EVALUATION OF RENAL FUNCTION

ART AND SCIENCE OF URINALYSIS

Introduction
UA : tool the clinical assessment of altered renal function patients Attention for collecting and preserving the specimen Physical and chemical property measurements of the urine and microscopic exam of cells, crystals, and organism

Specimen Collection
Concern to periuretrhal contact (female >>) Midstrem urine Catheterization is better chance to avoiding contamination Suprapubic aspiration is a sterile specimen

Specimen Collection
Should ideally be examined within 30 mnt The urine become progressively more alkaline (urea is broken down, generating ammonia) The pH dissolves cast and promotes cell lysis Can be preserved for up 6 hrs if refrigerated at 4 C.

PHYSICAL PROPERTIES
To be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

To

be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

Normal color is pale to yellow Dilute urine appears lighter and concentrate a darker yellow shade Red urine may be noted with - hematuria - large amount of foodstuffs with heme derivate pigments (the presence of excess urates,certain drugs,porphyria)

RBCs is clue to presence of Hb and myoglobin Black urine is describe in - homogentisic acid oxidase deficiency (alkaptonuria) - phenol poisoning - excess melanin production in melanoma

To be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

 Normal urine is clear Hazy if cellular elements ; cast and organism present, renal diseases Infections due to clarity decreased

To be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

 Normally should not have a strong odor Allowed to stand until urea has been converted to ammonia Specific odor may impact of infection, ketosis and medication excretion

To be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

 Foamy urine is usually associated with - high-grade protein or - bilirubinuria

To be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

 Measure using a urinometer, refractometer, or ionic reagent strip For ionic tes: - pH urine 6 7 - Alb, glucose,urea, some AB,contrast: give a falsely low specific gravity Urine osmolality measurement is much reliable than any of test Normal 1.010 1.020 ?

To be determined include Color Clarity Odor Foam Specific gravity Dipstick exam

Urine pH
Can bed measure very accurate and is quite reproducible Normally 4.5 7.8 Large meat consumption tend to acidic urine Vegetarian diets more alkaline urine High urinary pH due to : - prolonged storage (amonia from urea) - infection with urea splitting organisms (Proteus)

Glucose Sensitive measurement but not specific for quantification Most of labs give out semiquantitative (+ to ++++) but correlation with blood glucose is approximate and varies

Ketones
Are detected using a nitroprusside reaction Detects only - acetoacetics acid - beta-hydroxybutirate False-positive results to - ascorbic acid - phenazopyridine

Leukocyte Esterase and Urine Nitrite Depends on esterase released from granulocytes in urine Esterase produced from granulocyte lysis in : - long standing urine - of contaminating vaginal cells (may cause false positive) Hyperglycemia,albuminuria,tetracycline, cephalosporins and oxaluria inhibited reaction granulocyte with esterase -> false negative

 Presence of nitrite depends on the ability of bacteria to convert nitrate into nitrite Reaction to test strip inhibited by ascorbic acid and high specific gravity Low levels of urinary nitrate due to - diet - degradation of nitrite caused prolonged storage - inadequate conversion of nitrate to nitrites due to rapid transit in bladder may contribute to false negative despite the presence of urinary infection.

 Certain bacteria do not convert nitrate to nitrite (S.faecalis,N.gonorrhoe,M.tbc) Specificity for infection is best when both leukocyte esterase and nitrate are positive If both tests are negative, infection cannot be completely ruled out

Protein Important marker of kidney disease

MICROSCOPIC EXAM
Study sediment is very important and Underutilized tool to evaluate renal pathology Requires fresh urine 10 ml centrifuge at 400-450g/5mnt Bright field microscope is standard Polarized light is also helpful

Cells RBCs More than two RBCs per hpf is abnormal and Suggests bleeding from some point in the GU system

WBCs
Characterized by their cytoplasmic granulation Associated with infection and inflammation

Epithelial cells
Squamous epithelial cells; present due to shedding from the distal genital tract and essentially are contaminants Transitional epithelial cells; seen intermitten with bladder catheterization or irrigation, associated with malignancy

 Renal tubular epithelial cells; present in tubular injury Oval fat bodies ; typical seen in nephrotic syndrome and lipid uria

Casts Hyalline cast (physiologic states; excersice and dehydration) Granular cast Waxy casts Fatty casts Red cell casts White cell casts Epithelial casts

Crystals
Produced from pathologic excess of metabolic product In acidic urine : uric acid, monosodium urate, and Ca oxalat In alkaline urine : triple phosphate, ammonium biurate, Ca phosphate,Ca oxalat and Ca carbonate