Introduction: Urinalysis A.

RENAL BLOOD FLOW

 RENAL ARTERY supplies blood to the kidney.
URINARY SYSTEM  The kidneys receive a large blood flow (25%)
 Based on average body size of 1.73m²
Composed of four main components:  TOTAL RENAL BLOOD FLOW: approx. 1200 mL/min
 TOTAL RENAL PLASMA FLOW: 600 to 700
1. KIDNEY- where urine is formed by FILTRATION of blood ◦
2. URETERS- carry the urine to the bladder
3. BLADDER- stores the urine produced
4. URETHRA- delivers the urine for EXCRETION.

KIDNEY’S FUNCTION

 Maintaining homeostasis: regulation of body fluids, acid–base

balance, electrolyte balance
 Homeostasis- normal/balance
 Excretion of waste products  To maintain blood flow of the glomerulus- Afferent and Efferent
 Filtration process on glumerolous arteriole has contributing factor
 Concerned with the maintenance of blood pressure and  Renal blood flow depends on the body
erythropoiesis (process which produce rbc)
 Kidney secrete erythroporetin—kidney problems B. GLOMERULAR FILTRATION
results to low hemoglobin level
GLOMERULUS
RENAL ANATOMY & PHYSIOLOGY
 Consists of coil of approx. eight
NEPHRON capillary lobes referred to as
capillary tuft
 The functional unit of the kidney  Served as a sieve or a filter of
 Approximately 1 to 1.5 million each kidney plasma substances with molecular
weight of <70,000
PARTS OF NEPHRON  Located within the BOWMAN’S
CAPSULE (forms the beginning of
1. Glomerulus (Renal Corpuscle)- consists of a coil of approx. eight
the renal tubule)
capillary lobes (capillary tuft)
2. Bowman’s Capsule –surrounding glomerulus, beginning in
forming of the tubule
3. Proximal Convoluted Tubule (PCT) –1st tubule Factors influence the actual filtration process
4. Loop of Henle (descending/ ascending) –
5. Distal Convoluted Tubule (DCT)  Cellular structure of the capillary walls and Bowman’s capsule
6. Afferent arteriole – point of entry (UNFILTERD BLOOD)  Hydrostatic and oncotic pressures
7. Efferent arteriole – point of exit (FILTERED BLOOD)  Feedback mechanisms of the reninangiotensin- aldosterone
8. Peritubular capillaries –surround the proximal and distal system.(RAAS)
convoluted tubules—for immediate reabsorption of necessary
substances that are needed for circulation CELLULAR STRUCTURE OF GLOMERULARFILTRATION BARRIER
9. Vasa recta – located adjacent to the ascending and descending
loop of Henle  Must pass through 3 cellular layers:
1. Capillary wall membrane
2 TYPES OF NEPHRON  Contains pores and are referred to as fenestrated
 Pores- does not allow the passing through of large molecule but it
1. Cortical nephron contribute to the increase of glomerular permeability
 Approximately 85% 2. Basement membrane
 Responsible for removal of waste products &  Presence podocytes
reabsorption  Epithelial cells of the inner lining of Bowman’s capsule—
2. Juxtamedullary nephron (15%) intertwinding foot process—slit
 Primary function is concentration of the urine 3. Visceral layer of Bowman’s capsule
 Due to 3 layers—no cellular or protein present
RENAL FUNCTION

 Homeostasis
 Excretion of waste product
 Maintenance of Blood Pressure
 Erythrophoresis—controlled by the Kidney
A. Renal Blood Flow
B. Glomerular Filtration
C. Tubular Reabsorption
D. Tubular Secretion
 No filtrate when there is no blood, no reabsorption when there
is no filtrate then no secretion
 GLOMERULAR PRESSURE REABSORPTION MECHANISM
 Presence of HYDROSTATIC PRESSURE
 (cause by size of afferent and efferent arteriole) 1. ACTIVE TRANSPORT
 Inadequate supply of blood in glomerulus  Substance to be reabsorbed must combine to a carrier protein
Due to VASODILATION AND VASOCONSTRICTION contained in the membranes of the renal tubular cells.
 Can be influenced by the concentration of the substance being
HYDROSTATIC PRESSURE are necessary to overcome the opposition of transported.
pressure from the fluid from the Bowman’s capsule and the ONCOTIC  Renal threshold- plasma concentration at which active
PRESSURE of unfiltered plasma protein transport stops.
 Ex. Renal threshold for glucose is 160 to 180 mg/dL
 an auto regulatory mechanism within the juxtaglomerular  Substances to be reabsorbed—amino acid, electrolytes, glucose
apparatus maintains the glomerular blood pressure at a 2. PASSIVE TRANSPORT
relatively constant rate regardless of fluctuations in systemic  movement of molecules across membrane as a result of differences
blood pressure. in their concentration or electrical potential.
 BP drops - Dilation of the afferent arterioles and constriction of
the efferent arterioles NOTE: Exceeding the renal threshold of substances affects the
 prevent a marked decrease in blood flowing through the kidney, Maximal reabsorptive capacity of the tubules, leading to the
thus preventing an increase in the blood level of toxic waste appearance of the substance in the urine.
products. (maintin renal blood flow in the glumerolus
 Likewise, an increase in blood pressure results in constriction of NOTE: All parts of the tubules can reabsorb water except your Ascending
the afferent arterioles to prevent overfiltration or damage to the Loop of Henle because it is impermeable to water
glomerulus.—causes Acute kidney failure (trauma patient)
TUBULAR CONCENTRATION
RAAS (Renin-Angiotensin-Aldosterone System)
 Begins in the descending and ascending Loop of Henle
 regulates the flow of blood to and within the glomerulus.  Water is removed by osmosis in the descending loop of Henle,
 This system respond to changes in blood pressure and plasma and sodium and chloride are reabsorbed in the ascending loop
sodium content  Sodium and chloride—primary inorganic component of urine
 Counter current mechanism
 selective reabsorption process
 serves to maintain the osmotic gradient of the medulla

COLLECTING DUCT CONCENTRATION

 The final concentration of the filtrate through the reabsorption of

water begins in the late distal convoluted tubule and continues in the
 Monitored by JUXTAGLOMERULAR APPARATUS collecting duct.
 Reabsorption depends on the osmotic gradient in the medulla
 Low BP—may result because of low and the hormone VASOPRESSIN (ADH)
water retention within the circulation  Vasopressin—causes
 Renin- enzyme that produced by vasoconstriction and reabsorption
Juxtaglomerular apparatus, secreted of water in renal tubules
and react with the blood substrate  Production of vasopressin is
(Angiotensinogen) determined by the state of body hydration
 Anginotensin 1—inert hormone—the
problem is not yet corrected for the NOTE: Vasopressin- Antidiuretic hormone (ADH) = WATER REABSORPTION
blood flow. Then it will pass to alveoli
D. TUBULAR SECRETION
of lungs.
 Substances (glomerular filtrate) are removed from glomerulus
 Antigen converting enzyme- ACE = 1 2
and return to blood
 Anginotensin 2—correct the secretion of Renin then it decrease
 Involves the passage of all substances from the blood in
 Low Anginotensin—High Renin
Peritubular Capillaries to Tubular filtrate
 Changes in plasma-sodium concentration, then the renin increase
2 MAJOR FUNCTIONS:
GLOMERULAR FILTRATION
1. Elimination of waste products not filtered by the glomerulus
FUNCTIONS OF ANGIOTENSIN II:
 Ex. Urea & Medications
1) Vasodilation of afferent & vasoconstriction of efferent arteriole. 2. Regulation of acid- base balance (secretion of hydrogen ions)
 Maintain blood flow in glomerulus  As a result of its molecular size, hydrogen ion are readily filtered
2) Stimulate Sodium reabsorption in the Proximal Convoluted and absorbed.
Tubule(PCT)  Secretion of hydrogen ions by the renal tubular cells into the
3) Release of the hormone Aldosterone from adrenal cortex. filtrate prevents the filtered bicarbonate from being excreted
 Aldosterone- regulate the salt and water with having  BICARBONATE ACTS AS BUFFER TO THE BLOOD MAINTAINING
effect on the blood pressure NORMAL pH. 7.35-7.45
4) Release of Antidiuretic hormone from hypothalamus.(or kidney)  To maintain the pH of the blood, must eliminate some exes
 Causes kidney to release less water in the acid—these are from dietary intake and body
 High ADH –Less urine production mechanism or metabolism. To avoid acidosis.
 Less ADH—High urine production
History and Importance
C. TUBULAR REABSORPTION
References to the study of urine  At times it is necessary to verify that the fluid present in a urine
container is in fact urine.
1) Drawings of cavemen  The single most useful substance that identifies a fluid as urine is
2) Egyptian hieroglyphics. its uniquely HIGH CREATININE CONCENTRATION (approximately
50 times that of plasma)
1. Hippocrates (5th century BC) - Wrote a book on “uroscopy”  In addition, concentrations of urea, sodium and chloride are
(urinalysis) significantly higher in urine than in other body fluids.
2. 1140 AD, color charts has been developed that described the
significance of 20 different color URINE VOLUME
3. Chemical testing progressed from “ant testing” and “taste testing”
for glucose Urine volume depends on the amount of water that the kidney excrete.
4. Frederik Dekkers - Discover albuminuria (1694)—test albumin Amount excreted is usually determined by the body’s state of hydration.
5. Thomas Addis - Examination of urinary sediment - quantitating the
microscopic sediment Normal daily urine output: 1200 to 1500 mL a range of 600 to 2000mL
6. Richard Bright - Introduced concept of urinalysis as part of doctor’s isconsidered normal
routine patient examination (1827)
1) OLIGURIA - Decrease in urine output
Why study urine?  Result of excessive water loss from vomiting, diarrhea,
perspiration, or severe burn
 The kidney is the only organ with such a noninvasive means by  < 1ml/kg/hr Infants
which to directly evaluate its status.  < 0.5 ml/kg/hr Children
 Urine is an ULTRAFILTRATE of plasma  < 400 ml/day Adult
 Urine is a readily available and easily collected specimen 2) ANURIA
 Urine contains information, which can be obtained by  Cessation of urine flow result from any serious damage to the
inexpensive laboratory tests kidney or decrease flow of blood to the kidney
 According to CLSI, urinalysis define as “the testing of urine with  Cessation means zero
procedures commonly performed in an expeditious, reliable, 3) NOCTURIA
accurate, safe, and cost- effective manner”  Normally, kidneys excrete 2 or 3 times more urine during day
 Increase nocturnal excretion of urine during the night
Reasons for performing urinalysis 4) POLYURIA
 Increase in daily urine volume
 aiding in the diagnosis of disease,  Greater than 2.5 L/ day Adult
 screening asymptomatic populations for undetected disorders,  2.5- 3 mL/kg/day Children
 monitoring the progress of disease  Associated with Diabetes mellitus and Diabetes Insipidus
 the effectiveness of therapy  artificially induced by diuretics, caffeine and alcohol
DIABETES MELLITUS POLYURIA
Urine composition  Caused by defect in production of insulin or its function resulting
in increase in body glucose concentration.
Normally 95% of water and 5 % of solutes  Exceed renal threshold for glucose.
 Presence of dilute urine with high specific gravity 1.030 or above
ORGANIC COMPONENT:  Compensated with polydipsia and Polyuria
DIABETES INSIPIDUS POLYURIA
1) Urea- Major organic component, Product of protein and amino
 Decrease in production or function of ADH (antidiuretic
acid metabolism
hormone)
2) Creatinine- Product of creatine metabolism by muscles
 Water is not reabsorbed from the plasma filtrate.
3) Uric acid- common component in kidney stones; derived from
 Urine is dilute with low specific gravity 1.005
catabolism of nucleic acid in food.
 Compensated with polydipsia, Polyuria and Polyphagia
4) Hippuric acid- Benzoic acid is eliminated in this form, increases
with high vegetable diet. Urine SPECIMEN & Collection
 Other substances (carbohydrates, pigments, fatty acids, enzymes
etc  Containers
 Specimens must be collected in clean, dry, leak-proof containers
INORGANIC COMPONENT:  Labels
 All specimens must be labelled properly
1) Sodium Chloride- Primary inorganic component
 Labels must be attached to the body of the container, not to the
 Concentration of the tubules—Ascending loop of Henle
lid, and should not become detached if the container is
2) Found in combination with sodium (table salt)
refrigerated or frozen.
3) Potassium –
 Requisitions
4) Sulfate- Derived from amino acids
 A requisition form (manual or computerized) must accompany
5) Phosphate - Combines with sodium to buffer the blood
specimens delivered to the laboratory
6) Ammonium - Regulates blood and tissue fluid acidity
 Specimen Rejection
7) Calcium - Combines with chloride, sulfate, and phosphate
 Specimens in unlabelled containers
 Nonmatching labels and requisition forms
 Specimens contaminated with feces or toilet paper
 Containers with contaminated exteriors
 Specimens of insufficient quantity. 12-15 ml for microscopic test
 Specimens that have been improperly transported

IS THIS FLUID URINE? Specimen collection

 1. Gloves should be worn at all times (PPE)
2. Routine urinalysis protocols typically require 10 to 15 ml of
urine. Less than 12ml hinder performance of microscopic
examination.
3. Containers for urine collection must be clean, dry and made of
clear or translucent disposable material such as plastic or glass.
4. The container should stand upright have an opening of at least
4-5cm and have a capacity of 50 to 100 mL.
5. All specimen containers must be labelled before or immediately
after collection. Patient identification label is always placed
directly on the container holding the specimen. 7. Midstream “clean catch” specimen
6. Specimens should be delivered to the laboratory promptly and  Less traumatic method for obtaining urine for bacterial culture and
tested within 2 hours. (more than 2 hours repeat collection— routine urinalysis.
due to increase bacteria on specimen)  Used to avoid contamination (ex. Vaginal discharge)
 Before collection, the glans penis or urethral meatus are thoroughly
Types of Specimens
cleansed and rinsed.
 After cleansing, midstream specimen is obtained when the px passes
1. FIRST MORNINGSPECIMEN
some urine in the toilet and then stops and urinate the midportion to
 Also known as the 8 hour specimen
the container.
 The ideal screening specimen
 Care should be taken not to contaminate the specimen container
 It is a concentrated specimen thereby assuring detection of
chemicals and formed elements not seen in random specimen.
PROCEDURE
 Essential for preventing false- negative pregnancy tests and for
evaluating orthostatic proteinuria
 The specimen must be collected immediately and deliver to the
laboratory within 2 hours.
2. Random specimen
 Can be collected at any time, usually during daytime hours, and
without prior patient preparation.
 The most commonly received specimen.
 Usually satisfactory for routine screening and are capable of
detecting abnormalities that indicate disease process.
 Presence of UTI— pus cells and rbc
3. FASTING SPECIMEN (SECOND MORNING)
 The second voided specimen after a period of fasting.
 This specimen will not contain any metabolites from food 8. Catheterized specimen
ingested before the beginning of the fasting period.  insertion of a sterile catheter through urethra into the bladder.
 Recommended for glucose monitoring  Urine flows directly from the bladder through the indwelling
4. 2 hour- postprandial specimen catheter and accumulates in a plastic reservoir bag. w/calibrate
 The patient is instructed to void shortly before consuming a  Most often these specimen are sent for bacterial culture
routine meal and to collect a specimen 2 hours after eating. 9. Suprapubic aspiration specimen
 Specimen is tested for glucose  Involves collecting urine directly from the bladder by puncturing
 Results are used primarily for insulin therapy monitoring for the abdominal wall & distended bladder using needle & syringe.
persons with diabetes mellitus  provides a sample for bacterial culture that is completely free of
5. GLUCOSE TOLERANCE SPECIMEN extraneous contamination
 Collected correspond with blood samples drawn during glucose  The specimen can also be used for cytologic examination
tolerance test (GTT).  Detects the Bladder cancer and cell abnormality
 Number of specimens varies with the length of the test. 10. PEDIATRIC COLLECTION
 Urine is tested for glucose and ketones  Pediatric and newborn infants pose a challenge in collecting an
 Accompanied of urine and blood appropriate urine specimen.
 Fasting state blood of patient- 8 hour fasting, then  Commercially available plastic urine collection bags (wee bags)
admission of glucose solution (depends on request of with hypoallergenic in adhesive are used.
doctor – 75g or 100g) –after 1 hour collect blood sample on  The bag is placed over the penis in the male and around the
urine, 2 hour and 3 hour vagina(excluding the anus) in the female, and the adhesive is
6. 24 hour (timed) specimen firmly attached to the perineum. (have already calibration)
 Specimen used for urine quantitative assay. Many solutes 11. PROSTATITIS SPECIMEN
exhibit diurnal variation  Also known as “three glass collection” subject for culture
 Catecholamines, 17- hydroxysteroids, electrolytes 1st container- first passed urine
 The patient must begin and end the collection period with 2nd container- midstream portion of urine
empty bladder. 3rd container - urine with prostatic fluid
 On its arrival in the laboratory, the specimen must be thoroughly 4th container- post prostatic massage urine specimen(Stamey-Mears)
mixed and the volume accurately measured and recorded. IMPORTANCE:
 All specimen should be refrigerated or kept on ice during the 1st container -Urethral infection or inflammation
collection period. The most common error encountered are 2nd container -urinary bladder infection
related to specimen collection or to handling problems 3rd and 4th container -Prostatic infection (+ WBC and 10x bacteria
compared to 1st container)

12. Drug Specimen Collection: under drug testing laboratory

Sample 24-Hour (Timed) Specimen Collection Procedure
 Chain of custody (COC)

 Document proper sample identification from the time of

collection to the receipt of laboratory results
 Donor—provides urine for drug testing (instead of patient)
 COC is a standardized form that must document and accompany
every step of drug testing.
 Identification donor, analyst, and specimen collector
 withstand legal scrutiny
 No tampering of spx (clear labelling—seminar or traing from
PAMET RIZAL from test analyst)
 Spx must be handled securely
 Proper ID is required –of spx, spx collector and donor.
Determination of CREATININE is used for urine
 30-45ml required amount –subjected for confirmatory test
 U tempt must be checked within 4mins (32.5-37.7C)

 Saccomano—combination of ethanol and carbowax

 Concentrated analysis—use only for quantitative of drug analysis

Specimen Preservation

 Most routinely used method of preservation-refrigeration: 2ºC to 8ºC

 When a specimen must be transported over a long distance and
refrigeration is impossible, chemical preservatives may be added.  Phenol adds up to the ammonical odor of spx
 Examples of chemical preservatives
1. Thymol CHANGES IN UNPRESERVED URINE
2. Formalin
3. Saccomanno’s fixative
4. Acids (HCl, glacial acetic acid, Boric acid)
5. Sodium carbonate
6. Sodium fluoride
7. Toluene
8. Phenol

Ideal Preservative

1. Bactericidal
2. Inhibit urease
3. Able to preserve formed elements
4. Must not interfere with chemical tests
 Ideal preservative does not exist as of the moment

URINE PRESERVATIVE