Analysis Of Urine And Body Fluids PDF

**ANALYSIS OF URINE AND BODY FLUIDS (AUBF)** **Ruth Abegail C. Collao** 3rd yr 1st sem **INTRODUCTION:** Body fluids: 1. Urine 2. Saliva/sputum - TB 3. Sweat 4. Semen - fertility 5. CSF - brain/ spinal cord 6. Synovial fluid - joints 7. Amniotic fluid - fluid that surrounds/protect...

**ANALYSIS OF URINE AND BODY FLUIDS (AUBF)** **Ruth Abegail C. Collao** 3rd yr 1st sem **INTRODUCTION:** Body fluids: 1. Urine 2. Saliva/sputum - TB 3. Sweat 4. Semen - fertility 5. CSF - brain/ spinal cord 6. Synovial fluid - joints 7. Amniotic fluid - fluid that surrounds/protects the baby inside the mothers womb 8. Stool/feces - parasites 9. Serous fluid : **3 TYPES**: pericardial fluid - heart, peritoneal fluid - abdomen, pleural fluid - lungs MODULE 1: **SAFETY IN THE CLINICAL LABORATORY** **Hazard** - something that causes injury/harm or diseases. \- the effect of unpredictable and unanalyzable forces in determining events **TYPES OF HAZARD:** - **BIOLOGICAL HAZARD** - **SHARP HAZARD** - **CHEMICAL HAZARD** - **RADIOACTIVE HAZARD** - **ELECTRICAL HAZARD** - **FIRE HAZARD** - **PHYSICAL HAZARD** 1. **BIOLOGICAL HAZARD** - *eg*. microorganisms (*bacteria, virus*) that cannot be seen by the naked eye - can be acquired through the **specimens**. \- Microorganisms are being transmitted through the **CHAIN OF INFECTION:** SOURCE, MODE OF TRANSMISSION, SUSEPTIBLE HOST (SMS) **UNIVERSAL PRE-CAUTION** - *treat all specimens as potentially and highly infectious.* **PREVENTION OF BIOLOGICAL HAZARDS:** 1. **PPE** 2. **Hand washing** - most important to break the chain of infection. HBD song (2x) Rinse (downward position) **Hand contact** - is the primary method of infection transmission. **AGENCIES**: **CDC** - **C**enter for **D**isease **C**ontrol \- promotes hand washing \- Its [main goal] is to **protect** ppublic health and safety through the control and prevention of disease, injury, and disability in the US primarily **OSHA** - **O**ccupational **S**afety and **H**ealth **A**dministration \- ensures safe environment to those who are working by means of setting standards \- [Its mission] is to \"assure safe and healthy working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance\" **PROPER DISPOSAL OF THE SPECIMENS** 1. [All biological wastes], **except** **URINE**, must be placed in appropriate containers labeled with the biohazard symbol. 2. [Disinfection of the sink using] a **1:5** or **1:10** dilution of **sodium hypochlorite** should be performed daily. 3. Use of sodium hypochlorite (bleach) 1:10 ( 1mL bleach - 9mL h20) - use to disinfect the working area. eg: 1000 mL (1:10) 100mL (bleach) - 900mL (H20) 2\. **SHARP HAZARD** types of sharp: - Needles - Broken glassware - Lancet **PROPER DISPOSAL OF SHARPS:** 1. Puncture - resistant container 3\. **CHEMICAL HAZARD** **Chemical Spills:** - [Wash w/ running water] - **15 mins.** - **DO NO NEUTRALIZE CHEMICALS** that come in contact with the skin. **Chemical handling:** **Always remember:** **ALWAYS ACID TO WATER** \- to avoid splashing or explosion **NATIONAL FIRE PROTECTION ASSOCIATION** (NFPA) \- All Reagents should have NFPA label \- developed the Standard System for the Identification of the Fire Hazards of Materials, **NFPA 704.7** [This symbol system is used to inform fire fighters of the hazards they may encounter with fires in a particular area]. \- The **diamond shaped, color-coded symbol** [contains information relating to health, flammability, reactivity, and personal protection/special precautions]. Red - fire hazard /Flammable Yellow - sunlight/reactivity White - specific hazard Blue - safe/health hazard **MATERIAL SAFETY DATE SHEET** (MSDS) \- reagents can be classified its level of danger \- contains the information regarding all the chemical hazards of a certain products such as reagents and supplies that are present in the workplace. Information contained in an **MSDS** includes: 1. Physical and chemical characteristics 2. Fire and explosion potential 3. Reactivity potential 4. Health hazards and emergency first aid procedures 5. Methods for safe handling and disposal. 4\. **RADIOACTIVE HAZARD** Radio isotopes - not for pregnant - affect the fetus and the mother \- Exposure to radiation during pregnancy presents danger to the fetus. 5\. **ELECTRICAL HAZARD -** hazards from the machines - All electrical equipment must be grounded with three-pronged plugs. REMEMBER! Don\'t operate when hands are wet Things to do when electric shock happened: 1. Never touch the person/equipment, switch off the main circuit breaker. 2. Unplugged the equipment. 3. Move the equipment using a nonconductive glass or wood object 6\. **FIRE/EXPLOSIVE** **HAZARD** - Flammable chemicals should be stored in safety cabinets and explosion proof refrigerators in a remote area. - Persons with burning clothes should be wrapped in the blanket to smother the flames. Do **RACE** when discover fire - RESCUE, ALARM, CONTAIN, EXTINGUISH Use of FIRE EXTINGUISHER do **PASS** - PULL, AIM, SQUEEZE, SWEEP TYPES OF FIRE: 1. Class A - wood, paper, clothes - use **WATER** as Extinguisher 2. Class B - flammable organic chemicals (reagents/liquid) - use **DRY CHEMICALS, CARBON DIOXIDE, FOAM, HALON** as extinguisher 3. Class C - electrical - use **DRY CHEMICALS, CARBON Dioxide, HALON** as extinguisher 4. Class D - combustible metals - use **SAND, OR DRY POWDER** as extinguisher 7\. **PHYSICAL HAZARD** \- not unique to the laboratory, and routine precautions observed outside the workplace apply. **General Precautions to be observed:** 1. Avoid running in rooms and hallways. 2. Watch for the wet floors. 3. Bend knees when lifting heavy objects. 4. Keep long hair pulled back, 5. Avoid dangling jewelry 6. Maintain clean, organized work area. 7. Wear closed-toe shoes. **AEROSOL** happens when you centrifuge an uncap specimen. **URINARY SYSTEM** 4 components of US: 1. **Kidney** - where urine is formed 2. **Ureter** - carries the urine to urinary bladder 3. **Urinary bladder** - stores urine 4. **Urethra** - length Male - 25 cm long Female - 4 cm long Micturition reflex - 150 ml (urge to pee) 1\. **KIDNEY** \- bean shaped paired organ but not the same size \- located in posterior (front) wall of the abdomen \- male kidney (150g) female kidney (135g) \- 12. 5 cm length, 6 cm weight, 2.5 cm depth \- complexes : cortex, medulla, pelvis **NEPHRON** \- basic structural and functional unit of the kidney \- 1-1.5 million per kidney \- consist of: glomerulus and renal tubular \- **primary function:** 1. concentration of urine 2. Removal of waste products and absorption of nutrients **PARTS OF NEPHRON** 1. **Glomerulus** Compose of : - capillary endothelial cells - Epithelial cell - Mesangium - Basement membrane 2\. **PCT** - Proximal convoluted tubule 3\. **LOOP OF HENLE** - thin descending LOH - U-shaped segment - Thin and thick descending limbs 4\. **DCT** - Distal Convoluted Tubule 5\. **CT** - collecting ducts [RENAL FUNCTIONS:] 1. **Renal blood flow** \- 25% of cardiac output (left ventricle) \- 1200 ml /mn or 600 ml /kidney Blood flow: **renal artery** (supply) ➡️ **afferent arteriols** (to) ➡️ **efferent arteriols** (from) ➡️ **peritubular Capillaries** (surrounds PCT&DCT) ➡️ **vasa recta** (LOH) ➡️ **renal vein** (drainage) 2\. **Glomerular filtration** \- process of filtering the blood and forming the ultrafiltrate GLOMERULUS \- location with in bowmans capsule \- 70,000 MV \- capillary taft \- main purpose is to filter **FACTORS AFFECTING FILTRATION PROCESS** 1. **Cellular structure of the glomerulus** 2. **Glomerular pressure** - (hydrostatic pressure) Normal blood pressure : 120/80 ⬆️Hypertension ⬇️hypotension Dilation - big Constriction - smaller - (happens to prevent damage) 3\. **RAAS** (Renin Angiotensin Aldosterone System) - **controls the regulation of blood flow** to and with in the glomerulus  Things that trigger RAAS: 1. Low Na content 2. Low H20 3. Low blood volume 4. Low blood pressure **End effect of RAAS** : - increase in systematic blood pressure 3\. **Tubular reabsorption** \- substance removed from the filtrate are returned to the blood MAJOR SITE OF REABSORPTION: PCT Renal threshold for glucose: 160 - 180mg/dl Reabsorption mechanism ⬆️ Bodys hydration = ⬇️ ADH (antidiuretic hormone) = ⬇️ reabsorption of H20 = ⬆️ UV ⬇️ Bodys hydration = ⬆️ADH = ⬆️ reabsorption of H20 = ⬇️ UV 4\. **Tubular secretion** \- passage of substances from the PC to tubular filtrate **2 function of tubular secretion:** 1. **Elimination of waste products** 2. **Regulation of acid base balance** **[RENAL FUNCTION TESTS]** 1. Glomerular filtration - clearance tests (**inulin clearance** (Gold standard -not currently used, used as reference method) - **creatinine clearance** (most common - routinely used, not reliable indicator in PX suffering from muscle - wasting disease)) **Clearance test** - used to evaluate Glomerular filtration Procedure of Creatinine clearance test: 1. collect blood & urine 2. Urine 24-hr urine Greatest source of error: improperly timed specimen **Formula**: C= UV / P x 173 / A ➡️ U = urine crea.(mg/dl) V = urine vol. (ml/min) P = Plasma crea.(mg/dl) 1.73 = are Body surface area m³ A = actual body size in m² BSA Normal V: Male = 107 - 139 ml/min Female = 87 - 107 ml/min **Formula:** **C = U(V) / P** **Problem \#1:** Given: Urine crea = 160 mg/dl Plasma crea = 2 mg/dl Urine volume = 1500 ml/24hrs Convert to min.: V = 1500 ml/24~~hr~~ / 60 min (x) /24 ~~hr~~ = 1500 ml / 1440 min = [1.04 ml/min] C = 160 ~~mg/dl~~ (1.04 ml/min) / 2 ~~mg/dl~~ = [83.2 ml /min] Low creatinine, FEMALE **Problem \#2:** Given: Urine crea. = 120 mg/dl Plasma crea. = 1 mg/dl Urine vol. = 1440 ml/24hrs Convert to min.: V = 1440 ml/24hrs / 60min(x) /24hrs = 1440 ml / 1440 min = 1 ml/min C = 120 ~~mg/dl~~ (1ml/min) / 1 ~~mg/dl~~ = 120 ml/min Normal, MALE **Cockcroft & Gaulf** Ccr = (140-age)(wt in kg) / 72 x Serum crea mg/dl = (140-62) 75 kg / 72 x 8 mg/dl = 78 (75) / 576 mg = 5850 / 576 Ccr = [10.16] 2\. Tubular reabsorption **CONCENTRATION TEST -** test for tubular reabsorption **Obsolete**: 1. Fishberg test XH20 = 24hrs SG = 1.026 2\. Mosenthal test Urine day vs. Night \> volume \> SG **Commonly test:** 3\. Specific gravity \> number \> density of particles - urine 4\. Osmolarity \- number of particles in the urine 3\. Tubular secretion & renal blood flow 1. PAH (p-aminohippuric acid test) \- exogenous 2\. PSP (phenolsulfonphthalein test) \- not performed \- used dye \- endogenous **INTRODUCTION OF URINALYSIS** 3 analysis : 1. Physical, 2. chemical, 3. microscopic Invention of Microscope in the 7th century led to the examination of urinary sediments. **Thomas Addis** - develop the methods for quantitating the microscopic sediments. **Richard Bright** - introduce the concept of urinalysis as part of a doctors routine examination in **1827**. By 1930s began to disappear from routine examination **2 UNIQUE CHARATERISTICS OF URINE SPECIMEN ACCOUNT FOR THIS CONTINUED POPULARITY** 1. urine is a readily available and easily collected specimen 2. Urine contains information - which can be obtained by inexpensive laboratory test, about many of the body\'s major matabolic functions. **A. URINE COMPOSITION**  **B. SPECIMEN COLLECTION** ***Standard precautions*:** - Gloves should be worn all the time - Specimen must be collected in Clean, dry, leak-proof containers - Properly applied **screw-top lids** are **[less likely than snap on lids]** - Container for routine urinalysis: a. **WIDE-MOUTH** and wide, **flat bottom** [to prevent overturning] b. Made of **clear material** to [allow for determination of color and clarity] c. Recommended capacity is **50 ml** d. For microbiologic urine studies, individually package sterile container with secure closure should be used. e. Sterile container are also suggested if more than 2 hours elapse between specimen collection and analysis. - **ALL SPECIMEN MUST BE LABELED PROPERLY**, with the patient name, and identification number, the date and time of collection and additional information such as the patient age and location and the physicians name a. **Label must be attached to the container and not to the lid**. **POINTS/REASONS FOR URINE SPECIMEN REJECTION** ------------------------------------------------------- ---------------------------------------------------- **Specimen in unlabeled container** **Containers with contaminated exteriors** **Non matching label and request forms** **Specimen of insufficient quality** **Specimens contaminated with feces or toilet paper** **Specimen that have been improperly transported** ------------------------------------------------------- ---------------------------------------------------- **AFTER REJECTION, ALWAYS REQUEST FOR NEW SPECIMEN** **C. SPECIMEN HANDLING** - **Specimen integrity** - After collection, Specimens must be sent to the laboratory and be tested within  **2 hours** - Preserve the specimen by refrigeration or use of an appropriate chemical preservative - If not properly preserved, the following changes may occur: **D. SPECIMEN PRESERVATION** - **PHYSICAL** - Refrigeration - most routinely used TEMPERATURE: **2° to 8°C** **Effects:** 1. Decreases bacterial growth and metabolism 2. Increases specific gravity when measured by urinometer 3. Precipitation of amorphous phosphates and urates **AMORPHOUS URATES (acidic urine)** PINK PRECIPITATES **AMORPHOUS PHOSPHATE (alkaline urine)** [WHITE PRECIPITATES] - The specimen must return to the room temperature before chemical testing by reagent strips (this will correct specific gravity and may dissolve some of the amorphous urates  - **CHEMICAL** **-** the routine use of preservatives is **NOT** recommended \- **IDEAL PRESERVATIVES**: 1. Bactericidal 2. Can inhibit urease 3. Can preserve formed elements in the sediments 4. Should not interfere with chemical tests **E. TYPES OF URINE SPECIMEN** **DIFFERENT TYPES OF URINE SPECIMEN** +-----------------------------------+-----------------------------------+ | **1. Random/occasional/single** | **For routine and qualitative | | | UA** | +-----------------------------------+-----------------------------------+ | **2. First morning** | **ideal specimen for routine UA | | | and pregnancy test (hCG); most | | | concentrated, most acidic, for | | | well preservation of cells and | | | casts; for evaluation of | | | orthostatic proteinuria** | +-----------------------------------+-----------------------------------+ | **3. Second morning/fasting** | **2nd voided urine after a period | | | of fasting; for glucose | | | determination** | +-----------------------------------+-----------------------------------+ | **4. 2 hours postprandial** | **For diabetes | | | screening/monitoring** | +-----------------------------------+-----------------------------------+ | **5. Glucose tolerance** | **Optional with blood samples in | | | glucose tolerance test** | +-----------------------------------+-----------------------------------+ | **6. Functional specimen** | **At least 2 voided collection** | | | | | | **Series of blood and urine | | | collected at specific time | | | intervals to compare the | | | concentration of a substance in | | | urine with its concentration in | | | the blood (used in the diagnosis | | | of diabetes)** | +-----------------------------------+-----------------------------------+ | **7. Midstream clean-catch** | **For urine screening and | | | bacterial culture** | +-----------------------------------+-----------------------------------+ | **8. Catheterized** | **For bacterial culture** | +-----------------------------------+-----------------------------------+ | **9. Suprapubic aspiration** | **Bladder urine for anaerobic | | | bacterial culture and urine | | | cytology** | +-----------------------------------+-----------------------------------+ | **10. Pediatric specimen** | **Use of soft, clea, plastic bags | | | with adhesive** | +-----------------------------------+-----------------------------------+ | **11. Three-glass technique** | **For prostatic infection** | | | | | | **1. First portion of voided | | | urine** | | | | | | **2. Middle Portion of voided | | | urine** | | | | | | **3. Urine after prostatic | | | massage** | | | | | | - **Examine the 1st and 3rd | | | specimen microscopically, | | | then compare the number and | | | bacteria** | | | | | | - **Prostatic infection = if | | | the number of WBC and | | | bacteria in the 3rd specimen | | | greater than that of the 1st | | | (3rd\>1st)** | | | | | | - **21st specimen = CONTROL for | | | bladder and kidney infection, | | | if (+) for WBC bacteria, the | | | result from 3rd specimen is | | | considered INVALID.** | +-----------------------------------+-----------------------------------+ | **12. Timed specimen** | | +-----------------------------------+-----------------------------------+ | **A. 24 hours** | **Begin and end the collection | | | period with an empty bladder** | | **Example: 8am ➡️ 8am** | | | | **Requires preservatives** | +-----------------------------------+-----------------------------------+ | **B. 12 hours** | **For ADDIS count** | | | | | **Example: 8am ➡️ 8pm** | | +-----------------------------------+-----------------------------------+ | **C. 4 hours/first morning** | **For NITRITE determination** | | | | | | **Urine remains in the bladder | | | for at least 4 hours before being | | | collected** | +-----------------------------------+-----------------------------------+ | **D. Afternoon (2pm-4pm)** | **For UROBILINOGEN | | | determination** | +-----------------------------------+-----------------------------------+ **F. DRUG SPECIMEN COLLECTION** - **Chain of custody (COC) -** the process that **provides documentation** of proper sample identification from the time of collection to the receipt of laboratory result - Required volume : **30 - 45 mL** - Temperature (with in 4 mins) : **32.5 - 37.7°C** - **Bluing agent (dye)** - is added to toilet water reservoir to **prevent specimen adulteration.** **National references laboratory (NRL) -** drug testing laboratory **PHYSICAL EXAMINATION OF URINE** **Includes:** 1. Urine Volume 2. Urine Clarity 3. Urine Color 4. Specific Gravity 5. Urine Odor **PHYSICAL** - having material existence : perceptible especially through the senses and subject to the laws of nature. **A. URINE VOLUME** - Depends on the body's state of hydration - Factors that influence urine volume 1. **Fluid intake** 2. **Fluid loss from non-renal sources** 3. **Variations in ADH** 4. **Necessity to excrete increased amounts of dissolved solids such as glucose or salt.** **ROUTINE UA:** [Volume Required] = **10-15 mL** (For urinometry and reagent strip) ---------------------------------- --------------------- **NORMAL URINE OUTPUT (24 hrs)** **600 to 2000 mL** **AVERAGE URINE OUTPUT** **1200 to 1500 mL** **NIGHT:DAY RATIO** **1:2 to 1:3** ---------------------------------- --------------------- **VARIATIONS IN URINE VOLUME**: 1\. **OLIGURIA** -- **DECREASE** in urine output - \ - May result from any serious damage to the kidneys - Or from a decrease in blood flow to the kidney 3\. **NOCTURIA** -- **INCREASE** in nocturnal excretion of urine 4\. **POLYURIA** -- **INCREASE** in daily urine volume - 2.5-3 mL/kg/day in children - \2.5 L//day in adults - Often associated with DIABETES MELLITUS and DIABETES INSIPIDUS - May be artificially induced by diuretics, caffeine or alcohol **REMEMBER** URINE OUTPUT DURING Day & NIGHT: The kidneys excrete 2 to 3 times more during the DAY than during the night. DIABETES MELLITUS vs DIABETES INSIPIDUS +-----------------------------------+-----------------------------------+ | DIABETES MELLITUS | \- Problem is related with | | | INSULIN leading to increased | | | glucose concentration- The | | | kidneys excrete increased amounts | | | of water to remove the dissolved | | | glucose- The urine will have HIGH | | | SPECIFIC GRAVITY | +-----------------------------------+-----------------------------------+ | DIABETES INSIPIDUS | \- Problem is with ANTIDIURETIC | | | HORMON | | | | | | \- The water needed for adequate | | | body hydration is not reabsorbed | | | | | | \- The urine will have LOW | | | SPECIFIC GRAVITY | +-----------------------------------+-----------------------------------+ **B. URINE COLOR** - Normal urine has a wide range of color -- mainly determined by its CONCENTRATION - PALE YELLOW - DILUTE URINE (well-hydrated) - DARK YELLOW - CONCENTRATED URINE (dehydrated) --------------------- -------------------------------------------- NORMAL URINE COLOR: Pale yellow, yellow, dark yellow and amber URINE PIGMENTS: Urochrome, Uroerythrin, and Urobilin --------------------- -------------------------------------------- **URINE PIGMENTS**: **1. UROCHROME** -- causes the YELLOW color of urine \- Named by THUDICHUM in 1864 \- Constantly produced and excreted at a constant rarat \- Production is dependent on the body's metabolic state - Increased in thyroid conditions and fasting states and in urine that stands at room temperature 2\. **UROERYTHRIN** -- a PINK pigment most evident in REFRIGERATED SPECIMENS as a result of AMORPHOUS URATE PRECIPITATION 3\. **UROBILIN** -- oxidation product of urobilinogen and imparts an Orange-Brown color to urine that is not fresh. +-----------------------------------+-----------------------------------+ | How to Examine | Examine the specimen under a good | | | light source, looking down | | Urine Color? | through the container against a | | | white background | +-----------------------------------+-----------------------------------+ **VARIATIONS IN URINE COLOR:** 1\. **DARK YELLOW / AMBER / ORANGE** - **BILIRUBIN** -- produces a YELLOW FOAM when specimen is shaken vs WHITE Foam in increased protein concentration - **UROBILIN** -- when UROBILINOGEN is PHOTO-OXIDED (no yellow foam when shaken) vs photo-oxidation of bilirubin which imparts a yellow-green color. **MEDICATIONS**: - **PHENAZOPYRIDINE (Pyridium) or azo-gantrisin compounds** -- also causes yellow foam when shaken which can be mistaken for bilirubin 2\. **RED / PINK / BROWN** - Red blood cells (HEMATURIA) \- Produce RED AND CLOUDY URINE \- Imparts red color (usual) to brown color depending on the amount of blood, urine pH and length of contact - RBCs remaining in an acidic urine for several hours produce BROWN urine (due to oxidation of hemoglobin to methemoglobin) - **HEMOGLOBIN AND MYOGLOBIN** - Produce RED AND CLEAR URINE **Differences Between Hemoglobinuria and Myoglobinuria** +-----------------------------------+-----------------------------------+ | **HEMOGLOBIN** | **MYOGLOBIN** | +-----------------------------------+-----------------------------------+ | Results from the IN VIVO | Results from BREAKDOWN OF | | BREAKDOWN of | SKELETAL MUSCLES | | | | | RBCs | | +-----------------------------------+-----------------------------------+ | Accompanied by RED PLASMA | NO CHANGE in color of plasma | +-----------------------------------+-----------------------------------+ (*fresh urine containing myoglobin frequently exhibits a more reddish-brown color than hemoglobin*) - **PORPHYRINS**-- causes PORT-WINE color and results from the oxidation of porphobilinogen **NON-PATHOLOGIC CAUSES**: A. Menstrual contaminationB. Ingestion of highly pigmented foods - Beets -- red color in ALKALINE urine - Blackberries -- red color in ACIDIC urine C. Medications (Rifampin, Phenolphthalein, Phenindione, Phenothiazines) 3\. **BROWN / BLACK** - **Homogentisic Acid**- Metabolite of phenylalanine \- Imparts a black color to ALKALINE urine in patients with ALKAPTONURIA - **Melanin** \- Oxidation product of colorless pigment MELANOGEN \- Produced in excess when MELANOMA is present - **Medications** - Levadopa, Methyldopa, Phenol derivatives, Metronidazole (Flagyl) 4\. **BLUE / GREEN** - Bacterial Infections -- Green Color- UTI by Pseudomonas spp.- Intestinal tract infections resulting in INCREASED URINARY INDICAN - Clorets -- a breath deodorizer which imparts a GREEN COLOR **MEDICATIONS** -- may cause BLUE urine- Methocarbamol (Robaxin), Methylene Blue, Amitriptyline (Elavil), Azure A (Diagnex Blue Test)  C. **URINE CLARITY** - Refers to the TRANSPARENCY/TURBIDITY of a urine specimen - Provides a key to the microscopic examination results because the amount of turbidity should correspond with the amount of material observed under the microscope. **REMEMBER** NORMAL URINE CLARITY: Usually CLEAR(particularly if midstream clean-catch specimen)   D. **SPECIFIC GRAVITY** - Defined as density pf solution compared with the density of similar volume of water at a similar temperature - Used to measure the concentrating and diluting ability of the kidney in its effort to maintain homeostasis in the body **TUBULAR REABSORPTION** -- First function to diminish renal disease - Affected by both NUMBER AND SIZE of particles in the solution - In short, it is an indicator of concentration of dissolved material in the urine. **REMEMBER** NORMAL URINE SPECIFIC GRAVITY:Random: 1.003 to 1.00524-HOUR: 1.015 TO 1.025 Note: S.G. \ - A microprocessor corrects sample temperature - Result is valid up to a specific gravity of 1.080. **INDIRECT METHODS:** 1\. **REFRACTOMETER (Total Solids Meter)**Principle: - Measures the REFRACTIVE INDEX which is a comparison of the velocity of light in air with the velocity of light in a solution - The path of light is deviated when it enters a solution, and the degree of deviation or refraction is proportional to the density of the solution **ADVANTAGES**: USES SMALL VOUME OF SPECIMEN (1 to 2 gtts)- Calibrated between 15°C to 38°C (60°F to 100°F)  2\. **REAGENT STRIP** (*see Chemical Examination part*) E. **URINE ODOR** - Seldom of clinical significant and not part of the routine urinalysis - Freshly voided urine has a **FAINT AROMATIC ODOR** and as the specimen stands, the odor of ammonia (due to breakdown of urea) becomes more prominent - **LACK OF ODOR** in urine from patients with ARF suggests **ACUTE TUBULAR NECROSIS**  ----------------------------------- **CHEMICAL EXAMINATION OF URINE** ----------------------------------- **Chemical** - -acting or operated or produced by chemicals; detectable by chemical means -------------------- **REAGENT STRIPS** -------------------- A. **PRINCIPLE OF THE REAGENT STRIP**: - Consist of chemical-impregnated **absorbent pads** attached to a plastic strip - A color-producing chemical reaction takes place when the absorbent pad comes in contact with urine - Reactions are interpreted by comparing the color produced on the pad with a chard supplied by the manufacturer - By **careful comparison, results are described as** **TRACE, 1+, 2+, 3+, or 4+** B. **CARE OF THE REAGENT STRIPS**: - **Store with desiccant in an opaque**, tightly closed container - **Store below 30°C**; **DO NOT FREEZE** - **Do not expose to volatile fumes** - **Do not use past the expiration date** - **Do not use if chemical pads become discolored** - **Remove strips immediately prior to use** C. **QUALITY CONTROL:** - [Test open bottles of reagent strips with known] **positive and negative controls evert 24 hr**. - Resolve control results that are out of range by further testing - Test reagents used in backup tests with positive and negative controls - Perform **positive and negative controls on new reagents and newly opened bottles of reagent strips** - **Record all control results and [reagent lot numbers] -** to easily identify the error/damage The **two major types of reagent strips are** **manufactured under the tradenames** **MULTISTIX** and **CHEMSTRIP**. ----------------------------------------------- **DIFFERENT PARAMETERS OF THE REAGENT STRIP** ----------------------------------------------- 1\. **pH** - [Determined by the concentration of the **free H+**] - as **H+ increases, pH decreases** (acidic) - as **H+ decreases, pH increases** (alkaline) **REMEMBER!** **[NORMAL URINE pH:]** Random: **4.5 -- 8.0** First Morning: **5.0 -- 6.0** With Normal Protein Diet: **4.5 -- 6.5**   2\. **Protein** - Most **indicative of renal disease** - **Produces** **WHITE FOAM** **in urine when shaken.** **Proteins normally found in the urine:** - **ALBUMIN** -- major serum protein found in urine - **TAMM-HORSFALL PROTEIN** (uromucoid) -- a mucoprotein produces by the renal tubules and forms **[matrix of all types of casts]** - **Serum and tubular microglobulins** - **Proteins from prostatic, seminal, and vaginal secretions** **REMEMBER!** **[NORMAL URINE PROTEIN:]** \ - PRE-RENAL (before) OR OVERFLOW - RENAL - POST-RENAL (after) -------------------------------------------------- **PRE-RENAL ("Before") or OVERFLOW PROTEINURIA** -------------------------------------------------- - **NOT** [indicative of actual renal disease] and **NOT** [detected by reagent strip] - Results from increased quantities of plasma proteins (low molecular weight) in the blood readily passing through the glomerular filtration barriers into the urine - Caused by conditions that affect the plasma prior to its reaching the kidney: a. **Septicimia/severe infection or inflammation** -- acute phase reactant proteins b. **Hemoglobinuria** -- after a hemolytic episode c. **Myoglobinuria** -- follows muscle injury d. **Immunoglobulin paraproteins** -- abnormally produces in multiple **myeloma** and **macroglobulinemia** - **BENCE JONES PROTEIN** -- first recognized in **1847** by **Henry Bence-Jones** \- Abnormal protein excreted by patients with **MULTIPLE MYELOMA** (proliferative disorder of the immunoglobulin-producing plasma cells) \- **TESTS** : Serum electrophoresis, immunofixation electrophoresis \- **URINE** : **precipitates at 40-60°C** (cloudy) and **dissolves at 100°C** (clear) ---------------------------------------------- **RENAL PROTEINURIA ("True Renal Disease")** ---------------------------------------------- A. **Glomerular Proteinuria** \- Occurs in primary glomerular diseases or disorders that cause glomerular damage \- Most common type of proteinuria encountered and the most serious clinically 1\. **Diabetic Nephropathy** - Decreased glomerular filtration - May lead to renal failure - INDICATOR: **MICROALBUMINURIA** - Proteinuria undetectable by routine reagent strip - **Albumin Excretion Rate** (**AER**) = in ug/min or in mg/24 hours ❖ Normal AER = 0-20 ug/min ❖ Microalbuminuria = 20-200 ug/min (or 30-300 mg/24hrs) ❖ Clinical Albuminuria = \200 ug/min 2\. **Orthostatic / Cadet / Postural Proteinuria** - Proteinuria when **standing** due to increased pressure to renal veins  B. **Tubular Proteinuria** - Normally filtered albumin can **no longer be reabsorbed** 1\. Fanconi's Syndrome 2\. Toxic Agents/Heavy Metals 3\. Severe Viral infections -------------------------- **POST-RENAL ("After")** -------------------------- 1\. Lower UTI/Inflammation 2\. Injury/Trauma 3\. Menstrual Contamination 4\. Prostatic Fluid 5\. Vaginal Secretions ---------------------- **TEST FOR ALBUMIN** ---------------------- - **HEAT AND ACETIC ACID TEST (REFERENCE METHOD)** - Principle: **Urine is coagulated** by **heat** and **precipitated by** **acetic acid** (**5-10%**) and the degree of turbidity produced is proportional to the amount of protein present - Positive results: - 1+ = diffuse cloud - 2+ = granular cloud - 3+ = distinct floccule - 4+ = large floccule, dense, something solid - **SULFOSALICYLIC ACID TEST/COLD PROTEIN PRECIPITATION** - A cold precipitation test that reacts equally with all forms of proteins - Reagents: **3% SSA** - Principle: **most proteins are precipitated by dilute SSA** ------------------------------------- **SSA & REAGENT STRIP CORRELATION** ------------------------------------- - (+) SSA and (+) Reagent Strip = **PRESENCE OF ALBUMIN** - (+) SSA and (-) Reagent Strip = Presence of proteins **other than Albumin**  3\. **GLUCOSE** - **MOST FREQUENT** chemical analysis performed on urine - Clinical Significance -- **detection of DIABETES MELLITUS** - **Mellituria** -- presence of sugar (reducing or non-reducing) in urine - **Glycosuria** -- presence of any reducing sugar in the urine specimen - **Glucose, Lactose, Galactose, Fructose, Pentose** **REMEMBER!** **Renal Threshold for Glucose**: **160 to 180 mg/dL** **REMEMBER!** **Normal URINE GLUCOSE:** 15 mg/dL **Fasting**: 2 -- 20 mg/dL per 100 mL urine  ----------------------------- **OTHER TESTS FOR GLUCOSE** ----------------------------- - **Benedict's Test** -- general test for glucose and other reducing sugars - Reagent: **Benedict's Solution** - Principle: relies on the ability of the glucose and other reducing substances to reduce copper sulfate to cuprous oxide in the presence of alkali and heat  - **Copper Reduction Method** -- **CLINITEST TABLET** -- non-specific for **glucose** - **Sensitivity**: **200 mg/dL** (*vs reagent strip which is more sensitive*) - **Reagents**: - **COPPER SULFATE** - main reacting agent - **SODIUM CARBONATE AND CITRIC ACID** -- effervescent - **SODIUM HYDROXIDE** - provides alkaline medium - **Sodium hydroxide with water and citric acid** -- provides heat - 5 gtts urine + 10 gtts H2O + Clinitest tablet \-\-\-\-\-\-\-- then wait for 15 seconds - The test is reported as: **Negative, 1/4 % (trace), 1/2 % (1+), 3/4 % (2+), 1% (3+) or 2% (4+)** ----------------------------- **PASS-THROUGH PHENOMENON** ----------------------------- - May occur is \2g/dL sugar is present in urine - Prevented by changing 5 gtts to 2 gtts of urine - Subject to interference from other reducing sugars, ascorbic acid drug metabolites and antibiotics such as cephalosporins ------------------------------------------- **CLINITEST & REAGENT STRIP CORRELATION** ------------------------------------------- - +) CLINITEST & (+) REAGENT STRIP = presence of **glucose** - (+) CLINITEST & (-) REAGENT STRIP = presence of **non-glucose reducing sugar** - (-) CLINITEST & (1+) REAGENT STRIP = presence of **small amount of glucose** - (-) CLINITEST & (4+) REAGENT STRIP = **false positive** reaction 4\. **KETONES** - Presence of ketone bodies in urine **results from increase fat metabolism** due to inability to metabolize carbohydrates. - Acetone - 2% - Acetoacetic acid - 20% (*responsible for + results in reagent strip*) - ß-hydroxybutyric acid - 78% (*major ketone but not detected in reagent strip*) - Clinical Significance: - INSULINE DOSAGE MONITORING - Diabetes Acidosis - Starvation / Fasting - Weight Reduction / Dieting / Strenuous Exercise - Vomiting - Malabsorption / Pancreatic Disorders - Inborn errors of Amino Acid Metabolism **REMEMBER!** Normal Urine Ketone: NORMALLY NOT IN URINE Metabolized fats are completely broken down into CO2 and H2O in normal individuals  - **ACETEST** (Tablet Test) - Contains: Sodium nitroprusside, Disodium phosphate and Lactose (Lactose is added for better color differentiation) - Can be used to test urine, serum, plasma or whole blood - About 10x more sensitive to DIACETIC ACID than ACETONE - Does not detect ß-hydroxybutyric acid 5\. **BLOOD**  Normally, **NO BLOOD i**n the form of hematuria, hemoglobinuria or myoglobinuria should be detected in the urine. Presence of \5rbc/uL is **CLINICALLY SIGNIFICANT** (Microscopic Hematuria) 6\. **BILIRUBIN** - Yellow pigmented degradation product of hemoglobin - Conjugated Bilirubin (CB) -- water soluble - Early indication of liver disease - Amber urine with YELLOW FOAM - CLINICAL SIGNIFICANCE: - Pre-hepatic jaundice (hemolytic anemia) - Hepatic jaundice (hepatitis, cirrhosis) - Post-hepatic jaundice (biliary obstructions, gallstones, carcinoma) **REMEMBER!** Urine Bilirubin is excreted in very small amounts and normally should not be detectable in urine \**Only the conjugated form of bilirubin* *can appear in the urine*  - **ICTOTEST** (Tablet Test) - MORE SENSITIVE (0.05 to 0.10 mg/dL) than the DIAZO REACTION in reagent strips (0.40 mg/dL) - Less subject to interference - Consist of testing mats ad tablets containing: - p-nitrobenzene diazonium p-toluenesulfonate - SSA - sodium carbonate - Boric acid - Positive Result: **BLUE -- PURPLE COLOR** - Negative Result: colors other than blue or purple - **OTHER TESTS** - Foam-Shake Test, Oxidation Test, Gmelin's Test, Fouchet Test - Harrison Spot Test - Ferric chloride in the presence of TCA will oxidize **yellow bilirubin to green biliverdin** ---------------------- BILIRUBIN METABOLISM ---------------------- 1. Bilirubin comes from the breakdown of hemoglobin released from RBCs 2. Bilirubin released into the bloodstream from the peripheral tissue is water-insoluble and becomes reversibly bound to **ALBUMIN** making it **UNCONJUGATED BILIRUBIN** (unable to pass the glomerular filtration barriers and hence it cannot be excreted via urine) 3. When blood passes through the liver sinusoids, the hepatocytes rapidly remove bilirubin from albumin and then conjugates it with glucuronic acid to produce water-soluble **CONJUGATED BILIRUBIN** 4. Normally, all conjugated bilirubin is transported into the bile duct and ultimately into the small intestine 5. In the intestinal tract, it will be deconjugated and reduced by anaerobic intestinal bacteria to form the colorless tetrapyrrole **UROBILINOGEN** 6. About 20% of urobilinogen is reabsorbed and reenter liver via hepatic portal circulation (and then reexcreted again) while some portion is reduced to **STERCOBILINOGEN** (cannot be reabsorbed) 7. Urobilinogen and Stercobilinogen are oxidized in the large intestine forming **UROBILIN AND STERCOBILIN** which gives the stool its characteristic color 8. 2 to 5% of urobilinogen normally remains in the bloodstream and can be excreted in the urine when it passes through the kidneys 7\. **UROBILINOGEN** - A colorless pigment formed from the breakdown of bilirubin in the intestines - Appears in urine because as it circulates in the blood, en route to the liver, it may pass through the kidney and be filtered by the glomerulus (1% excreted in urine = 99% excreted in feces) - Urobilinogen excretion reaches peak levels between 2PM and 4PM - Same clinical significance as bilirubin **REMEMBER!** NORMAL URINE UROBILINOGEN: \