rbc, rbc casts, wbc, wbc casts, broad waxy casts, oval fat bodies, fatty cast Advanced renal disease eg. Lupus nephritis

Routine urinalysis : Microscopic examination Crystals   

Less significant, except pathologic crystals Normal acidic urine : Calcium oxalate, uric acid, etc. Normal alkaline urine : Calcium carbonate, triple phosphate, etc.

Abnormal crystals 



Cystine, acetyl sulfadiazine, cholesterol, bilirubin Amorphous – granular precipitates : amorphous urate, amorphous phosphate

Routine urinalysis : Microscopic examination Normal crystals

Calcium oxalate

Uric acid

Routine urinalysis : Microscopic examination Abnormal crystals

Cystine

Acetyl sulfadiazine

Routine urinalysis : Microscopic examination Abnormal crystals

Cholesterol

Bilirubin

Routine urinalysis : Microscopic examination Organisms    

Bacteria Fungus Parasite Etc.

Routine urinalysis : Microscopic examination Bacteria

Routine urinalysis : Microscopic examination Fungus

Yeast

Hyphae

Trichomonas vaginalis

Routine urinalysis : Microscopic examination Contaminants and artifacts

Spermatozoa

Starch granule

REPORT • CELL (10-15 high power field) 0-1, 1-2, 2-3, 3-5, 5-10, 10-20,…/ HPF or numerous • CAST (10-15 low power field) 0-1, 1-2, 2-3,…/ LPF • BACTERIA & CRYSTAL 1+, 2+, 3+ or few, moderate, numerous

Reference Values for Urine Sediment

• • • • •

Red blood cells White blood cells Renal epithelial cells Transitional epithelial cells Squamous epithelial cells

0-2/ HPF 0-5 / HPF few/HPF few/HPF few/HPF

Reference Values for Urine Sediment

• • • •

Casts Abnormal crystals Bacteria Yeast

0-2 hyaline cast /LPF Negative Negative Negative

THANK YOU FOR YOUR ATTENTION