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Abnormal Urine
Urine is an ultrafiltrate formed by the kidneys carrying the
waste and toxic substances from the blood. The
composition of urine is a mirror not only of renal function
but also of many physiological and metabolic processes
occurring in the body. Thus, examination of urine may lead
to the diagnosis of many metabolic and systemic diseases.
EXAMINATION OF URINE
Examination of urine includes:
1. Physical examination
2. Chemical examination
3. Microscopic examination.
SPECIMEN COLLECTION
1. Fresh mid-stream specimen of 10- 20 ml is collected in a
clean dry container.
2. For most of the qualitative tests, a random urine
sample
is satisfactory.
3. Morning specimen is desirable for normal analysis.
4. 24 hours urine is collected for total urinary proteins,
calcium, uric acid, ketosteroids and certain hormonal
assays, as the concentrations vary at different times of
the day. The patient is instructed to collect the urine
Qualitative Analysis of Normal Urine :
PRESERVATION OF URINE SAMPLES
1. Several changes like urinary decomposition,
precipitation of phosphates, crystallization of uric acid
and bacterial action may alter the urinary composition if it
is kept for long periods, especially in the collection of 24
hours urine samples. Also urine may become alkaline, due
to precipitation of uric acid and urates
ammoniacal odor.
Color Condition
Odor:
Specific Gravity
The specific gravity of normal urine varies in the range
of
1.012 to 1.024.
Inorganic Constituents:
Tests of inorganic constituents are as follows.
Test for Chloride
Principle: A white precipitate of silver chloride is formed
when acidified urine reacts with silver nitrate.
Points to Remember:
Chloride ion is the chief anion in urine.
Excreted as sodium chloride.
On an average diet, 10- 12 gm of chloride is excreted per
day.
Urates and phosphates can interfere with this test by
forming silver urates and silver phosphates. Hence, nitric
acid is added to prevent such interference.
Decreased urinary chloride is seen in:
Excessive sweating
Fasting
Diarrhea and vomiting
Diabetes insipidus
Cushings syndrome
Infections
Increased urinary chloride is seen in:
- Excessive intake of fluids
- Addisons disease
Test for Inorganic Sulfates:
Principle: Urine being acidified with hydrochloric acid
forms a white precipitate of barium sulfate by the reaction
with barium chloride solution.
Points to Remember:
There are three forms of sulfates:
Inorganic sulfates of sodium and potassium
(80-85%)
Organic sulfates- ethereal sulfates (5%)
Neutral sulfur (15-50%)
Sulfates are derived from the metabolism of sulfur
containing amino acids such as cysteine, cystine and
methionine.
The presence of hydrochloric acid prevents the
precipitation of other inorganic salts like phosphates.
On an average diet about 0.7-1 gram of inorganic sulfate
is excreted per day.
Excretion is increased in:
High protein diet
Acute hyperthyroidism
Cystinuria
Decreased in renal dysfunction.
Neutral sulfur increases in poisoning.
Points to Remember:
Normally 0.8-1 gm of phosphorus as phosphate is
excreted per day.
Phosphates are present in urine as salts of sodium,
potassium, ammonium, calcium and magnesium. These
are crystallized out in alkaline urine.
Excretion is increased in bone diseases like rickets,
osteomalacia, and parathyroid dysfunction.
Excretion is decreased in:
Diarrhea
Infections
Nephritis
Hypoparathyroidism
Pregnancy
Points to Remember:
The excretion of calcium is 100- 200 mg/day.
Excretion increases in:
Hyperparathyroidism
Hyperthyroidism
Hypervitaminosis D
Multiple myeloma
This test is known as Sulkowaskis test and is useful in
evaluating parathyroid abnormalities and cases of kidney
stones.
Urinary calcium level is related to serum calcium level.
When serum calcium level is less than 7.5 mg/ dl there
may be no detectable calcium in urine.
When serum calcium level is 7.5- 9 mg/ dl, urine shows
slight cloudiness in this test.
A heavy precipitate indicates high serum calcium.
Test for Ammonia:
Points to Remember:
Urinary ammonia is derived from glutamine and other
amino acids in kidney.
The average excretion of ammonia is about 0.7 gm/ day.
There is an increase in ammonia excretion when acid
forming foods are taken.
Ammonia is excreted as ammonium salts.
The kidneys manufacture ammonia in proportion to the
amount of acid radicals excreted in urine.
In alkaline urine, ammonium salts are absent.
Excretion of ammonia is increased in acidosis.
Excretion of ammonia is decreased in alkalosis
Impaired protein metabolism increases the output of
ammonia in urine.
To enhance the conversion of NH4 into NH3, the solution
is made alkaline before boiling.
If the solution is made strongly alkaline, urea will
interfere with the reaction.
Organic Constituents:
Tests for organic constituents are as follows:
Test for Urea
Sodium Hypobromite Test:
Principle: When urea is treated with Sodium hypobromite,
it
decomposes to give nitrogen, carbon dioxide and water.
Liberation of nitrogen gas produces brisk effervescence.
Points to Remember:
Urea is the major nitrogenous constituent of urine.
Urea is formed in liver as the end product of protein
metabolism and so its excretion depends on protein
intake.
About 20-40 grams of urea is excreted in 24 hours.
Excretion is increased in:
Points to Remember:
Uric acid is the end product of purine metabolism.
The daily output of uric acid varies in the range of 0.6 to
1 gm.
Excretion is increased in:
Leukemias especially during cytotoxic drug therapy
Wilsons disease
Points to Remember:
Creatinine is the anhydride of creatine.
Urinary creatinine is derived from muscle creatine.
It is not influenced by the protein intake.
Excretion in adults ranges from 1-2 gm/day.
In women and in elderly people the values are lower due
to lesser muscular mass.
Excretion is increased in:
High intake of meat, fish
Fever
Myopathy/wasting diseases
Excretion is decreased in:
Renal failure
Anemia
Paralysis
Chemical Constituents
Points to Remember:
The amount of protein excreted normally in 24 hours
urine is insignificant and it is less than 150 mg/day.
When proteins appear in detectable quantities in urine,
it is called proteinuria/albuminuria.
The presence of detectable amount of protein is
characteristic of kidney diseases.
The normal glomeruli of kidneys are not permeable to
substances with molecular weight of 70 kD. The plasma
proteins of molecular weight of more than 70 kD, hence
are absent in normal urine.
When glomeruli are damaged or diseased, they become
more permeable and plasma proteins appear in urine.
The smaller molecules of albumin pass through damaged
glomeruli more readily than the heavier globulin and so,
when the proteins appear in urine, the albumin fraction
predominates.
Bence Jones protein, an immunoglobulin appears in urine
in cases of multiple myeloma. Protein precipitates
between 40- 60C, disappears at 100C and reappears on
cooling.
Points to Remember:
The presence of detectable amounts of sugar in urine
iscalled glycosuria.
Positive Benedicts test is usually suggestive of
presence of glucose in urine.
Common causes of glycosuria are:
Diabetes mellitus
Endocrinal disorders such as hyperpituitarism,
hyperthyroidism, hyperadrenalism.
Emotional glycosuria: It is a benign condition seen in
anger, fear, etc. due to hypersecretion of adrenaline in
stress.
Renal glycosuria in which glucose reabsorption by kidney
tubules is defective.
Alimentary glycosuria: It is a benign condition which is
seen after excessive intake of carbohydrate or patient is
on glucose infusion.
Precaution:
A large number of substances such as aspirin,
antipyrin,salicylates, etc. may develop similar port-wine
color. If the urine is boiled, acetoacetic acid is converted
into acetone; but the other substances remain unchanged.
Now, if the urine gives negative test, it indicates the
presence of acetoacetic acid.
Fresh urine is necessary for this test as acetoacetic acid
is quickly decomposed into acetone and carbon dioxide.
Points to Remember:
Ketone bodies are acetone, acetoacetic acid and hydroxy butyric acid.
Ketone bodies do not appear in urine because
acetoacetic acid, which is produced nor mally in the liver,
is completely oxidized in tissues. Ketone bodies are
formed in excess when the glucose metabolism is
impaired as in
diabetes mellitus or when fat is used exclusively to give
energy as in starvation (starvation ketosis). This condition
is called as ketosis.
Points to Remember:
Bile salts are sodium and potassium salts of
glycocholates
and taurocholates.
Normally bile salts and bile pigments do not enter the
general circulation and therefore, they are absent in the
normal urine.
But, if there is intrahepatic or posthepatic obstruction to
the flow of bile, regurgitation occurs in the general
circulation and bile salts appear in urine.
Bile salts are present in urine along with bile pigments
in
obstructive jaundice.
This is not a specific test for bile salts but is usually
done
to detect bile salts.
Alcohol and salicylates give a false positive test.
Fouchets Test
Principle: Bile pigments adsorbed on barium sulfate
precipitate are oxidized to colored products by Fouchets
reagent.
Fouchets reagent: 10% ferric chloride in 25%
trichloroacetic acid.
Points to Remember:
This is a very sensitive test but not specific for blood.
Presence of blood in urine is called hematuria.
Causes:
Injury to urinary tract or kidney.
Infection of urinary tract.
Benign or malignant carcinoma of kidney or urinary
tract.
Enlargement of prostrate due to rupture of engorged
venous plexus.
Obstruction due to urinary stones.
Nephritis.
Nephrotic syndrome.
Due to trauma, caused by introduction of catheter
through the urethra.
Tuberculosis.
Acute glomerulonephritis.
Hematuria can be frank when urine appears red (due to
blood) or it can be microscopic when it is not visible to
naked eye (occult blood)
Microscopic hematuria may be seen in:
Malignant hypertension
Sickle cell anemia
Coagulation abnormalities
Polycystic kidney diseases.
Excretion of free hemoglobin in urine is called
Hemoglobinuria.
This occurs in severe burns, chemical poisoning,
incompatible blood transfusion, malaria, typhoid and
hemolytic jaundice.
This test is also positive when pus cells are present in
urine. These cells contain a peroxidase, which is
responsible for the positive reaction. However, if urine is
subjected to heat treatment (95-100C), the enzyme is
inactivated and the test becomes negative.
Heme, is stable to heat.
When high concentration of ascorbic acid is present in
urine, it is oxidized more readily than benzidine by oxygen
liberated from hydrogen peroxide. The benzidine reaction
then becomes negative although sufficient blood is
present in urine.