Understanding the Urinalysis Urinalysis Hematuria by mikeholy

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									                                      Urinalysis Testing Today -- Please Fill The Bottle.
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                                             Understanding the
                                                Urinalysis
                                                    Charles J. Foulks, M.D., FACP
                                              C.S. Lewis, Jr., M.D. Professor and Chair
                                                       Department of Medicine
                                                   School of Community Medicine
                                                     The University of Oklahoma




                                                    Urinalysis

                                    • Color: clear to dark yellow
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                                      – Green: urease bacteria OTC meds with
                                        methylene blue
                                      – Red: beets, quafenisin, blood
                                    • Odor
                                      – Ammonia
                                      – Coffee, asparagus




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                                                      Three urine samples are shown. The
                                                      one at the left shows a red, cloudy
                                                      appearance. The one in the center is
                                                      red but clear. The one on the right is
                                                      yellow, but cloudy.*

                                    *University of Utah




                                                            Urinalysis
                                         • Dipstick
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                                             – Blood: if +, look for hematuria on micro
                                             – Leucocyte esterase: if +, look for WBCs
                                               and bacteria
                                             – Nitrite: if +, look for WBCs and bacteria
                                             – Protein: quantitate; will miss light chains
                                             – Glucose: glycosuria in pregnancy, low
                                               renal threshold can be normal, can be part
                                               of Fanconi’s Syndrome: proximal tubular
                                               reabsorptive problems (AA, UA, Phos,
                                               etc.)




                                                            Urinalysis

                                         • Specific gravity: compares density of
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                                           urine to water. Typically means
                                           concentrated urine but high with urea,
                                           angio dye, gluc
                                         • WBCs: infection, interstitial nephritis
                                         • Hematuria: GN, drainage/bladder
                                           lesion, hemoglobinopathy
                                         • Granular casts: NORMAL, NON-
                                           DISCRIMINATORY




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                                    Red blood cells in urine appear as refractile disks. With hypertonicity of the
                                    urine, the RBC's begin to have a crenated appearance.*
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                                    Note the irregular outlines of many of these RBC's, compared to two
                                    relatively normal RBC's at the center left of the right panel. These abnormal
                                    RBC's are dysmorphic RBC's.*
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                                    These white blood cells in urine have lobed nuclei and refractile
                                    cytoplasmic granules.*




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                                    Oval fat bodies consist of degenerated tubular cells containing abundant
                                    lipid, which appears refractile.*
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                                    Under polarized light, oval fat bodies demonstrate the "Maltese cross"
                                    appearance.*
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                                    Large polygonal squamous epithelial cells with small nuclei are seen
                                    here.*




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                                    Hyaline casts, which appear very pale and slightly refractile, are common
                                    findings in urine.*
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                                    This histologic section at medium power with trichrome stain highlights
                                    red blood cells grouping together in tubules to form casts. The tubular
                                    epithelium is also damaged, with a foamy appearance, and is the basis for
                                    the appearance of oval fat bodies in urine in this case.*
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                                    The presence of this red blood cell cast in on urine microscopic analysis
                                    suggests a glomerular or renal tubular injury.*




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                                    Granular cast, can fool you if not careful.**
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                                    This white blood cell cast suggests an acute pyelonephritis.*
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                                     This renal tubular cell cast suggests injury to the tubular epithelium.*




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                                    These are granular casts, with a roughly rectangular shape.*
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                                    Casts which persist may break down, so that the cells forming it are
                                    degenerated into granular debris, as has occurred in this granular cast.*
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                                    This is a broad, waxy cast. Note that the edges are sharp and there are
                                    "cracks" in this cast.*




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                                    This section of renal cortex reveals tubules containing hyaline casts that
                                    are bile stained in a patient with hyperbilirubinemia.*
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                                    These are oxalate crystals, which look like little envelopes (or
                                    tetrahedrons, depending upon your point of view). Oxalate crystals are
                                    common.*
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                                    These "triple phosphate" crystals look like rectangles, or coffin lids if you
                                    are feeling depressed.*




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                                    These cystine crystals are shaped like stop signs. Cystine crystals are quite
                                    rare.*
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                                    Fiber
                                    Air bubble




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Sally McDonald presented to her physician with pains in her lower back following an
automobile accident. The physicain suspected renal trauma and ordered a
complete urinalysis. The results from the dipstick were negative for blood. The
technologist saw microscopic fields similar to the field shown above. What may be
a cause for the discrepancy in the results? **




                                             False Negative
                                     1. Ingestion of large doses of Vitamin C or antibiotics
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                                        such as tetracycline
                                     2. Testing the supernatant after centrifugation
                                     3. Elevated specific gravity and protein levels which
                                        may reduce lysis of RBC's
                                     4. Elevated nitrate and pH below 5.0 **




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     THE UNIVERSITY OF OKLAHOMA, TULSA   THE UNIVERSITY OF OKLAHOMA, TULSA                        THE UNIVERSITY OF OKLAHOMA, TULSA




                                              8 yo boy recent strep throat, dark, scant urine**




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                                    Uric acid rosettes**
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                                    Uric acid by polarized light.**




                                                           Urinalysis

                                    • WBC Casts: interstitial nephritis,
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                                      infection
                                    • RBC Casts: Nephritic Syndrome or
                                      vasculitis: DEMANDS STAT
                                      EVALUATION
                                    • Waxy casts: seen in nephrotic
                                      syndrome
                                    • Hyaline casts: NORMAL




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                                        Urinary Syndromes
                                    • Rock, scissors, paper
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                                    • Hematuria<Pyuria<Non-Neprotic
                                      Proteinuria<Nephrotic Syndrome<
                                      Nephritic Syndrome
                                    • Nephritic Syndrome is highest
                                    • Hematuria is lowest
                                    • E.G., patient with nephrotic syndrome
                                      and hematuria: work up as nephrotic
                                      syndrome




                                                Hematuria

                                    • Found on UA
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                                      – Urine Pro/Creat ratio; if > 3 work up as
                                        Nephrotic Syndrome, if not then
                                      – If gross hematuria, refer Urology
                                      – If > age 40, refer Urology
                                      – Risk factors for TCCA: smoking, aniline
                                        dye, schistosomiasis (travel to Nile delta)
                                      – If adolescent, young adult:
                                         • March or runner’s hematuria




                                                Hematuria
                                    • If child, adolescent: Alport’s Syndrome
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                                      (high frequency neurosensory hearing
                                      loss)
                                    • If black or from Mediterranean basin:
                                      hemoglobin electrophoresis for Hbg S
                                    • Hematuria very age dependent and
                                      history-driven
                                    • IgA: gross hematuria assoc. with febrile
                                      illnesses: biopsy




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                                                      Pyuria
                                    • UTI defined by + CULTURE
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                                    • Sterile pyuria:
                                       – Someone sterilized your culture
                                       – Interstitial nephritis
                                          • Urine EOS (Hanzel’s stain, centrifuged
                                            specimen)
                                          • Occas. fever, rash, eosinophilia
                                          • Drugs: PCN, Cephalosp., sulfa
                                            (thiazides/furosemide)
                                       – Renal TB
                                          • First void am urine for TB culture




                                     Non-nephrotic Proteinuria

                                    • 24 hr urine protein < 3 g/d
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                                    • Possibilities
                                      – Every nephrotic syndrome has to start
                                        somewhere
                                      – Residual of old glomerulonephritis
                                      – Orthostatic proteinuria
                                         • Supine and standing urine collections for protein
                                         • If 80% proteinuria is in the standing collection, it
                                           is orthostatic proteinuria, a BENIGN condition.




                                     Non-nephrotic Proteinuria

                                    • If not orthostatic proteinuria follow for 2
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                                      years:
                                       – BP, BUN/Creatinine, urine
                                         protein/creatinine ratio q 3 months for 2
                                         years.
                                       – If not nephrotic by 2 years, then most likely
                                         old sub-clinical GN with residual “scarring”
                                       – If urine protein > 3 g/d: nephrotic
                                         syndrome




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                                        Nephrotic Syndrome
                                    • Definition: > 3/d proteinuria
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                                      – Associated with edema, low albumin, high
                                        cholesterol
                                      – MUST PROVE NOT FROM SYSTEMIC
                                        DISEASE:
                                         • Diabetes Mellitus: fasting glucose, 2h pp gluc
                                         • Amyloidosis: ECHO cardiogram, biopsy
                                         • Multiple Myeloma: SIEP, UIEP
                                         • Hepatitis: Hep B Ags, Hep C Ab
                                         • Collagen Vascular: ANA, C3/C4
                                         • Cryoglobulinemia: cryoglobulins




                                         Nephrotic Syndrome

                                    • Associations
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                                      – Age<20: Minimal Change Disease
                                      – 20-40: Focal Segmental Glomerular
                                        Sclerosis
                                      – >40: Membranous
                                         • 10% assoc. with cancer in adults
                                      – >40, if Minimal Change
                                         • Associated with Hodgkin’s Disease




                                        Nephrotic Syndrome
                                      – If a primary nephrotic syndrome, no
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                                       bleeding diathesis, normal sized kidneys,
                                       not too big, no recently active heart
                                       disease, and patient expected to live a
                                       while:

                                      – BIOPSY




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                                         Nephritic Syndrome

                                    • RBC CASTS
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                                       – May have hematuria, nephrotic
                                         syndrome
                                       – Is it a systemic vasculitis?
                                       – This is an EMERGENCY
                                       – START THE WORK-UP AND CALL THE
                                         NEPHROLOGIST IMMEDIATELY




                                         Nephritic Syndrome
                                    • Think of organ system involvement:
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                                      – Pulmonary-renal: Goodpastures’: anti-GBM Ab
                                      – URI/pulm/renal: Wegener’s Granulomatosis: ANCA
                                      – Abdominal-renal: Polyarteritis Nodosa:
                                        Hep B Abs
                                      – CNS/fever/abdominal/low platelets/renal: TTP
                                      – Anemia (hemolysis)/AKI: Hemolytic-Uremic
                                      – Abd pain/lower body rash/hematuria: Henoch-
                                        Schoenlein Syndrome
                                      – More than 2 organ systems/renal: SLE: ANA,
                                        C3/C4, anti-DNA Ab




                                         Nephritic Syndrome
                                    • Cellulitis or pharyngitis: Post-strep GN:
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                                      C3/C4, anti-hyaluronidase, anti-DNase
                                      B, anti-NADase
                                    • Fever, heart murmur: SBE: C3/C4, blood
                                      cultures, ECHO
                                    • Raynaud’s, arthralgias: Hepatitis C and
                                      cryoglobulinemia
                                    • Skin rash: leucocytoclastic vasculitis
                                    • Recent angio, trash feet, abd pain:
                                      MCES




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                                            Further Study

                                    • * Slides of urinalysis are from the
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                                      University of Utah at
                                      http://library.med.utah.edu/WebPath/TU
                                      TORIAL/URINE/URINE.html#6
                                    • **Slides from University of Delaware at
                                      www.udel.edu/medtech/mclane/UAcase
                                      s.html




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