HIGH YIELD REVIEWER FOR CLINPATH PRAX

URINALYSIS
• SPECIMEN COLLECTION
Voided Urethral catheterization Suprapubic aspiration
Midstream sterile rubbing tubing anaerobic culture, critical
Clean catch (unable to void) bacterial quantification
20-30ml risk for infection infants

• Preservatives:
o Ref 4-6 C upto 8 hours
o Chemical (antimicrobial):
Toluene, formalin, thymol, chloroform
Boric acid (for hormonal assay: estriol, estrogen)
Na Fluoride (ideal for glucose)
o 50% alcohol (1:1) for tumor cell evaluation in urine

GROSS EXAMINATION
PARAMETERS NORMAL ABNORMAL
Color Pale yellow – amber Yellow-brown = nitrofurantoin, metronidazole, primaquine, sulfonamide, liver disorder
(urochrome) Orange-yellow = rifampin, warfarin, dihydroergotamine, b complex, carotene, dehydration, liver disorder
Red/pink = doxorubicin, ibuprofen, salicylate, heparin, methyldopa, blackberry, beet, hemoglobinuria
Transparency Clear – Slight Hazy Hazy/cloudy: UTI
Turbid: amorphous phosphate/urate, bacteria, blood, pus, mucus, epithelial cells, fat globules
Volume Newborn: 20-350 mL/24 hr Polyuria: 2000 mL/24 hr
(24 hr) Children: 750-1500 mL/24 hr Oliguria: <30 mL/hr or 500 mL/24 hr
Adult: 1250-1500 mL/24 hr
Odor Aromatic (influenced by disease, diet, bacteria)
SG 1.016-1.022 Hyposthenuric: low SG < 1.007 (Diabetes insipidus)
(Refractometer) Newborn: 1.012 Isosthenuric: severe renal damage 1.010
(Urinometer) Infants: 1.002-1.006 Hypersthenuric: high SG > 1.010
Indicates concentration of solids (urea, phosphate, chlorides), kidney’s concentrating & excretory ability
(Indirect) Refractometer = 1-2 drops, easy,
(Indirect) Reagent strip = based on pKa changes
(Direct) Urinometer = >15 mL urine (correction factor for temp, protein, glucose)
 CHEMICAL ANALYSIS
PARAMETER NORMAL PRINCIPLE INTERPRETATION
pH 5.5-8.0 >7 = Alkaline <7 = Acidic Influenced by diet, renal disease, metabolic disease, drugs
Double indicator Alkaline pH = Bacteria, UTI, Vegetarian, CRF, citrus fruit
Acidic Ph = High Protein, uncontrolled DM, diarrhea,
starvation, dehydration, metab/respi acidosis
Protein ---------- REAGENT STRIP Proteinuria > 150 mg/24 hr = renal disease
(most widely used: albumin only) Plasma protein
PROTEIN Fixed pH level Urinary tract protein
ERROR OF Scanty (Tamm horsfall glycoprotein, IgA, enzyme, desquamated WBC)
INDICATORS ACID PPT (confirm) Bence jones protein: mixture of abnormal serum protein of LMW
Protein denaturation Multiple myeloma, lymphoma, macroglobulinemia
Sulfosalicylic acid, Acetic acid, Nitric acid Electrophoresis & immunophoresis
2cc urine Heat & Acid test: Glomerular membrane damage, impaired
Negative, Trace, 1+ (Fine cloudy), 2+ (granular renal tubular absorption, MM, Diabetic nephropathy,
cloudy), 3+ (dense cloudy), 4+ (heavy ppt to solid preeclampsia, orthostatic/postural proteinuria
coagulum)
BJP
Electrophoresis & immunophoresis
Glucose -------- REAGENT STRIP Glycosuria > 180-200 mg/dL
Double sequential enzyme reaction: False (+): Strongly oxidizing cleaning agent (bleach, peroxide)
130 mg/24 hr Glucose oxidase & peroxidase False (-): NaF preservative
0.01-0.03 Glucose + O2 → Gluconic acid + H2O2 False (-): large Qty of homogentistic acid & ascorbic acid
mg/100 mL H2O2 + O-toluidine (peroxidase, chromogen)
→ Oxidized O-toluidine + H2O Benedict’s test: DM, Impaired tubular reabsorption, CNS
damage, thyroid disorder, GDM
COPPER REDUCTION TEST (-) Blue = none
Benedict’s & Clinitest (Trace) Pale green
(blue) CuSo4 + reduced glucose → 1+ Greenish ppt = traces of reducing sugar
2+ Yellow orange ppt
(yellow red) Cu2O + Oxidized glucose 3+ orange red ppt = moderate
8 drops urine + 5ml benedict’s reagent 4+ Brick-red ppt = large amount of reducing sugar
Bilirubin -------- Sample must be protected from light Bilirubinuria
OXIDATION TEST OXIDATION TEST
Bilirubin → biliverdin (+) Green; interfered by salicylate, phenazopyridine (purple)
BaCl2 PPT phosphates → concentrate bile pigment DIAZOTIZATION TEST
DIAZOTIZATION TEST (DIAZO) 2,4-Dichloroaniline = colored brown by bilirubin
More specific, reagent strip FOUCHET’S (HARRISON’S SPOT)
FOUCHET’S TEST (+) Blue green ppt
2 drop urine on filter paper Hepatic cirrhosis, biliary obstruction
+ 1 drop 10% BaCl2 + 1 drop Fouchet
Urobilinogen 0.5 – 2.5 unit/ EHRLICH’S ALDEHYDE TEST Liver disease, hemolytic disorder
24hr 5 cc urine
+ 7 drops ehrlich aldehyde reagent = 5 min Don’t expose to light
(colorless) → (red-purple)
Ketone bodies -------- Fresh urine (ketosis) Acetoacetic acid, beta-hydroxybutyric acid, acetone
125 mg/24hr Acetoacetic acid > B-OHbutyric acid > acetone Liver glycogen depletion
Metabolic end Standing: → arrested oxidation of ketone compounds → ketosis
products of FA Acetone > acetoacetic acid & B-OHbutyric acid In Glucose (+) urine, always test for ketone bodies
metabolism ROTHERA’S TEST
5 ml urine + ammonium sulfate crystal ROTHERA’S TEST
Saturate then add 2 drops Na nitroprusside
Overly with ammonium hydroxide
Diabetic ketoacidosis, starvation, excessive carbs loss
(+) Red-purple ring = acetone Starvation
Nitrite Nitrite reduction UTI
(+) = G(-) rods = E.coli, Klebsiella, Enterobacter, proteus

Leukocyte Granulocyte esterase reduction UTI

esterase (+) = presence of WBC
Blood PSEUDOPEROXIDASE activity of Hb

MICROSCOPIC ANALYSIS
WBC RBC RBC Look-alike
• Normal : • Normal : • Oil droplets: highly refractive, variable size
Male = 0-1/hpf Male = 0-2/hpf • Yeast cells: budding
Female = 1-5/hpf Female = 3-5/hpf Dilute acetic acid: dissolves RBC
• INC WBC = PYURIA • Highly refractive, round, yellowish, anucleated
• Granular with visible nucleus • Not fresh: faint, colorless circles/disc
 CASTS: Translucent cylindrical structure w/parallel sides & blunt round ends
Formed in renal tubules (protein accumulation & precipitation)
CELLULAR GRANULAR HYALINE (0-2 /LPO) WAXY
• Contain RBC, WBC, epithelial cells in protein • Contain remnants of • Occasionally present • Rare, final phase of dissolution
RBC glomerular lesion/ renal disintegrated cells in normal urine of granular casts
casts parenchymal bleeding • Fine/ coarse granules • Mild renal damage • Blunted edges, cracks, chronic
WBC renal parenchymal infection • Embedded in protein • Exercise, fever, CHF, renal autograph rejection, tubular
casts (tubule-interstitial disease) • Indicate serious damage diuretic tx inflammation, degeneration
PYELONEPHRITIS • Glomerulonephritis • Tamm horsfall • high refractive index = easily visualized
Epithelial renal allograph rejection, • Pyelonephritis • Pathologic > 2/LPF • RENAL FAILURE CASTS
casts acute tubular necrosis, virus, • Hyaline matrix + granules • Advance tubular atrophy
heavy metal poisoning • Dilatation of ESRD

EPITHELIAL CELLS: normal sloughing of aging cells

SQUAMOUS CELLS TRANSITIONAL CELLS RENAL TUBULAR EPITHELIAL CELL
Most common cell lining urethra Cells lining renal pelvis, bladder, upper male urethra Oblong/ egg shaped cells
Largest cell in normal urine, flat Round/pear shaped Coarsely granular cytoplasm
Distinct small nucleus, much cytoplasm Round & centrally located cytoplasm Most clinically significant epithelium
Vacuole and irregular nuclei
Oval fat bodies = renal tubular cells absorbing lipoprotein with cholesterol leaking from nephrotic glomeruli. (Lipiduria)
Polarized light = maltese cross formation
Rare, few, moderate per hpf. Abnormal crystals: averaged per lpf
ACIDC URINE ALKALINE URINE
Amorphous Yellow brown granules Amorphous Thorny apples (irregular spines)
urate Clumps: resemble granular casts biurates Yellowish, opaque, spheroidal bodies
Refrigerated specimen Old specimen
Pink sediment +/- ammonia (urea splitting bacteria)
Calcium Looks like envelopes with X intersection (envelope) Amorphous Colorless amorphous
oxalate Most common: Dihydrate (Colorless, octahedral, referactive) phosphate Granular masses
less common: monohydrate (dumbbell, oval) Cause white PPT
high potential for renal stone formation Doesn’t dissolve on warming
Uric acid Shapes: rhombic, whetstone (4-sided flat), wedges, rosettes Post-refrigeration
INC purines & nucleic acids Calcium Small, colorless, dumbbell, spherical
Leukemia receiving chemotherapy carbonate Clumps: resemble amorphous
Lesch Nyhan syndrome Distinguished by adding acetic acid:
Gout (+) gas formation
Triple Colorless, highly refractile prisms
phosphate Birefringent, alkaline urine
(Ammonium Mg 3-6 sides
phosphate) Urea splitting bacteria UTI
Coffin lid crystals, rosette shape
Calcium Pointing finger forms
phosphate Not much significance

OTHER CRYSTALS ABNORMAL CRYSTALS

Bilirubin Hepatic disorder Cholesterol Colorless, flat plate with notched corners
Sodium urates Nephrotic syndrome
Sulfonamide Inadequate hydration Refrigerated specimen (lipids remain in droplet form)
UTI treatment Cystine Colorless, refractile, flat hexagonal, Undequal sides
Cystinuria
Metabolic disorder: prevent reabsorption of cysteine by renal tubules
Leucine Yellow-brown spheres: concentric circles & radial striation
Less frequent than tyrosine crystal (should be accompanied by tyrosine)
Liver disease
Tyrosine Fine colorless to yellow needles
Clumps/ rosette formation: sheaves
In conjunction with leucine crystals and (+) bilirubin (chemically)
Liver disease, inherited AA metabolism disorder

SEROUS FLUID
PLEURAL PERICARDIAL PERITONEAL
• 5-15 mL • 10-50 mL • up to 50 mL
• Light’s criteria (exudate): • Pale yellow, clear • ascites > 50 mL
o protein ratio > 0.5 • viral infection • CHF, Cirrhosis, hypoproteinemia, infection, neoplasm
o LDH ratio > 0.6 • Light’s criteria applicable • ascites > 1.1 g/dL albumin gradient (transudate)
o LDH >2/3 serum upper limit • cell count, cytology • ascites < 1.1 g/dL albumin gradient (exudate)
• Chemical analysis: protein, lactate, glucose, • glucose, LDH, • paracentesis, peritoneal dialysis
lipid, pH, amylase, serology, tumor marker • G/S, culture • gross exam, wbc cytology & count, culture
• Microbiological: G/S, AFB
Transudate (clear, pale yellow-straw, odorless, unclotted)
Exudate (cloudy, turbid, clotted if not heparinized)
 CSF (3rd major body fluid)
supply nutrients, remove metabolic waste, mechanical barrier
produced by choroid plexus & reabsorbed by arachnoid villi
Adult 90-150 mL; Neonate 10-60 mL
Collection: Fetal position L3-L5 (ICP 90-180 mmH2O; 20 mL can be removed)
2-4 mL = Tube 1 (chemical, serology), Tube 2 (microbio), Tube 3 (cell count)
LP indication: infection, malignancy, SAH, demyelinating disease
GROSS/MACROSCOPIC CHEMICAL MICROSCOPIC
• NV = clear and colorless • NV = • Turbid = similar to water
• Pink/red = RBC > 6000 (Hemorrhage/traumatic tap) Protein 15-45 mg/dL • Cloudy/turbid = WBC > 200; RBC > 400, protein >
• Xanthochromic: RBC lysis, Hb breakdown, hyperBIL, • INC protein = INC 150, microorganism, radiocontrast dye
hyperVIT A, melanoma permeability in BBB, • lymphocyte : monocyte (70:30)
• Cloudy, milky, turbidity = lipid protein WBC meningitis, INC Ig • Pleocytosis: INC WBC in lymphocyte
• False (+) turbidity = long standing specimen/ detergent • Nephelometry • Normal wbc in adult = 0-5 (neonate 0-30)
contamination • CSF: serum albumin • normal rbc = 0
• Clot/pellicle = traumatic tap, froin’s syndrome, tb ratio < 9 (intact BBB) • Neutrophilia: bacterial meningitis, early infection (TB,
meningitis (web like) • DEC protein = removal fungal, viral meningitis), cerebral abscess, CNS
• Traumatic = uneven blood distribution, clot formation /leak of CSF hemorrhage/ infarct, seizure, repeated LP, radiographic dye
• Hemorrhage = even distribution, hemosiderin laden • DEC Glucose = bacteria • Lymphocytosis: TB, fungal, viral meningitis, MS, GBS,
macrophages, erythrophagocytosis, xanthochromic supernatant SSPE, Eosinophilia