Ketones Diabetic ketonuria

- Products of fat metabolism • Provide a warning of impending coma (DM: test for ketonuria when urine shows >1-
1. B-hydroxybutyric acid (78%) 2 g/dL of glucose
2. Acetoacetic acid (20%) • Ketoacidosis
3. Acetone (2%) • Warning of impending coma
Increased production in: Carbohydrate deprivation Lactic acidosis
Decrease: utilization of carbohydrates • Occurs with shock, DM, renal failure, liver disease and infections
Clinical significance: • In response to certain drugs (phenformin and salicylate poisoning)
Non diabetic ketonuria (increase tissue catabolism in the face of limited food intake) NITROPRUSSIDE TABLET TEST: Acetest
• In infants and children - Acute febrile diseases; toxic states with vomiting or • Reagents: Sodium nitroprusside; Glycine; Disodium phosphate; Lactose (Better color
diarrhea, inherited metabolic diseases differentiation)
• Vomiting in pregnancy; Cachexia; Following anesthesia • Sensitivity: 5 – 10 mg/dL AAA; 20 – 25 mg/DL Acetone
• Result: Lavender to deep purple
• Adv: it can be used for serum and other body fluid testing
• Disadv: Tablet is hygroscopic

TEST PRINCIPLE CORRELATION SENSITIVITY INDICATOR/ CHROMOGEN RESULTS REACTION

REAGENT INTERFERENCES
Ketones Nitroprusside Glucose Multistix: Multistix: Na -, +, ++, +++ False (+):
(Na nitroferricyanide) 9 – 10mg/dL of nitroprusside; • After use of
reaction DAA Glycine (+) beige to Negative, Small, phthaleins (BSP
70mg/dL Acetone violet Moderate, Large and PSP dyes)
w/n 60 seconds (Red)
Chemstrip: 5 – • Large amounts of
10mg/dL of DAA Chemstrip: Na phenylketones
nitroprusside; Buffer • Acetylcysteine
(+) pink-maroon (Strong red,
color in 15 seconds aerosol)
• Improperly timed
readings (Color
will darken)
• Antihypertensive
drugs

False (-):
• Loss of reagent
reactivity (Dip for
too long)
 • Improperly
preserved
specimen
(Ketones will
evaporate)

BLOOD (HEMATURIA, HEMOGLOBINURIA, MYOGLOBINURIA) o Transfusion reactions – renal damage

Clinical Significance: Causes o Hemolytic anemias
HEMATURIA – presence of intact red cells in urine (most common) o Severe burns
• Glomerulonephritis o Infections – malarial cells
• Pyelonephritis o Strenuous exercise
• Renal calculi o Toxins – Brown recluse spider; C. Welchii)
• Tumors • Urinary tract bleeding
• Trauma MYOGLOBINURIA (rare)
• Exposure to toxic agents • Muscle destruction (muscular trauma/crush syndromes; extensive exertion)
• Anticoagulants • Prolonged coma
• Strenuous exercise • Muscle-wasting diseases
• Menstruation (not pathologic) • Convulsions
HEMOGLUBINURIA (relatively common) – blood in urine has hemolyzed • Alcoholism
• Intravascular hemolysis • Drug abuse
TEST PRINCIPLE CORRELATION SENSITIVITY INDICATOR/ CHROMOGEN RESULTS REACTION
10 lysed RBC = REAGENT INTERFERENCES
0.3mg/dL Hb
Blood (RBC, Peroxidase-like Proteins, Multistix: Peroxide Multistix: Hb and myoglobin: (-) False (+):
Hemoglobin, activity of heme Microscopic 5 – 20RBCs/uL Diisopropylbenzene yellow -> green – • Strong oxidizing
Myoglobin) (RBC) 0.015 – dehydroperoxide blue agents
0.062mg/dL tetramethylbenzidine • Formalin
Intact RBC: - speckled &Captopril (
Chemstrip: 5 Chemstrip: pattern Decrease
RBCs/uL 2,5dimethyl-2,5 reactivity
Hb ~ 10 RBCs/uL dihydroperoxide • Bacterial
tetramethylbenzidine peroxidases
• Menstrual
Chromogen: contamination
tetramethylbenzidine False (-):
• High SG
• Formalin
 • Captopril
• Chemstrip: +
Iodate to oxidize
Ascorbic acid
• Multistix: Uses
peroxide that is
not reduced by
ascorbate

HEMOGLUBINURIA MYOGLOBINURIA HEMATURIA

HISTORY Muscular damage (Rhabdomylosis) Intravascular hemolysis Bleeding
URINE COLOR Clear Red Cola Red Red / Hazy
PLASMA COLOR Red Clear Normal
SERUM CHEMISTRY Depleted haptoglobin Increase muscle enzymes No significant serum level
BLONDHEIM (Salt Precipitation test) – 2.8g Precipitate: Red Precipitate: None
NH4 sulfate Supernatant: (-) Supernatant: (+)
Note: 5mL urine -> 5 minutes -> Filter/
Centrifuge
Note: if P is Red and S is positive: Both are present

• Testing mat: Urine absorbs, while bilirubin remains on the surface

BILIRUBIN: (Hepatic and Pre-Hepatic) • Result: Blue to Purple in 60 seconds
- Degradation products of Hb • False (+) – Increase levels of Indican, Pyridium, Rifampin
• NV: 0.02mg/dL Note:
• For the early indication of liver disease Procedure:
Clinical Significance: - 10 drops of Urine in the mat
• Liver damage: Hepatitis; Cirrhosis - Place tablet on mat
• Biliary obstruction: Gallstones, Carcinoma - 1 drop H2O
ICTOTEST - After 10 seconds, another drop of H2O
• Sensitivity: 0.05 – 0.1 mL/dL - After 60 seconds, observe color change in mat
• Tablet: p-nitrobenzene-diazonium-p-toluenesulfonate, SSA, Sodium Carbonate, Wash through tablet
Boric Acid - Add 10 drops of water (x2 the original test)
TEST PRINCIPLE CORRELATION SENSITIVITY INDICATOR/ CHROMOGEN RESULTS REACTION
REAGENT INTERFERENCES
Bilirubin DIAZO reaction Urobilinogen Multistix: 0.4 – Multistix: 2,4- Negative, Small, False (+):
0.8mg/dL dichloroaniline Moderate, Large -Multistix:
diazonium salt
Chemstrip:
0.5mg/dL Chemstrip: • Highly Pigmented
2,6dichlorobenzene urine
diazonium • Indicans
tetrafluoroborate • Metabolites of
Iodine -Chemstrip:
Note: • Highly Pigmented
Reagent: Diazonium urine
salt
False (-):
-Multistix:
• Improperly stored
urine
• Increase NO2 &
Ascorbic Acid -
Chemstrip:
• Old specimens
• Increase NO2
• Formalin
UROBILINOGEN (Hepatic and Post-Hepatic) o Complete obstruction of the common bile duct; Cancer of the pancrease
- Main pigment on prolonged standing of urine and the ampulla of vater
- Degradation products of Hb o Use of Broad-spectrum antibiotics
• Produced in the Intestine from the reduction of bilirubin Ehrlich’s tube test
• NV: <1 Ehrlich Unit (0.5 – 2.5 mg/24 hours) • 1 part Ehrlich reagent + 10 parts urine -> cherry red color (+)
Clinical Significance: • Na Acetate – enhances the reaction
• Increased in: • Specimen: 2 – 4 in the afternoon specimen
o Liver Disease Watson-Schwartz Test
o Hemolytic Disorders • Reagents:
• Persistent absence of urinary urobilinogen o Chloroform: Bottom layer
o Butanol: Top Layer
Porphobilinogen • Reagent: Ehrlich’s reagent in 6M HCl
- Synthesize the Heme • Sensitivity: 2mg/dL
• Intermediate compound in heme synthesis • Interferences:
• Seen in porphyria o Highly pigmented urine
• Porphyrins: uroporphyrin, coproporphyrin, protoporphyrin o Methyldopa
Hoesch Screenung Test o Indicans

Correlation with Bilirubin

Urine Bilirubin Urine Urobilinogen Color of Stool
Normal - + Dark Yellow-Brown
Bile Duct Obstruction +++ Decrease / Normal Pale / Clay / Acholic (Absence of Bile
pigment)
Liver Damage + or - ++ Early: Pale
Late: Dark
Hemolytic Disorders - +++

Watson-Schwartz Test Results

Extraction Urobilinogen Porphobilinogen Ehrlich Reactive Compounds
Butanol
Urine
Urine
Chloroform
Note: If both Red, Both urobilinogen and porphobilinogen are present

TEST PRINCIPLE CORRELATION SENSITIVITY INDICATOR/ REAGENT CHROMOGEN RESULTS REACTION INTERFERENCES
Urobilinogen Ehrlich’s Bilirubin Multistix: p- False (+):
 Aldehyde dimethylaminobenzaldehyde -Ehrlich Reactive
Reaction • Compounts
Chemstrip: • Porpholibilogen
DIAZO RXN: 4methoxybenzenediazoniumtetrafluoroborate • Sulfonamides; Methyldopa
Chemstrip • Procaine
• Indicans
-Highly Pigmented urine
(Chemstrip)

False (-):
• Old specimens
• Formalin

INDIRECT TESTS FOR URINARY TRACT INFECTION

• Nitrite
o Nitrate reductase
• Leukocyte Esterase
o Neutrophil = pus cell
NITRITE
• Based on the ability of some bacteria to reduce NO3 to NO2
• (+) w/ reductase enzyme
Clinical Significance:
• Cystitis, pyelonephritis & monitoring of patients at high risk for UTI
• Evaluation of Antibiotic therapy
• Screening of urine for culture

TEST PRINCIPLE CORRELATION SENSITIVITY INDICATOR/ CHROMOGEN RESULTS REACTION

10 lysed RBC = REAGENT INTERFERENCES
0.3mg/dL Hb
Nitrite Greiss Reaction Protein, Multistix: 0.06 – Multistix: p-arsanilic +/- False (+):
Leukocyte, 0.1mg/dL acid • Improperly
Microscopic tetrahydrobenzo- preserved urine
Chemstrip: quinolin3-ol • Highly pigmented
0.05mg/dL urine
Chemstrip:
sulphanilamide, False (-):
 hydroxytetrahydro • Improperly
benzoquinoline collected
specimen
• Lack of Dietary
NO3
• Old specimen
• Some medications

LEUKOCYTE ESTERASE
Clinical Significance:
• UTI
• Inflammation of the Urinary Tract
• Screening of Specimens for urine culture
• Lymphocytes, eosinophils, basophils, monocytes, trichomonas

TEST PRINCIPLE CORRELATION SENSITIVITY INDICATOR/ CHROMOGEN RESULTS REACTION

REAGENT INTERFERENCES
Leukocyte esterase Hydrolysis of Acid Protein, Multistix: 15 – Multistix: amino acid False (+):
ester Nitrite, 30mg/dL ester and diazonium • Strong oxidizing
Microscopic salt agent
Chemstrip: • Formalin
6mg/dL Chemstrip:
• Highly pigmented
indoxylcarbonic acid
urine
and diazonium salt
• Nitrofurantoin

False (-):
• CHON >500mg/dL
• Glucose >3g/dL
• High SG
• Inaccurate timing