Urine Screening for Metabolic Disorder

Introduction
Many of the abnormal results are obtained in the routine
urinalysis are related to metabolic rather than renal disease
Urine as an end product of body metabolism may contain
additional abnormal substances not tested for by routine
urinalysis
Positive screening tests can then be followed up with more
sophisticated procedures performed in other sections of the
laboratory
Over Flow vs. Renal Disorders
The appearance of abnormal metabolic substances in the urine
can be caused by a variety of disorders that can be grouped
into 2 categories:
o Renal Type abnormal accumulations are caused by
malfunctions in the tubular reabsorption mechanism
o Overflow Type result from the disruption of a
normal metabolic pathway that causes increased
plasma concentrations of the non-metabolized
substance

Disorders Classified by Defects

Inherited Overflow
Phenylketonuria
Tyrosinemia
Maple Syrup Urine
Disease
Organic Acidemias
Cystinosis
Porphyria
Mucopolysaccharidoses
Galactosemia
Lesch-Nyhan Disease

Metabolic Overflow
Infantile
Tyrosinemia
Melanuria
5-Hydroxyindoleacetic acid
Pophyria

Renal Disorder
Hartnup Disease
Cystinuria

Newborn Screening
Performed primarily to detect and monitor newborns for
inborn error of metabolism
Current state-mandated screening for as many as 29 inborn
errors of metabolism
Urine test are primarily for follow-up
Heel stick blood tests are used for testing
o Performed before infant leaves hospital
o Metabolites appear first in the blood
o Gene testing is being worked on
Phenylalanine-Tyrosine Disorders
Most frequently requested special urinalysis proceudres are
associated with phenylalanine-tyrosine metabolic pathway
Major inherited disorders include:
o Phenylketonuria (PKU)
o Tyrosyluria
o Alkaptonuria

Phenylalanine-Tyrosine Disorders
Disorder

Phenylketonuria

Etiology

Abnormal Urinary
Constituents

Clinical manifestation

Failure to inherit the gene to produce

phenylalanine hydroxylase that
converts phenylalanine to tyrosine
Mousy odor urine
Cause decrease production of tyrosine
Severe mental retardation,
and its pigmentation metabolite,
if uncured
Increased amount
melanin
Fair complexion
of keto acids
(phenylpyruvate)
Most well-known of the
aminoacidurias
1:10,000 20,000 births

Laboratory Test

Result

Ferric Chloride Tube Test

(urine)
Urine test for
phenylpyruvic acid
Based upon the ferric
chloride reaction
performed by the tube
test
Nonspecific may react with
other amino acids and
commonly ingested
medications

Permanent blue-green
color

Microbial Inhibition Assay

(blood)
Developed by Guthrie

Growth of Bacillus subtilis

around the paper disk
containing beta-2thienylalanine

Treatment

Eliminate
phenylalanine from
diet (milk)
Alternate pathways
as child matures
Avoid high in
phenylalanine foods
(aspartame)

Other Information

Phenylalanine can be
detected in blood as
early as 4 hours after
birth
Can b detected in urine
in 2 6 weeks

Tyrosyluria

Melanuria

Alkaptonuria

Mental retardation
Type I
Generalized renal
tubular disorder and
progressive liver failure
in infants soo after birth
Type II
Develop corneal erosion
and lesions on the
palms, fingers, soles of
the feet believed to be
caused by crystallization
of tyrosine in the cells
Type III
Result in mental
retardation if dietary
restrictions of
phenylalanine and
tyrosine are not
implemented

Accumulation of excess tyrosine in the

plasma (tyrosinemia) producing
urinary
Either inherited or metabolic defect
Urine may contain excess tyrosine or
its degradation products phydroxyphenylpyruvic acid or phydroxyphenyllactic acid

Increased urinary melanin production

by the second metabolic pathway for
tyrosine

Failure to inherit the gene that

produces the enzyme homogentisic
acid oxidase causing accumulation of
homogentisic acid in the blood, tissues
and urine

Darkened urine
after exposure to
air due increased
urinary melanin

Darkened urine
after after
standing at room
temperature
(alkali lover)

Malignant melanoma
Overproliferation of
melanocytes
Secrete 5,6dihydroxyindole which
oxidizes melanogen to
melanin = dark urine

Brown pigments in the

body (especially in the ear)
and cartilages (arthritis)
Cardiac and liver disorders

Blood from a heelstick is

absorbed into filter paper
circles
Blood-impregnated disks are
then placed on culture media
streaked with the bacterium
Bacillus subtilis
Nitroso-naphthol Test (urine)
Nonspecific
Place 5 drops of urine in
tube
+ 1 mL 2.63 N nitric acid
+ 1 drop 21.5% sodium
nitrite
+ 0.1 mL 1-nitroso-2naphthol
Mix
Wait 5 minutes
Observe color

Increased phenylalanine
levels counteracts the
action of beta-2thienylalanine (inhibitor)

Ferric Chloride Tube Test

(urine)

Green color that fades

rapidly

Ferric Chloride Tube Test

Gray or black precipitate

Red
Reverts back to greenblack color after addition
of glacial acetic acid
Acetone (purple)
Creatinine (amber)
Red
Red
Transient deep blue color
Yellow precipitate

Sodium Nitroprusside Test

Acetest
Ehrlich Reagent
Ferric Chloride Tube Test
Clinitest
Alkalization
Interference: Ascorbic acid
Addition of Silver Nitrate and
Ammonium Hydroxide
Spectrophotometry and
Chromatography

Orange-red color

Darkening of urine
Black urine
Quantitative result

Type I
Deficiency of
fumarylacetoacetate
hydrolase (FAH)
Type II
Lack of tyrosine
aminotransferase
Type III
Lack of phydroxyphenylpyruvi
c acid dioxygenase
Transitory Tryosinemia
Premature infants
Most frequently seen
Due to
underdevelopment
of the liver function
required to produce
enzymes (tyrosine
metabolism

Does not manifest in

early childhood
Observation of brownstained, black-stained
and reddish-stained
disposable diapers

Branched-chain Amino Acid Disorders

Having a methyl group that branches from the main aliphatic carbon chain
Two Major groups
o Accumulation of one or more of the early amino acid degradation products
o Result in accumulation of organic acids produced further down amino acid metabolic pathway
Branched-chain Amino Acid Disorders
Disorder

Maple Syrup Urine

Disorder (MSUD)

Etiology
Failure to inherit the gene for the
enzyme necessary to produce
oxidative carboxylation of the keto
acids from leucine, isoleucine and
valine
Caused by an IEM

Abnormal Urinary
Constituents

Maple syrup odor

due to
accumulation of
keto acids

Clinical manifestation

Failure to thrive after 1

week
Severe mental retardation

Laboratory Test
2,4-Dintirophenylhydrazine
Test
Used for homemonitoring of diagnosed
patients
Not specific for MSUD
Ferric Chloride Tube Test
Acetest

Organic Acidemias
Generalized symptoms:
o Vomiting accompanied by metabolic acidosis, hypoglycemia, ketonuria, and increased serum ammonia
Three most frequently encountered disorders are:
o Isolaveric acidemia
o Propionic acidemia
o Methylmalonic acidemia

Result

Yellow turbidity or
precipitate

Green-gray color
Purple

Treatment
If detected by the 11th
day, dietary regulation
and careful monitoring
of the urinary keto acid
concentrations can
control the disorder

Other Information