Urine dipstick testing + Common Renal Problem

Done By

Ainul Arina Madhiah

URINE DIPSTICK : Introduction

Abnormalities in the urine analysis can be indicative of diseases of : The urinary system Other organ systems (liver diseases, acid-base status abnormalities, and carbohydrate metabolism defects.)

Types of sample collection

There are 3 ways to obtain a urine specimen: spontaneous voiding ( the best & simplest) urethral catheterization (invasive, time consuming) suprapubic transabdominal bladder aspiration

Once sample is collected, it should be: - transport to the lab within 2 hours - reserved appropriately in refrigerator Because if it is left over a long time. Microbacterial proliferation will change the pH alkaline Glucose metabolization will give false negative and change the pH acidic Release of peroxidase will give false positive for blood screening in urine dipstick

Spontaneous Voiding
Clean catch mid stream urine Its constituents are more likely to reflect kidney origin. Early morning sample more concentrated and most informative

Urinary Catheterization
Only in required cases like comatose patient Invasive high risk of Iatrogenic Urinary Tract Infection

Suprapubic Transabdominal Bladder Aspiration

For patient which difficult to obtain their urine (newborn, infant) Disadvantages false positive for hematuria, invasive and need skilled personel

Urine analysis
 MARCOSCOPIC EXAMINATION OF THE URINE 1. Color 2. Clarity 3. Odor CHEMICAL EXAMINATION USING DIPSTICK 1. Proteinuria 2. Glycosuria 3. Hematuria 4. Ketones 5. Nitrites 6. Leukocyte esterase test 7. Specific gravity 8. Osmolality 9. pH MICROSCOPIC EXAMINATION OF URINE: 1. Red Blood Cells 2. White Blood Cells 3. Epithelial Cells 4. Casts 5. Crystals 6. Bacteria 7. Yeast

Macroscopic examination (Examination by eye and nose)

Color: Normal fresh urine -pale to dark yellow Red or red-brown (abnormal) color could be from a food dye, eating fresh beets, a drug, or the presence of either hemoglobin or myoglobin. Lack of color - excessive fluid intake. Orange to yellow - Bile pigment Dark urine - Acute intermittent porphyria Green urine - Pseudomonas infection Clarity: cloudy urine -generally the result of phosphates (usually normal), but may be due to leucocytes and bacteria. . Turbidity -spillage of RBCs, WBCs, bacteria,fat, mucus or pus from the bladder or kidney infection. A foamy or frothy specimen -sign of protein in the urine. Odor: Fouly smelling urine -indicative of UTI. A sweet or fruity odor- associated with ketone formation (DM, starvation or dehydration).

Chemical examination using dipsticks

 CHEMICAL EXAMINATION 1.Proteinuria 2.Glycosuria 3.Hematuria 4. Ketones 5.Nitrites 6.Leukocyte esterase test 7.Specific gravity 8.Osmolality 9.pH

Proteinuria
Most healthy individuals excrete : 30-130 mg/day of protein in urine. More than 150 mg/day is defined as Proteinuria. Trace proteinuria = 10mg/dl 1+ proteinuria = 30mg/dl 2+ proteinuria =100mg/dl 3+ proteinuria =300mg/dl 4+ proteinuria = 1gm/ dl The urine dipstick is most sensitive to albumin and is often insensitive to other proteins. this may give a false negative result with immunoglobulin light chains (Bence-Jones protein) or microalbuminuria. False positive may occur if there is delay in reading the strip

Cause of protienuria are due to 3 abnormalities: Distruption of capillary wall barrier Tubular damage - inhibit normal resorbtive capacity Increase production of normal or abnormal plasma protein (Nephritic syndrome , UTI, Fever, DM, Orthostatic, Pregnancy) Proteinuria can be: Transient occurs commonly especially in children and usually resolves within a few days often associated with fever, exercise or stress. In older patients may be due to CHF. Intermittent frequently associated with postural changes. Commonly occurs in upright position in young adults and rarely exceeds 1g/day. Resolves spontaneously in about half of patients and not associated with disease. Persistent usually due to glomerular cause with >2g protein/day of which major component is albumin. Some may also coexist with haematuria.

Glucose
Glycosuria (excess sugar in urine) generally means diabetes mellitus..

Blood sugar Above renal threshold (10mmol/l or 180mg/dl) will appear in urine
[ Normally all glucose will be reabsorbed in prox. tubules ]

Causes: 1-Renal tubular damage 2-DM 3-Sepsis 4-Pregnancy

Urine pH
In most situations pH measurement obtained with a dipstick is accurate. pH of normal urine is between 4.5 and 7.8, but usually it ranges between 5.0 and 6.0, A more acidic pH may be the result of fever, phenylketonuria, alkaptonuria, or metabolic acidosis. Alkaline urine may occur in urinary tract infections, or metabolic or respiratory alkalosis.

Occult blood
 Positive test indicates either haematuria, haemoblobinuria or myoglobinuria  Positive results appears as both coloured dots and change in the colour field  False positive readings most often due to contamination with menstrual blood.

Hematuria vs. Hemoglobinuria and Myoglobinuria absence of RBC's on the microscopic examination

Hemoglobin vs. Myoglobin depends on other tests like free hemoglobin in plasma, level of CPK or use of specific assays in urine immunodiffusion techniques.

Hematuria is presence of occult blood in urine which is defined as >3 RBC/hpf of centrifuged sediment under microscope. ( due to glomerular damage, tumors, kidney trauma, urinary stones, acute tubular necrosis, UTI and nephrotoxins.. ) .

Ketones (

acetone, aceotacetic acid, beta-hydroxybutyric acid)

* Ketones result from metabolic breakdown of fats, which occurs in the absence of normal glucose metabolism (calorie deprivation )
1. 2. 3. 4. diabetic ketoacidosis (emergency!) starvation pregnancy rapid weight loss

* urine dipstick detects only acetoacetate and acetones and not beta-hydroxybutyric acid (BHBA)

Dipstick test presence of acetoacetic acid at 5-10mg/dl

Bilirubin and urobilinogen

- Urine normally contains no bilirubin and only very little urobilinogen.

Urobilinogen its concentration in urine is usually

<1mg/dl If urobilinogen levels increase in the urine severe infection, liver damage, or hemolytic anemia Conjugated bilirubin vs. Unconjugated bilirubin (pink change) *Unconjugated bilirubin is water soluble found in urine *conjugated bilirubin is bound to albumin does not appear in urine.

Leucocyte esterase and nitrite test

Leucocyte esterase
Used to detect leucocytes in the urine The test is positive if there are more than 5 leucocytes/hpf. A negative leukocyte esterase test means that an infection is unlikely

Nitrite test
Normal urine does not contain nitrites. Urine nitrite test is used for screening for bacteria A positive test indicates presence of more than 10 organisms/ml..

Specific gravity and Osmolality

Specific gravity determines the ability of the kidney to concentrate or dilute urine. (best taken early in the morning) Specific gravity depends on both the weight and the number of particles in solution The normal range is between 1.005 and 1.035 osmolality is dependent only on the number of particles Osmolality of urine is between 40 to 1200mosm/kg.

MICROSCOPIC EXAMINATION OF URINE:

1-RBC :if > 3 RBc in urine which abnormal and this due to: - Infection - Trauma - polycystic kidney - Glomerulonephritis

2-WBC:
Pyuria refers to the presence of abnormal numbers of leukocytes which > 5 WBC / hpf that may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis.

3-Casts: are cylindrical body formed in the lumen of distal tubules.

- hyaline cast : are found in normal urine and inc. in fever .exercise - red cell cast: indicative of glomerulonephritis - white cell cast: occur in pyelonephritis - tubular cell cast : occur in acute tubular necrosis.

4-Bacteria: more than 100,000/ml of one organism reflects significant

bacteriuria

5-Crystals: Common crystals seen even in healthy patients include

calcium oxalate, triple phosphate crystals and amorphous phosphates Epithelial Cells: Squamous epithelial cells from the skin surface or from the outer urethra can appear in urine.

Topic : COMMON KIDNEY PROBLEM

nd 2

FIRST CASE :  3mmad is 28 year old male presents to the ED with left sided flank pain. the pain was acute in onset approximately 1hour ago. , colicky in nature , radiates to his left upper abdomen and he rated . 9/10 on the pain scale.  The patient is nauseous and had one episode of vomiting prior to arrival in the ED. He denies any trauma to the area or any previous history of similar back pain.  The patient also complain of dysuria , oligouria , with & change in the urine color to the pink .  His past medical & surgical history is negative .  And he is not allergic to any thing .

Cont
Physical Exam:  Vital signs: temp 37.1 c - BP 130/82; Resp. 22; Pulse 88  Abdomen: tenderness of LUQ, no masses, Investigation :  The urine analysis reveal presence of RBC and WBC and increase in calcium level .  And ct-scan image show the presence of a stone in his left kidney .

Kidney Stone

Definition
A kidney stone is a solid piece of material that forms in the kidney out of substances in the urine. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. However, these inhibitors do not seem to work for everyone. Kidney stones may contain various combinations of chemicals.

Types of kidney stone

 Calcium :(75 to 80%)
The most common kidney stone type contains calcium in combination with either oxalate or phosphate. These are called calcium oxalate stones or calcium phosphate kidney stones-irregular in shape & cover with projections

 Struvite: (10-20%)
 A struvite stone, also known as an infection stone, may form after there is an infection in the urinary system. This type of kidney stone contains the mineral magnesium and the waste product ammonia.

 Cystine: (1%)
Uncommon multiple cystineurea (congenital error of metabolism )-radio opaque

 Uric acid : (5%) Which tend to be multiple hard radiolucent

Cystine.

Calcium oxalate

Uric acid stone

Etiology
According to the cause of formation into metabolic and nonmetabolic :  1- Metabolic causes : 1. Cystinuria . 2. Hypercalceuria . 3. Hypercalcaemia. 4. Hyperuricaemia. 5. Hyperoxaluria. 6. Hypocitrateuria. 7. Hypomagnesemia .

Cont
2- Non metabolic :  1- Anatomical causes : stricture - stenosis congenital anomalies .  2- enviromental factors : hot clame secretary work .  3- infections :  4- drugs : diuretics thiazide-aids drugs  5- hyperparathyrodism: hypercalciuria hpercalcaemia  6- immobilization

Approach
History Examination Investigation

History :
Pain analysis : Sharp, cramping pain in the back, side, or groin Nausea/vomiting Hematuria Pyuria Dysuria. Oliguria:

Examination
physical examination the patient often appears restless, unable to find a comfortable position. The abdomen may be slightly distended and pain is often elicited by gently tapping on the flank region.

Investigation
laboratory Tests Initial laboratory tests include: Urine analysis to assess for the presence of blood in the urine KFT to determine kidney function serum electrolyte . urine culture to assess for the presence of urinary infection

Cont..
 Imaging :
1- CT-scan without contrast ( the best imaging tool to
diagnose - show all types of stone we use it without contrast cause contrast will show hyper dense regions so we will not be able to differentiate the stone )

2- plain x-ray (KUB):

20% of stones are radio-lucent so they will not appear .

3- IVU ( intravenous urogram ) 4- Ultrasound : ( operator dependent small stone will not
appear )

CT scan

KUB

Treatment
 Most kidney stones pass out of the body as fluids are increased (pain medicine will be prescribed as needed).     Extracorporeal Shock Wave Lithotripsy Ureteroscopy Tunnel Surgery (percutaneous nephrolithotomy.) Open surgery

SECOND CASE  36 years old married woman presents with complaints of burning micturition for 3 days. She also complaints of the need to go to the bathroom frequently. Currently she also feels urgency, as though she will not be able to make it to the bathroom in time, but each time she only voids a small amount of urine. She also fell suprapubic pain .continuous , mild, and doesn t radiate to any where . no nausea or vomiting .  There is fever but not associated with chills .  Past medical and surgical Hx is negative .  Examination reveals tenderness over the suprapubic area. There is no costo-vertebral angle tenderness. The rest of the examination is normal. Urinalysis shows 15 - 20 pus cells per high power field.

URINARY TRACT uti INFECTION

Definition
 A urinary tract infection, or UTI, is an infection that can happen anywhere along the urinary tract. Urinary tract infections have different names, depending on what part of the urinary tract is infected.  Bladder -- an infection in the bladder is also called cystitis or a bladder infection  Kidneys -- an infection of one or both kidneys is called pyelonephritis or a kidney infection  Ureters -- the tubes that take urine from each kidney to the bladder are only rarely the site of infection  Urethra -- an infection of the tube that empties urine from the bladder to the outside is called urethritis

Risk factors
 Intercourse: sexually active women, sex is the cause of 75 90% of
bladder infections,

 Sex: F>M  blockages in the urinary tract: Kidney stones or an enlarged

prostate can trap urine in the bladder and increase the risk of urinary tract infection.

 urinary tract abnormalities: that don't allow urine to leave the

body or cause urine to back up in the urethra

 catheter to urinate:  Diabetes  Advanced age

Causes
 Escherichia coli (E. coli) causes about 80% of urinary tract infections (UTIs) in adults. These bacteria are normally present in the colon and may enter the urethral opening from the skin around the anus and genitals.  other bacteria that cause urinary tract infections include Staphylococcus saprophyticus (5 to 15% of cases), Chlamydia trachomatis, and Mycoplasma hominis. Men and women infected with Chlamydia trachoma or mycoplasma hominis can transmit the bacteria to their partner during sexual intercourse, causing UTI.

Sign & Symptoms

               The symptoms of a bladder infection include: Cloudy or bloody urine, which may have a foul or strong odor Low fever (not everyone will have a fever) Pain or burning with urination Pressure or cramping in the lower abdomen (usually middle) or back Strong need to urinate often, even right after the bladder has been emptied If the infection spreads to the kidneys, symptoms may include: Chills and shaking or night sweats Fatigue and a general ill feeling Fever above 101 degrees Fahrenheit Flank (side), back, or groin pain Flushed, warm, or reddened skin Mental changes or confusion (in the elderly, these symptoms often are the only signs of a UTI) Nausea and vomiting Severe abdominal pain (sometimes)

Diagnosis
 CBC + blood culture .  Urine dipstick : pyuria on microscopic examination urine WBC  Middle stream urine culture: bacterial account > 105/ml The following tests may be done to help rule out problems in your urinary system that might lead to infection or make a UTI harder to treat:  CT scan of the abdomen  Intravenous pyelogram (IVP)  Kidney scan  Kidney ultrasound  Voiding cystourethrogram

Treatment
Rest Drinking large amount of water Antibiotics: 10-14 days until symptom free Treat related diseases: diabetes, renal stones, vaginal infection, etc

Uncomplicated
 simple infection
      Sulfamethoxazole-trimethoprim (Bactrim, Septra, others) Amoxicillin (Larotid, Moxatag, others) Nitrofurantoin (Furadantin, Macrodantin, others) Ampicillin Ciprofloxacin (Cipro) Levofloxacin (Levaquin)

 Usually, symptoms clear up within a 7-14 days of treatment. But you may need to continue antibiotics for a week or more. Take the entire course of antibiotics prescribed by your doctor to ensure that the infection is completely eradicated.

Cont
severe infection:
For severe urinary tract infections, hospitalization and treatment with intravenous antibiotics may be necessary.

Proginosis :
A urinary tract infection is uncomfortable, but treatment is usually successful. Symptoms of a bladder infection usually disappear within 24 48 hours after treatment begins. If you have a kidney infection, it may take 1 week or longer for your symptoms to go away.

upper UTI  Fever +  Percussion of the + costovertebral angle  WBC casts +  Urinary concentrating decrease ability  Urine NAG, 2-MG increase  Ab-coated bacteria + in urine  Recurrent early, same bacteria  IVU may abnormal

lower UTI normal normal late, new bacteria usually normal