URINALYSIS:

BIOCHEMISTRY LABORATORY
NEPHRON
Basic parts
NEPHRON
Basic function
NEPHRON
 URINALYSIS
 is a group of physical, chemical, and
microscopic tests.

 The tests detect and/or measure

several substances in the urine,
such as byproducts of normal and
abnormal metabolism, cells, cellular
fragments, and bacteria.

 is a useful laboratory test that

enables the clinician to identify
patients with renal disorders, as
well as some nonrenal disorders.
SPECIMEN COLLECTION

• One to two ounces of urine is collected in a clean container.

• Collected at any time. In some cases, a first morning sample may be

requested because it is more concentrated and more likely to detect
abnormalities.

• "clean-catch" urine sample. It is important to clean the genital area

before collecting the urine.

• Note: Bacteria and cells from the surrounding skin can contaminate the sample and interfere
with the interpretation of test results. With women, menstrual blood and vaginal secretions
can also be a source of contamination. Women should spread the labia of the vagina and
clean from front to back; men should wipe the tip of the penis. Start to urinate, let some
urine fall into the toilet, then collect one to two ounces of urine in the container provided,
then void the rest into the toilet.
TYPES OF ANALYSIS

• Macroscopic examination
• Chemical (semiquantitative test)
• Microscopic examination
• Culture (not covered in this lecture)
• Cytological (not covered in this lecture)
MACROSCOPIC EVALUATION
Odor:
− Ammonia-like: (Urea-splitting bacteria)
− Foul, offensive: Old specimen, pus or inflammation
− Sweet: Glucose
− Fruity: Ketones
− Maple syrup-like: Maple Syrup Urine Disease

Color: (from urochrome or urobilin)

− Clear to yellow Normal urine
− Colorless Diluted urine
− Deep Yellow Concentrated Urine, Riboflavin
− Yellow-Green Bilirubin / Biliverdin
− Red Blood / Hemoglobin/ myoglobin
− Brownish-black Homogentisic acid (Melanin)
Note: Fresh urine is not cloudy or hazy. But may become cloudy urates (acidic
environment) or phosphates (alkaline environment) is present. Urine changes is pH
dependent.
 MACROSCOPIC EVALUATION
Red to Myoglobin Crush injuries, electric shock, seizures, cocaine-induced
orange muscle damage

Hemoglobin/ Hemolysis (malaria, drugs, strenuous exercise)

erythrocytes menstrual contamination; kidney stones

Porphyrins Porphyria, lead poisoning, liver disease

Drugs/chemicals Rifampin

Food Beets, blackberries, cold drink dyes, carrots

Blue to Biliverdin Oxidation of bilirubin

green
Bacteria Pseudomonas or proteus in urinary tract infection
(rare)

Drugs/chemicals Methylene blue

 MACROSCOPIC EVALUATION
Brown to Myoglobin Crush injuries, electric shock, seizures,
black cocaine-induced muscle damage
Bile pigments Hemolysis
Melanin Melanoma (prolonged exposure to air)
Porphyrins Porphyria and sickle cell crisis

Drugs/chemicals Ferrous sulphate

MACROSCOPIC EVALUATION

Turbidity:
− Typically cells (RBC and WBC)or crystals.

− Cellular elements and bacteria will clear by

centrifugation.
− Crystals dissolved by a variety of methods (acid or
base).
− Microscopic examination will determine which is present.

− Unusual amount of amount of foam may be from protein

or bile acids.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Specific gravity
• an indication of the ability of the kidney to concentrate urine
• Unusually low specific gravity would suggest that the kidneys are not
able to concentrate urine appropriately.

Low specific gravity High specific gravity

(hyposthenuria)
• chronic renal failure
• or diabetes insipidus
(hypersthenuria)
• dehydration, congestive
heart failure (CHF), toxemia
of pregnancy, or syndrome
of inappropriate antidiuretic
hormone (SIADH).
• increased excretion of
glucose or protein greater
than 2 g/day
 CHEMICAL (SEMIQUANTITATIVE TESTS)
pH
• Normal values for pH are from 4.5 to 8.
• Normal urine specimens are acidic. The average pH value is approximately 6.0
Postprandial (specimens voided shortly after meals)

Alkaline Vegetarians (vegetables do not produce fixed acid residues)

Metabolic or Respiratory alkalosis (hyperventilation, severe vomiting, gastrointestinal suctioning)

UTI (Proteus bacteria) splits urea to ammonia

Renal Tubular acidosis (Impaired tubular acidification) of urine and low bicarbonates and pH in blood

Drugs (Acetazolamide, bicarbonate salts, thiazides, citrate and acetate salts)

Drugs (ammonium chloride, ascorbic acid (high dose))

Acidic Food (Cranberries, fruit juices)

Ketoacidosis (Diabetes mellitus, starvation, high fever)

Metabolic acidosis (increased ammonium excretion and cellular hypoxia with lactic acid production (shock))

Sleep (Mild respiratory acidosis)

 CHEMICAL (SEMIQUANTITATIVE TESTS)

Leukocyte esterase
• The normal value should be from zero to trace.
• Semiquantitative estimate of pyuria (pus in the urine)

• indication of WBCs
Positive (neutrophils) in the urine
• Indirect indication of UTI
 CHEMICAL (SEMIQUANTITATIVE TESTS)

Nitrates
• The normal value is negative.
• colonization or infection with gram-negative organisms (Klebsiella, Enterobacter,
Proteus, Staphylococcus and Pseudomonas)

• Gram-negative bacteria are

capable of converting dietary
Positive nitrates into nitrites
• Indirect indicator of UTI

False - • Non-nitrite producing organism

(Enterococcus)
negative
 CHEMICAL (SEMIQUANTITATIVE TESTS)
Urea
• Urea nitrogen is an end product of protein catabolism
• It is produced in the liver, transported in the blood, and cleared by the kidneys.
• BUN concentration serves as a marker of renal function.

Increased • acute or chronic renal failure,

• CHF, gastrointestinal bleeding (gut flora metabolizes
BUN blood to ammonia and urea nitrogen),
• high-protein diet, shock, dehydration,
(azotemia) • antianabolic and nephrotoxic medications

Decreased • liver failure because of inability of the liver

to synthesize urea, and in disease states
BUN such as SIADH and acromegaly
CHEMICAL (SEMIQUANTITATIVE TESTS)
Proteins
• Trace protein in the urine is a common clinical finding and often has no
clinical significance.
• Normal excretion: about 8-100mg/day

Repeated positive tests or proteinuria of

greater than 150 mg/dL may be a marker of
renal disease.
• diabetic nephropathy, interstitial nephritis,
hypertension, fever, exercise,
pyelonephritis, multiple myeloma, lupus,
and severe CHF.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Proteins •High blood pressure
Mild •Lower UTI
• Normal urinary •Fever

proteins:
proteinuria •Renal tubular damage
•Exercise

– albumin
– low molecular weight
serum globulins •CHF
•Acute and Chronic glomerulonephritis
• Proteinuria – general Moderate •Diabetic nephropathy
•Pyelonephritis
term that refers to the proteinuria •Multiple myeloma
renal loss of protein •Preeclampsia
(albumin and or
globulins)
• Albuminuria – •Glomerulonephritis
specifically refers to the Significant •Amyloid
•Severe chronic glomerulonephritis
abnormal renal excretion proteinuria •Diabetic nephropathy
•Lupus-nephritis
of albumin
CASE: DIABETIC NEPHROPATHY

A 52-year old woman with T2DM diagnosed 1

year ago referred to you for evaluation of
proteinuria noted first 3 months ago.

Family history is positive for diabetic nephropathy.

Physical examination shows blood pressure (BP)
of 140/95mmHg and normal fundal examination
findings and is otherwise unremarkable.

Laboratory reports show serum creatinine

concentration of 0.9mg/dL and urinalysis shows
protein (3+) with unremarkable sediments
https://www.osmosis.org/learn/Diabetic_nephropathy
Wider slits
CHEMICAL (SEMIQUANTITATIVE TESTS)
Bile pigments
CHEMICAL (SEMIQUANTITATIVE TESTS)
Bile pigments
High • Intrahepatic cholestasis
• Normal value should • Obstruction of the bile duct (stones or
be from zero to trace Bilirubin tumor)

• Bilirubin
– Bilirubinuria- a dark
yellow or greenish
brown color in the
urine Low levels of • Antibiotics (neomycin, chloramphenicol,
tetracycline) that reduce the intestinal flora
• Urobilinogen– Formed urobilinogen producing this substances.
by bacterial conversion
of conjugated bilirubin in
the intestine (normally
present). • Hemolytic anemia
– Increases: • Congestive heart failure with liver
abnormally rapid High level of congestion
• Cirrhosis
turnover of heme Urobilinogen • Viral hepatitis
pigments • Drug induced hepatotoxicity
CASE: JAUNDICE (OBSTRUCTIVE)

O.J a 70-year old man had his medical

check-up in SWU Medical Center. His eyes
were visible for jaundice which Dr. Home had
noticed to be deepening in color. Upon
evaluation he has no history of pain, fever or
any drug intake, but he complained of some
weight loss and pale stools from the past few
days. He was a moderate drinker. There was
no history of such like episode before. The
patient seemed to be bothered about his
condition.
Assumed that he had undergone blood test
and urinalysis test.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Occult blood
Common • infection
• nephrolithiasis
• The normal value causes of
should be negative to • malignancies, and benign
trace. hematuria prostatic hypertrophy (BPH)

• Hematuria
– Blood in the urine
– may indicate urinary
tract damage • When povidone iodine is
• Hemoglobinuria
False used as a cleansing agent
positive before urine specimen
– Free hemoglobin in collection.
urine
• Myoglobinuria
– Myoglobin in urine
– May be caused by • patients taking high doses
rhabdomyolysis False of vitamin C or ascorbic
(acute destruction of acid.
the muscle) negative
CASE: Benign prostatic
hypertrophy (BPH)
A 75 year old asian male referred to SWU
Medical center due to dysuria, irritative,
voiding and symptoms difficulty with urination.
Physical examination showed blood pressure
(BP) 120/80 mmHg; Temperature 98F; Pulse
rate 74-beats/minute (bpm). He was a smoker
for about 20 years and used to work in an
environment with known harmful chemicals,
fumes, dust and other environmental or
occupational allergens. He had no known
history of allergy to any drug.
Laboratory tests including Blood complete
panel report (CP), and Ultrasound Reports
with remarkable prostatic enlargement. Urine
test showed blue ring appearance.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Glucose
• Should be negative
– Although glucose is filtered in the glomerulus, it is almost
completely reabsorbed in the proximal convoluted tubule
• Glucose begins to spill into urine (glucosuria) when serum blood
glucose is greater than 180mg/dL blood in the urine

• diabetic, suggests the need for

Glucosuria improved glucose control.
• Cushing disease,
or • pancreatitis,
• thiazide diuretics,
• steroids,
glycosuria • oral contraceptives.
CASE: Diabetes mellitus

• B.A. is a retired 69-year-old man went to SWU Medical

Center due to unexplained episodes of nocturia,
increase appetite and unexplained thirst.

• B.A.’s diet history reveals excessive carbohydrate

intake in the form of bread and pasta. His normal
dinners consist of 2 cups of cooked pasta with
homemade sauce and three to four slices of Italian
bread. During the day, he often has “a slice or two” of
bread with butter or olive oil. He also eats eight to ten
pieces of fresh fruit per day at meals and as snacks.
He prefers chicken and fish, but it is usually served
with a tomato or cream sauce accompanied by pasta.
His wife has offered to make him plain grilled meats,
but he finds them “tasteless.” He drinks 8 oz. of red
wine with dinner each evening. He stopped smoking
more than 10 years ago, he reports, “when the cost of
cigarettes topped a buck-fifty.” The attending physician
advised him for a routine urinalysis and complete blood
count (CBC). Urine test revealed brick red color
precipitate.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Ketone
• Should be negative
– Excess amounts of ketones form when carbohydrate
metabolism is altered.

• Diabetic ketoacidosis
(DKA),
• starvation,
Ketonuria • high-protein/low-
carbohydrate diets,
• alcoholism
CASE: Diabetic ketoacidosis

• A 19 year old diabetic comes to the accident

and emergency department. She gives a 2-day
history of vomiting and abdominal pain. She is
drowsy and her breathing is deep and rapid.
This is a distinctive smell from her breath and
urine. Upon microscopic evaluation of the
urinalysis test for qualitative pathological
constituents revealed yellow iodoform six
pointed star crystals.
 Upon the assumption of the test conductive what analyte might
be associated to have significant elevated amount that would
predispose to the signs and symptoms?

 Ketone ( revealed yellow red form six pointed star crystals)

 * High ketone levels in urine may indicate DKA, a complication

of diabetes that can lead to a coma or even death because
ketones in urine can mean that you are not getting enough
insulin.
What qualitative test for pathological
constituents will be conducted?
Explain how the test would produce
positive result?

Ketone Bodies (Gunning test). The

appearance of a yellow precipitate
(Iodoform crystals yellowish six
pointed stars or six sided plates
Describe the pathophysiology of the disorder/disease and its relationship with the
increase level of analyte, assuming that the assessment of the analyte that you made is
correct.

 SYMPTOMS :
– Vomiting
– Abdominal pain
– Deep gasping breathing
– Increased Urination
– Confusion
– A specific smell

Diabetic Ketoacidosis – the test measures ketone levels in your urine normally , your
body burns glucose (sugar) for energy If your cells don’t get energy glucose , your body
burns fat for energy instead. High ketone levels in urine may indicate diabetic
ketoacidosis (DKA), a complication of diabetes then can lead to a coma or even death.
If such, what are the treatment and management of this condition?

MANAGEMENT:
• Drink extra water to flush them out of your body
• Test your blood sugar every 3 to 4 times
• Do not exercise if you have blood sugar and high ketones

TEATMENT:
• Intravenous fluids, Insulin, Electrolytes through IV
CHEMICAL (SEMIQUANTITATIVE TESTS)
Uric acid
• excessive production of purines or inability
• Normally of the kidney to excrete urate
present • renal dysfunction, metabolic acidosis,
tumor lysis syndrome, purine-rich diet,
– Uric acid is Hyperuricemia • use of furosemide, thiazide diuretics, and
niacin.
the main • gouty arthritis, nephrolithiasis, and gouty
metabolic tophi
end product
of the
purine
bases of
DNA • low-protein diet
• deficiency of xanthine oxidase,
Hypouricemia • or use of allopurinol, probenecid, or high
doses of aspirin or vitamin C.
CASE: Gouty arthritis

• A 49 year old male presented to the emergency

department of SWU Medical Center with sever right
toe pain. The patient was in usual state of health until
early morning when he woke up with severe pain in
his right big toe. The patient denied trauma to the toe
and no previous history of such pain in other joints.
He did not say that he had a “few too many” beers
with the guys last night. Patient’s past medical history
was significant for hypertension, diabetes mellitus,
chronic alcoholism and renal stones for which he
underwent left nephrectomy about 25 years ago.
Family history was non-contributory.
• On examination, he was found to have a temperature
of 38.2oC and in moderated distress secondary to the
pain in his right toe. The right big toe was swollen,
warm, red, and exquisitely tender. The remainder of
the examination was normal. Synovial fluid was
obtained and revealed rod-or-needle-shaped crystals
that were negatively birefringent under polarizing
microscope.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Creatinine
• Description
– Muscle creatine and phosphocreatine break down to form
creatinine.
– Creatinine is released into the blood and excreted by
glomerular filtration in the kidneys.
– As long as muscle mass remains fairly constant, creatinine
formation remains constant.
– An increase in serum creatinine in the face of unchanged
creatinine formation suggests a diminished ability of the kidneys
to filter creatinine.
– Thus, serum creatinine is used as a tool to identify patients with
renal dysfunction.
CHEMICAL (SEMIQUANTITATIVE TESTS)

Creatinine
• renal dysfunction,
• dehydration,
• urinary tract obstruction,
• vigorous exercise,
Increased • hyperthyroidism,
• myasthenia gravis,
• increased meat intake,
• use of nephrotoxic drugs such as cisplatin and
amphotericin B.

• cachexia, inactive elderly

Decreased or comatose patients, and
spinal cord injury patients
CASE: Exertional rhabdomyolysis

• A 17 years old healthy young boy participated in full-

contact football practice followed by conditioning (2.5
hours) in preparation for Siglakas. After practice, he
entered a coach-mandated post-practice cold-water
immersion and had no signs of heat illness before
developing leg cramps, for which he presented to the
athletic training staff. After 10 minutes of repeated
stretching, massage, and replacement of electrolyte-
filled fluids, he was transported to the emergency
room. Laboratory tests indicated a CK-myoglobin
fraction of 8.5 ng/mL (normal < 6.7 ng/mL), and CK-
myoglobin relative index of 30% (normal range,
25%– 30%). Myoglobin was measured at 499 ng/mL
(normal = 80 ng/mL). One analyte was significantly
raised 2545 IU/L (normal range, 45–260 IU/L) during
serum blood test and which appeared orange color
fomations with urinalysis test, The attending
physician treated the athlete with intravenous fluids.
• CASE: A 25 year old woman was rushed to SWU
Medical Center by a man name G.L due to altered
sensorium. The man reported that the patient had
history of abdominal pain since 1 week along with
constipation and infrequent vomiting. This had
progressed to a severe sudden onset of abdominal
pain along with abdominal distension and
constipation since 1-2 days. Her past medical
history was not significant (only their past) according
to G.L. There was no past history of diabetes,
hypertension or tuberculosis. For a while, the patient
sort for bidi smoking, occasional alcohol intake and
became uncontrollably voracious after their
relationship crumbled. She was fun of eating high
amount of burgers and always have 3 servings of
mongo, massive amount of pork and chicken
barbeque and deep fried pork chop. Her breakfast
would always be a combination of sauges, hot dogs
and ham with cheese. A history of strong antacid
intake was there. On general examination, her pulse
rate was found to be feeble 130/min and her blood
pressure was non recordable. However, her routine
urinalysis test revealed blue color reaction.
• Stated in the situation, the patient was
experiencing severe abdominal pain along
with abdominal distension and constipation.
According to her urinalysis test, it revealed a
blue colored reaction. For Indican test, the
positive result will depend on the different
levels of Indican in the urine. The analyte that
would be associated with the Indican Test is
indoxyl sulfate (Indican)
• Indican Test a indole produced when bacteria in the intestine act
on the amino acid, tryptophan. It is an indicator of intestinal
toxemia and overgrowth of anaerobic bacteria.

• Slight Positive = yellow, light blue, mint green

• Positive = dark blue, light green, golden brown
• High Positive = violet, indigo, dark brown
• Very High Positive = jet black
 Malabsorption occurs when people are unable to absorb
nutrients from their diets, such as carbohydrates, fat, minerals,
proteins or vitamins.
 Indigestion occurs when there is a pain or discomfort in upper
abdomen (dyspepsia) or burning pain behind breastbone
(heartburn)
 Use of strong antacid work by reducing or preventing the
secretion of stomach acid
 Increase level of Indican indicate intestinal toxemia and
overgrowth of anaerobic bacteria, putrefaction of undigested
food in the bowels, stomach disorder (constipation
malabsorption), intestinal disorders and pancreatic insufficiency.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Indican test aka Obermayer test
• Description
– can be a useful tool for monitoring degeneration or
improvement in digestive efficiency of your system in dealing
with protein.
– Indican is formed by an abnormal metabolism of tryptophan.
This is a by-product of putrefaction (protein degradation),
usually in the intestine, but possibly in other locations as well.
– Putrefaction is the anaerobic bacterial decomposition of
proteins – not ideally the healthy way for your body to deal with
proteins.
– This product of this putrefaction (called indole) is absorbed into
the bloodstream, an increase in urinary indican is seen.
– This increase can also be seen if the bacterial decomposition of
body tissues or fluids occurs, as in gangrene, abscesses, etc.
CHEMICAL (SEMIQUANTITATIVE TESTS)
Indican test
• Description
– which is an indicator of intestinal toxemia and overgrowth of
anaerobic bacteria.
– Indican is an indole produced when bacteria in the intestine act
on the amino acid, tryptophan.
– Most indoles are excreted in the feces. The remainder is
absorbed, metabolized by the liver, and excreted as indican in
the urine.
– Normally, only a small amount of indican is found in the urine.
The amount of urine indican increases with high protein diets or
inefficient protein digestion.
– If protein is not digested adequately, bacteria act on the protein
causing putrefaction in the colon and the production of indoles,
which are absorbed and converted in the liver to Indican.
CHEMICAL (SEMIQUANTITATIVE TESTS)

Indican test: Relative presence

CHEMICAL (SEMIQUANTITATIVE TESTS)

INDICAN TEST
• Hypochlorhydria (insufficient stomach acid; use
Maldigestion of antacids or H2 blockers)
• Stomach cancer
and/or • Insufficient digestive enzymes (proteases such
as trypsin, pepsin, chymotrypsin)
malabsorption • Malabsorption syndromes (sprue, Hartnup
of protein disease, a rare disorder in which amino acids
are poorly absorbed from the intestine, etc.

Bacterial
overgrowth in • intestinal obstruction
• concurrent intestinal parasitic
the small infections
and/or large • concurrent intestinal fungal infection
intestine