AUBF PRELIMS

Analysis of Urine & Body Fluids
 Safety in the Clinical Laboratory
 Renal Function
 Introduction to Urinalysis
 Physical Examination of Urine
LABORATORY STANDARDS
CLSI (Clinical Laboratory Standards Institute)
 Formerly NCCLS
 Publishes national and international standard
documents on a variety of laboratory testing
procedures and policies for guidance on
achieving better testing outcomes.
QUALITY ASSESSMENT
• Variables Affecting the Quality of Laboratory
Testing
o Internal proficiency testing is also helpful for
quality
o Establishing a Quality Assessment
Program Ensures
SAFETY IN THE CLINICAL LABORATORY
OSHA (Occupational Safety and Health
Administration)
 Worker safety issues
CDC (Centers for Disease Control and Prevention)
 Implements public health regulations, monitors
reportable diseases and trends, categorizes lab
tests

BIOLOGICAL HAZARDS
1. Chain of Infection
 Source
 Mode of Transmission
 Susceptible Host
2. Proper Handwashing and
Personal Protective
Equipment (PPE)

Universal Precautions
1. All patients considered as possible carriers of
bloodborne pathogens.
2. Recommends wearing of gloves, face shields,
• Establishing a Quality Assessment Program proper disposal of sharps.
o effective communication 3. EXCLUDED: urine & body fluids not visibly
o adherence to established policies contaminated with blood
o accurate and thorough documentation
practices Body Substance Isolation
o use of delta checks 1. Modification from Universal Precaution
o timely verbal reporting of all critical 2. Not limited to bloodborne pathogens
values 3. Personnel at all times should wear gloves
• Performing Quality Control Tests 4. MAJOR DISADVANTAGE: does not
o Quality Control recommend handwashing after removal of
o A set of procedures and practices to gloves unless visual contamination is present
monitor the testing process and verify
the reliability, accuracy, and precision Standard Precautions
of the test. P atient-care equipment
o You must monitor each test with H andwashing
M ask, eye protection, face
standards and controls (at least two L inens
shields
levels) E nvironmental Control
P atient Placement
o New tests must be validated G loves
O ccupational Health & Blood
• Participating in Proficiency Testing Borne Pathogens
o External proficiency testing is mandated by G owns
CLIA ‘88 Personal Protective
o Unknowns from CAP or other approved lab Equipment
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1. Gloves  Store flammable chemicals properly
2. Fluid-resistant gowns  Compressed gas should be located away from
3. Eye and Face shields heat
4. Centrifuge using capped tubes or cover  Fire blankets must be present in the lab
centrifuge when using  If person’s clothes are burning, wrap in blanket
5. Special precautions to specimen submitted via to smother the flames
suspicious containers PHYSICAL HAZARDS
Handwashing  Avoid running in rooms and hallways
- Hand contact as number one method of  Watch for wet floors
infection transmission  Bend knees when lifting heavy objects
Disposal of Biological Waste
 Keep long hair pulled back
1. Incineration
 Avoid dangling jewelry
2. Autoclaving
 Maintain clean and organized work area
3. Pick-up by certified hazardous waste company
 Wear closed toe-shoes
SHARP HAZARDS
- Discard sharps in puncture resistant containers
located within work area.
RENAL FUNCTION
 Renal Physiology
CHEMICAL HAZARDS  Renal Blood Flow
Chemical Spills  Glomerular Filtration
 Flush area with large amount of water  Tubular Reabsorption
 Contaminated clothing should be removed  Tubular Secretion
immediately  Renal Function Tests
 Do not neutralize chemicals o Glomerular Filtration Tests
Chemical Handling o Tubular Reabsorption Tests
 Never mixed chemicals unless specified o Tubular Secretion & Renal Blood Flow
 Wear goggles when preparing reagents Tests
 Do not pipette by mouth
Chemical Labeling Parts and Function of the Urinary system
 Poisonous
Kidney
 Corrosive
- bean shape organ that is roughly oval with a medial
 Carcinogenic
indentation.
- Located on either side of the vertebral column and
RADIOACTIVE HAZARDS
extend from the level of the last thoracic vertebra to
 Effects of radiation is cumulative
just above the third lumbar vertebra.
 Degree of exposure related to:
- Average size is 11cm x 7cm x 3cm. The left kidney
o Time
is slightly larger than the right
o Distance
- The right kidney is a little bit lower than the left,
o Shielding
because the liver takes some of the space above the
 Wear measuring device to detect amount of right kidney
accumulated radiation - A heavy cushion of fat encases each kidney and
 Post radioactive symbols on doors if so. holds it in position including connective tissue and
renal fasciae.
ELECTRICAL HAZARDS
 Continually observe for frayed cords and Hilum - A concave notch in the middle surface of the
overloaded circuits kidney
 Avoid unplugging equipments with wet hands or - Structure enter or leave the kidney through this
while cleaning. notch.
 Remove source of electricity if electrical shocks Renal cortex - The outer region
are encountered or avoid transfer of the current Renal medulla - The inner region
Renal pyramids
R escue
FIRE/EXPLOSIVE HAZARDS
A larm
C ontain
E xtinguish
AUBF PRELIMS
- A dozen or so triangular wedges that makes up
much of the medullary tissue
- The base of each pyramids faces outward and
the narrow papilla of each faces toward the
hilum.
Calyx – Cup-like structure that adjoins with the renal
papilla.
Renal pelvis
- Are large collection reservoir that joins calyces
together
- It narrows as it exits the hilum to become the
ureter.
Renal Blood Flow Glomerular Filtration
1. Consists of 8 capillary lobes or tufts
2. Glomerulus located within the Bowman’s
capsule
3. Nonselective filter of plasma substances with
molecular weight <70,000 da
4. Factors influencing the plasma filtration process
a. Cellular Structure of the Capillary Wall
 Capillary Wall Membrane
 Basement Membrane (Basal Lamina)
 Visceral Epithelium of the Bowman’s Capsule
b. Hydrostatic & Oncotic Pressure
 Each kidney having 1-2M nephrons  Hydrostatic Pressure in the arterioles
o Cortical nephrons  Oncotic Pressures in the Bowman’s
o Juxtamedullary nephrons Capsule
 Renal arteries supplies blood to the kidney c. Renin-Angiotensin-Aldosterone System
 Receives 25% of the blood pumped through the Tubular Reabsorption
heart at all times. Active Transport
 Renal blood flow = 1,200 ml/min  Movement of a substance across a cell membrane
 Total Renal plasma flow= 600-700 ml/min and against an osmotic gradient
based on BSA 1.73 m²  Needs a carrier protein to transport substance;
 Blood enters the capillaries of the nephron:  Requires energy
1. Afferent arteriole  PCT
2. Glomerulus o Glucose
3. Efferent arteriole o Amino acid
4. peritubular capillaries  ALoH - salts in Chloride
a. PCT - immediate reabsorption of  DCT - Sodium
Passive Transport
essential substances from the fluid  Movement of molecules
b. Loop of Henle - major exchanges of
across a membrane as
water and salt takes place between the result of differences in the
blood and medullary interstitium. electrical potential on
Thus, maintaining osmotic gradient
opposite sides of the
(salt conc.) necessary for renal conc.
membrane
c. DCT - final adjustment of urinary
 Does not need carrier
composition
protein
5. vasa recta in the juxtamedullary nephron.
 Does not require energy
a. ALoH
 PCT – Water, urea
b. DLoH
 ALoH – urea, sodium
Renal physiology  DLoH & Collecting tubules
– Water
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(…)Tubular Reabsorption

Active Transport distinguishes excess solute filtration

and extent renal tubular damage
 Maximal Reabsorptive Capacity (Tm)
- Highest level a substance is reabsorbed
before appearance of substance in the urine
ex. Glucose is at 350 mg/min.
 Renal threshold
- Plasma concentration at which active
transport stops
* ex. Glucose is at 160-180mg/dL
 Countercurrent Mechanism
a. Selective reabsorption process
b. Prevents excessive water reabsorption
through the water-impermeable walls of
the ALoH

Arginine Vasopressin or Antidiuretic Hormone

Decreased Decreased body

Increased ADH
urine volume hydration

Tubular Secretion
 Involves passage of substances from the blood
in the peritubular capillaries to the tubular
filtrate
 Functions:
a. Elimination of waste products not filtered
by the glomerulus
b. Regulation of acid base balance in the body
through secretion of hydrogen ions
Tubular Secretion
Renal Function Tests
AUBF PRELIMS
Glomerular Filtration Tests 6. Cystatin C
1. standard test measuring: - Low molecular weight
a. Filtering capacity of the glomeruli - Potential marker for long-term monitoring of
b. Measures rate at which kidneys are able to renal function
remove filterable substances from the blood - Constant in serum levels
2. To test accuracy of the substance being measured: - Independent of age, gender, and muscle mass
a. Substance analyzed must be neither - Higher analysis cost
reabsorbed nor secreted by the tubules
b. Stable in a 24-hour collected urine
c. Consistent in the plasma level
d. Availability of the substance in the body;
availability of the tests for chemical Standard Formula to calculate milliliters of plasma
analysis of the substance cleared per minute (C) is:
Clearance Test Substance 𝑈𝑉
1. Urea 𝐶=
𝑃
- Present in all urine specimen but replaced by Urine creatinine (U) = 400 mg/dL
other substances Plasma creatinine (P) = 5.0 mg/dL
2. Inulin Urine volume (V) = of 2500 mL, from a 24-hour
- Polymer of fructose specimen
- Extremely stable substance not reabsorbed nor Glomerular filtration rate = ?
secreted by the tubules Calculation:
- Not a normal body constituent and infused at a 2500 𝑚𝐿 𝑚𝐿
𝑉= = 1.74
constant rate throughout the testing period 60 𝑚𝑖𝑛𝑢𝑡𝑒𝑠 𝑚𝑖𝑛𝑢𝑡𝑒
(24 ℎ𝑜𝑢𝑟𝑠 )
- Seldom choice if suitable substance is already 1 ℎ𝑜𝑢𝑟
𝑚𝑔 𝑚𝐿
present in the body 400 𝑥 1.74 𝑚𝐿
𝐶= 𝑑𝐿 𝑚𝑖𝑛𝑢𝑡𝑒 = 139.2
3. Radionucleotides 5.0 𝑚𝑔/𝑑𝐿 𝑚𝑖𝑛𝑢𝑡𝑒
- Measures plasma disappearance of infused * Creatinine filtration and excretion
substances thus eliminating need for
urine collection Clinical Significance in the interpretation of results for
- Injection of radionucleotides to: Creatinine Clearance:
o visualize plasma disappearance 1. Determines the number of functioning nephrons
radioactive material 2. Functional capacity of the nephrons
o enable visualization of the filtration of
one or both kidneys Results may be used to:
4. β2microglobulin 1. Measure extent of nephron damage
- Dissociates from human leukocyte antigen and 2. Monitor effectiveness of treatment in the
removed from the plasma by glomerular prevention of further nephron damage
filtration 3. Determine feasibility of administering
5. Creatinine
- Waste product of muscle metabolism and found Cockcroft and Gault Formula:
140 – 𝑎𝑔𝑒
at a constant rate in the blood 𝐶= 𝑚𝑔
𝑠𝑒𝑟𝑢𝑚 𝑐𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛𝑒 ( )
𝑑𝐿
Calculations:
1. Greatest source of error: improper timed
specimen
2. GFR reported in mL/min. Tubular Reabsorption Tests
3. UV  Also known as Concentration tests
P  Involves Water Deprivation Tests
U = urine creatinine in mg/dL a. Fishberg Test - patients deprived of
V = urine volume in mL/min. fluid for 24 hours prior to measuring the
P = plasma creatinine in mg/dL specific gravity
b. Mosenthal Test – compared the
Calculate the urine volume for a 4-hour specimen volume of day and night urine samples
measuring 1L: to evaluate concentrating ability
4 ℎ𝑜𝑢𝑟𝑠 𝑋 60 𝑚𝑖𝑛𝑢𝑡𝑒𝑠 = 240 𝑚𝑖𝑛𝑢𝑡𝑒𝑠
1000 𝑚𝐿 𝒎𝑳
= 𝟒. 𝟏𝟕
240 𝑚𝑖𝑛𝑢𝑡𝑒𝑠 𝒎𝒊𝒏
AUBF PRELIMS
 Free Water Clearance a. Polyuria – excretion of increased
o How much water must be cleared each amount of urine at daytime
minute to produce a urine with the b. Nocturia – excretion of increased
same osmolarity as with the plasma amount of urine at nightime
o Determines the ability of the kidney to c. Oliguria – excretions of decreased
respond to the state of body hydration amount of urine
d. Anuria – cessation of urine flow
Tubular Secretion and Renal Blood Flow Tests  Difference between Diabetes Mellitus from
1. Test to measure tubular secretion of non- Diabetes Insipidus
2. filtered substances and renal blood flow
3. Test: ρ-amino hippuric acid test (PAH) using Diabetes mellitus Diabetes Insipidus
the dye phenolsulfonphthalein Definition of Malfunctioned Decrease in production or
the Disease pancreas/malfunctioned function of ADH
insulin
Titratable Acidity & Urinary Ammonia Urine Specific increased Decreased to normal
1. Ability of kidney to produce acid urine depends Gravity

on tubular excretion of ammonia by the cells of Specimen Collection

1. Clean, dry, leak-proof
the DCT
2. Should be disposable and screw-capped
2. Inability to produce acid urine: Renal Tubular
3. Wide mouth with flat bottom
Acidosis
3. Measurement of total hydrogen ion excretion in 4. Recommends 50mL capacity for:
urine a. Additional specimen for repeat collection
b. Enough room for swirling urine
INTRODUCTION TO URINALYSIS
Specimen Handling
Urine Formation
in vivo and in vitro changes in urine
 kidneys continuously form urine as an
utrafiltrate of plasma
Specimen Integrity
Urine Composition
After collection, urine delivered to lab promptly and
 Urea (major dissolved solid)
tested within 2 hours
 Creatinine, uric acid
 Inorganic substances: chloride, sodium,
Specimen Preservation
potassium
 Recommended:
 Others: sulfates and phosphates
Refrigeration at 20-80C or at 40-60C
 Factors influencing its concentration:
 Increases specific gravity when measuring
a. Dietary intake
using Urinometer
b. Physical activity
 Ideal preservatives should be:
c. Body metabolism
a. Bactericidal
d. Endocrine functions
b. Inhibit urease
e. Body positions
c. Preserve formed elements in the sediment
 May also contain cells, casts, crystals, mucus
and bacteria
 Urea and Creatinine: tests to differentiate urine
from other body fluids. Types of Urine Specimens
Urine Volume 1. RANDOM URINE SPECIMEN
 Depends on amount of water excreted by the  Most commonly received
kidneys
 May produce erroneous results caused by
 Factors influencing its volume: dietary intake or physical activity prior to
o Fluid intake collection
o Fluid loss from nonrenal sources
o Variations in the secretions of ADH 2. FIRST MORNING URINE SPECIMEN
o Necessity to excrete increased amounts of
 Ideal screening test
dissolved solids such as glucose and salts
 Essential for preventing false-negative
 Terms related to abnormal urine volume:
pregnancy results
 For evaluation of Orthostatic Proteinuria
AUBF PRELIMS
 Provides a concentrated urine assuring  For cytological examination
detection of chemicals and formed elements
10. THREE-GLASS COLLECTED URINE SPECIMEN
3. FASTING URINE SPECIMEN  For prostatic infection
(SECOND MORNING SPX)
 Second voided specimen after a period of
fasting

4. 2-HOUR POST PRANDIAL URINE SPECIMEN

 Patients instructed to void shortly before
consuming routine meal and to collect urine 2
hours after eating
 Monitors insulin therapy in patients with DM
11. PEDIATRIC URINE SPECIMEN
5. GLUCOSE TOLERANCE TEST URINE  Poses great challenge in urine collection
SPECIMEN
 Collected to correspond with blood specimens 12. URINE FOR DRUG TESTING
 Tested for glucose and ketones  Chain of custody – process that provides
 Tests the patient’s ability to metabolize documentation for proper sample identification
measured amount of glucose and therefore from the time of collection to the receipt of
correlated with the renal threshold for glucose laboratory results

Physical Examination of Urine

COLOR
 Varies from colorless to black
 Factors affecting variations in color:
o Normal metabolic function
o Physical activity
o Ingested materials
o Pathologic conditions
6. 24-TIMED URINE SPECIMEN Normal Urine Color:
 Dark yellow
 Measures the kind and amount of chemicals  Light yellow
 Amber
present  Yellow
 Examine with good light source, against white
7. CATHETERIZED URINE SPECIMEN background
 Urine collected under sterile condiitons  Urochrome
 Bacterial culture - pigment responsible for urine color
 Specimens for left and right kidneys may be - established by Thudichum (1864)
collected separately - product of endogenous metabolism
produced at constant rate
8. MIDSTREAM CLEAN-CATCH URINE SPECIMEN - increased amounts in thyroid conditions,
 Alternative to catheterized specimen fasting state, prolonged standing
 Safer, less traumatic  Other pigments:
 Specimen less contaminated by epithelial cells o Uroerythrin
and bacteriad  pink pigment evident in specimen after
 Strong bacterial agents such as refrigeration
hexachlorophene and povidone-iodine should  attaches to urates producing pink color
not be used prior to collection o Urobilin
 imparts orange-brown color to urine that is not
9. SUPRAPUBIC ASPIRATED URINE SPECIMEN fresh
 External introduction of needle to the bladder  Dark Yellow
 Sample for bacterial culture completely free of Abnormal Urine Color  Amber
extraneous contamination  Dark yellow/amber  Orange
AUBF PRELIMS
 may signify abnormal pigment
bilirubin (produces yellow foam)
 Yellow-orange specimen
 caused by administration of
o phenazopyridine (pyridium
compounds)
o azo-gantrisin produces yellow foam
when shaken and mistaken for
bilirubin
 Red/Pink/Brown - Presence of blood
Factors affecting the changes of urine
in the presence of blood:
 amount of blood
 pH of urine
 length of contact
 RBC suspended in urine for hours will produce
brown urine (oxidation of hemoglobin to
methemoglobin)
 brown urine may indicate glomerular bleeding
 Myoglobin & Hemoglobin
- produces red urine and positive chemical test
for blood
 Hemoglobin – breakdown of RED with red
plasma
 Myoglobin – breakdown of skeletal muscle
with clear plasma
Non-pathogenic color of urine:
 menstrual contamination
 ingestion of highly pigmented food
 medications
 ingestion of beets in genetically susceptible
individuals in alkaline urine
 Brown/Black
- If negative test for reagent strip for blood,
possible presence of melanin or homogentisic
acid
 Blue/Green
 Pathogenic causes: bacterial infections and
intestinal tract infections resulting in increased
urinary indican
 Clorets
 Purple staining in catheter bags:
o presence of indican or bacterial
infections associated with Klebsiella or
Providencia
CLARITY
 Refers to transparency or turbidity of a urine
specimen
 Common terminologies:
o Clear – no visible particles, transparent
o Hazy – few particulates, print easily
seen through urine
o Cloudy – many particulates, print
blurred through urine
o Turbid – print cannot be seen through
urine
o Milky – many precipitate or be clotted
Normal Clarity
 Normally clear when freshly voided
Nonpathologic Turbidity
 SEC – on women resulting in hazy but normal
urine
 Specimen allowed to stand at room temp.
 Semen, fecal contamination, radiographic contrast
media, talcum powder, vaginal creams
Pathologic Turbidity
 RBC, WBC, bacteria – commonly occuring
 Clarity of urine should always correspond to
microscopic analysis
SPECIFIC GRAVITY
 detects possible dehydration or abnormalities of
ADH
 density of a solution compared with the density of a
similar volume of distilled water at a similar temp.
 influenced by the number of particles present and
the sizes of the particles
 aids in the evaluation of renal tubular function
Urinometer or Hydrometer
 Consists of a weighted float sinking at
o specific gravity of 1.000 in a distilled water
 200C – calibrated temp. of urinometer
 For cold specimen, 0.001 must be subtracted from
the reading for every 30C that the specimen temp.
is below the urinometer calibration temp.
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Urine specific gravity of 1.025 measured from a  Diabetic ketones – sweet or fruity odor
specimen maintained at 140C, what is the corrected  MSUD – maple syrup
urine specific gravity?  Phenylketonuria – Mousy
200°𝐶 − 140°𝐶 = 60°𝐶  Tyrosinemia – Rancid
1.025 − 0.002  Isovaleric acidemia - Sweaty Feet
= 𝟏. 𝟎𝟐𝟑 corrected urine specific gravity  Methionine malabsorption – Cabbage
 Contamination – Bleach
 must be added for every 30C rise above the
calibrated temp.

Urine specific gravity of 1.025 measured from a

specimen maintained at 260C, what is the corrected
urine specific gravity?
260°𝐶 − 200°𝐶 = 60°𝐶
1.025 + 0.002
= 𝟏. 𝟎𝟐𝟕 𝑐𝑜𝑟𝑟𝑒𝑐𝑡𝑒𝑑 𝑢𝑟𝑖𝑛𝑒 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑔𝑟𝑎𝑣𝑖𝑡𝑦

 Presence of protein and glucose in both urinometer

and refractometer:
 presence of protein : urine specific gravity
usually rises by 0.003
 presence of glucose: urine specific gravity
usually rises by 0.004

A urine specimen containing 5 g/dL of protein and 3

g/dL of glucose has a specific gravity reading of
1.035. Calculate the corrected reading.
𝑔
1.035 − 0.015 (5 𝑥 0.003) 𝑝𝑟𝑜𝑡𝑒𝑖𝑛
𝑑𝐿
= 1.020 – 0.012 (𝑔𝑙𝑢𝑐𝑜𝑠𝑒)
= 𝟏. 𝟎𝟎𝟖 corrected specific gravity

Refractometer
 Measures specific gravity through refractive
index
Harmonic Oscillation Densitometry
 employs the principle of
sound waves in Yellow Iris
(International Remote
Imaging Systems)

Clinical Correlations
 specific gravity of plasma entering the
glomerulus is usually 1.010
o Isosthenuria – sg = 1.010
o Hyposthenuria – below 1.010
o Hypersthenuria – above 1.010

ODOR
 Freshly voided urine – faint aromatic odor
 Breakdown of urea – ammoniacal odor
 Bacterial infection – strong, unpleasant odor