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A. BIOLOGICAL HAZARDS

CHAIN OF INFECTION
 Requires a continuous link between:
- A source
- A method of transmission
- A susceptible host

PREVENTION:

I. Personal Protective Equipment (PPE)

1. Gloves
2. Fluid-resistant gowns
3. Masks, Eye & face shields
4. Countertop shields

II. Proper Handwashing

III. Disposal of biological wastes

 ALL biological wastes, EXCEPT urine, must be placed in appropriate containers labelled with the biohazard symbol.

B. SHARPS HAZARDS

C. CHEMICAL HAZARDS
 Chemical spills
- DO NOT NEUTRALIZE CHEMICALS that come in contact with the skin
 Chemical Handling

 Chemical Labelling
 Hazardous chemicals should be labelled with a description of their particular hazard
 National Fire Protection Association (NFRA) has developed the Standard System for the
identification of the Fire Hazards of Materials, NFPA 704

NATIONAL FIRE PROTECTION ASSOCIATION (NFPA)

Yellow Quadrant White Quadrant Blue Quadrant Red Quadrant

Reactivity/ Stability Specific Hazard Health Hazard Flammability hazard

hazard

0 = Stable OXY = Oxidizer 0 = Normal material 0 = Will not burn

1 = Unstable if heated 1 = Slightly hazardous 1 = Above 2000F
2 = Violent chemical ACID = Acid 2 = Hazardous 2 = Below 2000F
change 3 = Extreme danger 3 = Below 1000F
3 = Shock & heat may ALK = Alkali 4 = Deadly 4 = Below 750F
deteriorate
4 = May deteriorate COR = Corrosive

W = use NO water

= Radiation

D. RADIOACTIVE HAZARDS

E. ELECTRICAL HAZARDS
- If electrical shock occurs, never touch the person or the equipment involved.
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TYPES OF FIRE & FIRE EXTINGUISHER

FIRE TYPE EXTINGUISHER MATERIAL COMPOSITION OF FIRE EXTINGUISHER

Class A Water

Class B Dry Chemicals, CO₂, foam, halon

Class C Dry Chemicals, CO₂, halon

Class D Metal X; Fought by fire fighters only

RENAL PHYSIOLOGY

 NEPHRON

 1 to 1.5 million nephrons each kidney

TYPES OF NEPHRON
 Cortical Nephrons

 Juxtamedullary Nephrons

 ORDER OF URINE FORMATION:

1. Glomerulus
2. Proximal convoluted tubule (PCT)
3. Loop of Henle (LH)
4. Distal convoluted tubule (DCT)
5. Collecting duct (CD)
6. Calyx
7. Renal pelvis

I. RENAL BLOOD FLOW ORDER

1. Renal artery (blood in)
2. Afferent Arteriole
3. Glomerulus
4. Efferent arteriole
5. Peritubular capillaries (PCT & DCT)
6. Vasa recta (Loop f Henle)
7. Renal vein (blood out)

 Total Renal Blood Flow: 1,200 ml/min

 Total Plasma Flow: 600 to 700 ml/min
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II. GLOMERULAR FILTRATION

 GLOMERULUS

 GLOMERULAR PRESSURE

 JUXTAGLOMERULAR APPARATUS

RENIN – ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS)

 Angiotensinogen--------> Angiotensin I ----------> Angiotensin II -------->

- Release of Aldosterone and ADH

- Increased sodium and water reabsorption
- Increased blood pressure

III. TUBULAR REABSORPTION

 Active Transport

 Passive Transport

 Renal threshold – the plasma concentration of which the active transport stops

TUBULAR REABSORPTION

ACTIVE TRANSPORT PASSIVE TRANSPORT

SUBSATNCE LOCATION SUBSTANCE LOCATION
Glucose, amino acids, salts PCT Water PCT, Descending LH & CD
Chloride Ascending Loop of Henle Urea PCT & Ascending LH
Sodium PCT & DCT Sodium Ascending LH

IV. TUBULAR SECRETION

 The passage of substances from the blood in the peritubular capillaries to the tubular filtrate

 PCT – major site for removal of unfiltered substances

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ACID-BASE BALANCE

 Bicarbonate (HCO₃⁻) - responsible for buffering capacity of blood

 Hydrogen ions – prevents filtered bicarbonate from being excreted in the urine

Glomerular Filtration Tests

a. Urea – earliest glomerular filtration tests

b. Inulin clearance – a polymer of fructose
c. Creatinine clearance – an endogenous procedure for evaluating glomerular function
d. Radionucleotides – I-iothalamate
e. β₂ macroglobulin – from HLA
- sensitive indicator of GFR than creatinine clearance
f. Cystatin C – from nucleated cells

TUBULAR REABSORPTION
 Fishberg Test
 Mosenthal Test
Free Water Clearance

 Tubular Secretion & Renal Blood Flow Tests:

- It is measured by a substance that is secreted rather than filtered through the
glomerulus
- p-aminohippuric acid (PAH) & phenolsulfonpthalein (PSP)

I. PAH test

C PAH (ml/min) = U (mg/dl PAH0 x V (ml/min urine)

P (mg/dl PAH)

II. Titratable Acidity & Urinary Ammonia

 Specimen: fresh voided or toluene preserved specimen

URINE COMPOSITION
- 95% water
- 5% solutes

Organic:
- Urea, Creatinine, Uric acid, Hippuric Acid, other substances

Inorganic:
- Chloride, sodium, Potassium, Sulfate, Ammonium, Magnesium, Calcium

URINE VOLUME
I. Normal: 1,200 – 1, 500 ml

II. Oliguria:
- Infant :
- Children:
- Adults:

III. Nocturia:

IV. Polyuria:
- Adult: urine volume greater than 2.5 L day
- Children: uring volume than 2.5-3 ml/kg/day

V. Anuria
Causes:
 Complete obstruction (stones, carcinomas)
 Toxic agents
 Decreased renal blood flow
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SPECIMEN HANDLING

Urine Preservatives
Preservatives Advantages Disadvantages Additional Information
Refrigeration Does not interfere with Raises specific gravity by Prevents bacterial growth
chemical tests hydrometer 24 h3
Precipitates amorphous
phosphates and urates
Thymol Preserves glucose and Interferes with acid precipitation
sediments well tests for protein

Boric acid Preserves protein and formed May precipitate crystals when Keeps pH at about 6.0
elements well used in large amounts Is bacteriostatic (not
bactericidal)
at 18 g/L; can use
for culture transport4
Interferes with drug and
hormone analyses
Formalin Excellent Acts as a reducing agent, Rinse specimen container
(formaldehyde) sediment preservative interfering with chemical tests with formalin to preserve
for glucose, blood, leukocyte cells and casts
esterase, and copper reduction

Toluene Does not interfere with Floats on surface of specimens

routine tests and clings to pipettes
and testing materials

Sodium fluoride Prevents glycolysis Inhibits reagent strip tests for May use sodium benzoate
Is a good preservative for glucose, blood, and leukocytes instead of fluoride for
drug analyses reagent strip testing5

Phenol Does not interfere with Causes an odor change Use 1 drop per ounce of
routine tests specimen
Commercial preservative Convenient when May contain one or more Check tablet composition
tablets refrigeration of the preservatives including to determine possible effects
not possible sodium fluoride on desired tests
Have controlled concentration
to minimize interference

Urine Collection Contains collection cup,

Kits6 (Becton Dickinson, C&S preservative tube or
Rutherford, NJ) UA tube
Gray C&S tube Sample stable at room Decreases pH; do not use if Preservative is boric acid
temperature urine is below minimum and may not be used for UA
(RT) for 48 hr; fill line
preserves bacteria
Yellow plain UA Use on automated Must refrigerate within Round or conical bottom
tube instruments 2 hours
Cherry red/yellow top Stable for 72 hours at RT; Bilirubin and urobilinogen may Preservative is sodium
tube instrument-compatible be decreased if specimen is propionate;
exposed to light and left at RT conical bottom

Saccomanno Preserves cellular elements Used for cytology studies

Fixative
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Types of Urine Specimens

Random Routine screening

First morning or 8 hour specimen Routine screening
Pregnancy tests
Orthostatic protein
Fasting (second Diabetic screening/monitoring
morning)
2-hour postprandial Diabetic monitoring

24-h (or timed) Quantitative chemical tests

Catheterized Bacterial culture
Midstream clean-catch Bacterial culture
Routine screening
Suprapubic aspiration Bacterial culture
Bladder urine for bacterial
culture
Cytology
Three-glass collection Prostatic infection
Glucose tolerance test Optional with blood samples
in glucose tolerance test

DRUG SPECIMEN COLLECTION

Chain of Custody
- Process that provides documentation of proper sample identification from the time of collection to the receipt of laboratory
results
 Required urine volume
 Temperature strip
 Blueing agent (dye)

URINE COLOR
 Normal = Colorless to deep yellow

 Abnormal: = Red/ Red brown (most common)

Laboratory Correlation of Urine Color

Color Cause Clinical/Laboratory Correlations
Colorless Recent fluid consumption Commonly observed with random specimens
Pale yellow Polyuria or diabetes insipidus Increased 24-hour volume
Diabetes mellitus Elevated specific gravity and positive glucose test result
Dilute random specimen Recent fluid consumption
Dark yellow Concentrated specimen; Strenuous
exercise, First morning specimen
Amber Deydration from fever or burns
Orange Bilirubin Yellow foam when shaken and positive chemical test results for bilirubin
Acriflavine Negative bile test results and possible green fluorescence
Nitrofurantoin Antibiotic administered for urinary tract infections
Phenindione Anticoagulant, orange in alkaline urine, colorless in acid urine
Yellow-green Bilirubin oxidized to biliverdin Colored foam in acidic urine and false-negative chemical test results
Yellow-brown for bilirubin
Green Pseudomonas infection Positive urine culture
Blue-green Amitriptyline Antidepressant
Methocarbamol (Robaxin) Muscle relaxant, may be green-brown
Clorets None
Indican Bacterial infections
Methylene blue Fistulas
Phenol When oxidized
Chloropyll
Pink, Red Hematuria Cloudy urine with positive chemical test results for blood and RBCs visible
microscopically
Hemoglobinuria Clear urine with positive chemical test results for blood; intravascular
hemolysis
Myoglobinuria Clear urine with positive chemical test results for blood; muscle damage
Alkaline urine of genetically susceptible persons
Beets Tuberculosis medication
Rifampin Cloudy specimen with RBCs, mucus, and clots
Menstrual contamination
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Burgundy/ Porphyrins Negative chemical test results for blood

Purplish red, Detect with Watson-Schwartz screening test or fluorescence under
Portwine ultraviolet light
Brown, Black Methemoglobin Denatured hemoglobin
Homogentisic acid (alkaptonuria) Seen in alkaline urine after standing; specific tests are available
Melanin or melanogen Urine darkens on standing and reacts with nitroprusside and ferric
Phenol derivatives chloride
Argyrol (antiseptic) Interfere with copper reduction test
Methyldopa or levodopa Color disappears with ferric chloride
Metronidazole (Flagyl) Antihypertensive
Darkens on standing

URINE COLOR CHANGES WITH COMMONLY USED DRUGS

Drug Cause
Levodopa (TX: Parkisonism) Cola-colored (red then brown, alkaline)
Mepacrine (Atabrine), (antimalarial), Tx: intestinal worms Yellow
Giardiasis)
Methyldopa (Aldomet) antihypertensive Green-brown
Metronidazole (Flagyl)) Tx:Trichomoniasis Darkening, reddish brown
Phenazopyridine (pyridium) Tx: UTI Orange- red, acid pH
Rifampin (Tx: TB) Bright orange-red
Riboflavin (Multivitamins) Bright yellow

LABORATORY CORRELATIONS IN URINE TURBIDITY

Acidic urine
Alkaline urine
Soluble w/ heat
Soluble in Dilute acetic acid
Insoluble in Dilute Acetic acid WBCs, bacteria, yeast, spermatozoa
Soluble in ether

A. Specific Gravity
- The density of a solution compared with the density of a similar volume of distilled water at a similar temperature.

 Direct Methods:
- Urinometer
- Harmonic oscillation densitometry (HOD)

 Indirect methods:
- Refractometer
- Chemical reagent strip

I. Urinometer

- Consists of a weighed float attached to a scale that has been calibrated in terms of urine specific gravity
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II. Refractometer
- Dissolved particles present in the solution determines the velocity and angle at
which light passes through a solution

III. Harmonic Oscillation Densitometry

- The frequency of a sound wave entering a
solution changes in proportion to the
density of the solution

URINE ODOR
Odor Cause
Aromatic Normal
Foul, ammoniacal
Fruity, sweet Ketones
Caramelized sugar, curry, maple syrup Maple Syrup Urine Disease (MSUD)
Mousy, musty
Rancid butter Tyrosinemia
Sweaty feet, acrid
Cabbage Methionine malabsorption
Bleach Contamination
Sulfur Cystine disorer
Pungent Ingestion of onions, garlic & asparagus
Swimming pool Hawkinsinuria
Cat urine 3- hydroxyl-3-methylglutaric aciduria

CHEMICAL EXAMINATION OF URINE

I. pH
 First morning specimen: 5.0 to 6.0
 Random specimen: 4.5 to 8.0

Causes of Acid urine Causes of Alkaline Urine

 Cranberry juice  Renal Tubular

 Emphysema acidosis
 Dehydration  Presence of urease-
 Diarrhea producing bacteria
 Presence of acid-
producing bacteria(
E. coli)
 Medications

II. PROTEIN

Other proteins:
a. Serum & Tubular microglobulins
b. Tamm-Horsfall protein (a.k.a Uromodulin)
c. Protein derived from prostatic & vaginal secretion
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 CAUSES oF Proteinuria

A. PRE- RENAL (“Before”) or OVERFLOW PROTEINURIA

a.1. Intravascular hemolysis

a.2. Muscle injury
a.3. Severe infection & inflammation
a.4. Multiple myeloma

(Bence Jones Protein)

B. RENAL PROTEINURIA (“True reanal disease”)

b.1. Glomerular Proteinuria

Ex. Amyloid material, toxic substances, immune complexes, diabetic nephropathy, Strenuous exercise,
dehydration, hypertension, orthostatic proteinuria, pre-eclampsia

b.2. Tubular Proteinuria

Ex. Fanconi Syndrome, Toxic Agents/heavy metals, severe viral infections

b.3. Orhtostatic proteinuria

b.4. Microalbumin: EIA

- 24 hour urine sample (Quantitative Test)
- Significant value : ______________

C. POST- RENAL PROTEINURIA (“after”)

- Lower UTI/inflammations
- Menstrual contamination
- Injury/ trauma
- Vaginal secretions
- Prostatic fluid/ Spermatozoa

 SULFOSALICYLIC ACID (SSA) PRECIPITATION TEST

 False (+): Radiographic dyes, tolbutamide metabolites,
cephalosporins, penicillins, & sulphonamides
 False (-): highly alkalie urine

 Microalbumin Testing
 Micral Test
 Principle: Enzyme immunoassay
 Sensitivity: 0–10 mg/dL
 Reagents: Gold-labeled antibody, β-galactosidase, Chlorophenol
red galactoside
 Interference: False (-): Dilute urine

III. GLUCOSE
Other Sugars in Urine:
1. Fructose (Levulose)
2. Galactose
3. Lactose (Glu + Gal)
4. Pentose = ↑benign essential pentosuria (Xylulose, Arabinose)
5. Sucrose (Glu + Fru) = ↑Intestinal disorders, sucrose intolerance: (-) Copper Reduction Test (non-reducing
sugar)

Hyperglycemia- Associated Renal associated

 DM  Fanconi Syndrome
 Cushing’s Syndrome  Advanced Renal Disease
 Pheochromocytoma  Osteomalacia
 Acromegaly  Pregnancy
 hyperthyroidism

COPPER REDUCTION TEST (CLINITEST/ BENEDICT’S TEST)

Test Nonspecific test for reducing sugar
Principle Reducing substance
CuSO₄--------------------------------------> (+) Cu₂O
(Blue) alkali + heat ( brick-red)
False (+) CuSO₄---------------------------------------> (+) Cu₂O
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False (-) CuSO₄---------------------------------------> (+) Cu₂O

IV. KETONES

Seen in:
 DM
 Vomiting
 Starvation
 Malabsorption/ pancreatic disorders
 Strenuous exercise
 Insulin dosage monitoring

V. BLOOD

HEMATURIA HEMOGLOBINURIA MYOGLOBINURIA

Cloudy red urine Clear red urine Clear red urine
Seen in: Seen in: Seen in:
- Renal calculi - Transfusion reactions - Muscular trauma/crush
- Glomerulonephritis - Hemolytic anemias - syndromes
- Pyelonephritis - Severe burns - Prolonged coma
- Tumors - Infections/malaria - Convulsions
- Trauma - Muscle-wasting diseases
- Exposure to toxic - Alcoholism/overdose
- chemicals - Drug abuse (Heroin)
- Anticoagulants - Extensive exertion
- Strenuous exercise - Cholesterol-lowering
- statin medications

HEMOGLOBIN VS MYGLOBIN
TEST HEMOGLOBIN MYOGLOBIN

Plasma concentration Red plasma Normal appearing plasma

(Ammonium sulphate)

Procedure: Red precipitate Red plasma

Urine + 2.8 gNH₄SO₄ (80% satd.)

Filter/ Centrifuge
- +
Test supernatant for blood with a
reagent strip

VI. BILIRUBIN
- Conjugated bilirubin (CB) – water soluble
- Amber urine w/ yellow foam

 Clinical significance – Liver disorders:

- Hepatitis
- Cirrhosis
- Biliary obstruction (gallstones,carcinoma)

 Ictotest (Tablet)
Contains:
 P-nitrobenzene-diazonium p-toluenesulfonate
 SSA
 Sodium carbonate
 Boric acid
FALSE (+):
 Indican & metabolites of the medication & Iodine
FALSE (-):
 Use of not freshly voided specimen
 High conc. Of nitrite & ascorbic acid
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VII. UROBILINOGEN
 Bile pigment that result from hemoglobin degradation

 HOESCH TEST (INVERSE EHRLICH REACTION)

Procedure: 2dtts urine + 2ml Hoesch reagent (Ehrlich’s reagent in 6M or ^N HCl)-----> (+) Red

Reading Time Urine Parameter Principle Positive color

Glucose Double sequential enzyme Green to brown
30 secs. reaction
Bilirubin Diazo reaction Tan or pink to violet
40 secs. Ketones Sodium nitroprusside reaction ( Purple
Legal’s Test)
45 secs. Specific Gravity pKa change of a polyelecrolyte Blue to yellow
Protein Protein ( Sorensen’s) error of Blue
indicators
pH Double indicator system Orange (pH 3.0) to blue (pH
9.0)
60 secs. Blood Pseudoperoxidase activity of
hemoglobin
Urobilinogen Erhlich reaction Red
Nitrite Greiss reaction Uniform pink

120 secs. Leukocytes Leukocyte esterase Purple

MICROSCOPIC EXAMINATION OF URINE

 Addis count
 Quantitative measure of formed elements of urine using hemacytometer

 Normal Values:
 RBCs = 0 – 500,000/12-hr urine
 WBCs = 0 – 1,800,000/12-hr urine
 Hyaline casts = 0 – 5,000/ 12-hr urine
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