It

1
Its not just water !

• An introduction to Urinalysis
• as performed in the
• Clinical Laboratory.

2
Student Objectives

• Upon completion of this lecture presentation and
  the laboratory analysis, students will be
  expected to
• 1. Describe the major functions of the
  kidney.
• 2. List the major structures of the kidney
  involved in urine formation.
• 3. Describe the importance of
  performing Urinalysis.

3
Student Objectives - continued

• 4. Observe the various urine elements detected
  via dipstick chemical analysis.
• 5. Observe the basic cell types found in the
  microscopic analysis of urine sediment.
• 6. Name the clinical laboratory professionals
  who perform urinalysis testing and explain the
  education each requires.

4
Topics

• This presentation covers the following topics
• What is Urinalysis?
• Review of kidney function
• Macroscopic examination of urine
• Chemical examination of urine
• Microscopic examination of urine
• Who performs urinalysis testing?
• Summary and References

5
What is Urinalysis?

• Urinalysis or the analysis of urine is one of
  the oldest laboratory procedures in the practice
  of medicine.
• It is a good test for assessing the overall
  health of a patient.

Courtesy of the National Library of Medicine
6
What is Urinalysis?

• It provides information about
• The state of the kidney and urinary tract.
• Metabolic or systemic (non-kidney) disorders.
• Urinalysis can reveal diseases that have gone
  unnoticed because they do not produce striking
  signs or symptoms.
• Examples include diabetes mellitus, various forms
  of kidney failure, and chronic urinary tract
  infections.

7
Review of Kidney Function

• Urine is composed of approximately 96 water and
  4 dissolved substances derived from food or
  waste products of metabolism.
• The actual composition of urine varies, depending
  on diet, metabolism, general health of the body,
  and health of the kidney.
• Urinalysis is performed to assess the urines
  composition as well as kidney function.

8
Review of Kidney Function

• Recall the urinary system consists of two
  kidneys, two ureters and the bladder.

9
Review of Kidney Function

• Also recall the role of blood - to bring
  nutrients and oxygen to cells of the body and to
  carry waste materials away from those cells.
• The kidney has the largest role in controlling
  the chemical composition of the blood in order
  to maintain proper cell function in the body.

10
Review of Kidney Function
In the kidney, blood undergoes filtration and
dialysis to separate waste compounds that will be
removed from the body from those that will be
returned to the circulating blood.
Figure 1
11
Review of Kidney Function

• More specifically, the kidney has the functions
  of
• removal of waste products from the blood
• retention of nutrients such as proteins and
  glucose
• maintenance of acid-base balance
• regulation of water and electrolyte (salt)
  content of the body
• hormone synthesis

12
Review of Kidney Function

• Urine is formed in the kidney structure called
  the nephron.
• Each kidney contains about one million nephrons.
• The nephron is made up of a glomerulus and a set
  of tubules.

Cross section of a nephron
13
Review of Kidney Function

• The tubular portion of the nephron consists of
  several structures
• Proximal convoluted
  tubule
• Loop of Henle
• Distal convoluted
  tubule
• Collecting duct

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Review of Kidney Function

• Urine is formed through a three phase process of
• Filtration
• Reabsorption
• Secretion

15
Review of Kidney Function

• Filtration of the blood occurs within the
  specialized collection of capillaries in the
  glomerulus.
• The glomerulus permits water and small molecules
  and ions from the blood to enter a surrounding
  tubule called the Bowmans capsule. This is
  called the filtrate.
• Blood cells and large protein molecules remain in
  the blood and return to the venous circulation.

16
Review of Kidney Function

• Reabsorption of essential chemicals the body
  needs (glucose, amino acids, NaCl and other
  salts, water and vitamins) occurs within the
  nephrons proximal tubule, Loop of Henle, and
  distal tubule.
• Reabsorption prevents the loss of necessary body
  compounds but also adjusts the concentration of
  urine so it is more dilute when the body has more
  water (i.e., hydrated) and more concentrated when
  the body is short of water (i.e., dehydrated).

17
Review of Kidney Function

• Secretion of foreign chemicals the body does not
  need (ammonia, drugs, hormones, toxins) begins in
  the proximal tubules and continues in the distal
  tubule and the collecting duct.
• Secretion of excess ions such as H and K help
  establish electrolyte and acid-base balance.

18
Review of Kidney Function

• All three processes of filtration, reabsorption
  and secretion occur simultaneously as a result of
  complex cellular transport mechanisms and
  buffering mechanisms within the nephron tubules.
  
• The glomerular filtrate becomes more concentrated
  and acidic after it leaves the distal tubule and
  enters the collecting duct.
• The fluid that leaves the collecting duct is now
  urine.

19
Review of Kidney Function

• The processes of glomerular filtration and renal
  tubular reabsorption and secretion are can become
  affected when the kidney is compromised by
  disease.
• Loss of renal function can be caused by variety
  of conditions such as
• congestive heart failure
• injury to the glomerulus or tubules caused by
  drugs, heavy metals and viral infections
• diabetes, hypertension and kidney stones.

20
Urinalysis

• Renal function tests, such as the urinalysis, are
  used to screen for the cause and the extent of
  renal dysfunction.
• Urinalysis consists of the following
  measurements
• Macroscopic exam
• Chemical exam
• Microscopic exam of the sediment

21
Macroscopic Exam

• Examination of the physical properties
  including.
• Color
• Clarity (or transparency)

22
Macroscopic Exam

• Color - normal
• yellow (straw to amber)
• Color - abnormal (due to disease, drugs or diet)
• pale to colorless
• amber (dark yellow)
• orange
• pink or red
• green
• brown or black

23
Macroscopic Exam

• Clarity (or transparency) - normal
• clear
• Clarity - abnormal (due to insoluble elements
  such as cells, crystals, etc.)
• hazy
• cloudy
• turbid

24
Macroscopic Exam
Left to right Straw, clear yellow, clear
yellow, hazy yellow, clear red-orange, clear
brown, hazy.
25
Chemical Exam

• The presence of normal and abnormal chemical
  elements in the urine are detected using dry
  reagent strips.
• These plastic strips contain absorbent pads with
  various chemical reagents for determining a
  specific substance.

26
Chemical Exam

• When the test strip is dipped in urine the
  reagents are activated and a chemical reaction
  occurs.
• The chemical reaction results in a specific color
  change.

27
Chemical Exam

• After a specific amount of time has elapse, this
  color change is compared against a reference
  color chart provided by the manufacturer of the
  strips.

28
Chemical Reaction Chart
29
Chemical Exam

• The intensity of the color formed is generally
  proportional to the amount of substance present.

30
Typical Substances Tested Significance

• pH - partial assessment of acid base status
  alkaline pH indicates old sample or urinary tract
  infection
• Specific Gravity - state of kidney and hydration
  status of patient
• Protein - primarily detects protein called
  albumin important indicator in the detection of
  renal disease
• Glucose - primarily detects glucose (sugar)
  important indicator of diabetes mellitus

31
Typical Substances Tested Significance

• Blood - red blood cells, hemoglobin, or myoglobin
  (muscle hemoglobin) sensitive early indicator of
  renal disease
• Ketone - normal product of fat metabolism
  increased amounts seen in diabetes or starvation
  (extreme dieting)
• Bilirubin - detects bilirubin (a product of red
  cell breakdown) indicator of liver function
• Urobilinogen - another by-product of red cell
  breakdown increased amounts seen in fever,
  dehydration, hemolytic anemia and liver disease

32
Typical Substances Tested Significance

• Nitrite - certain bacteria convert normal urine
  nitrate to nitrite indicator of urinary tract
  infection
• Leukocyte Esterase - detects esterase enzyme
  present in certain white blood cells (e.g,
  neutrophils, monocytes) indicator of urinary
  tract infection

33
Example Chemical Analysis Results ...
34
Elevated pH (alkaline)

• (Normal for comparison)

35
Positive Glucose

• (Normal for comparison)

36
Positive Blood Ketones

• (Normal for comparison)

37
Positive Blood and Leukocyte Esterase

• (Normal for comparison)

38
Microscopic Exam

• Most commonly used procedure for the detection of
  renal and/or urinary tract disease.
• This exam consists of reviewing the solid
  material suspended in the urine - both chemical
  and cellular.

39
Microscopic Exam

• Requires a well-trained laboratory professional
  who is
• skilled in the use of various microscopic
  techniques such as bright field and phase
  microscopy
• able to distinguish normal or contaminating items
  from abnormal, pathologic elements
• knowledgeable of the clinical significance of
  each finding and its relationship to the chemical
  and physical analysis

40
Microscopic Exam

• The urine specimen is centrifuged and the liquid
  portion is poured off.
• The concentrated cellular sediment .

41
Microscopic Exam

• . is then placed on a
  microscope slide, covered with a coverslip and .

42
Microscopic Exam

• viewed under a microscope.

43
Microscopic Exam

• A variety of normal and abnormal cellular
  elements may be seen in urine sediment such as
• Red blood cells
• White blood cells
• Mucus
• Various epithelial cells
• Various crystals
• Bacteria

44
Microscopic Exam

• Red blood cells
• presence of a few is normal
• higher numbers are indicator of renal disease
• result of bleeding at any point in urinary system

40x objective
45
Microscopic Exam

• White blood cells
• a few are normal
• high numbers indicate inflammation or infection
  somewhere along the urinary or genital tract

40x objective
46
Microscopic Exam

• Mucus
• look like long, ribbon-like threads
• common finding in urine sediment
• secreted by glands in the lower urinary tract

40x objective
47
Microscopic Exam

• Epithelial cells
• cells are large and flat
• normal cells that line the urinary and genital
  tract or renal tubules

40x objective
48
Microscopic Exam

• A variety of normal and abnormal crystals may be
  present in the urine sediment.

49
Microscopic Exam

• Crystals of calcium oxalate
• colorless octahedron
• found in acid urine
• Crystals of triple phosphate
• colorless, coffin-lid prism
• common finding not clinically significant

50
Microscopic Exam

• Hyaline Casts
• colorless and fatter than mucus
• a few are normal
• may be increased after strenuous exercise
• form when protein solidifies in the nephron

Hyaline cast epithelial cell, 40x objective
51
An additional note ...

• The chemical and microscopic analysis of urine
  can be performed manually or with automated
  analyzers.
• In many laboratories, abnormal automated findings
  are confirmed by manual techniques.

52
Who performs urinalysis testing?

• In most clinical laboratories, urinalysis is
  performed by medical laboratory professionals
  called
• Medical Laboratory Technicians or Clinical
  Laboratory Technicians (MLT/CLT)
• Medical Technologists or Clinical Laboratory
  Scientists (MT/CLS)

53
What education is required to be a laboratory
professional?

• Associates degree
• Medical Laboratory Technician (MLT)
• Clinical Laboratory Technician (CLT)
• Bachelors degree
• Medical Technologist (MT)
• Clinical Laboratory Scientist (CLS)
• For more info, visit our web site at
• www.medlabcareers.msu.edu

54
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55
Summary

• Urinalysis in an important clinical diagnostic
  test.
• Urinalysis can reveal diseases that have gone
  unnoticed because they do not produce striking
  signs or symptoms.
• Urinalysis provides information about the kidney,
  urinary tract, and systemic (non-kidney)
  disorders.
• The results of the macroscopic, chemical and
  microscopic analysis must be interpreted together
  to arrive at a proper diagnosis.

56
Summary

• Although urinalysis is easily performed with
  reagent test strips, the results are dependent
  on
• correct technique
• an understanding of the limitations and
  interference's
• Thus, technologists and technicians performing
  these tests must be properly trained, especially
  in correctly recognizing microscopic elements.

57
References

• Urinalysis and body fluids - a colortext and
  atlas, Ringsrud, K Linne, J, Mosby - Year Book,
  Inc., 1995.
• MTS Lab Training Library, University of
  Washington, Department of Laboratory Medicine,
  2003.
• Modern chemistry, Bayer Corporation, Diagnostics
  Division, Tarrytown, NY, 1996.
• Multistix? 10SG Urinalysis Reagent Strips product
  insert AN30516C, Bayer Corporation, April, 1999.

58
References

• Figure 1 Your Kidneys and How They Work,
  National Kidney and Urologic Diseases Information
  Clearinghouse,
• http//www.kidney.niddk.nih.gov/kudiseases/pubs/y
  ourkidneys/index.htm
• Figure 2 Update in Anaesthesia - Physiology of
  the Kidney, Issue 9 (1998) Article 6, World
  Anaesthesia (WA) and World Federation of
  Societies of Anaesthesiologists (WFSA),
  http//www.nda.ox.ac.uk/wfsa/html/u09/u09_016.htm

59
The End

• Students
• Perform a Chemical Analysis on the urine
  specimens provided by your teacher.
• Teachers
• After students complete chemical analysis, show
  students the following Microscopic Images for the
  Microscopic Analysis portion of the lesson.

60
Its not just water !

• Microscopic Images
• for
• Urinalysis Laboratory Lesson

61
Patient 1 -40x objective
62
Patient 2 - 100x objective
63
Patient 3 -100x objective
64
Patient 4 - 40X objective