Documente Academic
Documente Profesional
Documente Cultură
kidney function
kidneys to clear waste products selectively from the blood maintain the bodys essential water and electrolyte balances
Nephrons
renal blood flow glomerular filtration, tubular reabsorption tubular secretion
juxtamedullary
with longer loops of Henle that extend deep into the medulla of the kidney primary function is concentration of the urine.
Renin-Angiotensin System
Renal Concentration
Urine Formation
I. Water 2. Organic Solids Urea, Creatinine, Uric Acid 3. Inorganic Solids Chloride, Sodium, Potassium Trace amounts of: magnesium, calcium, iron, ammonia, etc. 4. Other components (may be present or not): hormones, vitamins, medications 5. Formed Elements (not part of the original plasmas filtrate): cells, casts, crystals, mucus, and bacteria
1. Fluid Intake 2. Fluid loss from nonrenal sources 3. Variations in Secretions of antidiuretic hormone (ADH) Substances that affect ADH secretion: caffeine, diuretics, alcohol 4. Necessity to excrete amounts of dissolved solids (ex. Glucose or salts) Volume: Average Daily Output: 1200-1500ml Normal Range: 600-2000ml
1. Specimen must be collected in a clean, dry container 2. Container must be properly labeled w/ : patients name, date and time of collection, hospital #, doctors name 3. the specimen must be delivered to the laboratory w/in 1 hour after collection, or refrigerate it or add preservatives
Refrigeration Thymol Boric Acid Formaldehyde Chloroform Toluene Sodium fluoride Phenol Commercial Preservative Tablets Urine C + S Transport Kit
NORMAL COLOR: yellow, pale yellow, light yellow, dark yellow and amber (due to the presence of urochrome)
Urine Appearance
Pathogenic Cause
measures the ability of the kidneys to reabsorb essential chemicals and water from the glomerular filtrate
detects possible dehydration or abnormalities in ADH used to determine whether specimen concentration is adequate for chemical tests
1. pH
Clinical Significance:
1. Respiratory or metabolic acidosis 2. Respiratory or metabolic alkalosis 3. Defects in renal tubular secretion and reabsorption of acids and bases 4. Precipitation of crystals and calculi 5. Treatment of urinary tract infections 6. Determination of unsatisfactory specimen
2. Proteins
Normal Urine Protein: < 10 mg/dL or 100 mg/24 hours
Commonly Found Proteins: albumin, serum and tubular microglobulins, Tamm-Horsfall proteins produced by the tubules, proteins from prostatic, seminal and vaginal secretions
2. Proteins
Clinical Significance: 1. Glomerular Membrane Damage a. Immune complex disorders (SLE, Streptococcal glomerulonephritis) b. Amyloidosis c. Toxic Agents 2. Impaired tubular reabsorption 3. Multiple Myeloma 4. Diabetic nephropathy 5. Pre-eclampsia 6. Orthostatic or postural proteinuria
3. Glucose
Clinical Significance: 1. Diabetes Mellitus 2. Impaired Tubular Reabsorption Fanconis Syndrome Advance tubular renal disease 3. CNS damage 4. Thyroid Disorders 5. Pregnancy w/ possible latent DM
4. Ketones
Clinical Significance: 1. Diabetes mellitus 2. Insulin dosage monitoring 3. Starvation 4. Excessive carbohydrate loss
5. Blood
Clinical Significance: A. Hematuria 1. Renal calculi 2. Glomerulonephritis 3. Pyelonephritis 4. Tumors 5. Trauma 6. Exposure to toxic chemicals or drugs 7. Strenuous exercise B. Hemoglobinuria 1. Transfusion reactions 2. Hemolytic Anemias 3. Severe burns 4. Infections 5. Strenuous exercises/ RBC trauma C. Myoglobinuria 1. Muscular trauma 2. Prolonged coma 3. Convulsions 4. Muscle wasting diseases 5. Extensive exertions
6. Bilirubin
Clinical Significance: 1. Hepatitis 2. Cirrhosis 3. Other Liver disorders 4. Biliary obstruction
7. Urobilinogen
Clinical Significance: 1. Early detection of liver disease 2. Hemolytic disorders
URINE BILIRUBIN AND UROBILINOGEN IN JAUNDICE Urine Bilirubin Urine Urobilinogen Bile duct obstruction +++ Normal Liver damage + or ++ Hemolytic Disease negative +++
8. Nitrite
Clinical Significance 1. Cystitis 2. Pyelonephritis 3. Evaluation of antibiotic therapy 4. Monitoring of patients of high risk for UTI 5. Screening of urine culture specimen
9. Leukocytes
Clinical Significance: 1. UTI 2. Screening of Urine culture specimen
1. Patients hydration and dehydration 2. Loss of renal tubular concentrating ability 3. Diabetes insipidus 4. Determination of unsatisfactory specimen due to low concentrations
TEST Color Turbidity Specific Gravity pH Glucose Ketones Blood Protein Bilirubin Urobilinogen Nitrate for Bacteria Leukocyte Esterase Casts Red Blood Cells
NORMAL VALUES Pale yellow to amber Clear to slightly hazy 1.015-1.025 4.5-8.0 Negative Negative Negative Negative Negative 0.1-1.0 Negative Negative Occasional hyaline casts Negative or rare
TEST Crytals
NORMAL VALUES Acid Urine: Amorphous urates Uric acid Calcium oxalate Sodium acid Urates Alkaline Urine Amorphous phosphates Calcium phosphate Ammonium blurate Triple phosphates Calcium carbonate
Microscopic elements
RBCs WBCs
Physical
Turbidity Red color Turbidity
Chemical
+Blood +Protein +Nitrite +Leukocyte
Exceptions
Number Hemolysis Number Lysis Number
Epithelial cells
Turbidity
Casts
Bacteria Turbidity
+protein
pH +nitrite +leukocytes
Number
Number and type
Crystals
Turbidity Color
pH
Normal Values:
Red blood cells in urine appear as refractile disks. With hypertonicity of the urine, the RBC's begin to have a crenated appearance
Note the irregular outlines of many of these RBC's, compared to two relatively normal RBC's at the center left of the right panel. These abnormal RBC's are dysmorphic RBC's
These white blood cells in urine have lobed nuclei and refractile cytoplasmic granules.
From the linings of the genitourinary system Not pathologic unless present in large numbers
Squamous epithelial cells in urine - Large polygonal cells with small nuclei, contamination with skin flora
Transitional epithelial cells from the renal pelvis, ureter, or bladder have more regular cell borders, larger nuclei, and smaller overall size than squamous epithelium.
Lipiduria occurs, tahese cells contain endogenous fats When filled with numerous fat droplets, such cells are called oval fat bodies
Hyaline casts
Hyaline casts, which appear very pale and slightly refractile, are common findings in urine
Uncommon crystals include: 1. cystine crystals in urine of neonates with congenital cystinuria or severe liver disease 2. tyrosine crystals with congenital tyrosinosis or marked liver impairment, 3. leucine crystals in patients with severe liver disease or with maple syrup urine disease.
Calcium oxalate
Cystine crystals
Accumulation of abnormal metabolic substances in the urine overflow type: increased production of metabolites
due to defects in normal metabolic pathway
PHENYLALANINE-TYROSINE PATHWAY
Phenylketonuria
mousy odor urine absence of gene that codes for the enzyme phenylalanine hydroxylase increased keto acids including phenylpyruvate decreased tyrosine and its pigmentation metabolites normal conversion of phenylalanine to tyrosine is disrupted results to severe mental retardation phenylalanine should be eliminated in the diet
Phenylketonuria
o TESTS: 1.Bacteria (Bacillus subtilis) inhibition tests: counteract of -2 thienylalanine that inhibits B. subtilis 2.Chemical and immunologic test 3.Automated (Fluorescence) 4.Phenixtix: blue-gray green-gray color 5.Ferric chloride tube test: blue-green color
Tyrosyluria
o excess tyrosine or its degradation product: phydroxyphenylpyruvic acid and p-hydroxyphenyllactic acid o transitory tyrosinemia in premature infants due to underdevelopment of the liver function necessary to complete the tyrosine metabolism o TESTS:
1. Ferric chloride: green color that fades rapidly (to distinguished from PKU)
Alkaptonuria (alkali-lover )
o urine darkens upon standing at room temperature o failure to produce the enzyme homogentisic acid oxidase o not clinically manifested in early childhood o brown or black stained cloth diapers or reddish-skinned diapers (disposable) o lead to arthritis, liver, and cardiac disorders
Alkaptonuria (alkali-lover )
o TESTS:
1. Ferric chloride tube test: transient deep blue color 2. Phenixtix: negative 3. Benedicts test for Clinitest: yellow precipitate 4. Addition of alkali to freshly voided urine: darkening color (more specific)- interfere by the presence of ascorbic acid 5. Addition of silver nitrate and ammonium hydroxide: produce black urine 6. Spectrophotometric method
Melanuria
o Increased urinary melanin (dark urine after exposure to air) o Overprolifertaion of normal melanin-producing cells (eg. Malignant melanoma) o Secretion of 5,6-dihydroxyindole (precursor of melanin) oxidizes to melanogen, then to melanin o TESTS:
1. Ferric chloride tube test: gray or black precipitate 2. Sodium nitroprusside (nitroferricyanide): red color
Organic Acidemia
o symptoms sever illness, vomiting, hypoglycemia, ketonuria, increased serum ammonia, o 3 most frequent disorders: 1. Isovaleric acidemia
sweaty-feet odor Accumulation of isovalerylglycine due to deficiency of isovaleryl CoA in the leucine pathway No screening test; isovalerylglycine detected by chromatography
Organic Acidemia
2 proionic academia 3. methylmalonic acidemia
Screening test for mathylmalonic acid:
o One drop of urine is placed in the test tube followed by 15 drops of 0.1% -nitroaniline in 0.16M HCl and 5 drops of 0.5% nitrite. The solution is mixed resulting to the partial decolorization and 1 ml of 1M sodium acetate buffer st pH 4.5 is added. The solution is the boiled for one minute and 5 drops of 8N NaOH are added. The presence of methylmalonic acid is indicated by the appearance of emerald green color
TRYPTOPHAN DISORDERS
Indican
o Occurs in intestinal obstruction, presence of abnormal bacteria, malabsorption syndrome, and hartnup disease (inherited disorder) o Presence of indicant in the urine, colorless to dye indigo blue upon air exposure
urinary indicant reacts w/ acidic ferric chloride to form a deep blue or violet color that can subsequemtly extracted into chloroform
b. First morning urine is used for 24-hour urine preserved w/HCl or Boric Acid c. Interference: serotonin-rich foods (bananas, pineapples, tomatoes), medications (phenothiazines & acetanilids)
CYSTINE DISORDERS
Cystinuria
o Defect in renal tubular transport of amino acids o Elevated amounts of acid cystine in the urine o Primary clinical consideration: defective reabsorption of all 4 amino acids (cystine, lysine, arginine, ornithine); formation of calculi o TEST: cystine crystals in the first morning specimen Cyanide nitroprusside: red to purple color Interference: presence of ketones & homocystines
CYSTINE DISORDERS
Cystinosis o genuine error of metabolism o Crystalline deposits of cystine in many parts of the body (including: cornea, bone marrow, lymph nodes, internal organs) o Fanconis syndrome: major defect in renal tubular reabsorption occurs o Inability to reabsorb amino acids, sugars, phosphorus, potassium, and water o Polyuria, general aminoaciduria, positive test for reducing substances, lack of urinary concentration
CYSTINE DISORDERS
Homocystinuria
o Defects in the metabolism of homocystine o Results in: cataract, mental retardation, thromboemboli problems, and deaths o TESTS:
o Cyanide-nitroprusside: red to purple color o Silver-nitroprusside test: red to purple
Porphyrin disorders
o porphyries : collective term in the appearance of porphyrinuria o Causes:
Hereditary Acquired- erythrocytic and hepatic malfunction (eg. Metabolic disease, toxic agents)
o Lead poisoning: most common cause o Red discoloration of an infants diapers (congenital porphyria) o TESTS:
Ehrlichs reaction: only for detection of ALA and porpobilinogen Fluorescence- other porphyrias Watson-Schwartz test- differentiates between the presence of urobilinogen and porpobiliogen Hoesch test: rapid method to detect porpobilinogen
Mucopolysaccharde disorders
o Mucopolysaccharide or glycosaminoglycans found in the connective tissue o Inherited disorders o Accumulation of degradation products (eg. Dermatan sulfate, keratin sulfate, and heparin sulfate) o Best known type of mucopolysaccharaoidosis
Mucopolysaccharde disorders
o Abnormal skeletal structures and cause severe mental retardation
Hurlers syndrome- also accumulates in the cornea of the eye Hunters syndrome Sanfilippos syndrome- only cause mental retardation
o TESTS:
Acid albumin and cetyltrimethyl ammonium bromide (CTAB) turbidity test: thick white turbidity Metachromatic staining spot test: blue spots; cant be washed out by dilute acidified methanol solution
Purine Disorders
o Known as Lesch-Nyhan disease o Inherited disorder which results to massive excretion of urinary uric acid crystals o Failure to produce enzyme hypoxanthine guanine phosphoribosyl transferase o Severe motor defects, mental retardation, self destruction tendency, gout, renal calculi o Orange sand diapers in infants 6-8 months old
Functions: 1. Supply nutrients to the nervous tissues 2. Remove metabolic wastes 3. Procedure mechanical barrier: cushions the brain and the spinal cord against trauma Volume: - 20 ml produced every hour in choroids plexus and reabsorbs by the arachnoid villi - 140-170 ml in adults - 10-160 ml in neonates
Specimen collection - Lumbar puncture between 3rd 4th or between 4th & 5th lumbar vertebrae - Collection in 3 sterile tubes
o Tube 1: for chemical and serologic tests (frozen if not done immediately) o Tube 2: for microbiology (tested as soon as possible) o Tube 3: for cell count (refrigerate if can not be done within an hour)
Cell Count 1. WBC Count routinely performed 2. RBC Count: perform only for traumatic puncture to correct WBC count Normal value: 0-5 WBC/ L in adults ; 0-30 WBC/ L in newborns 3. improved neubauer counting chamber is used # of cells counted X dilution --------------------------------------------------# squares counted X volume of 1 square
Cells/ L =
4. Total Cell Count - no overlapping of cells is seen (undiluted count) - overlapping cells (diluted count in NSS) 5. WBC Count - 3% acetic acid, tolouidine blue O and saponin sodium solution (lyses RBCs and stain WBCs) 6. RBC Count - total cell count/ L WBC count/ L 7.Differential count - should only e done when there is sufficient amount - Wrights stain, count 100 cells (classify and report)
2. Xanthochromia - pink, orange or yellow Pink: slight amount of oxygenated hemoglobin Orange: heavy hemolysis Yellow: oxyhemoglobin converted to unconjugated bilirubin Others: high bilirubin, pigment carotene, protein concentration, melanoma pigment, immature liver functions
3. Grossly bloody CSF - intracranial hemorrhage (cerebellar) - traumatic collection: puncture of blood vessels
VISUAL EXAMINATION OF GROSSLY BLOODY CSF 1. Uneven distribution of blood - cerebral hemorrhage: even distribution of blood in all tubes - traumatic tap: tube1 w/ heaviest concentration of blood; streaks of blood may be seen 2. Clot Formation - cerebral: not contain enough fibrinogen t clot - traumatic: clots due to plasma fibrinogen 3. Xanthochromic supernatant (2 hours noticeable hemolysis) - cerebral: finding of macrophages ingested RBCs Presence of RBC is unreliable
Significance of abnormal cells: Immature leukocytes eosinophils, plasma cells, macrophages, increased tissue cells, malignant cells 1. Increased macrophage- previous hemorrhage 2. Ependymal cells- pneumoencephalograohy 3. Eosinophils- parasitic infections, reactions to foreign proteins in the CSF, intracranial shunt malfunctions 4. Nucleated RBCs- bone marrow contamination during spinal tap 5. Reactive lymphocytes- ( increased cytoplasm and clumped chromatin): viral infection, MS 6. Blast formation and immature WBCs- leukemias and lymphomas