SEMINAR 1 o Fasting (2nd morning)

Urinalysis  Diabetic monitoring

o Timed specimen
I. Introduction to Urinalysis  24-hour specimen
 Composition of Urine  Substances that vary
o Water (95%)  Start with an empty bladder
o Analytes  12-hour specimen
 Organic  Used for Addis Count with formalin as preservative
 Urea  2-hour post prandial
 Creatinine, uric acid, ammonia, nitrogen  For monitoring insulin therapy in persons with DM
 Inorganic  Usually compared with fasting specimens
 Chloride  Afternoon specimen (2-4 PM)
 Sodium, potassium, phosphorus, calcium, magnesium,  Used for urobilinogen determination
and iron o Catheterized
o Others  Bacterial culture
 Hormones, vitamins, medications, formed elements o Midstream clean catch
 Specimen Collection & Handling  Bacterial culture
o Clean dry container  Routine urinalysis
o Label: body of container o Suprapubic aspiration
 Patient’s name  Bacterial culture
 Date & time of collection  Cytologic examination
o Should be examined within one hour o Three-glass collection
o Should be refrigerated if not tested within 30 mins of  Prostatic infection
collection  Drug specimen collection
o Urine culture should be tested within 24 hours if the sample o Chain of custody
is refrigerated at 2-8’ C  Correct sample identification from the time of collection
 Urine preservatives to the receipt of laboratory result
o Refrigeration o Required amount by DOH: 60 ml (30-45 ml)
 Raises specific gravity (urinometer) o Urine temperature: 32.5-37.7’C
 Precipitates amorphous  Within 4 minutes from the time of collection
o Thymol o DOH directive: waterless urinal
o Boric acid  Specimen evaluation
o Formalin o For single specimen submitted for multiple
o Sodium fluoride measurements, bacteriologic exam should be done first
 Glucose determination o Proper labeling
 Drug analysis  Patient’s full name
o Saccomanno’s  Date of collection
o Gray C&S tubes (boric acid)  Time of collection
 Stable at room temperature for 48 hours  Urine collection
o Yellow plain UA tube o Visible signs of contamination
 Automated instruments o 50 ml disposable container: 10-15 ml of urine
o Cherry red & yellow top tube o Proper specimen for the requested test
 Sodium propionate o Any transportation delays
 Stable at room temperature for 72 hours
 Changes in unpreserved urine II. Physical Examination
Increase Decrease  Color
Bacteria Glucose o Normal: straw to amber (light yellow to dark yellow)
Turbidity Ketones o Urochrome: yellow pigment
pH* Bilirubin o Urobilin: orange-brown
Nitrite* Urobilinogen o Uroerythrin: pink to red pigment
Cells & casts o Laboratory correlation of urine color
 Routine urinalysis  Colorless, straw, pale yellow
o First morning samples  Dilute
o Concentrated acidic urine  Polyuria
o Casts dissolve in dilute alkaline urine  Diabetes insipidus
 Types of urine specimen  Diabetes mellitus
o Random specimen  Dark yellow
 Routine screening  Concentrated
o First morning  First morning specimen
 Concentrated  After strenuous exercise
 Ideal for routine urinalysis
 Pregnancy test
  Amber/orange  Radiographic contrast media
 Yellow foam (+) bilirubin  Talcum and vaginal creams
 Orange with foam  Pathologic
 Pyridium (phenazopyridine)  RBCs (>500 RBCs/μl)
 With thick orange pigment  WBCs (>200 WBCs/μl)
 White foam  Bacteria
 Protein  Yeast
 Red/pink (pathologic)  Non-squamous epithelial cells
Hematuria Hgbnuria Myoglobinuria  Abnormal crystals
Blood test + + +  Lymph fluid
Transparency Turbid or Clear Clear  Lipids
cloudy  Odor
Plasma color Pale yellow Red Pale yellow o Normal odor
RBCS  Faint, aromatic (fresh specimen)
microscopically o Characteristic urine odors
 Red/pink (non-pathologic)  Ammoniacal: bacterial contamination
 Porphyrins  Sweet/fruity: diabetic acidosis
o Blood test (-)  Pungent: asparagus
o Reddish purple color or port wine  Sweaty feet: isovaleric & glutaric acidemia
o Schwartz Watson (+)  Maple syrup: MSUD
o Fluorescence (+)  Cabbage: methionine malabsorption
 Blackberries  Mousy: phenylketonuria
o Acid urine  Rotting fish: trimethylaminuria
 Beets  Rancid: tyrosinemia
o Alkaline urine of genetically susceptible persons  Volume
 Rifampin o Normal values
 Menstrual contamination  Adults
o Cloudy with RBCs and mucus clots  Average: 1200-1500 ml
 Brown/black  Range: 600-2000 ml
 RBCs oxidized to methemoglobin  Night urine in general is not in excess of 400 ml
o Acidic urine o Factors that influence urine volume
o Blood test (+)  Fluid intake
 Homogentisic acid (alkaptonuria)  Fluid loss
o Alkaline urine  Variations in ADH secretions
 Melanin  Necessity to excrete increased amounts of dissolved
o Reacts with nitroprusside and ferric chloride solids
 Methyldopa/levodopa o Nocturia
 Metronidazole (Flagyl)  More than 500 ml with a specific gravity of less than
 Clarity 1.018 at night
o Urine clarity o Oliguria
 Clear: transparent  Excretion of less than 500 ml of urine daily
 Hazy: print easily seen o Anuria
 Cloudy: print blurred  Complete or total suppression of urine formation
 Turbid: print can’t be seen  Specific gravity
 Milky: may precipitate o Density of substance compared with density of H2O at
o Bacterial growth specified temperature
 Uniform opalescence o Proportion of dissolved solid components to total volume
 Not removed by filtration nor acidification of the specimen
o Leukocytes o Reflects the density of the specimen
 White cloud (remains after acidification) o Evaluates the kidney’s ability to reabsorb
o Urates o Detects possible dehydration or abnormalities in ADH
 Pink cloud secretion
o Uric acid o Aids in evaluating the concentrating and diluting abilities
 Orange cloud of the kidneys
o Causes of turbid urine o Clinical correlations
 Non-pathologic  Normal values
 Squamous epithelial cell  Average: 1.016-1.022
 Mucus  Range: 1.003-1.035
 Amorphous urates/phosphates  Isosthenuric: specific gravity is 1.010
 Semen  Hyposthenuric: specific gravity is below 1.010
 Fecal contamination  Hypersthenuric: specific gravity is above 1.010
  Excretion of radiographic contrast media and dextran
will give a very high urine specific gravity reading (over
1.035)
o Methods
 Urinometry
 Uses urinometer or hydrometer
 Principle: water displacement or buoyancy
 Disadvantage: requires 10-15 ml
 Accuracy may be checked by measuring the specific
gravity of:
o Distilled water: 1.000
o Potassium sulfate: 1.015
 Reading is affected by:
o Temperature
 Subtract 0.001 from the reading for every 3
degrees centigrade that the specimen
temperature is below the urinometer temperature
 Add 0.001 to the reading for every 3 degrees
centigrade that the specimen temperature is
above the urinometer temperature
o Glucose
 Subtract 0.004 for every gram of glucose/dl of
urine
o Protein
 Subtract 0.003 for every gram of protein/dl of
urine
 Specific gravity correction
o Temperature
 Specific gravity: 1.035, UT: 20’C, ST: 8’C
 Find the difference: 20 - 8=12
 Divide by 3: 12 / 3=4
 Multiply by 0.001: 4 x 0.001=0.004
 Add/subtract to or from the specific gravity: 1.035
- 0.004=1.031
o Protein & glucose
 A specimen containing 2 g/dl of protein and 1 g/dl
of glucose has a specific gravity of 1.035
 1.035 – 0.006 (protein) – 0.004 (glucose) = 1.025
o Dilution
 Insufficient amount of urine or specific gravity
readings greater than the scale can be diluted and
retested
 Multiply the decimal factor by the dilution factor
to get the actual specific gravity reading
 Dilution factor is computed by dividing the
volume of specimen and water by the volume of
specimen alone
 Refractometry
 Determines the concentration of dissolved particles in
a specimen by measuring the refractive index
o Refractive index is the comparison of the velocity of
light in air with the velocity of light in a solution
o Total solids meter
 Refractometer may be calibrated using the following:
o Distilled water: 1.000
o 5% NaCl: 1.022
o 9% sucrose: 1.034
o The specific gravity reading on the refractometer is
generally slightly lower than a urinometer reading by
about 0.002
 Advantages
o Uses small amount of urine (1-2 drops)
o No temperature corrections are required
o Simple to operate
o Gives rapid reliable results
 Reagent strip (dipstick)
 Principle: pKa change of polyelectrolytes in relation to
ionic concentration of urine
 Inc. specific gravity: increased H+ released, low pH
(acidic): yellow color
 Dec. specific gravity: less H+ released, high pH
(alkaline): blue color
 Main components in the reagent area
o Polyelectrolytes
o Indicator: bromthymol blue
o Buffer
 Results
o Blue (1.000) through shades of green to yellow
(1.030)
o Color chart provided indicates values of 1.000-
1.030 in increments of 0.005
 Reaction interferences
o Measures only ionic solutes
o Not affected by urea, glucose, radiographic media
o Falsely elevated: high concentration of protein
o Falsely decreased: highly alkaline urine
 Harmonic oscillation densitometry
 Sound wave frequency and automated instruments
 A volume of urine is maintained in a U-shaped tube
and a sound wave of fixed frequency is transmitted to
one end of the tube
 Specific gravity is directly related to the change in
frequency recorded as the sound wave exits the other
end of the tube
 Falling drop
 Timing the fall of a drop of body fluid of known size
through a definite distance in a mixture
 Heavier drop will fall faster
III. Routine Chemical Examination
 Reagent strips
o Plastic strips that contain one or more chemical-
impregnated absorbent pads
o Procedure
 Mix urine
 Insert reagent strip
 Remove excess urine
 Time according to manufacturer’s directions
 Compare test areas closely with corresponding color
charts
 Hold strip horizontally and close to the color blocks
o Storage and general precaution
 Must be kept with desiccant in opaque, tightly-capped
containers
 Store the container preferably at room temperature
 Keeps trips in their original container
 Do not expose the strips to volatile fumes
 Do not touch the test areas
 Do not use if the chemical pads become discolored
 Do not use past the expiration date
o Sources of error
 Unmixed specimen
 Strip in urine for extended period
 Leaching of reagents from the pad
  Excess urine in the strip (run-over between chemicals) o Important renal marker
 Distortion of colors o Most of the albumin: not filtered
 Blot the edge of the strip o Filtered albumin: reabsorbed by tubules
 Hold horizontally o Other proteins in urine
 Refrigerated specimen  Microglobulins
 False negative  Tamm-Horsfall glycoprotein
o Quality control o Postural/orthostatic proteinuria
 Newly opened bottles of reagent strips should be tested  Urine CHON: (+) day, (-) night
with known positive or negative controls  First voided urine: (-) CHON
 Should be tested with known positive and negative  2 hours standing or walking: (+) CHON
controls daily  Exaggerated lordotic posture
 pH o Accidental or false or pseudoproteinuria
o Reflects the ability of the kidney to maintain normal  Urine is contaminated directly or indirectly with
hydrogen ion concentration in plasma and extracellular albuminous fluids, pus cells, blood, vaginal discharge
fluid  Examples: vaginitis and cystitis
o To maintain acid-base balance in the body o Pathologic proteinuria
o Blood must buffer and eliminate excess acids  Renal diseases and indicates increased permeability of
o Buffering capacity of blood depends on bicarbonate ions the glomerular filter
(HCO3-)  Causes of pathologic proteinuria
o Secretion of hydrogen ions causes reabsorption of  Pre-renal
bicarbonates o Multiple myeloma (Bence Jones Protein)
o Acid-base balance o Intravascular hemolysis
 Secretion of hydrogen in the form of ammonium ions, o Acute phase reactants
hydrogen phosphate, and weak organic acids  Renal
 H+ + ammonia = ammonium ions o Glomerular disorders
 H+ + phosphate = hydrogen phosphate o Tubular proteinuria
 By the reabsorption of bicarbonate from the filtrate in o Orthostatic proteinuria
the PCT o Microalbuminuria
o Normal values o Pre-eclampsia
 First morning: 5.0-6.0  Post-renal
 Random: 4.5-8.0 o Lower UTI
o Urine pH o Menstrual contamination
 Acid urine o Vaginal secretions
 Increased protein o Vaginal inflammation
 Cranberries o Prostatitis
 Acid-producing bacteria (E. coli) o Acid precipitation techniques
 Starvation  Heat and acetic acid
 Dehydration  Principle: urine is coagulated by heat and precipitated
by acetic acid (5-10%)
 Diarrhea
 Sulfosalicylic acid test (Exton’s)
 Diabetes mellitus
 Alkaline urine  Positive result: precipitation
Grade Turbidity Protein Range
 Increased consumption of fruits and vegetables
in mg/dl
 Citrus fruits
NEG No inc. in turbidity <6
 Less acidic after meal (alkaline tide)
TRACE Noticeable turbidity 6-30
 Renal tubular acidosis
1+ Distinct turbidity with 30-100
 Urease-producing bacteria
no granulations
 Hyperventilation
2+ Turbidity with 100-200
 Old specimen
granulations and no
o Reagent strip
flocculation
 Principle: double indicator system (methyl red &
3+ Turbidity with 200-400
bromthymol blue)
granulation and
 Indicators
flocculation
 Methyl red (red to yellow): pH 4-6
4+ Clumps of protein >400
 Bromthymol blue (yellow to blue): pH 6-9
 Causes of error
 Results
 False negative
 Orange to green to blue as pH increases
o Highly alkaline urine
 Protein
 False positive
o Normal values
o Iodinated dyes (x-ray contrast media)
 100 mg of protein in 1 day (150 mg)
o Penicillin
 Average random: 2-10 mg/dl
o Salicylate
 Clinical proteinuria: >30 mg/dl
o Tolbutamide
o Reagent strip  Glucose
 Principle: protein error of pH indicators o Detectable amount of glucose in urine: glucosuria
 Indicators change in color in the presence of protein o Renal threshold: 160 mg/dl to 180 mg/dl
(pH is constant at 3.0)  Blood level at which tubular reabsorption stops
 Protein (anion) accepts ions from the indicator o Hyperglycemia-associated glucosuria
 Albumin contains more amino groups which allows it to  Diabetes mellitus
readily accept H+ as compared to other proteins  Pancreatitis
 Indicator: tetrabromphenol blue  Pancreatic cancer
 Results  Acromegaly
 Positive result: green then blue  Cushing’s syndrome
 Negative result: yellow  Hyperthyroidism
 Reaction interferences  Pheochromocytoma
 False positive  CNS damage
o Highly buffered alkaline urine  Stress
o High specific gravity  Gestational diabetes
o Quaternary ammonium compounds o Renal-associated glucosuria
o Bence Jones proteinuria  Fanconi’s syndrome
 Associated with:  Advanced renal disease
 Multiple myeloma  Osteomalacia
o Malignant disorder that results in infiltration of  Pregnancy
bone marrow by plasma cells o Copper reduction method
 Macroglobulinemia  Ability of glucose to reduce copper sulfate to cuprous
 Malignant lymphomas oxide in the presence of alkali and heat
 Coagulates between 40’C and 60’C  Benedict’s test
 Dissolves at 100’C  Benedict’s reagents
 Methods o Copper sulfate
 Heat and acetic acid test o Sodium hydroxide
 Bradshaw o Sodium carbonate
 Toluene sulfonic acid (TSA) test o Citric acid
 Electrophoresis Negative Blue
o Indicated by single sharp peak in γ-globulin region Trace Green without precipitate
o Best method 1+ Green with yellow precipitate
 Immunofixation electrophoresis (IFE) 2+ Yellow green with yellow precipitate
o Microalbuminuria 3+ Muddy orange with yellow precipitate
 Albumin in urine above the normal level but below the 4+ Orange to red precipitate
detectable range of the reagent strip  Clinitest
 Predictor of clinical nephropathy in insulin-dependent  Principle: copper reduction
diabetes mellitus (diabetic nephropathy)  Store in dry environment, away from sunlight
 Methods  Normal appearance: spotted bluish white tablet
 Radioimmunoassay o Discard if tablet turns dark blue to brown
 Fluorescent and enzyme immunoassay  Clinitest reagents
 Nephelometry o Copper sulfate
 Micral II test strip o Sodium hydroxide
o Immunologic test (EIA) o Sodium carbonate
o Procedure o Sodium citrate
 Dip strip into the urine for 5 seconds  Self-heating (hydrolysis of sodium hydroxide and its
 Stand for 1 minute reaction with sodium citrate)
o Positive result: pink to red color  Positive result: blue to orange/red color
 Immunodip  Pass-through phenomenon: >2 g/dl of sugar
o Immunologic test (immunochromatography) Five-drop method Two-drop method
 Clinitek microalbumin 5 drops of urine and 10 2 drops of urine and 10
o Dye-binding method drops of water drops of water
o Reported as albumin:creatinine ratio Negative Negative
 Multistix pro Trace 0.25 g/dl Trace
o Reported as albumin:creatinine ratio 1+ 0.5 g/dl 1+ 1 g/dl
o Correlation of reagent strip and heat & acetic acid test: 2+ 0.75 g/dl 2+ 2 g/dl
Reagent Heat & Interpretation 3+ 1.0 g/dl 3+ 3 g/dl
strip HOAc 4+ 2.0 g/dl 4+ 5 g/dl
+ - Albumin present o Reagent strip
+ + Proteinuria  Specific for glucose only
- + Bence Jones proteins, globulins  Principle: double sequential enzyme
  Oxidase and peroxidase  Non-diabetic ketonuria
 Glucose + O2 glucose oxidase gluconic acid + H2O2  Acute febrile disease and toxic states accompanied by
 H2O2 + chromogen peroxidase ox. chromogen + H2O vomiting or diarrhea
 Reaction interferences o Reagent strip
 False positive  Only detects acetoacetic acid
o Oxidizing cleaning agents (peroxide)  Acetone is measured upon addition of glycine and alkali
 False negative  Beta-hydroxybutyric acid cannot be measured
o Vitamin C  Principle: sodium nitroprusside reaction or sodium
o Upon standing nitroferricyanide reaction
o High specific gravity  Acetoacetic acid + sodium nitroprusside 
 Types of reagent strips violet/purple color
 Reagent strips differ in chromogen used  Positive result: violet/purple color
 Multistix  Types of reagent strips
o Potassium iodide chromogen  Chemstrip
o Positive result: color changes from blue to green to o Sodium nitroferricyanide and glycine
brown in 30 seconds o Measures acetoacetic acid and acetone
 Chemstrip  Multistix
o Aminopropyl-carbazol o Measures acetoacetic acid only
o Positive result: yellow to orange brown o Nitroprusside tablet test (Acetest)
 Clinistix  Glycine-impregnated
o O-toluidine chromogen  Measures acetoacetic acid and acetone
o Positive result: pink to purple  Used if urine has interfering color
 Reporting of results  Sensitive to humidity
Negative  Acetest tablet
Trace 100 mg/dl  Sodium nitroprusside
1+ 250 mg/dl  Glycine
2+ 500 mg/dl  Lactose
3+ 1000 mg/dl  Specimen
4+ >2000 mg/dl  Whole blood
o Correlation of glucose oxidase and Benedict’s test:  Plasma
Reagent Benedict’s Interpretation  Urine
strip test  Positive result: lavender to deep purple
1+ - Glucose (small amount)  Blood
+ + Glucose and reducing sugars Hematuria Hgbnuria Myoglobinuria
- + Non-glucose reducing sugars Urine Smoky, Clear, pink Clear, red to
3+ - Oxidizing agents pink to to red to brown
brown, lots brown,
IV. Special Chemical Examination of RBCs occasional
RBCs
 Ketone bodies
o Products of incomplete fat metabolism Plasma Normal Pink Normal
 Defect in CHO metabolism Haptoglobin Normal Decreased Normal
 Inadequate CHO in diet CK Normal Normal High
o Ketones Aldolase Normal Normal Increased
 Acetone (2%) o Hematuria
 Acetoacetic/diacetic acid (20%)  Blood cells in urine
 Measured in reagent strip  Relatively common
 Beta-hydroxybutyric acid (78%)  Smoky, cloudy urine
o Clinical significance of urine ketones  Causes
 Diabetic acidosis  Renal calculi (most common cause)
 Insulin dosage monitoring  IgA nephropathy
 Starvation  Glomerulonephritis
 Excessive carbohydrate loss  Pyelonephritis
 Malabsorption/pancreatic disorders  Trauma
 Strenuous exercise  Tumors
 Vomiting  Exposure to toxic chemicals
o Ketonuria  Excessive exercise
 Diabetic ketonuria o Hemoglobinuria
 Uncontrolled diabetes and presence of ketoacidosis  Free hemoglobin in urine (>50 mg/dl)
or ketosis  Uncommon
 Warning of impending coma  Clear red urine
 Test ketonuria (>1-2 g/dl glucose)  Positive for intravascular hemolysis
  Causes o Blondheim ammonium sulfate test
 Transfusion reactions  5 ml urine with ammonium sulfate
 Hemolytic anemias  Centrifuge
 Severe burns  Results
 Malaria  Myoglobin: colored (red) supernatant
 Strenuous exercise/red cell trauma  Hemoglobin: colorless supernatant
 Brown recluse spider bites Hemoglobinuria Myoglobinuria
o Myoglobinuria Clear, red urine with red Clear, red urine with pale
 Myoglobin in urine plasma yellow plasma
 Rare Associated with Associated with
 Clear red urine transfusion reaction rhabdomyolysis
 Acute destruction of muscle fibers after trauma Precipitated by ammonium Not precipitated by
 Rhabdomyolysis sulfate ammonium sulfate
 Associated with acute renal failure Produces hemosiderin
 Presence of red-brown pigment granules (yellow-brown
 Marathon, karate granules) in urinary
 Patient is positive for muscle tenderness sediments (indicative of
 Causes previous bleeding)
 Muscular trauma/crush syndromes  Bilirubin
 Prolonged coma o B2 or conjugated bilirubin seen in urine
 Convulsions o Clinical significance
 Muscle-wasting diseases  Hepatitis
 Alcoholism  Liver cirrhosis
 Drug abuse  Other liver disease
 Extensive exertion  Biliary obstruction (gallstones, cancer)
 Statin medication (lowers cholesterol) o Reagent strip
 Laboratory findings  Principle: Diazo reaction
 Urine  Coupling reaction of bilirubin with diazonium salt in
o Red-brown urine (cola drink) acid solution forming azobilirubin
o Positive for hemoglobin and protein  Results
o Few RBCs  Positive result (Multistix): buff to tan
 Serum  Positive result (Chemstrip): pink to violet
o Clear, increased creatine kinase and aldolase  Reaction interference
o Normal haptoglobin  False positive
o Reagent strip o Highly pigmented urine (phenazopyridine)
 Positive in hemoglobinuria, myoglobinuria, and o Indican
hematuria (in well mixed urine)  False negative
 Principle: pseudoperoxidase activity of hemoglobin o Exposure to light
 H2O2 + chromogen hemoglobin/peroxidase oxidized o Ascorbic acid (competes with bilirubin in Diazo)
chromogen + H2O o Increased nitrite (competes with bilirubin in Diazo)
 Indicator: tetramethylbenzidine o Ictotest
 Results  Confirmatory test for bilirubin
 Positive result: green to blue  More sensitive than the reagent strip
o Intact RBCs: speckled green  Ictotest: 0.05-0.10 mg/dl
 Negative result: yellow  Reagents trip: 0.40 mg/dl
 Reaction interferences  Principle: bilirubin reacts with p-nitrobenzene
 False positive diazonium p-toluene sulfonate
o Strong oxidizing agents (hypochlorite/bleach)  Procedure
o Bacterial peroxidases  Add 10 drops of urine to the mat
 False negative  Put the tablet on the mat
o High specific gravity  Add 1 drop of water
o Crenated cells (non-hemolyzed)  Wait for 5 seconds
o Formalin (reducing agent)  Add 1 drop of water
o Increased nitrite  Positive result: blue or purple color
o Increased ascorbic acid o Other tests for bilirubin
o Captopril (anti-hypertensive drug)  Gmelin
o Methods  Smith
 Guaiac  Foam
 Orthotolidine  Fouchet
 Benzidine
 Teichman
  Urobilinogen  Hoesch reagent: Ehrlich reagent in 6 M HCl
o Product of conversion of bilirubin in intestine  Positive result: red
o ½ goes to feces and becomes urobilin (pigmentation)  Urobilinogen is inhibited by the highly acidic pH (only
 Urobilin normal value: <0.02 mg/dl stable in alkaline urine)
o ½ goes back to liver and is transported in small amounts  Nitrite
to the kidney o Indirect test for UTI
o Normal values o Reduced form of nitrate
 <1 mg/dl or Ehrlich unit (8 mg/dl) o Process initiated by certain bacteria such as E. coli,
o Colorless and labile Klebsiella, Enterobacter, Proteus, Staphylococci
o Increased in alkaline urine (not stable in acid urine) o Specimen: first morning mid-stream catch
o Clinical significance o Clinical significance
 Early detection of liver disease  Cystitis
 Liver diseases  Pyelonephritis
 Hemolytic disorders  Evaluation of antibiotic therapy
o Urine bilirubin & urobilinogen in jaundice  Monitoring of patients at high risk for UTI
Urine bilirubin Urine urobilinogen  Diabetic patients and pregnant women
Obstructive jaundice / 3+ Normal  Screening of urine culture specimen
post-hepatic jaundice o Method: depends on the conversion of nitrate to nitrite
Liver damage + or - 2+ o Requires overnight bladder incubation (min. 4 hours)
Hemolytic jaundice Negative 3+ o Positive result: do culture
o Reagent strip
Jaundice Conditions Urine Urine Fecal  Principle (Multistix): Greiss reaction
bilirubin urobilinogen color  P-arsinilic acid + nitrite in acid pH produces
Pre- Hemolytic Negative Increased Normal diazonium salt and tetrahydrobenzoquinolin thus
hepatic disorders, to dark forming a pink azo dye
ineffective brown  Positive result: pink
erythropoiesis  Reaction interferences
Hepatic Hepatitis, Positive Normal to Normal  False positive
cirrhosis increased o Improperly preserved specimen
Post- Gallstones, Positive Decreased to Pale o Highly pigmented urine
hepatic tumor absent chalky  False negative
acholic o Non-reductase containing bacteria
o Ehrlich test o Ascorbic acid
 Principle: Ehrlich’s reaction o Lack of nitrate in diet
 Ehrlich’s reagent reacts with urobilinogen and other o Insufficient contact time
chromogens producing urobilinogen aldehyde o Large quantities of bacteria
 Ehrlich’s reagent: p-dimethylaminobenzaldehyde  Leukocyte Esterase
 Positive result: cherry red color o Indirect test for UTI
o Reagent strip o Human neutrophil primary granule has esterolytic
 Principle: Ehrlich aldehyde reaction activity
 Formation of red azo dye o Sensitivity: 5-15 WBCs/hpf
 Results o Positive result in either intact or lysed
 Positive result (Multistix): PDAB produces red color o Longest reaction time: 2 minutes
 Not specific to urobilinogen, fresh urine needed o Reagent strip
 Reaction interferences  Principle: neutrophilic esterases catalyze the hydrolysis
 False positive of ester to produce an aromatic compound and an acid
o Porphobilinogen, sulfonamide, procaine, 5HIAA,  Indoxylcarbonic acid ester with leukocyte esterase
indole, methyldopa produces acid indoxyl and diazonium salt thus
o Highly pigmented specimen producing a purple azo dye
 False negative  Positive result: purple
o Old specimen  Purple intensity is proportional to the number of
o Formalin preservation WBCs present
o Watson Schwartz differentiation test  Reagent: derivatized pyrrole AA ester, diazonium salt
 Urobilinogen  Reaction interferences
 Soluble in both chloroform and butanol  False positive
 Red chloroform and butanol layers o Contamination with vaginal fluid
 Porphobilinogen o Trichomonas, eosinophil
o Strong oxidizing agents
 Insoluble in both chloroform and butanol
o Formalin
 Colorless chloroform and butanol layers
o Hyperpigmented urine
o Hoesch test
 False negative
 Screening test for porphobilinogen
o Vitamin C
 Other UTI tests o Gives false negative reaction in the following reagent
o Rapid diagnostic: urine lactoferrin (WBC granule testing) strip tests:
o Rapid confirmatory: microscopic exam (bacteria & WBC)  Glucose
o Gold standard: culture (colony forming units)  Blood
 Ascorbic acid  Bilirubin
o 11th parameter  Nitrite
 Leukocyte esterase

Parameter Reading time Principle Reagents (Multistix) Positive result

Leukocyte esterase 2 minutes Granulocytic esterase reaction Derivatized pyrrole AA ester, Purple
diazonium salt
Nitrite 60 seconds Griess reaction P-arsinilic acid, diazonium, Pink
tetrahydrobenzoquinolin-3-
ol
Urobilinogen 60 seconds Ehrlich reaction P- Red
dimethylaminobenzaldehyde
Protein 60 seconds Protein error of indicators Tetrabromphenol blue Green to blue
pH Timing not critical Double indicator system Methyl red, bromthymol blue Orange-yellow-
green-blue
Blood 60 seconds Pseudoperoxidase activity of Diisopropyl-benzene Green to blue green
hemoglobin dehydroperoxide,
tetramethylbenzidine
Specific gravity 45 seconds pKa change of polyelectrolytes Bromthymol blue Blue to green to
yellow
Ketones 40 seconds Sodium nitroprusside reaction Sodium nitroprusside Pink to purple
Bilirubin 30 seconds Diazo reaction 2-4-dichloroaniline Buff to tan
diazonium salt
Glucose 30 seconds Double sequential enzyme Glucose oxidase, peroxidase, Green to brown
reaction potassium iodide

Parameter False positive reactions False negative reactions

Leukocyte esterase Strong oxidizing agent, formalin, highly pigmented Increased concentration of protein, glucose, ascorbic
urine acid
Nitrite Improperly preserved specimen, highly pigmented Non-reductase bacteria, insufficient contact time, lack of
urine urinary nitrate, bacteria (conversion of nitrite to
nitrogen), increased ascorbic acid and specific gravity
Urobilinogen Porphobilinogen, indican, sulfonamide, highly Old specimen, formalin preservation
pigmented urine
Protein Highly buffered alkaline urine, pigmented Proteins other than albumin, microalbuminuria
specimen (phenazopyridine), quaternary
ammonium compounds, high specific gravity
pH No known interfering substances, run-over from
adjacent pads, old specimen
Blood Strong oxidizing agent, bacterial peroxidases High specific gravity, crenated cells, formalin, increased
nitrite, increased ascorbic acid
Specific gravity High concentration of protein Highly alkaline urine
Ketones Highly pigmented urine, phtalein dyes Improperly preserved specimen
Bilirubin Highly pigmented urine (phenazopyridine), Exposure to light, ascorbic acid, increased nitrite
indican
Glucose Oxidizing agents Increased ascorbic acid, increased ketones, increased
specific gravity, low temperature, improperly preserved
specimen
V. Microscopic Examination  (+) nitrite
 Procedure  Increased pH
o Place 10-15 ml (12 ml) of mixed urine in a test tube o Neutrophils
o Centrifuge for 5 mins at 1500-2500 rpm or 400 RCF  Spherical
o Decant (volume of sediment: 0.5-1 ml) and flick tube  Granular cytoplasm
o Place a drop on a slide (0.02 ml) and cover with cover slip  12-14 μm
o Examine under LPO then HPO  Multi-lobed nucleus
o Observe in 10-20 fields  Confused as RTEs and RBCs
 Reference intervals  Dilute acetic acid enhances nuclear detail
Component Number Magnification o Glitter cells
RBC 0-2 HPF  WBCs in dilute or hypotonic urine
 Neutrophils swell and cytoplasmic granules show
WBC 0-5 HPF Brownian movement
Hyaline cast 0-2 LPF  WBC lysis: alkaline and hypotonic urine
Squamous EC Few LPF o Eosinophils
Transitional EC Few HPF  Not normally seen in urine
 Stains
Renal Tubular EC 0-2 HPF  Hansel stain
Bacteria & yeast Negative HPF o Preferred
 RBCs o Uses methylene blue in eosin Y
o Appearance  Wright
 Non-nucleated  C/S tubulointerstitial disease
 Biconcave disk (7 μm)  Hypersensitivity to drugs (penicillin, drug-induced
 Hypertonic, concentrated urine: crenated interstitial nephritis)
 Hypotonic, dilute urine: ghost/shadow cell o Clinical significance
o Sources of identification error  Pyuria
 Yeast cells  Increase in urinary WBCs
 Oil droplets  Infection or inflammation
 Air bubbles  Renal origin if with WBC casts
 WBCs  Bacterial infections
o Reporting  Pyelonephritis
 Average/10 hpf  Cystitis
 Normal value: 0-2/hpf  Prostatitis
o Correlation  Urethritis
 Color
 Acute urethral syndrome
 Blood reagent strip
 Dysuria (painful urination), pyuria
o Dysmorphic RBC
 Non-bacterial disorders
 RBC with protrusion or fragmentation
 Glomerulonephritis
 Renal/glomerular bleeding
 Wright’s stain: hypochromic with presence of cellular  Lupus erythematosus
blebs and protrusions  Interstitial nephritis
o Clinical significance  Tumors
 Glomerular membrane damage (glomerulonephritis)  Epithelial cells
 Vascular injury within the GUT (trauma, acute o Squamous epithelial cells
infection/inflammation, and coagulation disorders)  Largest, most frequently seen, least significant
 Renal calculi  40-60 μm
 Most common  Large, flat, abundant cytoplasm with small, round,
 Clumping of crystals and hematuria central nuclei
 Malignancy  Sternheimer malbin stain: pink
 Increased RBCs and RBC casts: renal bleeding  Location: distal 1/3 of urethra, vagina, vulva
(glomerular bleeding or nephritis)  Sources of identification error
 Increased RBCs but no RBC casts: bleeding distal to the  Folded cells may resemble casts
kidney (cystitis)  Reporting
 Leukocytes/pus cells  Rare, few, moderate, many (per lpf)
o Sources of identification error  Correlation
 RTEs  Clarity
 RBCs (add acetic acid to dissolve RBC)  Clue cells
o Reporting  Abnormal
 Average/10 hpf  Squamous EC coated with Gardnerella vaginalis
 Normal value: 0-5/hpf o Transitional epithelial (uroepithelial) cells
o Correlation  Small, round, pear-shaped, central nucleus
 (+) leukocyte esterase  Sometimes binucleated
  Less coarse granules o Formed when protein precipitates and gels in the lumen
 20-40 μm o Cylindrical with parallel sides and rounded ends
 Few in normal urinalysis o Sole site: kidney
 Location: upper urethra, bladder, ureters, renal pelvis o Tamm-Horsfall protein (uromodulin)
 Caudate  Matrix of all casts
 Transitional epithelium with saw-tooth tail  Meshwork traps cells
 Found in the urinary bladder and pelvis of the kidney  Produced by RTEs
 Clinical significance o Increased cast formation
 Transitional cell carcinoma  Lower pH (acidic)
o (+) large clumps  Increased ionic concentration
 Renal transplantation rejection  Obstruction and stasis
 Catheterization  Proteinuria (increased albumin and globulin)
 Malignancy or viral infection  Plasma proteins combine with Tamm-Horsfall
o With vacuoles and irregular nuclei o Urinary casts
o Renal tubular epithelial cells  Cylindroiduria or cylindruria
 Most significant type of epithelia cell in urine  Presence of casts in urine
 Large nuclei with coarse granules  Formed at the junction of DCT and Loop of Henle
 Reporting o Cast formation
 Average/hpf  Aggregation of Tamm-Horsfall protein into protein
 Normal value: 0-2/hpf fibrils attached to RTEs
 RTE from PCT  Interweaving of protein fibrils
 Larger than other RTEs  Further protein fibril interweaving to form solid
structure
 Rectangular shape
 Possible attachment of urinary elements to solid matrix
 Columnar or convoluted
 Detachment of protein fibrils from the epithelial cell
 Coarsely granulated cytoplasm
 Excretion of the cast
 Resembles casts  Cellular cast  coarse granular cast  fine granular
 RTE from DCT
cast  waxy cast
 Occur singly (14-16 μm) o Hyaline cast
 Oblong or egg-shaped cells with coarse granules  Non-pathologic
 RTE from collecting tubules  Most frequently seen
 12-20 μm  Entirely Tamm-Horsfall
 Cuboidal or polygonal with slightly eccentric nucleus  Translucent, low refractive index
 Nuclei make up 60-70% of the cells  Difficult to visualize under the microscope
 Clinical significance  Appearance
 C/S  Colorless, homogenous matrix
 Increased in acute tubular necrosis  Sources of identification error
 Tubular damage  Mucus, fibers, hair, increased lighting
 Drug and heavy metal poisoning  Reporting
 Viral infection (CMV)  Average number per lpf
 Pyelonephritis  Normal value: >0-2/lpf
 Allergic reactions  Correlation
 Acute allogenic transplant rejection  Protein
 Oval fat bodies  Blood (exercise)
 Lipid-containing RTE cells  Color (exercise)
 Highly refractile, nuclei difficult to observe  Clinical significance
 Usually seen with free-floating fat droplets  Stress and exercise
 Identification  Heat exposure
o Staining with Sudan III or Oil Red O produces  Fever
orange-red droplets  Glomerulonephritis
o Polarized microscopy (Maltese cross formations)  Pyelonephritis
 Reporting  Congestive heart failure
o Average number per hpf o Less renal blood flow and urine output
 Bubble cells  Athletic pseudonephritis
 Degenerated renal tubular epithelial cells o In collaboration with RBC casts
 RTE cells containing large, non-lipid-filled vacuoles o Waxy cast
 Seen in acute tubular necrosis  Non-pathologic
 May be seen along with normal renal tubular  Final phase of dissolution of fine granules of finely
epithelial cells and oval fat bodies granular casts
 Casts  CRF, become denser: waxy
o Formed within the lumen of the DCT and collecting duct  Brittle: cracks
 Area of concentration where most casts are formed  High refractive index
  Sources of identification error  Correlation
 Fibers and fecal material o WBCs
 Reporting o Protein
 Average number per lpf o Leukocyte esterase
 Correlation  Clinical significance
 Protein o Infection or inflammation within the nephron
 Cellular casts o Pyelonephritis
 Granular casts o Acute interstitial nephritis
 WBCs  RTE casts
 RBCs  Hard to differentiate from WBC cast
 Clinical significance  Most reliable: singular round nuclei
 Tubular inflammation and degeneration  Clinical significance
 Nephrotic syndrome o Acute tubular necrosis
 Extreme stasis of urine flow o Viral diseases
 Chronic renal failure o Salicylate intoxication
 When broad (2-6x bigger), renal failure cast  Mixed cellular casts
 Seen in tubular atrophy  Two distinct cell types present within a single cast
o Granular cast  Reported as hyaline or granular, not as mixed cast
 Non-pathologic  Combo meals
 Finely granular or coarsely granular o RBC and WBC casts: glomerulonephritis
 Fairly common o WBC and RTE cell casts: pyelonephritis
 Pathologic conditions o WBC and bacterial casts: pyelonephritis
 Disintegration of cellular casts o Broad cast
o Glomerulonephritis (RBCs)  2-6 times the diameter of a normal cast
o Pyelonephritis (WBCs)  Sources of identification error
o Tubulointerstitial disease (RTEs)  Fecal material
 Protein aggregates  Fibers
 Non-pathologic conditions  Clinical significance
 Lysosomes excreted by tubular cells  C/S
o Fatty cast  Tubular dilatation
 Protein matrix (hyaline cast) with oval fat bodies  Extreme stasis
 Positive for Maltese cross formation  Chronic renal failure
 Seen in nephrotic syndrome, toxic tubular necrosis,  Telescoped sediment
diabetes mellitus, and crush injuries o All types of casts
o Crystal cast o Elements of glomerulonephritis
 Urates, calcium oxalate, sulfonamide o Elements of nephrotic syndrome (fatty casts)
 May accompany hematuria o RBCs, RBC casts, cellular casts, broad waxy casts, lipid
o Cellular casts droplets, oval fat bodies, fatty casts
 RBC casts o Clinical significance
 Cast matrix containing RBCs (RBCs in hyaline cast)  Collagen vascular disease (lupus nephritis)
 Red-orange color  Subacute bacterial endocarditis
 Extremely fragile and degenerates to granular casts  Crystals
 Sources of identification error o Precipitation of urine solutes
o RBC clumps (round without matrix)  Inorganic salts, organic compounds, and medications
 Reporting (iatrogenic compounds)
o Average number per lpf o Subject to changes in pH, temperature, concentration
 Correlation o Solute precipitates more readily at low temperature
o RBCs o Most crystals are of limited clinical significance
o Blood o Urine pH is important
o Protein o Crystals in normal acidic urine
 Clinical significance  Generally soluble in dilute sodium hydroxide
o Bleeding in the nephron  Amorphous urates
o Glomerular damage  Aggregates or precipitate of certain chemicals like Ca,
o Glomerulonephritis Na, Mg
o Strenuous exercise  Yellow-brown small granules
 WBC casts  Seen in acidic and neutral specimen
 Cast matrix with WBCs  Appear as pink-orange to reddish brown “brick dust”
 Sources of identification error  Soluble in heat (60’C) and dilute alkali
o WBC clumps (round without matrix)  “Pseudocast”
 Reporting
o Average number per lpf
  Uric acid  Common form: colorless, three to six sided prisms
 Very low pH: 5-5.5 with oblique ends
 Yellow or reddish brown  Rare form: Flat fern leaf form, sheets, and flakes
 Four-sided, flat rhombic plates or prisms  Soluble in dilute acetic acid
 Lemon-shaped/diamond rosettes (yellow)  Clinical significance
 Whetstone o Recurrent UTI caused by urea-splitting bacteria
 Rare, colorless hexagonals such as Proteus species
 Soluble in alkali (NaOH) and ammonia  Calcium carbonate
 Insoluble in alcohol and acids such as HCl  Small and colorless with dumbbell or spherical shapes
 Clinical significance  Bigger than calcium oxalate
o C/S  May occur in clumps that resemble amorphous
o Renal stones material
o Gout  Formation of gas after the addition of acetic acid
o High purine metabolism  Soluble in acetic acid
o Lesch Nyhan syndrome  Birefringent
o After chemotherapy for lymphoma and leukemia  No clinical significance
 Calcium oxalate  Calcium phosphate
 Common form: small, colorless, octahedrals that  Colorless, rectangular plates or prisms in rosette
resemble envelopes forms
 Two pyramids joined at their bases  Dissolves in dilute acetic acid
 Rare form: dumbbell, ovoid forms  Ammonium biurate
 Seen in acidic and neutral specimen  Yellow-brown spheres
 Dihydrate  Spicule-covered spheres
o Envelope-shaped  Referred to as thorn apples showing irregular
o Positive birefringence projection or thorns and horns
 Monohydrate  Soluble in heat (60’C) and acetic acid
o Dumbbell and ovoid rectangle  Seen in old urine
 Soluble in dilute HCl o Crystals in abnormal urine
 Insoluble in acetic acid  All abnormal crystals are found in acidic urine
 Clinical significance  Cystine
o Seen in normal individuals after ingestion of  Colorless, refractile, hexagonal plates
oxalate-rich food and large doses of vitamin C  Soluble in ammonia and dilute HCl
o Renal stones  Clinical significance
o Ethylene glycol poisoning (monohydrate form) o Cystinuria
 Sodium urates o Kidney disease
 Slender prisms o Fanconi syndrome
 Usually colorless or sometimes yellowish  Tyrosine
 Arranged in fan or leaf-like manner  Long, fine, silky needles
 Referred to as peacock-like crystals  Arranged in sheaves of wheat or clumps
 Hippuric acid  Soluble in alkali (ammonia and KOH) and in dilute HCl
 Needle-like crystals  Insoluble in alcohol or ether
 Colorless and sometimes yellowish brown  Clinical significance
 Appear in singly o Tyrosinuria
 Seen in acidic, neutral, and alkaline urine o Liver disease (along with leucine)
 Soluble in hot water and alkali  Leucine
 Clinical significance  Yellow, oily appearing spheres
o Ingestion of excessive benzoic acid  Have radial and concentric striations
o Crystals in normal alkaline urine  Scallop-like crystals
 Generally soluble in dilute acetic acid  Soluble in hot alcohol and alkali
 Amorphous phosphates  Insoluble in ether
 Calcium and magnesium  Clinical significance
 Granular aggregates like amorphous phosphates but o Liver disease (along with tyrosine)
seen in increased pH o MSUD
 Seen in neutral and alkaline urine  Cholesterol
 Colorless granules  Rarely seen unless specimens have been refrigerated
 Insoluble in heat as lipids remain in droplet form
 Soluble with acetic acid and dilute HCl  Colorless, flat plate with corner notch
 Triple phosphate  Stair-step/broken window shape
 Aka ammonium magnesium phosphate or struvite  Accompanies fatty casts and oval fat bodies
 Coffin-lid crystals  Soluble in chloroform, ether, and hot alcohol
  Birefringent (polarized light)  Phosphate
 Clinical significance o Pale, friable, fragile
o Nephrotic syndrome  Cystine
 Bilirubin o Color of old, yellow-brown soap, greasy
 Short, clumped needles or granules with o Chemical examination
characteristic yellow color (reddish brown)  Pulverize and cut (if too big)
 Clinical significance  50 mg powdered stone
o Seen in the matrix of casts in viral hepatitis  Add 15 drops of HCl
o Other crystals in urine  Positive: formation of bubbles/effervescence
 Sulfonamides (sulfadiazine) (carbonates)
 Iatrogenic  Centrifuge and separate supernatant from the sediment
 Colorless or yellow-brown  Test on the supernatant
 Resemble sheaves of wheat with central bindings Composition Reagent/s Positive result
 Rosettes, arrowheads, petals, needles, round forms Calcium Ammonium White
with striations oxalate precipitate
 Seen in acidic and neutral urine Ammonium NaOH, KI Rusty,
 Confirm with Diazo reaction: magenta brownish red
 Ampicillin precipitate
 Long, fine, colorless needles that tend to form bundles  Test on the sediment
following refrigeration Composition Reagent/s Positive result
 Radiographic dye Oxalate HCl, MnO2 Bubbles
 Urine has a very high specific gravity reading (>1.035)  Test on the stone
 Differentiate from cholesterol by looking at the Composition Reagent/s Positive result
specific gravity Phosphate HCl, ammonium Blue
molybdate
VI. Renal Calculi Uric acid Na2CO3, sodium Blue
 Aka kidney stones tungstate
 Solid aggregates of mineral salts Cystine NH4OH, sodium Red
 Location nitroprusside
o Calyces o X-ray crystallography
o Pelvis  More comprehensive analysis
o Ureters  Determines the arrangement of atoms within a crystal
o Bladder  Beam of x-rays strikes a crystal and causes the beam of
 Clumps of crystals (with RBCs) in freshly voided urine light to spread into many specific directions
o No casts because these are made up of uromodulin  Produce a three-dimensional picture of the density of
 Clinical significance electrons within the crystals
o Urolithiasis  No more manual chemical examination
o Nephrolithiasis  Techniques for analysis
o Renal lithiasis o Chemical examination
o Hematuria o X-ray crystallography
o Associated with renal colic (extreme pain) o Infrared spectroscopy
o Usually asymptomatic (little to no pain) o Radiographic diffraction
o Increased interleukin 6 o Electron microscopy
 Released during muscle contraction o Polarizing microscopy
o Large stones may result to hydronephrosis  Methods of detection
 Distention (dilation) of the kidney with urine caused by o Cytoscopy
backward pressure on the kidney when the flow of  Cytoscope equipped with a lens to examine the lining of
urine is obstructed the bladder and urethra
 Stone analysis o X-ray evaluation (KUB)
o Physical/gross examination  Calcium-containing stones are radiodense or
 Wash the stones (usually covered with blood) radiopaque
 Record the dimension of the stone  Calcium phosphate has the greatest density, followed
 Size by calcium oxalate and triple phosphate
 Sand, gravel, stone (in millimeters)  Cystine calculi: faintly radiodense
 Calyces and pelvis: large, rounded, staghorn  Uric acid stones: entirely radiolucent
 Bladder: large, smooth round o Intravenous pyelogram
 Appearance  Special x-ray
 Uric acid  Examination of the kidneys, bladder, and ureters
o Yellow, brownish red, moderately hard o Ultrasound and CT scan
 Calcium oxalate  Ultrasound: children or pregnant women
o Dark color, very hard, rough surface  Compared with CT, renal ultrasonography more often
fails to detect small stones (especially urethral stones)
  Management techniques o Beta hCG can be detected in maternal plasma or urine by
o pH incompatible with crystallization of particular 8-9 days after ovulation
chemicals aka “stone dissolution”  hCG level correlations
 Acidify alkaline urine and vice versa then administer o Early pregnancy
medications  hCG levels in the blood double every 2-3 days
o Adequate hydration o Ectopic pregnancy
o Dietary restrictions  Longer doubling time
 Oxalates  May lead to false-negative results
 Avoid tea, cocoa, coffee, cola, beans, rhubarb, spinach, o hCG concentrations will drop rapidly following a
nuts, berries, citrus, vitamin C miscarriage
 Uric acid o if hCG does not fall to undetectable levels, it may indicate
 Avoid dietary intakes of purines, liver, dried beans, remaining hCG-producing tissue that has to be removed
some fish, meat  Indications
 Removal of renal stones o Suspicion of possible pregnancy
o For stones >1 mm in diameter o To investigate completeness of abortion
o Lithotripsy o To evaluate ectopic pregnancy
 Break stones into smaller pieces o To differentiate true pregnancy from other trophoblastic
 For stones >4 mm in diameter diseases like hydatidiform mole, choriocarcinoma, and
o Surgery testicular tumors (seminoma and teratomas)
 Types of renal stones o Trophoblastic disease
Chemical % pH Causes  Abnormal pregnancy in which there is no fetus, only an
composition abnormal mass growth
Calcium 75 5.5-6.5 Idiopathic hypercalciuria,  Ectopic pregnancy
oxalate bone disease, primary o Fetus develops outside the uterus
(70%) hyperparathyroidism,  Hydatidiform mole
Calcium excessive o Molar pregnancy
phosphate milk/alkali/vitamin D o Is a rare mass or growth that forms inside the uterus at
(10%) intake the beginning of a pregnancy (result of a genetic error
Struvite 15 >7.0 Recurrent infection with during the fertilization process)
urea-splitting bacteria o Type of gestational trophoblastic disease (GTD)
Uric acid 10 <5.5 Gout, uromodulin- o Non-viable, fertilized egg implants in the uterus
associated kidney disease o Results from over-production of the tissue that is
Cystine 1-2 <5.5 Defect in cystine supposed to develop into the placenta
metabolism o Grape-like cell clusters
 Mineralogical names o Positive for hCG
o hCG levels are high (both blood and urine) and may go as
Calcium oxalate (monohydrate) Whewellite
high as 350 000 – 3 000 000 IU/L
Calcium oxalate (dihydrate) Weddellite
 Choriocarcinoma
Calcium phosphate Apatite
o Complication of hydatidiform mole
Calcium hydrogen phosphate Brushite
o Quick-growing form of cancer that occurs in the uterus
Triple phosphate Struvite o Abnormal cells start in the tissue that would normally
become the placenta
VII. hCG o hCG levels are persistently high
 Produced by trophoblastic cells of the developing placenta  Positive hCG not associated with pregnancy
 Trophoblasts o Female: vesicle tumors
o Cells forming the outer layer of a blastocyst which o Male: testicular tumors (teratomas and seminomas)
provide nutrients to the embryo and develop into a large  hCG test results
part of the placenta o Expressed in IU/ml or mIU/ml
 Used to diagnose conditions other than pregnancy  mIU/ml is more commonly used
 Glycoprotein with alpha polypeptide and beta polypeptide o Specimen used may be serum or urine
subunits  First morning urine is more commonly used
o Alpha subunit: identical to FSH, prone to false positive o Tests should detect beta hCG
o Beta subunit: measured o Causes of false positive result
 Differentiation from other trophoblastic diseases  Error in test performance
 hCG levels  Inaccurate reading of result
o Trophoblastic cells secrete hCG 6-8 days after conception  Proteinuria
(6-12 days after ovulation) which doubles every 2-3 days  Hematuria
o hCG levels rise rapidly until reaching a peak of 100 000  Drug metabolites
mIU/ml of serum 60-80 days after last menstrual period o Causes of false negative result
o Peak: 10th week of gestation (2 ½ months)  Low titer of hCG
o hCG levels decrease from peak to plateau of 10 000-20  Low sensitivity of the test
000 mIU/ml after the first trimester  Presence of certain drugs
  Dilute urine
o Women should not drink large amounts of fluid before
collecting a urine sample for a pregnancy test
 Methods
o Bioassay
Method Animal Positive result
Ascheim Zondek Female mouse Enlargement of
corpus luteum
Friedmann Female rabbit Ovulation
Hogben Female toad Ovulation
(Xenopus laevis)
Galli Mainini Male frog Release of
(Rana pipiens) spermatozoa
Male toad Release of
Commonly used spermatozoa
o Immunoassay
 Positive result within 2 minutes
Method Reagents Positive Negative
Hemagglutin Anti-hCG No Agglutin
ation serum, RBCS agglutin ation
Inhibition with hCG, ation
(HAI) sheep’s RBCs
Latex Anti-hCG No Agglutint
agglutination serum, latex agglutio ion
inhibition particles with nation
(LAI) hCG
Direct latex Latex with anti- Agglutin No
agglutination hCG ation agglutina
(DLA) tion
 Radioimmunoassay
 Most sensitive method
 Not commonly used because of cost-effectiveness and
long incubation time (2 hours)
 Competitive binding assay
 hCG in serum and radiolabeled hCG compete for
binding with anti-hCG Antibody
 An inverse correlation exists between the number of
radioactive counts in the antibody complex and the
amount of hCG in the patient’s serum
o Positive result: decreased radioactive count
o Negative result: increased radioactive count
 High sensitivity: 5-9 mIU/ml
 Enzyme immunoassay
 Most commonly used
 Uses double monoclonal antibody (sandwich method)
 First antibody is bound to solid phase
 Second antibody Is linked to an indicator enzyme such
as alkaline phosphatase
 Substrate becomes cleared
 Sensitivity: 20-50 mIU/ml
 Rapid: 2 minutes
 Affordable
 Results
o Positive result: double bar
o Negative result: single bar
o Control: always has a line
o Testing: blank at first
 Home test kit assay
 Immunochromatography strip test
 Lateral flow test
 Competitive or sandwich assays