ANALYSIS OF URINE AND OTHER BODY FLUIDS

Prepared by: Jedidiah P. Calunsag

Renal Function and Test

Renal Physiology
1.Each kidney- contains approximately 1 to 1.5 million functional units called nephrons.
 the human kidney contains two types of nephrons.
 Cortical nephrons, which make up approximately 85% of nephrons, are situated primarily in the cortex
of the kidney. They are responsible primarily for removal of waste products and reabsorption of
nutrients.
 Juxtamedullary nephrons have longer loops of Henle that extend deep into the medulla of the kidney.
Their primary function is concentration of the urine.
2. Nephron-basic structural unit of the kidney
3.Two types of Nephron
a. Cortical- which make up approximately 85% of nephrons, are situated primarily in the cortex of the
kidney. They are responsible primarily for removal of waste products and reabsorption of nutrients.
b. Juxtamedullary nephrons- have longer loops of Henle that extend deep into the medulla of the
kidney. Their primary function is concentration of the urine.
4.Blood Flow : (AEPV) Afferent, Efferent arteriole, Peritubular capillaries, Vasa recta
5.Kidney receives approximately 25% of the blood
6. Glomerulus:
a. consist of coils of capillary lobes (8)
b. Glomerular filtration Barriers
I. Capillary wall membrane – fenestrated (has pore)
II. Basement membrane
III. Visceral epithelium of Bowman's capsule
c. Podocytes - Epithelial cells of the inner lining of Bowman’s capsule that contain footlike processes
 Contribute to the negative charge of glomerulus, this is called shield of negativity
 Cause na hindi tayo nagmamanas
d. Shield of Negativity - repels negative charge protein
e. Glomerulus only allows less than 70 kl KD 70,000; several factors influence the actual filtration
process.
f. Specific Gravity of Plasma filtrate entering the glomerulus is 1.010.

7.Glomerular filtration tests

 Indicator of the level of the kidney function. It is used to monitor the extent of damage, and not the
detection of early damage.
 Ilan ang nakakapasok per unit
a. Clearance test-the standard test used to measure the filtering capacity of the glomeruli.
b. The greatest source of error in any clearance procedure using urine is the use of Improperly timed
urine specimen
c. Exogenous:
I. Inulin clearance- gold standard (reference method). The characteristics is filtered only
 Blood to glomerulus we called it filtered. Tubules to blood, we called it reabsorption. Blood to tubules,
we call it secretes or secretion.
 Inulin should be increase in urine and decrease in blood
 Inulin, a polymer of fructose, is an extremely stable substance that is not reabsorbed or secreted by the
tubules. It is not a normal body constituent, however, and must be infused at a constant rate throughout
the testing period. A test that requires an infused substance is termed an exogenous procedure and is
seldom the method of choice if a suitable test substance is already present in the body (endogenous
procedure). Therefore, although inulin was the original reference method for clearance tests, it is
currently not used for glomerular filtration testing.

II. Radionucleotides - Valuable to viability of a transplanted kidney

 Iodine 125/ Iothalamate will inject to reject kidney it retains to the blood instead of the urine.
Radioactive meaning kidney has a problem
  In good kidney iodine 125 proceeds to urine and the transplantation is success and no graft rejection.
 Kidney: most transplanted organ

d. Endogenous:
I. Urea- old
II. Cystatin C - Small protein produced by all nucleated cells, filtered then reabsorbed and broken
by RTE (renal tubular epithelial cell). If the glomerulus is good cystatin C is normal. If the
glomerulus is damage the cystatin C will increase
III. Beta 2 microglobulin - from HLA and removed from plasma by filtration.
 HLA1 is found in nucleated cells
IV. Creatinine - Most commonly used. It is not the gold standard because
1. Disadvantages- Drug interference, bacteria, heavy Meat diet, and rhabdomyolysis
(muscle wasting)
2. CREATININE CLEARANCE
a. Formula:
b. Where:
Ccr = creatinine clearance
U = urine creatinine (mg/dL)
P = plasma creatinine
V = urine volume (mL/min)
A = body surface
c. NV: male: 107-139 mL/min
: Female: 87-107 mL/min
d. Sample Problem:
Given the following data, compute for creatinine clearance:
Urine crea: 120mg/dL
Plasma crea: 1 mg/dL
Urine vol. in 24 hrs: 1440mL
Patient of average body surface area

8. Proximal convoluted tubule

 Main tubular reabsorption secretion
a. both reabsorption and secretion of substance
b. Tubular Reabsorption
I. Ascending loop of henle – does not reabsorb water. This is where cast are produced
II. 65% of reabsorption of substances.
III. Reabsorbs bicarbonate, urea, salt, water, amino acid and glucose (BUSWAG)
 IV. Glucose Renal Threshold 160-180 mg/dL
 Example may pumasok na 250 glucose, ang ibabalik lang is 160-180, yung 70 na natitira
magshushutdown and matatapon na sa urine.
V. Aldosterone – for sodium retention
 High aldosterone is CONS- increase sodium and decrease potassium
 Low aldosterone is Addison- decrease sodium and increase potassium

c. Tubular Reabsorption Tests

I. Concentration test used to evaluate tubular reabsorption.
 Unhealth: decrease concentration
 Healthy: increase concentration
II. the loss of tubular reabsorption capability is often the first function affected in renal disease
III. Old Tests: F.M.
1. Fishberg: patients were deprived of fluids for 24 hours prior to measuring specific
gravity.
 H2O deprivation for 24 hours
 Normal: greater than or equal to 1.026
 Kidney damage: less than 1.026
2. Mosenthal: compared the volume and specific gravity of day and night urine samples to
evaluate concentrating ability

IV. New test: S.O
1. Specific Gravity: affected by size or density and number
2. Osmolality: number only
a) urine to serum ratio of 3:1 = normal/ controlled fluid
b) urine osmolarity of 800 mOsm or greater indicates = normal.
c) Normal random condition (US 1:1)
d) Plasma Osmolality = 275-295 mmol/kg

d. Tubular Secretion
I. Elimination of waste product products not filtered by the glomerulus
II. regulation of the acid-base balance in the body through the secretion of hydrogen ions.
III. Renal Tubular Acidosis Metabolic Acidosis
1. Inability to produce acidic urine
2. Hydrogen ions are not excreted
IV. Tubular Secretion and Renal Blood Flow Tests
1. PAH (p-aminohippuric acid test)
a) Most common associated with Tubular secretion and renal blood flow
b) PAH→ Secreted from the Peritubular capillaries to PCT → Urine → Measured in
urine
c) PAH kapag di nakapasok mababa siya sa urine may problem sa tubules

2. PSP (phenolsulfonphthalein) test

a) not currently Performed: possible anaphylaxis
b) Results are too difficult to interpret.

9. Distal convoluted tubule

a. Final adjustment of the urinary composition
b. Secretes ammonia (NH3) and sodium (Na+) Reabsorbs

10. Collecting Duct

a. permeable to water only in the presence of ADH
b. Antidiuretic Hormone (ADH/Vasopressin)
I. Released by the posterior pituitary gland by the stimulation of RAAS (renin-angiotensin
aldosterone system)
II. Regulates water reabsorption in the DCT and CD
 III. Diabetes insipidus = ADH deficient or resistant (polyuria with low SG)
 Hindi umiinom pero ihi ng ihi
1. ADH Test for Osmolality for Diabetes Insipidus:
 Neurogenic DI (ADH deficient)
 Nephrogenic DI (ADH resistant)
 Causes polyuria
IV. SIADH = ADH excess
 Inom ng inom pero walang urge umihi
 Syndrome of inappropriate ADH secretion
V. Factors that suppress the secretion of Antidiuretic hormone: Anti CAD
C- coffee A- alcohol D- diuretics

URINALYSIS
History
Names Contribution
Hippocrates (5th century BC) Uroscopy
Frederik Dekkers’ (1694) Discovered albuminuria by boiling urine
Pisse Prophets Charlatans who compromised urinalysis
Thomas Bryant (1627) Wrote about the charlatans -
Richard Bright introduced urinalysis as part of doctor's routine
patient exam
Thomas Addis Quantitating of urine sediments

Urine Formation
1. Urine is the ultrafiltrate of plasma
2. Total renal blood flow: approximately 1200 mL/min
3. Total renal plasma flow/filtered plasma: ranges 600 to 700 mL/min

Urine Composition
1. Urine is 95% water and 5% solutes
2. It is composed of organic and inorganic component.
3. Urine is normally acidic
4. Urea- principal ORGANIC
5. Creatinine- from muscle metabolism
6. Uric Acid- form purine
 Organic: urea, creatinine and uric acid
7. Chloride-principal inorganic
 Inorganic salt: sodium chloride (NaCl)
8. Potassium K-Combined with chloride and other salt
9. Sulfate (SO4) - Derived from amino acids
10. Phosphate- combine with hydrogen
11. Ammonium (NH4)-Regulates blood and tissue fluid acidity
12. Urea and Creatinine-constituents that indicate that a fluid is a urine
13. Formed elements of urine: Cells, casts, crystals, mucus and bacteria

Urine Volume
1. Normal urine daily output: 1,200 – 1,500/ day (600-2L/ day = normal)
2. Oliguria- less than 400 mL
3. Anuria cessation of urine flow
4. Nocturia - increase Urine at night. Normal 400 mL
5. Polyuria-Greater than 2.5 L/day

Specimen Collection/Rejection/Handling/Integrity/Preservation
1. Specimen is collected in clean, dry, leak-proof containers.
2. Container capacity: 50 mL
3. Needed specimen volume: 12 mL
 4. Label must be attached to the container not to the LID
5. Rejection:
a. unlabeled
b. nonmatching labels and request form,
c. contaminated with feces or toilet papers.
d. contaminated exteriors.
e. insufficient quantity, and
f. improperly transported
6. NEVER DISCARD a specimen before checking with a supervisor
7. HANDLING: Specimen should be delivered and tested: within 2 hours / less than 2 hours
8. Increase in unpreserved Urine: pBaON
a. Bacteria: multiplication
b. pH: ammonia (alkaline)
c. Odor: odor of ammonia
d. Nitrite: bacteria
Causes turbid urine
9. Decrease in Unpreserved Urine:
a. Clarity: consume bacteria
b. Glucose: consume bacteria
c. Ketones: consume bacteria and volatile
d. Bilirubin: photooxidation (biliverdin)
e. Urobilinogen: photooxidation (urobilin)
f. RBC/WBC and cast: disintegrate in alkaline urine

10. Not Affect in unpreserved Urine: protein

11. PRESERVATION:
a. Refrigeration = most common preservation (2-8 degrees) (it increase the specific gravity due
to precipitation of amorphous)
b. Boric acid-Bacteriostatic = culture and sensitivity (interfere with drugs and hormones analysis)
c. Formalin (formaldehyde) – excellent sediment preservative
d. Sodium fluoride- inhibits glycolysis.
e. Saccamano fixative-Used for cytology studies

Types of Specimens
1. Random
 Most common
2. 1st morning
 Concentrated
 Possible for pregnancy test
 Cadet proteinuria
3. Diabetes Mellitus
a. Fasting (2 morning)
b. 2 hour Postprandial
c. Glucose tolerance Test (GTT)
4. For Quantitation
a. 24 hour (time specimen) = chem test (electrolytes, WBC, catecholamines)
b. 12 hour -For addis count = formed elements (hyaline cast)
5. Bacterial Analysis
a. Midstream clean catch
b. Catheterized- use of catheter, papunta sa urethra papunta sa urinary bladder
c. Suprapubic aspiration = optimal sample (hindi nya dadaan ang urethra, tha is contaminated
with catheterized)
6. 3 glass collection
 1st = urethra, contaminated
 2nd = uncontaminated, represents urinary bladder
 Before 3rd collection is massage the prostate
  3rd = urine and prostate fluid. It should be sterile. Check for WBC and culture
 Prostitis = 3rd glass is 10 x WBC and bacterial count than 1st glass
 Invalid = if growth in 2nd glass
 If growth in all glasses there is presence of cystitis and UTI

7. Pediatric specimen
 Uses plastic bag or wee bag
8. 4 hour
 Nitrate
9. Afternoon (2pm - 4pm)
 Urobilinogen (ayawa nya ng acid, gusto niya acid lang)
 Alkaline tide
10. 5 hour
 Dixyloce test (for maldigestion and malabsorption)
11. Drug testing Specimen
a. Urine volume: 30-45 mL
 Matagal masira ang drusgs sa urine
b. Urine temperature: 32.5-37.7 degrees Celsius
c. Chain of custody- is the process that provides the documentation of proper sample ID from
the time of collection to the receipt of lab results. All handling personnel is noted.

PHYSICAL EXAMINATION OF THE URINE COLOR

1. Good light source against white background
2. Urochrome- gives normal color to urine (yellow) (from metabolism and any condition causes
increase metabolism caused dark yellow)
3. Uroerythrin- pink pigment (usually after refrigeration)
4. Urobilin- an oxidation product of urobilinogen (orange brown)

COLOR, CAUSE, AND CLINICAL LAB CORRELATIONS

1. Colorless -Recent fluid consumption - In random specimens, polyuria and DI
2. Pale yellow
a. Polyuria, DI-Inc. 24 hr volume
b. DM-Elevated specific gravity and (+)Glucose
3. Dark yellow
a. Concentrated specimen - After strenuous exercise and 1" morning specimen
b. Dehydration - burns, fever
c. Bilirubin (eg, hepatitis virus)- yellow foam when shaken and (+) chemical test
4. Orange-yellow-Pyridium (phenazopyridium) - UTI antibiotic
 Orange foam that is viscous
5. Yellow-green
a. Bilirubin oxidized to biliverdin - Colored foam in acidic urine
6. Green
a. Pseudomonas infection-(+) urine culture
7. Blue green/ indicant
a. Amitriptyline – Antidepressant
b. Methocarbamol (Robaxin) - Muscle relaxant
8. Pink
a. RBCS- cloudy urine can turn into clear due to hemolysis of intact RBC
b. Cloudy urine w/ (+) blood chem test and microscopy: hematuria, menstrual contamination
9. Red
a. Hemoglobin- clear urine (+) blood chem test. Intravascular hemolysis
b. Myoglobin-Clear urine. (+) blood chem test. Muscle damage / rhabdomyolysis
c. Porphyrins - Negative chem test for blood but detected with, Watson- schwartz screening test
d. Beets - Alkaline urine genetically susceptible person
e. Rifampin - Tuberculosis medication
 f. PSP-red color in alkaline

10. Port wine/ burgundy

a. Porphyrins - Negative for blood test

11. Red-brown
a. RBCs oxidized to methemoglobin-Seen in acidic urine after standing. (+) chem test result
for blood

12. Brown
a. Homogentisic acid (alkaptonuria) - Seen in alkaline urine
b. Fresh brown urine may be an indicative of glomerular bleeding resulting from conversion of
hemoglobin to methemoglobin

13. Black
a. Malignant melanoma – melanin
I. Urine darkens upon air exposure
 Release melanogen (clear) +O2 = black

14. Cola colored methyldopa-rhabdomyolysis

White foam: albumin

CLARITY
1. Refers to transparency/turbidity.
2. The specimen in front of a light source, against a, newspaper print.

CLARITY AND TERM

1. Clear -NO visible particulates, transparent
2. Hazy- few Particulates print easily seen through urine
3. Cloudy- many Particulates, print blurred through urine
4. Turbid - Print cannot be seen through urine
5. Milky- May precipitate or be clotted

NONPATHOLOGIC CAUSES OF URINE TURBIDITY

1. Squamous epithelial cells
2. Mucus
3. Amorphous Phosphates
4. Amorphous urates
5. Semen
6. Fecal contam
7. Radiographic contrast media
8. Talcum Powder
9. Vaginal creams

PATHOLOGIC TURBIDITY
1. RBC, WBC, and Bacteria
2. Bacteria
3. Yeast
4. Non squamous epithelial cells – RTE (because of its origin)
5. Abnormal crystals
6. Lymph – chyluria (chyle) (chylomicron) (milky)
7. Lipids – nephrotic syndrome

SOLUBILITY/ ability to dissolve

1. Acidic Urine-Amorphous urate. Radiographic contrast media
 2. Basic urine-Amorphous phosphates, carbonates
3. Soluble with heat (60 degrees Celsius) – amorphous urates, Uric acid crystals
4. Soluble in Dilute acetic acid -RBCs, Amorphous phosphates
5. Insoluble in Dilute Acetic Acid- WBCs, Bacteria, yeast, Spermatozoa --- still turbid
6. Soluble in ether - Lipids, Lymph, Chyle
 Chyle, Ether, Lymph, Lipid (C E L L)

SPECIFIC GRAVITY
1. Density of solution vs. Density of Distilled water
2. is influenced not only by the number of particles present but also by their size/ density

TERMS
1. Isosthenuria = 1.010
2. Hyposthenuria = LESS THAN 1.010
3. Hypersthenuria = GREATER THAN 1.010
4. SG>1.040= radiographic dye and hypovolemic taking plasma expanders

Urinometry (Urinometer/Hydrometer)
1. Calibration Temp: 20 °C
2. Requires Temp. correction
a. -0.001 for every 3 °C below the calibration temp (<20C)
b. +0.001 for every 3 °C above the calibration temp. (>20C)
3. Require Correction for glucose and proteins
a. 1g/dL Glucose = -0.004
b. 1g/dL Protein = -0.003
4. Urine volume required: 10-15 mL

Refractometry (Refractometer/ TS (total solid) meter)

 Kung saan tumapat ang ilaw yung ang SG
1. it uses prism to direct a specific wavelength
2. based on refractive index (RI)
3. Compensated to temperature
4. Requires correction for glucose and protein
5. Calibration:
a. Distilled water: 1
b. 5% NaCl: 1.022 +/- 0.001
c. 9% Sucrose: 1.034 +/- 0.001
d. Triple distilled water: 1
6. Refractometry reading is lower than the urinometer reading by 0.002
7. Sample: urine drop

Harmonic Oscillation Densitometry

1. Based on the principle that the frequency of a sound wave entering a solution change in proportion to
the density of the solution
2. SG 1.080
3. U shaped glass with an electromagnetic coil.

Falling Drop Method

1. It is more accurate than the refractometer, and is more precise than the urinometer

ODOR
1) Aromatic: normal
2) Foul, ammoniacal/ pungent: UTI or old specimen
3) Fruity, sweet: ketones
4) Caramelized sugar, maple syrup: maple syrup urine disease
 5) Mousy: pKU
6) Rancid Butter: tyrosinemia
7) Sweaty feet: isovaleric acidemia
8) Cabbage, hops: methionine malabsorption
9) Bleach: contamination
10) Sulfur: cystine disorder
11) Rotting fish: trimethylaminuria
12) Pungent: onion and garlic intake

Chemical Examinations of Urine

REAGENT STRIP TECHNIQUE
1. Room temp
2. Dip the reagent strip less than 1 sec
3. Remove excess by touching the edge of the strip to the container
4. Blot the edge of the strip on an absorbent
5. Wait for specified reading time (1 minute to 2 minutes)
6. Compare the color reaction to the manufacturer's chart

ERRORS CAUSED BY IMPROPER TECHNIQUE

1. unmixed specimen = RBC and WBC will settle that causes false decrease
2. reagent pad leaching = prolonged dip
3. run-over to other pad = runover

CARE OF REAGENT STRIPS

1. opaque tightly closed container
2. store below 30 degrees Celsius (room temperature), don’t freeze
3. Do not expose to volatile fumes
4. Do not use past the expiration date
5. Do not use if chemical pads become discolored
6. Remove strips immediately prior to use.

AUTOMATED REAGENT STRIP READERS:

1. Principle = Reflectance Photometry
 Reflection is inversely proportional to concentration

ENZYME-BASED TESTS
1. Glucose = enzyme is reagent
2. Blood = no enzyme but hemoglobin (pseudoperoxidase)
3. Leukocyte = enzyme is the sample

GLUCOSE (DEXTROSE)
1. The most frequent chemical analysis performed on urine.
2. In conjunction with blood glucose.
3. Threshold substance: 160-180 mg/dL
4. tested with Ketones or HbA1c for DM.
5. Unpreserved urine - greatest technical error in false negative glucose
6. Fasting
7. Clinical Significance
Renal associated Hyperglycemia associated
Blood glucose: normal Blood glucose: high
Urine glucose: high Urine glucose: high

ESRD (END-STAGE RENAL DISEASE) GLUCAGON

FANCONI SYNDROME ACTH
PREGNANCY (lower threshold) GWORTH HORMONE
CORTISOL
 EPINEPHRINE

DIABETIS MELLITUS
CUSHING
STRESS
ACROMEGALY
NEUROBLASTOMA
HYPERTHYROIDISM

8. Reagent Strip Reaction for Glucose (30 seconds)

a. Principle: Double sequential enzyme
b. Glucose + O2 (air) ---Glucose oxidase---> Gluconic Acid + H202
H2O2 + Chromogen --Peroxidase--> Oxidized Chromogen + H20
c. Interference:
i. False positive-strong oxidizing agents and detergent, low SG
ii. False Negative (prevents oxidation of chromogen) - reducing agent - High level of
ascorbic acid.

9. Copper Reduction Test (benedict's test)

a. Test: Nonspecific test for Reducing sugars except the sucrose
b. Principle: Copper reduction test
c. CuSO4 + Reducing Substance ----------- > (+) Cu20

d. Interference:
I. False Positive: Reducing agents: Vit C. Uric Acid.homogentisic acid
II. False Negative: Oxidizing Agent: Detergents

10. Clinitest Procedure (copper reduction)

a. 5gtts urine + 10 gtts H20+ Clinitest tablet
b. Clinitest components: CuSo4, NaCO3, Sodium Citrate, NaOH

11. Reagent Strip for Glucose is more sensitive and specific for glucose than CLINITEST

BLOOD
1. Rgt strip detects: Hematuria, Hemoglobinuria, and Myoglobinuria
2. Most accurate means for determining the presence of blood.
3. Clinical Significance:

Hematuria Hemoglobinuria Myoglobinuria

Cloudy urine/ intact RBC
Strenuous exercise
Clear  Crush syndrome
 Rhabdomyolysis
 Microangiopathic  Prolonged coma
hemolytic  Convulsion
anemia  Alcoholism
 Statin (side effect in
Strenuous exercise muscle damage)

Strenuous exercise
 4. Reagent strip: pseudoperoxidase of hemoglobin

a. (-) Yellow (+) Green to Blue

b. Speckled/Spotted = hematuria
c. Sensitive: it can detect as low as five RBC per microliter
d. Interferences:
I. False Positive: Strong oxidizing agent, Bacterial peroxidases E.coli peroxidase,
menstrual contam
II. False Negative: High SG. crenated cells, formalin, captopril. High Conc. Of nitrite. Vit C.
unmixed specimen.
e. iodate impregnated mesh = oxidize the vitamin C because it is interfering substance

5. Blondheim's Test
a. Differentiate Hemoglobin and Myoglobin which are both clear red urine
b. Reagent: Ammonium sulfate
c. Procedure: 5 mL centrifuged Urine +2.8 g NH4 sulfate → Filter/Centrifuge→ Test supernatant
for blood with rgt strip
d. Result
i. Hemoglobin = Precipitated by the NH4 sulfate negative rgt strip test
ii. Myoglobin = Not precipitated by the NH4 sulfate positive rgt strip test

LEUKOCYTE ESTERASE (enzyme is sample)

1. Significance: UTI/inflammation
 If WBC lyse, negative microscopic
2. Screening of urine culture specimen
3. More standardized means for the detection of leukocytes.
4. most frequently accompanied by the presence of bacteria
5. LE test contributes significantly more to the reliability than does the nitrite test.
6. Reagent Strip Reaction For Leukocytes (120 Sec)
a. Principle: leukocyte esterase

b. Notes Contain Esterase = granulocytes, monocytes, and trichomonas (strawberry cervix,

ping pong disease)

CHEMICAL-BASED TESTS
PH
1. Major regulators of Acid base balance: lungs and kidneys
2. First morning specimen: pH 5-6
3. Normal random specimens: 4.5 to as high as 8 (8.5 reject meaning old specimen)
4. NO normal values are assigned to urinary pH:
5. Clinical Significance

Acid urine Alkaline urine

 Diabetes mellitus = I-ketoacidosis, II-  Vomit
Nonketoacidosis  Vegetarian
 Starvation = ketoacids  Renal tubular acidosis
  Any na  Urine: base
nagpapababa  Blood: acid
ng glucose,  Hyperventilation: kabaliktaran ng emphysema
tumataas ang (increase carbon dioxide excreation)
ketones
 Emphysema = CO2 retention
 Diarrhea
 Meat diet

6. renal calculi: formed by acidic pH

7. identification of crystals: pH is important/ utilized
8. Reagent Strip: double indicator
 Methyl red: acid
 Bromthymol blue: less acid

PROTEIN
1. The most indicative associated with early renal disease.
2. Normal urine contains very little protein, but not detectable
3. Albumin – major serum protein found in normal urine (only detected in the strip)
4. Normal Values:
a. <10mg/dL or <100 mg/24hr
b. Protein Trace value: less than 30mg/dL
5. Clinical Significance

Proteinuria
Prerenal/ overflow Renal (kidney) Post renal (ureter down Orthostatic
(originate in blood to urethra)
 Multiple myeloma  Glomerular  Lower UTI/ Also called Postural or
(increase bence disease cystitis cadet
jones protein)  Tubular disease  Lower bleeding  Proteinuria due to
 Intravascular posture
hemolysis
(increase 1st morning = negative
hemoglobin) 2 hours standing =
 Rhabomyolisis positive urine
(increase
myoglobin)
 Inflammation
(increase acute
phase reactant)

Bakit nagmamanas ng tao?

 It is due to hydrostatic pressure
 Kapag di ka nagmamanas ni drag ni albumin yung water which is called oncotic or osmotic pressure

6. Bence Jones Protein (light chains)

a. multiple myeloma, macroglobulinemia and malignant lymphoma
b. Solubility test: screening
I. Coagulates at: 40-60 degrees Celsius (turbid)
II. Dissolves at: 80-100 degrees Celsius (clear)
 c. Confirmatory: electrophoresis

7. Non Pathologic Proteinuria/ benign proteinuria

1. strenuous exercise
2. High fever
3. Dehydration
4. Exposure to cold.
5. Orthostatic (postural proteinuria)

8. Reagent strip for protein: principle (protein error of indicator/ Sorensen)

a. Interference: False Positive

I. Highly buffered alkaline urine.
II. High SG,,QUATS, detergent, anti-septic

9. SULFOSALICYCLIC ACID (SSA) PRECIPITATION TEST

 Non specific
a. reacts equally with all forms of protein
b. SSA Procedure: 3 mL of 3% SSA + 3 mL centrifuged urine = (+) Cloudiness
c. Reporting of SSA

Ketones
1. Ketone bodies
a. 78%-Beta-hydroxybutyric acid = major ketone
b. 20%-Acetoacetic Acid = parent ketone
c. 2%-Acetone = least ketone
2. Clinical Significance
 Every mababa ang glucose tumataas ang ketones
 Diabetes mellitus
 Starvation
 Vomit
 Diarrhea
 Malabsorption
3. REAGENT STRIP for KETONES (40 SECONDS)
a. Principle: legal’s test
b. Reagent: Sodium Nitroprusside
c. Reaction: Acetoacetic acid + Na Nitroprusside ------>(+) purple
d. Glycine: if acetone is detected
e. Interference:
I. False positive: Dyes, levodopa, MESNA (mercaptoethane sulfonate medium) and
captopril.
II. False Neg: volatilization, use by bacteria.
 4. Acetest (tablet) (confirmatory)

BILIRUBIN
1. Early indication of liver disease
2. Conjugated Bilirubin (CB) – water soluble
3. Amber urine w/yellow
4. Clinical Significance:

Urine Bilirubin (conjugated) B2 Urine Urobilinogen

Hemolytic disease Negative +++
Liver damage + + or - ++
Bile duct obstruction +++ Normal to absent ----- pale yellow
to gray stool

5. REAGENT STRIP for BILIRUBIN (30 SECONDS)

a. Principle: diazo reaction

b. Notes: (+) or pink to violet

c. Tablet Test=ictotest

UROBILINOGEN
1. Intestinal Conjugated Bilirubin + Normal Flora → Urobilinogen
2. Normal in the urine: <1mg/dL or 1 ehrlich unit
 3. Specimen: afternoon urine (2-4 pm due to alkaline tide)

4. REAGENT STRIP for UROBILINOGEN (60 SEC)

Multistix

a. PRINCIPLE: Ehrlich reaction

b. Note: Ehrlich Reactive compound: Porphobilinogen, Indican. P-aminosalicylic acid, sulphonamides,
methyldopa, procaine, chlorpromazine.

5. WATSON - SCHWARTZ TEST

a. Uses extraction with organic solvents: chloroform and butanol
b. Urobilinogen – soluble to both
c. Porphobilinogen- insoluble to both
d. Other Ehrlich Reactive Compound: soluble to butanol

 Mas mabigat ang chloroform kaysa urine, may mabiagt ang urine
kaysa sa butanol
 End result: U C B U : Red na si chloroform and butanol

6. HOESCH TEST
a. rapid screening test for porphobilinogen
NITRITE
1. Rapid screening test for UTI/ bacteriuria
2. Specimen: 4 hour
3. used to monitor antibiotic therapy
4. Reductase: -6(-)
5. Low yield on random specimen
6. green leafy vegetables decrease NO3/NO2
7. Large number of bacteria: false negative
8. Terms:
a. Pyuria -pus in the urine
b. Nephritis -inflammation of the kidney
c. Pyelonephritis -inflammation in the kidney and renal pelvis infection.
d. Glomerulonephritis-inflammation of the capillary loops in the glomeruli of the kidney/nephron.
e. Cystitis -inflammation and infection of the bladder.
f. Nephrosis- degeneration of the kidney w/o inflammation
 9. REAGENT STRIP REACTION for NITRITE (60 SEC)
a. PRINCIPLE: Greiss Reaction

b. NOTES: Pink spots/edges: negative

SPECIFIC GRAVITY
1. Reagent Strip Reaction: pK, change of Polyelectrolyte
a. Urine Conc= hydrogen ions (H+) release = acidity
b. Indicator-Bromothymol Blue
c. Color Result: Blue (1.000) thru Green to Yellow (1.030)
d. False Positive: High Concentration of Protein
e. False negative: Highly alkaline urine
f. Clinical Significance:
I. Monitoring of patient hydration and dehydration
II. Loss of renal tubular concentrating ability (decrease
concentration and specific gravity)
III. Diabetes insipidus (increase H20 and decrease
specific gravity)
IV. Determination of unsatisfactory specimen to low conc

ASCORBIC ACID
1. false negative reactions on (BBLANG) (BLOOD, BILIRUBIN, LUEKOCYTENITRATE, GLUCOSE)
2. 11th reagent pad: Ascorbic
3. GC-MS
a. C stix = 10 sec
b. Stix = 60 sec.

Reading time Urine parameter Principle Positive color Disease correlation

30 seconds Glucose Double sequential *Green to brown Diabetes
enzyme
Bilirubin Diazo Reaction Tan or pink to violet Liver disease
Jaundice biliary
obstruction
40 seconds Ketones Sodium Nitro Purple Diabetes (type 1)
Prusside Starvation
Malabsorption
diabetic acidosis
45 seconds Specific gravity Pka change of Blue (SG 1.000) to
Polyelectrolyte Yellow (1.030)
60 seconds Protein Protein Blue Early renal disease
(sorensen's) error Diabetic
PPBUN of indicators nephropathy
pH Double indicator Orange (pH 5.00 to Renal tubular
system Blue (pH19.0) acidosis
Alkalosis
Blood Pseudoperoxidase Uniform green blue Hematuria
 activity of (Hgb or Mgb) Hemoglobinuria
hemoglobin Speckled/spotted Myoglobinuria
(intact RBCs)
Urobilinogen Ehrlich's reaction Hemolytic disease
bile duct
obstruction Liver
damage
Nitrate Greiss Reaction Uniform pink Infection
120 seconds Leukocyte Leukocyte esterase purple Infection and
inflammation
If potassium iodide chromogen is used

MICROSCOPIC EXAMINATION OF URINE

SEDIMENT PREPARATION
1. 12 mL urine
2. Centrifuge: 5 min and 400 RCF
3. Decant and take 20 uL
4. Placed on glass slide covered by a, 22 x 22 mm glass cover slips

SEDIMENTS STAIN
Stain Action Function
Sternheimer-Malbin (most common) Delineate structures and WBC
contrasting colors of the nucleus CAST EPITHELIAL CELL
and cytoplasm
Toluidine Blue Enhances nuclear detail WBC vs RTE
2% Acetic Acid Lyse RBC enhances nuclei of Distinguishes RBCs from WBCs,
WBCS yeast, oil droplets, & crystals
Lipid Stains Stains TAG and neutral fats -Free fat droplets
orange red -Lipid filled cells
Gram stain Differentiates Gram + and Gram -bacterial casts
(-) bacteria
Hansel stain Stains eosinophilic granules -eosinophils
Prussian blue Stains structures containing iron Hemosiderin: RTE with Fe 3+
Papanicolaou Cytodiagnostic Urine Test Prep Malignancy
of Permanent Slide

MICROSCOPES
1. Bright Field microscopy (routine)
2. Phase-contrast microscopy (for low refractive index (cast and trichomonas)
3. Polarizing microscopy (maletese cross = fatty acid, OFB, cholesterol, starch)
4. Dark field microscopy(T. pallidium sub pallidium)
5. Fluorescence microscopy (fluorescent organism)
6. Interference-contrast microscopy (3d microscopy)
a. Nomarski (Differential)
b. Hoffman (modulation)
Need Him

SEDIMENT CONSTITUENTS
 1. RBCs (hematuria) NV = 0-2 or 0-3/HPF a
a. 7mm, Smooth, non-nucleated, biconcave disks
b. most difficult urine element for students to recognize
c. glomerular bleeding----- dysmorphic
d. Renal calculi
2. WBCs (pyuria) NV-0-5 or 0-8/HPF - 12mm
a. Neutrophils-predominant
b. Eosinophils -assoc. Drud -induced interstitial nephritis
c. Mononuclear Cells -lymphocytes (smallest), macrophages, monocytes, and Histiocytes
 We can seen in graft rejection

3. Epithelial Cells
a. Squamous
I. Largest epithelial cell, irregular cytoplasm and Prominent nucleus.
II. From linings of vagina, female, urethra and lower Portion of male urethra
b. Transitional Epithelial (Urothelial) cell
I. Spherical, polyhedral or caudate with centrally located nucleus. Read per/HPF
II. Derived from the linings of renal pelvis, ureter. Urinary bladder and upper portion of male
urethra
c. Renal Tubular epithelial (RTE) cell
I. most clinically significant epithelial cell
II. Origin: nephron
III. Greater than 2 RTE/hpf= tubular injury
IV. RTE cells variations
1) Oval fat body = lipid filled RTE, nephrotic syndrome, crush syndrome
2) Bubble cell = non lipid filled RTE
Clue cell- with gardnirella
4. Bacteria
a. Enterbactericeae E.coli (most common)
b. cannot be ID w/microscopic
5. Yeasts
a. True yeast infection= yeast + increase WBC
b. small, refractile oval structures that may or may not bud
6. Parasites
a. T. vaginalis - most frequent parasite in urine
 Strawberry cervic
 Ping pong disease
 Jerky motility
 Mistaken as WBC
b. Schistosoma haematobium ova = terminal spine ova
c. Enterobius Vermicularis ova =fecal contaminant (most common)
7. Spermatozoa

REPORTING OF BACTERIA, YEAST, AND EPITHELIAL CELLS: Rare, Few, Moderate, or many
MICROSCOPIC QUANTITATIONS
1. average of 10 representative fields.
2. Budding yeast, mycelia elements, trichomonas, or sperm = note their precense
CASTS (CYLINDRURIA)
1. Unique to the kidney
2. Ascending loop of Henle and Distal Convoluted Tubule (DCT)
3. Major Constituent = Tamm Horsfall --- Produced by RTE cells
4. Sequence from least clinical significant to the most clinical significant: H.C.C.F.W.
a. Hyaline ------ > Cellular ------ > Coarsely Granular > Finely granular --- > Waxy
HE CELL COARSE FINE WAX

URINARY CAST
1. Hyaline cast
a. Prototype cast- beginning
b. Normal value = 0-2/LPF
c. Physiologic: Stress and Strenuous exercise
d. Pathologic:
I. Glomerulonephritis
II. Pyelonephritis
III. Congestive Heart failure
2. RBC cast: bleeding in nephron
a. Dirty Brown Cast+ Rgt strip (+) + RTE = massive hemoglobinuria
b. Glomerulonephritis and Strenuous exercise ah Ca
3. WBC cast: inflammation within the nephron
4. Epithelial (RTE) cells cast: tubular necrosis
5. Bacterial cast: upper UTI/ pyelonephritis
6. Fatty cast
a. Not stained with Sternheimer - Malbin stain
b. Nephrotic syndrome
c. Identification:
I. Triglycerides and neutral fats= sudan III/ oil red o
II. Cholesterol= maltese cross by polarizing microscope
7. Granular Cast
a. Nonpathologic: Lysosome granules from RTE metabolism.
b. Glomerulonephritis. Pyelonephritis. Stress Strenuous & exercise"
8. Waxy cast
a. Final degenerative form of all types of cast. Brittle, highly refractile, with jagged ends
b. Stasis (obstruction) of urine flow and Chronic renal failure
9. Broad cast: renal failure cast (it has grave prognosis)
a. destruction of the tubular walls (widen)
b. Bile stained broad Waxy cast = viral hepatitis
c. Extreme urine stasis and Renal failure

CRYSTALS (CRYSTALLURIA)
1. Formed by precipitation of urine solutes
2. Factors that contribute to crystal formation
a. Temperature (decrease temperature causes precipitation)
b. Solute concentration
c. Ph
NORMAL URINARY CRYSTALS
1. ALKALINE/BASIC/HIGH PH
a. Amorphous phosphates – white precipitate
b. Ammonium biurate – thorny apple (seen in old specimen)
c. Triple phosphate/magnesium ammonium phosphate/struvite - Colorless, prism shaped or coffin
lid. Fern leaf appearance
d. Calcium Phosphate/ apatite - Colorless, flat plate, thin prisms often in rosette form
e. Calcium carbonate (create gas after adding acetic acid)- dumbbell shape

2. ACID/LOW PH = yellow to red

a. Amorphous urates - Brick dust/yellow brown granules
b. Uric Acid - Rhombic, wedge. hexagonal, four-sided flat plate, lemon shaped (most pleomorphic)
 Mistaken as Cystine
c. Calcium oxalate
I. Dihydrate (wheddelite) = most common (envelope shape) (usually decrease oxalic acid=
tomato asparagus, orange, ascorbic acid)
II. Monohydrate (whewellite) = dumbbell shape (ethylene glycol)
d. Hippuric Acid- insignificant, needle shape
e. Sodium urate- insignificant, needle shape
f. Calcium Sulfate -long, thin colorless needles or prisms (no clinical sig)

URIC ACID vs. CYSTINE CRYSTALS

Uric acid Cystine

Color Yellow-brown Colorless
Solubility in ammonia (base) Soluble Soluble
Solubility in dilute HCI Insoluble Soluble
Birefringence Positive Negative
Cyanide – nitroprusside rnx Negative Positive

ABNORMAL URINARY CRYSTALS

Abnormal crystal Clinical Significance

1. Cystine (hexagonal) Cystinuria - renal tubule disorder
Cystinosis-metabolic disorder (genetic disease)
2. Cholesterol (stairstep/ stair case pattern) Nephrotic syndrome(lipiduria)
(rectangle with notch)
3. Radiographic dye CT scan
SG > 1.040
4. Tyrosine (yellow clump of needle with black LIVER DISEASE
center) Tyrosine being more common
5. Leucine (spherical, concentric circle with striation)
6. Bilirubin (bright clump of needle)
7. Sulfonamide Possible tubular damage
(may deposit in nephrons)
8. Ampicillin Massive dose of penicillin
Fan shape or formation

URINARY SEDIMENT ARTIFACTS

 1. Starch granules = maltese cross
2. Oil droplets
3. Air bubbles
4. Pollen grains = sphere (like leucine)
5. Hair and fibers = mistaken as cast
6. Fecal contamination-
7. Cloth fibers (most common)
8. Glass Fragments
9. Talcum powder = maltese cross

RENAL DISEASE
Classifications of renal Disease
1. Glomerular Disorders
2. Tubular disorders
3. Interstitial disorders

GLOMERULAR DISODERS (mostly immunologic)

1. Wegener's Granulomatosis - demonstration of Anti-neutrophilic cytoplasmic autoantibody
(ANCA)
2. Henoch schonlein purpura - Occurs in children following upper respiratory infection (vasculitis, red
patches on the skin)
3. Membranoproliferative glomerulonephritis - Increase cellular proliferation (TRAM track appearance)
4. Diabetic Nephropathy - Deposition of glycosylated proteins found in basement membrane. Most
common cause of end stage renal disease (no antibody involved)
5. Acute Post Streptococcal Glomerulonephritis - Deposition of immune complex Group A
Streptococcus (basement membrane)
6. Rapidly Progressive (crescentic) - deposition of immune complexes from systemic immune
disorders. Example SLE
7. Membranous Glomerulonephritis- thickening of glomerular membrane. Example SLE/ sjogrem,
syphilis, hepatitis B
8. IgA nephropathy -Deposition of IgA (or berger disease) (most common cause of glomerulonephritis)
9. Goodpasture syndrome - autoantibody to the basement membrane
10. Chronic glomerulonephritis - glomerular damage precipitated by other renal disorders
11. Alport syndrome - thining of glomerular basement membrane (no antibody involved)
12. Nephrotic syndrome - Disruption of the shield of negativity
a. Focal segmental Glomerulosclerosis (FSGS) -Disruption of podocytes in certain numbers
numbers and areas of glomeruli
 AIDS and heroins
b. Minimal change disease - Disruption of podocytes
 vaccine

TUBULAR DISORDERS
1. Acute tubular necrosis ischemia (-) o2, infarction decrease oxygen
a. Ischemia
I. trauma-crushing injuries, and surgical procedures
II. Shock-sepsis, anaphylaxis, massive hemorrhage, and High voltage electricity
 b. Toxic to tubules-aminoglycoside antibiotic, amphotericin B, cyclosporine, radiographic
dye, ethylene glycol, heavy metals, toxic mushrooms, large Hb, and myoglobin.

2. Fanconi syndrome- Generalized failure of tubular reabsorption in the PCT

3. Uromodulin-associated kidney disease (increase TAMM Horsfall--- accumulation in RTE leading to
cell death)
4. Nephrogenic Diabetes insipidus (DI)
a. Neurogenic DI-failure of the hypothalamus to produce ADH
b. Nephrogenic DI-inability of the renal tubules to respond to ADH
5. Renal Glucosuria
a. blood glucose: normal
b. Urine Glucose: high

INTERSTITIAL DISORDERS
1. Common Findings
a. Leukocyturia
b. Bacteriuria
c. proteinuria
d. Hematuria
2. Cystitis (lower uti) = urethra and bladder (most common) ((-) in cast)
3. Acute pyelonephritis (upper uti) - renal pelvis, tubules, interstitium
4. Chronic Pyelonephritis= (+) waxy/ broad cast
5. Acute Interstitial Nephritis= (+) WBC cast, (-) bacteria
RENAL FAILURE: END STAGE RENAL DISEASE
 Gromerulus and tubules ay nasira, hindi na siya nakakapag tapon pa.
 Decrease and glomerular filtration rate (less than 25/mL/min)
 Increase urea, decrease creatinine
 Hindi na rin natatapon ang urea and creatinine cause azotemia
 Hindi na tatapon ang hydrogen ions. H+ is absorbed by all release potassium result in electrolyte
imbalance
 increase
 Blood (acid) = base (urine) causes Renal tubular acidosis
 Albumin is sobrang maliit kaya natatapon pa rin sila so nakikita natin ay proteinuria and glucosuria
 You will see a waxy broad cast or telescope sediment

TELESCOPE SEDIMENT
a. Cells and casts lipid droplets, oval fat bodies are simultaneously seen.
b. Seen in acute or chronic glomerulonephritis, nephrotic syndrome and SLE

RENAL CALCULI/RENAL LITHIASIS

Conditions favoring the Formation of Renal Calculi
1. pH
2. Chemical conc
3. Urinary stasis
Renal Calculi
1. Calcium oxalate -major constituent (75%) of Renal calculi (very sturdy; rough surface)
2. Uric acid -Yellowish to brownish red and Moderately hard
3. Cystine - Yellow-brown, greasy and resembles an old Soap
4. Phosphate- pale and friable
5. Triphosphate- infections involving urea splitting bacteria (struvite- staghorn calculi shape/appearance)

CEREBROSPINAL FLUID
1. Production: CHOROID PLEXUS
2. 20 mL/ hour= rate of CSF production
3. 3rd major body fluid
4. Physical support
5. Supply nutrients to the nervous system and maintain ionic homeostasis
6. Prevent CSF Reflux: arachnoid granulation cells
 Arachanoid sarado ang hydrocephalus
7. Remove metabolic waste

MENINGES
1. Dura mater - lines the skull and vertebral canal
2. Arachnoid - filamentous inner membrane
3. Pia mater- thin membrane lining the surface of the brain and
spinal cord
 Pia = soft
 Mater= mother

SPECIMEN COLLECTION
1. Method: lumbar puncture
between third, fourth, and fifth
vertebra
Pagkatusok sa vertebra, maglalagay pa ng tube to check the opening
pressure
2. OP: 90-180 mmHg
3. Tubes:
1 = chemistry and serology = freezer
2 = microbiology (no skin contaminant) = room temperature
3 = hematology (in case of traumatic tap) = refrigerator
4 = microbiology and serology

CSF APPEARANCE
 1. Pellicle Formation: (+) TB, seen after 12-14 hours refrigeration
2. Xanthochromia - is a term used to describe CSF supernatant that is pink, orange, or yellow.
3. TRAUMATIC TAP VS. INTRACRANIAL HEMORRHAGE
Habang padagdag ng padagdag ang tube, paonti ng paonti ang blood

TRAUMATIC INTRACRANIAL HEMORRHAGE

A. DISTRIBUTION OF BLOOD Uneven Even
ON 3 TUBES
B. SUPERNATANT Clear Xanthocromic or xanthocromia
C.CLOT FORMATION Positive Negative
D.ERYTHROPHAGE Negative Positive
E. D-dimer negative positive

CSF CELL COUNT

1. Immediate
a. WBC and RBC disintegration- within less than1 hour
b. 40% WBC disintegrate- within less than 2 hours
2. Clot formation (decrease WBC)
3. CSF Dilution

Appearance Dilution
Clear Undiluted
Slightly hazy 1:10
Hazy 1:20
Slightly hazy 1:100
Cloudy/ slightly cloudy 1:200
Bloody/ turbid 1:10000

4. WBC COUNT
a. Routinely performed
b. 3% Acetic acid w/methylene blue (differentiate WBC) = lyse RBC
c. Cytocentrifuge
I. Monolayer size
II. 30% albumin
1. Increases cell yield/recovery
2. Decreases cellular distortion
d. Normal Values
I. Adults: 0-5/ul
II. Neonates: 0-30/ul
III. Specimen with 200 WBCs or 400 RBCs/uL may appear = CLEAR
 5. CSF DIFFERENTIAL COUNT
a. Wright stain
b. Sedimentation, filtration, centrifugation or cytocentrifugation (the best) -

6. CSF WBC Constituents

 adults: 70:30 = 70 lymphocyte: 30 monocytes
 neonates: 70-80:30 = 70-80 monocyte: 30 lymphocytes
a. Pleocytosis - Abnormal condition where there is an increased number of normal cells in CSF
b. Predominant:

PREDOMINANT CELLS SEEN IN CSF

Type of cell Major clinical significance
1.Lymphocyte and monocyte -Normal
-Viral, tubercular and fungal
meningitis
-Multiple sclerosis
-HIV and AIDS
2. Neutrophils -Bacterial meningitis
-Cerebral hemorrhage
3. Macrophage -RBCs in spinal fluid.
-contrast media
4.Blast Forms -Acute leukemia
5.Lymphoma cells -Disseminated Lymphoma
6. Plasma cells -Multiple sclerosis,
-lymphocyte reactions
7.Ependymal, choroidal and -Diagnostic procedures
spindle-shaped cells
8 Malignant cells of -Metastatic carcinomas
Nonhematologic origin -primary CNS carcinoma
9.Eosinophil -Parasitic infection
-Fungal infection
-medication and shunts
-foreign material intro
Microscopic Findings
-All stages of development may be
found.
-Granules may be prominent in
blood -Cells disintegrate rapidly
-May contain phagocytized RBC
appearing as empty vacuoles
-hemosiderin granules and
hematoidin crystals
-Lymphoblasts, myeloblasts,
monoblast
-Resemble lymphocyte with cleft
nuclei
-Traditional and classic forms
seen
-Pneumoencephalography
Primary CNS tumor ------
astrocytomas retinoblastoma,
medulloblastomas

Chemistry Tests
1. CSF PROTEIN
a. Hemorrhage and meningitis – increase CSF protein
b. Albumin-(56%-76%) = MAJOR
c. Alpha globulins -Haptoglobin and ceruloplasmin
d. Beta-globulins - Beta transferrin (tau) = only protein seen in CSF
e. GAMMA-GLOBULINS - IgG and some IgA
f. Normal values
I. Adults = 15-45 mg/dl
II. Infants = 150 mg/dl
 III. Immature 500 mg/dl
g. Increased in
h. Blood brain barrier damage and Immuno globulin production
1. Meningitis
2. Hemorrhage
3. MS
4. Guillain-Barre syndrome
5. Myxedema
6. Cushing disease
7. Polyneuritis
8. Diabetes
9. uremia
10. Connective tissue disease
11. Neurosyphilis
i. Decreased in
1. CSF leakage = rhinorrhea
2. Recent puncture
3. Rapid CSF prod increase CSF---- decrease dilution
4. Water intoxication

PROTEIN FRACTIONS DETERMINATION

1. CSF/serum albumin Index
a. Normal value = <9
b. Abnormal Value = >9
c. Correlates the degree of damage of blood brain barrier
CSF ALBUMIN DIVIDED BY SERUM ALBUMIN

2. IgG Index
a. Assess conditions with IgG production within the CNS (ex. Multiple sclerosis)
b. Normal Value = less than 0.70
c. Abnormal = greater than 0.70
CSF IgG DIVIDED BY SERUM IgG DIVIDED CSF ALBUMIN DIVIDED BY SERUM ALBUMIN

CSF ELECTROPHORESIS
1. Detection of Oligoclonal bands in the y region
 Monoclonal= 1 band
 Oligoclonal = more than 1 band
2. Perform with serum electrophoresis
3. Oligoclonal Band in CSF and Serum: leukemia, lymphoma and
multiple myeloma
4. Oligoclonal bands in CSF but not in serum: multiple
sclerosis (ORIGINATE IN BRAIN), neurosyphilis, GBS
(Guillain-Barre syndrome)
5. Myelin Basic Protein (MBP)
 Myelin sheath has (+) Myelin basic protein
 a. Protein component of the myelin sheath
b. Used to monitor the course of MULTIPLE SCLEROSIS.

CSF GLUCOSE
1. Must be in conjunction with Blood glucose
2. Two hours prior to spinal tap is VENIPUNCTURE for blood glucose
 Blood glucose then 2 hours CSF glucose the lumbar puncture
 CSG glucose contain microbes then increase CSF lactate= exception is the VIRUS (need
glucose, nabubuhay sa pagpatay ng cel)
3. Meningitis
4. Normal Values: 60-70% of blood glucose (50-80mg/dl)
5. Increased: Hyperglycemia
6. Decreased
a. Bacterial meningitis = decrease glucose, increase WBC primarily neutrophil
b. Tubercular meningitis = decrease glucose, increase WBC primarily lymphocyte
c. Fungal meningitis = decrease glucose, increase WBC primarily monocyte
7. Normal in VIRAL MENINGITIS

CSF LACTATE
1. Normal Values: 10-22 mg/dl
2. Increased
a. Bacterial meningitis = 35 mg/dL
b. Tubercular meningitis = less than 25 mg/dL
c. Fungal meningitis
3. Normal in: Viral meningitis - <25mg/dL.

CSF GLUTAMINE
1. Product of ammonia (NH3)
 Ammonia is toxin
 Liver can damaga the aspirin
 Ammonia in healthy liver will be going to be UREA
 Ammonia in unhealthy liver will not be going to convert to UREA it become INCREASE UREA. It
go to brain and convert to increase CSF glutamine, that will decrease the neurotransmitters
that will lead to coma

2. Normal Values:8-18 mg/dl
3. Increased in:
a. Liver disorders.
b. Disturbance of consciousness(coma)
c. Reye's syndrome = aspirin ingestion

CSF MICROBIOLOGY
1. Agent of Bacterial Meningitis
a. Age group
 Birth to 1 month old1 month to 5 years old
5 to 29 years old
>29 years old
Infants, elderly, and immunocompromised
Causative Agent

 S.agalactiae and L.monocytogenes

 H. influenza
 N. meningitides
 S.pneumoniae
 L. monocytogenes

Quality control
1. Centrifuge (speed is monthly) (disinfect is weekly)

SEMINAL FLUID
1. REASON FOR ANALYSIS
a. Fertility testing
b. Post vasectomy semen analysis
c. Forensic analysis
2. Composition and Physiology of the fluid in semen
a. Seminiferous tubule(testes) – Spermatogenesis
b. Epididymis-sperm mature and stored
c. Seminal Vesicles
 Contributes Produce most of the fluid in semen 60-70 %
I. High in FRUCTOSE (sperm energy) and Flavin (semen color = gray)
d. Prostate Gland (20-30%)
I. Acidic Fluid
II. Contains ACP, zinc, citric acid and other enzymes, prostate
III. For coagulation and liquefaction
IV. Bulbourethral gland-Thick, alkaline mucus = to neutralize vaginal acid

3. Specimen Collection
 a. Abstinences- 3 days but not more than 5 days (7 days 6th ed strat)
I. WHO Recommends 2-3 Samples be collected not less than 7 or more than 3 weeks
apart
Once 1 week not 3/week
b. Methods of Collection
I. Masturbation= most common
II. Coitus interruptus= not reliable (loss fluid)
III. Condom method= not reliable (due to spermicidal)
c. 1st Part of ejaculation: if missing
I. Sperm count= false decrease
II. pH= false increase
III. Liquefaction= delayed
d. Last part of ejaculation
I. Sperm count= false increase
II. pH= false decrease
III. Clot= delayed
e. Specimen Transport
I. Within 1 hour of collection (RT)
II. Specimen awaiting analysis should be kept 37 degrees celcius

4. Macroscopic Appearance
a. Appearance
I. Gray-white, translucent = normal, bleach odor
II. Clear= decrease sperm concentration
III. White turbid= infection
IV. Red or brown= RBC
V. Yellow= increase abstinence
b. Volume = 2-5 mL
I. Increase= increase abstinence
II. Decrease= infertile
c. Viscosity
I. Normal= pour in droplets
II. Viscous= greater than 2-centimeter thread
III. Reporting= 0: watery 4: gel like
d. pH
I. Measure time= 1 hour
II. Normal= alkaline (7.2-8)
III. Increase pH= infection
IV. Decrease pH= increase prostatic fluid
e. Liquefaction Time
I. Clot and liquefy= 30-60 minutes

5. Sperm Concentration
a. Normal Value: 20-160million/ml
b. Method
I. Neubauer chamber
1. Dilution- 1:20
2. Diluents: Formalin , Sodium bicarb, Saline, and H2O ==== to mobilize sperm
 II. Makker Counting Chamber
1. For undiluted specimen
2. Uses heat to immobilize sperm cells
c. Round Cells (WBC or sperm without flagellum= spermatid)
1. Immature sperms
2. 1 million WBCs/mL= inflammation
3. 1 million spermatids/mL= disruption of spermatogenesis
d. Formula:
1. Sperm Conc.= # of sperms ctd. x dilution /# of squares ctd. x depth (0.1)
2. 2 WBC squares = # of sperm ctd x 100,000
3. RBC squares = # of sperm ctd. X 1,000,000.00

6. Sperm Count
A. Normal Values >40 million/ejaculation
B. Formula Sperm concentration (million/mL) x Specimen Volume

7. Sperm Motility
a. Undiluted
b. Evaluation: 20 hpf
c. Normal: atleast (greater than or equal to) 50% motile, Grade 2
d. Increased Immobile sperm= sperm viability test
e. CASA (computer assisted semen analysis)= sperm velocity and trajectory
f. WHO SPERM MOTILITY GRADING

Grade WHO criteria

4.0 a Rapid, straight line
3.0 b Slow, some lateral
2.0 b Slow, noticeable lateral
1.0 c No forward progress
0d No movement

8. SPERM MORPHOLOGY
a. HEAD: 3 um wide and 5 um length
I. Normal = Oval

b. Tail
I. 45 um
II. Abnormal = Poor motility

c. Acrosomal Cap
I. Critical to ovum penetration
II. Half (1/2) of the HEAD, 2/3 of sperm nucleus

d. Midpiece
I. 7.0 um thickest part because surround by Mitochondrial sheath.

e. Normal Values:
I. WHO Routine criteria = greater than 30% normal forms
 II. Kruger's strict criteria = greater than 14% normal forms

9. Additional Testing
a. Sperm Viability (modified bloom’s test)
I. Reagent= eosin and nigrosine
Penetrate in dead cell
Non penetrate in viable cell
II. Viable= unstained, bluish white
III. Nonviable= red
b. Fructose
I. Resorcinol - (+) orange -red color
II. Low sperm cone low/absence of fructose
III. Tested within 2 hours
c. Antisperm Antibodies
I. Specimen = semen, serum or vaginal mucosa
II. Methods
1. Mixed Agglutination Reaction
a. Presence of IgG coated - sperm
b. <10% normal
2. Immunobead Test (more specifc)
a. IgG, IgM, IgA, and area affected
b. 20% normal

d. Microbial-Presence of greater than 1 million WBC/mL culture for C.trachomatis. M.hominis, and
U.urealitycum
e. Chemical
I. Fructose - decrease seminal fluid
II. Neutral a-glucosidase - epididymis disorder
III. Zinc - decrease prostatic fluid
IV. Citric acid - decrease prostatic fluid
V. Acid phosphatase - decrease prostatic fluid

10. Post Vasectomy Analysis

a. Sperm ID
b. 2 months after surgery and 2 consecutive months
November, December, January, February (pacheck ulit sya den after nun monthly na), April and
march
Dapat walang sperm para successful (4 months)

11. Terminology

Terminology Definition Terminology Definition

ASPERMIA No ejaculate Asthenozoospermia Sperm motility <40%
Azoospermia (-) sperm Teratozoospermia Sperm morphology >
40%
Necrospermia Dead sperm Necrozoospermia Dead sperm
Necrospermia Low sperm concentration Necrozoospermia Increase sperm
concentration