Department of Clinical Pathology

Medical Faculty Brawijaya Univ

 Introduction

A significant amount of information can be

obtained through the examination of urine.
Therefore, examination of the urine is an
important laboratory function.
The Role of
Urinalysis
The basic (routine) urina
The types of urine specimen
The changes in urine if it is
delayed more than 2 hour
Bacteria
Leucocyte

Yeast
 Urine Volume

Factors that influence urine volume

include fluid intake, fluid loss from
nonrenal sources, variations in the
secretion of antidiuretic hormone,
and need to excrete increased
amounts of dissolved solids, such as
glucose or salts.
The normal daily urine output is
usually 1200 to 1500 mL, a range of
600 to 2000 mL is considered normal.
 Urine Volume, contd
Oliguria, a decrease in urine output, less
than 1 mL/kg/hr in infants, < 0.5 mL/kg/hr in
children, and < 400 mL/d in adults, ex
vomiting, diarrhea, perspiration, or severe
burns.
Anuria, cessation of urine flow, result from
serious damage to the kidneys or a decrease
in the flow of blood to the kidneys.
Nocturia, An increase in the nocturnal
excretion of urine.
Polyuria, an increase in daily urine volume
(> 2.5 L/d in adults & 2.53 mL/kg/d in
children), ex. DM & diabetes insipidus
 Specific Gravity (SG)

An assessment of the kidneys ability to

reabsorb
Also detects: possible dehydration or
abnormalities in ADH and to determine
whether specimen concentration is
adequate to ensure the accuracy of
chemical tests.
Specific gravity of the plasma filtrate
entering the glomerulus is 1.010.
Isosthenuric: urine with a fix SG of 1.010.
Normal random specimens: 1.003 to 1.035.
Urine Multistix reading dipstick
results manually; colors are
matched to those on the bottle
label; timing is critical for each
pad.
 Urinary pH

The pH of normal random samples: 4.5

to 8.0.
It must be considered in conjunction
with other patient information: the
acid-base content of the blood, renal
function, the presence of a UTI, dietary
intake, and the age of the specimen
The precipitation of inorganic
chemicals dissolved in the urine forms
urinary crystals and renal calculi. This
precipitation depends on urinary pH.
 Protein

Proteinuria does require additional

testing: represents a normal or a
pathologic condition.
Clinical proteinuria: 30 mg/dL (300
mg/L).
Benign proteinuria: transient. Ex,
strenuous exercise, high fever,
dehydration, and exposure to cold.
Prerenal Proteinuria

It is caused by increased levels of low

molecular-weight plasma proteins
Because reagent strips detect
primarily albumin, prerenal
proteinuria is usually not discovered
in a routine urinalysis.
Ex: Bence Jones protein by persons
with multiple myeloma.
Renal Proteinuria

Glomerular Proteinuria:
glomerulonephritis, hypertension
Tubular Proteinuria: tubular
dysfunction
Orthostatic (Postural) Proteinuria:
A persistent benign proteinuria occurs
frequently in young adults, following
periods spent in a vertical posture
Renal Proteinuriacontd

Microalbuminuria:
Onset of renal complications of DM
can first be predicted by detection of
microalbuminuria
30 to 300 mg of albumin is excreted
in 24 hours
It is also associated with an increased
risk of cardiovascular disease.
Postrenal Proteinuria

Bacterial and fungal infections and

inflammations produce exudates
containing protein.
The presence of blood as the result
of injury or menstrual
contamination contributes protein,
as does the presence of prostatic
fluid and large amounts of
spermatozoa.
 Source of error/interference
False positive False negative
Highly buffered alkaline Proteins other than
urine albumin
Pigmented specimens, Microalbuminuria
phenazopyridine
Quaternary ammonium
compounds (detergents)
Antiseptics, chlorhexidine
Loss of buffer from
prolonged exposure of
the reagent strip to the
specimen
High specific gravity
 Glucose

In hyperglycemia, as occurs in diabetes

mellitus, the tubular transport of glucose
ceases, and glucose appears in the urine.
The level exceed renal threshold.
Renal glycosuria: Glycosuria occurs in the
absence of hyperglycemia, when the
reabsorption of glucose by the renal
tubules is compromised. The renal
threshold is decreased.
 Interference

False-positive:
Contamination by oxidizing
agents and detergents
False-negative:
High levels of ascorbic Acid,
High levels of ketones
High specific gravity
Low temperatures
Improperly preserved specimens
 Ketones

Intermediate products of fat metabolism:

acetone, acetoacetic acid, &
betahydroxybutyric acid
Ex: DM, starvation & malabsorption
In type 1 diabetes mellitus: Ketonuria
shows a deficiency in insulin
Increased accumulation of ketones in the
blood leads to electrolyte imbalance,
dehydration, &, if not corrected, acidosis
& eventual diabetic coma
 Keton

Results are reported qualitatively as

negative, trace, small (1+),
moderate (2+), or large (3+), or
semiquantitatively as negative, trace
(5 mg/dL), small (15 mg/dL),
moderate (40 mg/dL), or large (80 to
160 mg/dL).
 Blood

The finding of a positive reagent

strip test result for blood indicates
the presence of red blood cells,
hemoglobin, or myoglobin.
Microscopic examination can be
used to differentiate between
hematuria and hemoglobinuria
Table 1. Summary of Clinical Significance of a
Positive Reaction for Blood
Hematuria Hemoglobinur Myoglobinuria
ia
1. Renal calculi 1.Transfusion 1. Muscular
2. Glomerulone- reactions trauma/crush
phritis 2. Hemolytic syndromes
3. Pyelonephritis anemias 2. Prolonged coma
4.Tumors 3. Severe burns 3. Convulsions
5.Trauma 4. 4. Muscle-wasting
6. Exposure to Infections/mala diseases
toxic ria 5.
chemicals 5. Strenuous Alcoholism/overdo
7. Anticoagulants exercise/red se
8. Strenuous blood cell 6. Drug abuse
exercise trauma 7. Extensive
6. Brown exertion
recluse spider 8. Cholesterol-
 Blood

False-positive: Bacterial
peroxidases, Menstrual
contamination
False-negative: High specific
gravity/crenated cells, Formalin,
Captopril, High concentrations of
nitrite, Ascorbic acid 25 mg/dL,
Unmixed specimens
 Bilirubin & Urobilinogen

Conjugated bilirubin appears in the urine

when the normal degradation cycle is
disrupted by obstruction of the bile duct or
when the integrity of the liver is damaged
Urobilinogen appears in the urine
because, as it circulates in the blood en
route to the liver, it passes through the
kidney. Therefore, a small amount of
urobilinogenless than 1 mg/dL or Ehrlich
unitis normally found in the urine.
Figure 1. Hemoglobin degradation
Table 2. Urine Bilirubin and
Urobilinogen in Jaundice
Urine Urine
Bilirubin Urobilinoge
n
Bile duct +++ Normal
obstruction
Liver + or ++
damage Negative +++
Hemolytic
disease
 Bilirubin

False-positive: Highly pigmented

urines, phenazopyridine, Indican
(intestinal disorders), Metabolites of
Iodine
False-negative: Specimen exposure
to light, Ascorbic acid 25 mg/dL, High
concentrations of nitrite
 Urobilinogen

False-positive: Porphobilinogen,
Indican, p-aminosalicylic acid,
Sulfonamides, Methyldopa, Procaine,
Chlorpromazine, Highly-pigmented
urine
False-negative: Old specimens,
Preservation in formalin
 Nitrite
The chemical basis: the ability of certain
bacteria to reduce nitrate to nitrite
(Enterobacteriaceae).
Urine has remained in the bladder for min. 4 h.
Clinical Significance:
1. Cystitis
2. Pyelonephritis
3. Evaluation of antibiotic therapy
4. Monitoring of patients at high risk for urinary
tract infection (UTI)
5. Screening of urine culture
 Leukocyte Esterase

The test is not designed to measure the

concentration of leukocytes, and recommend
that quantitation be done by microscopic
examination
It can detects the presence of leukocytes that
have been lysed.
Clinical Significance:
1. Bacterial and nonbacterial UTI
2. Inflammation of the urinary tract
3. Screening of urine culture
 Leukocyte esterase

False-positive: Strong oxidizing

agents, Formalin, Highly pigmented
urine, nitrofurantoin
False-negative: High concentrations of
protein, glucose, oxalic acid, ascorbic
acid, gentamicin, cephalosporins,
tetracyclines, inaccurate timing
 Red Blood Cells

The presence of RBCs in the urine is

associated with damage to the
glomerular membrane or vascular
injury within the genitourinary tract
Dysmorphic: RBCs that vary in size,
have cellular protrusions, or are
fragmented: glomerular origin.
Erythrocytes are found in small numbers (0-2
cells/hpf) in normal urine.

Fig 2. Normal (left) and dysmorphic RBCs (right) 400x

 White Blood Cells

Normal urine: fewer than 5

leukocytes per hpf (higher
numbers in females).
An increase in urinary WBCs
(pyuria): pyelonephritis,
cystitis, prostatitis, urethritis
Also in nonbacterial
disorders: glomerulonephritis,
LE, interstitial nephritis, and
tumors.
Fig 3. Leukocytes (400
 Epithelial Cells

Squamous epithelial
cells: most frequent
epithelial cell seen in
normal urine, and
likewise the least
significant
Renal tubular
epithelial cells (RTE):
more than 2/hpf
indicates tubular injury
Fig 4 Squamous (top) and Renal tubular epithelial cells (
 Oval fat bodies

Tubular cells that have

absorbed lipoproteins
with cholesterol and
triglycerides leaked
from nephrotic
glomeruli.
The presence of any or
all of these lipid forms
accompanied by
marked proteinuria is Fig 5. Oval fat bodies
characteristic of the
 Casts

The presence of urinary casts is termed

cylindruria.
The major constituent: Tamm-Horsfall
protein, a glycoprotein excreted by the RTE
cells of the distal convoluted tubules and
upper collecting ducts
The protein gels more readily under
conditions of urine-flow stasis and acidity.
 Hyaline casts

Normal: 0 - 2 hyaline casts

per low power field (lpf)
Erythrocyte casts
Finding these casts in the
urine is quite significant
because they are an indication
of bleeding within the nephron
Most common in acute
glomerulonephritis
Leukocyte casts
Reflect tubulointerstitial disease
with neutrophilic exudates and
interstitial inflammation.
Most common in pyelonephritis
 A B

Granular casts: in both pathologic and

nonpathologic conditions, like pyelonephritis,
strenuous exercise. A. Coarsely granular casts, B.
Waxy casts Broad casts (renal failure
in chronic renal casts) like waxy casts
diseases, some represent extreme urine
stasis.
casts become They indicate tubular
denser in dilation and/or stasis in
appearance the distal collecting duct.
and are known Typically seen in
as waxy. individuals with chronic
renal failure (with a poor