Urinalysis and other

diagnostic modalities in
Nephrology
Emmanuel Lazaro MMED2 IM

Supervisor: Dr. Alfred Meremo

Outline
1. Urinalysis

2. Assessment of renal function

3. Radiological assessment of kidney diseases

4. Kidney biopsy
Urinalysis (introduction)
• The urinalysis is an informative and a noninvasive diagnostic
investigation that together with other modalities (hx, Ex, chemistry)
plays a central role in evaluating acute and chronic kidney disease.

• A complete urinalysis consists of three components:

• Gross evaluation

• Dipstick analysis

• Microscopic examination of the urine sediment.

Urinalysis
• Gross evaluation
• Specific gravity
• pH
• Leukocyte esterase
• Nitrites Dipstick analysis
• Glucose
• Ketones
• Protein
• Blood
• Microscopic examination
Urinalysis (sample collection)
• The specimen should be collected into a clean dry container.

• Patients should be directed to clean the external genitalia and provide a

midstream specimen.

• In patients with indwelling urinary catheters, obtain a recently produced urine

directly from the catheter tubing.

• The specimen should be examined at room temperature within 2hrs or

refrigerated at 2 to 8 degrees Celsius and then re-warmed to room
temperature prior to assessment.
Urinalysis (gross evaluation)
• Visual assessment of urine color and turbidity.

• Normal urine is non turbid and light yellow in color (darker when concentrated).

• Red to brown urine indicate blood or certain foods (beets) or drugs (propofol,
chlorpromazine)

• Turbid urine may be due to infection, precipitated crystals or chyluria.

• Further evaluation is required for turbid and red to brown urine

Urine dipstick
Urine dipstick
Urinalysis (dipstick)
• Specific gravity

• Is a measure of the concentration of solutes in the urine.

• It measures the ratio of urine density compared with water density and provides
information on the kidney’s ability to concentrate urine and is directly proportional
to urine osmolality

• Specific gravity between 1.002 and 1.035 on a random sample is normal

• The urine specific gravity generally varies with the osmolality, rising by
approximately 0.001 for every 35 to 40 mosmol/kg increase in urine osmolality
Urinalysis
• Specific gravity: Decreased: < 1.005

• Excessive hydration (volume resuscitation with IV fluids).

• Inability to concentrate urine such as in Nephrogenic diabetes insipidus, acute

glomerulonephritis, pyelonephritis, acute tubular necrosis.
Urinalysis
• Specific gravity: Increased >1.035

• Increased specific gravity indicates a concentrated urine with a large volume

of dissolved solutes.

• Dehydration (fever, vomiting, diarrohea), SIADH, adrenal insufficiency, pre‐

renal renal failure, hyponatraemia with oedema, CCF, nephrotic syndrome.

• Elevation in specific gravity also occurs with glycosuria (e.g. diabetes mellitus
or IV glucose administration), proteinuria, IV contrast.
Urinalysis (dipstick)
• Hydrogen ion concentration, (pH):
• The kidneys play an important role in acid‐base regulation within the body to
maintain a normal urinary pH range

• The urine pH ranges from 4.5 to 8, depending upon the systemic acid-base
balance.

• The urine pH is most often used clinically in patients with metabolic acidosis.

• The appropriate renal response to acidemia is to increase urinary acid

excretion, with the urine pH falling below 5. A higher value suggests the
presence of renal tubular acidosis
Urinalysis
• Urine pH in evaluation of RTA:

• Type 1 RTA is impairment in hydrogen ion secretion in the distal tubule,

resulting in a persistently high urine pH (>5.5) and systemic acidosis.

• Type 2 RTA is impairment in bicarbonate resorption in the proximal tubules,

producing a urine pH > 7.
Urinalysis
• Urine pH in evaluation of UTI:

• Due to urea-splitting organisms, such as proteus and klebsiella, typically have

alkaline urine.
Urinalysis
• Urinary pH in evaluation of stones:

• A higher (alkaline) urinary pH level is associated with Calcium oxalate/calcium

phosphate, magnesium-ammonium phosphate, and staghorn calculi.

• Uric acid and cystine calculi are associated with a low pH (acidic) urine.
Urinalysis (dipstick)
• Leucocytes:
• WBCs contain an enzyme known as leukocyte esterase, which is released
when WBCs undergo lysis.

• A positive leukocyte esterase test result indicates pyuria and hence UTI.
However, the diagnosis may be missed in up to 20% of cases if a negative
urinalysis dipstick is used to exclude UTI.

• Sterile pyuria is seen in analgesic nephropathy and UTIs due to organisms

that do not grow by standard culture techniques (eg, Chlamydia,
Mycobacterium tuberculosis, Ureaplasma urealyticum).
Urinalysis (dipstick)
• Leucocytes:

• False positive: Contaminated specimen, trichomonas vaginalis

• False negative: Intercurrent or recent antibiotic therapy (especially

gentamicin, tetracycline and cephalosporins), glycosuria, proteinuria, high
specific gravity. Low bacteria count UTI (especially in women).
Urinalysis
• Nitrites:

• Nitrates in the urine are converted to nitrites in the presence of Gram‐negative

bacteria such as E.coli and Klebsiella.

• A positive nitrite test is a surrogate marker of bacteruria.

• Some bacteria are not capable of converting nitrates to nitrites (eg, Staphylococcus,
Streptococcus, Haemophilus), and these bacteria may still be present in the urinary
tract despite a negative test result

• Hence Positive test strongly suggests infection but negative test does not exclude it
Urinalysis
• Glucose:

• Glucose is not normally present in the urine with < 0.1% of glucose normally
filtered by the glomerulus appears in urine (< 130 mg/24hr).

• Glycosuria occurs in patients with:

• hyperglycaemia, ( ≥10mmol/l or 180mg/dl )

• Reduced glucose reabsorption ( eg in renal tubular disease )

• Pregnancy.
Urinalysis (dipstick)
• glycosuria with a normal plasma glucose:

• a primary defect of proximal tubule reabsorption needs to be considered.

• Patients receiving sodium-glucose cotransporter 2 inhibitors.

• Glycosuria may also be an isolated defect (isolated renal glycosuria)

associated with genetic mutations affecting renal glucose transport.
Urinalysis (dipstick)
• Protein:
• The urine dipstick test for albumin protein in urine.

• Detect severe albuminuria (>300mg/day) but insensitive to moderate

albuminuria (30 -300mg/day).

• May underestimate the degree of albuminuria or give a false negative if the

urine is very dilute. A concentrated urine may register as 3+ but may not
indicate high-grade albuminuria.

• Recent exposure to iodinated radiocontrast agents can induce transient

albuminuria.
Urinalysis (dipstick)
• Dipstick proteinuria results are as follows:
Urinalysis (dipstick)
• Protein
• A patient with a persistently positive dipstick test for protein should have
albuminuria quantified with assessment of the albumin-to-creatinine ratio on
a random (spot) urine sample or with a 24-hour urine collection.

• The KDIGO classification defines three stages of albuminuria:

• A1: Less than 30 mg/g creatinine (normal to mild)

• A2: 30 to 300 mg/g creatinine (moderate)

• A3: Greater than 300 mg/g creatinine (severe)

Urinalysis (dipstick)
• Protein:

• The dipstick is insensitive to non-albumin proteins (eg immunoglobulin light

chains). These are screened with the sulfosalicylic acid test (SSA).

• Sulfosalicylic acid (SSA) detects all proteins in urine. A positive SSA test with a
negative dipstick indicates the presence of non-albumin proteins.

• SSA may be useful in patients with AKI of unclear etiology

Urinalysis (dipstick)
• Sulfosalicylic acid (SSA) test results are as follows:
Urinalysis (dipstick)
• Overall, proteinuria can be classified as transient or persistent.
• Persistent proteinuria is then further classified into:

• Glomerular (disruption of filtration barrier) eg nephrotic syndrome

(3.5g/24hrs) and glomerulonephritis

• Tubular (defective reabsorptive capacities in the proximal tubules) eg ATN,

AIN

• Overflow (overproduction of immunoglobulin light chains) eg multiple

myeloma and myoglobinuria
Urinalysis (dipstick)
• Blood:

• Blood in the urine is detected through the peroxidase reaction of

erythrocytes, free haemoglobin or myoglobin.

• A positive result may be indicative of haematuria, hemoglobinuria or

myoglobinuria.

• All positive results should be confirmed by microscopy

Urinalysis (dipstick)
• Blood:

• If urinary dipstick is positive for blood and urine microscopy is positive for
RBCs, hematuria is confirmed.

• But dipstick positive for blood and no RBCs by microscopy, indicates:

• Myoglobinuria (caused by rhabdomyolysis)

• Hemoglobinuria (caused by infections such as Plasmodium falciparum or Clostridium

welchii, transfusion-related reactions)
Urinalysis (dipstick)
• Blood:

• Presence of semen in urine may cause a positive heme reaction

• Menstruation mimics hematuria

Urinalysis (dipstick)
• Causes of Hematuria

• Renal: renal mass, glomerular pathologies

• Ureter: malignancy, stone

• Bladder: malignancy, radiation, cystitis

• Prostate/urethra: BPH, malignancy, prostatic procedures, traumatic

catheterizations, urethritis
Microscopy (urine sediments)
• Cells
• casts
• crystals
Urinalysis (Microscopy)
• RBCs:
• Distinguishing between glomerular and non glomerular causes is the first key
step in the evaluation of unexplained hematuria.

• Isomorphic (monomorphic) RBCs have an appearance similar to erythrocytes

in the circulation and can be seen with any cause of hematuria.

• Dysmorphic RBCs (ie, acanthocytes) are suggestive of glomerular disease.

• Presence of RBC casts and/or albuminuria together with hematuria highly

suggest a glomerular origin.
Urinalysis (microscopy)
WBCs:
• Entire spectrum of WBCs may be seen in the urine but neutrophils and
eosinophils are the cell of practical interest

• Neutrophils are associated with bacteriuria. However, if the corresponding

urine culture is negative (sterile pyuria), interstitial nephritis, renal
tuberculosis, and nephrolithiasis should be considered.

• Urinary eosinophils may help diagnose acute interstitial nephritis (AIN).

Eosinophiluria is seen with AIN, but the absence of eosinophiluria does not
rule out AIN.
Urinalysis (microcopy)
• Epithelial cells:

• Epithelial cells may appear in the urine after being shed from anywhere
within the genito-urinary tract and their presence represents contamination
by genital secretions
Urinalysis (microcopy)
• Casts:
• cylindrical structures that are formed in the tubular lumen; several factors
favor cast formation: urine stasis, low pH, and greater urinary concentration.

• Casts will assume the shape and size of the renal tubule in which they are
formed

• RBC casts suggests an underlying proliferative glomerulonephritis, for which

numerous etiologies exist. However, their absence does not rule out a
proliferative glomerulonephritis
Redcell cast
Urinalysis (microcopy)
• Casts
• WBC casts are indicative of interstitial or glomerular inflammation. Their
absence do not rule out AIN.

• Renal tubular epithelial cell casts These may be observed in any setting where
there is desquamation of the tubular epithelium, including ATN, AIN and
proliferative glomerulonephritis

• Hyaline casts are associated concentrated urine or with diuretic therapy and
are generally nonspecific

• Muddy brown casts indicate acute tubular necrosis

Urinalysis (microcopy)
• Crystals: solid forms of a particular dissolved substance in the urine.
• Uric acid crystals are observed in acid urine which favors the conversion of
the relatively soluble urate salt into the insoluble uric acid
• Calcium oxalate or calcium phosphate crystals usually found in acidic urine
• Cystine crystals with their characteristic hexagonal shape, are diagnostic of
cystinuria
• Magnesium ammonium phosphate crystals are constituents of struvite
stones. Normal urine is undersaturated with ammonium phosphate. Struvite
stone formation occurs only when ammonia production is increased and the
urine pH is elevated, which occur only in the setting of a UTI with a urease-
producing organism, such as Proteus or Klebsiella
Assessment of renal function
• Estimation of the GFR is used clinically to assess the degree of kidney
impairment and to follow the course of the disease.

• GFR is the rate in milliliters per minute at which substances in plasma

are filtered through the glomerulus

• The normal value for GFR depends upon age, sex, and body size, and
is approximately 130 and 120mL/min/1.73 m2 for men and women,
respectively, with considerable variation even among normal
individuals
Assessment of renal function
• The characteristics of an ideal marker of GFR are as follows:
1. It should appear endogenously in the plasma at a constant rate
2. It should be freely filtered at the glomerulus
3. It can be neither reabsorbed nor secreted by the renal tubule
4. It should not undergo extra renal elimination
Assessment of renal function
• As no such endogenous marker currently exists, exogenous markers of
GFR are used.
• Assessment of GFR using inulin is considered the reference method for
the estimation of GFR. It involves the infusion of inulin and
measurement of blood levels after a specified period to determine the
rate of clearance of inulin.
• Use of exogenous markers is not practical in daily practice due to that
the testing is done in specialized centers, and the difficulty to assay
these substances, has encouraged the use of endogenous markers.
Assessment of renal function
• Creatinine:
• Is the by-product of creatine phosphate in muscle, and it is produced at a
constant rate by the body.

• For the most part, creatinine is cleared from the blood entirely by the kidney.
Decreased clearance by the kidney results in increased blood creatinine.

• The amount of creatinine produced per day depends on muscle bulk. Thus,
there is a difference in creatinine ranges between males and females
Assessment of renal function
• Creatinine:
• Diet also influences creatinine values. Creatinine can change as much as 30%
after the ingestion of red meat.

• As GFR increases in pregnancy, lower creatinine values are found in

pregnancy.

• serum creatinine is a later indicator of renal impairment-renal function is

decreased by 50% before a rise in serum creatinine is observed.
Assessment of renal function
• Creatinine clearance
• The calculated clearance of creatinine is used to provide an indicator of GFR.
• This involves the collection of urine over a 24-hour period or preferably over an accurately timed
period of 5 to 8 hours. Creatinine clearance is then calculated using the equation:

C = (U x V) / P
C = clearance, U = urinary concentration, V = urinary flow rate (volume/time i.e.
ml/min), and P = plasma concentration
• Improper or incomplete urine collection is one of the major issues affecting the accuracy of this
test and also due to tubular secretion
• creatinine overestimates GFR by around 10% to 20%.
Assessment of renal function
• Serum creatinine is also utilized in GFR estimating equations such as
the:
• Cockcroft-Gault (CG) equation.

• Modified Diet in Renal Disease (MDRD) equation.

• CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation.

• These eGFR equations are superior to serum creatinine alone since

they include other variables ( race, age, and gender).
Assessment of renal function
• The Cockcroft-Gault (CG) equation (1976):
• CrCl (male) = ([140-age] × weight in kg)/(serum creatinine × 72)
• CrCl (female) = CrCl (male) × 0.85

• Limitations include:
• Overestimate GFR
• Require pt weight
• The equation is not adjusted for body surface area
Assessment of renal function
• MDRD equation (1999):
• eGFR =175 x (SCr)-1.154 x (age)-0.203 x 0.742 [if female] x 1.212 [if Black]

• Limitations include:
• Imprecise for eGFR> 60ml/min/1.73m2
Assessment of renal function
• CKD EPI equation (2009):
• eGFR = 141 x min(SCr/κ, 1)α x max(SCr /κ, 1)-1.209 x 0.993Age x 1.018 [if female] x
1.159 [if Black]

• SCr (standardized serum creatinine) = mg/dL

• κ = 0.7 (females) or 0.9 (males)
• α = -0.329 (females) or -0.411 (males)
• min = indicates the minimum of SCr/κ or 1
• max = indicates the maximum of SCr/κ or 1
• age = years
Assessment of renal function
• CKD-EPI is superior when GFR is normal or mildly reduced
• more accurate with higher GFRs (>60ml/min/1.73m2)

• Given the data on the improved performance, especially at higher

levels of GFR, it is recommended using the CKD-EPI equation for the
general population.
Assessment of renal function
•Cystatin C:
• Is a low-molecular-weight protein that functions as a protease inhibitor
produced by all nucleated cells in the body. It is formed at a constant rate and
freely filtered by the kidneys.
• Serum levels of cystatin C are inversely correlated with the glomerular filtration
rate (GFR).
• The renal handling of cystatin C differs from creatinine. Once cystatin C is filtered,
it is reabsorbed and metabolized by proximal renal tubules, unlike creatinine.
Thus, under normal conditions, cystatin C does not enter the final excreted urine
to any significant degree
Assessment of renal function
• Cystatin C:
• The advantages of cystatin C over creatinine are that it is not affected by age,
muscle bulk, or diet, and it is a more reliable marker of GFR than creatinine,
particularly in early renal impairment.
• Cystatin C has also been incorporated into eGFR equations, such as the
combined creatinine-cystatin KDIGO CKD-EPI equation.
• Cystatin C concentration may be affected by the presence of cancer, thyroid
disease, and smoking.
Assessment of renal function
• CKD EPI cystatin C equation

• eGFR=133 × (Scys/0.8)−0.499 × 0.996Age [× 0.932 if female]

• CKD EPI cystatin c – creatinine equation

• eGFR (female)=130 × (Scr/0.7)−0.248 × (Scys/0.8)−0.375 × 0.995Age [× 1.08 if black]

• eGFR (male)=135 × (Scr/0.9)−0.207 × (Scys/0.8)−0.375 × 0.995Age [× 1.08 if black]

Assessment of renal function
• Choice of equation?
• Since creatinine is widely available and inexpensive, and estimated
GFR from creatinine using the CKD-EPI equation is accurate in most
settings KDIGO 2013 recommend using the creatinine-based CKD-EPI
equation as an initial test.
Race & eGFR equations
• Adjusting for black race using the MDRD and CKD-EPI equations accounts for
~16% and ~18% increase in eGFR, respectively.

• In nephrology, GFR 20 ml/min/1.73m2 and 30 ml/min/1.73m2 represent two

scenarios around which important decisions regarding patient care are made.

• A slight over- or under-estimation of GFR in these regions could impact patient

care in a number of ways including missing a potential window for intervention

• An argument is made that in these equations race shouldn’t have been used as a
variable
Assessment of renal function
•Blood Urea Nitrogen (BUN)
• Urea or BUN is a nitrogen-containing compound formed in the liver as the end product
of protein metabolism and the urea cycle.
• About 85% of urea is eliminated via kidneys; the rest is excreted via the
gastrointestinal (GI) tract. Serum urea levels increase in conditions where renal
clearance decreases
• The ratio of BUN: creatinine can be useful to differentiate pre-renal from renal causes
when the BUN is increased.
• In pre-renal disease, the ratio is close to 20:1,

• In intrinsic renal disease, it is closer to 10:1.

Renal radiological assessment
• Renal ultrasonography:
• Is the test of choice to exclude urinary tract obstruction

• Ultrasonography can also be useful in differentiating a simple benign cyst from

a more complex cyst or a solid tumor and

• Used to identify cortical thinning, loss of cortical medullary differentiation or

decreased kidney size, indicative of irreversible kidney disease (CKD)

• Doppler renal ultrasonography can be used to evaluate renal vascular flow in

multiple disorders such as renal vein thrombosis, renal infarction, and renal
artery stenosis.
Renal radiological assessment
• CT scan:
• Non contrast low-dose CT scanning is the gold standard for the radiologic
diagnosis of renal stone disease including the detection of stones not
visualized on plain films or sonography.

• Is also used to confirm and localize ureteral obstruction

• Used to evaluate and stage renal tumors

• Used to diagnose renal vein thrombosis and polycystic kidney disease.

Renal radiological assessment
Magnetic resonance imaging (MRI):
• Used in suspected renovascular hypertension, renal vein thrombosis.

• Used in the evaluation of renal masses, including suspected or confirmed

renal cell carcinoma.

• However, the administration of gadolinium during MRI has been linked to

nephrogenic systemic fibrosis (NSF) among patients with reduced estimated
glomerular filtration rate (eGFR), particularly those requiring dialysis.
Renal biopsy
• A percutaneous kidney biopsy is obtained for a number of reasons,
including:

• Establishment of the exact diagnosis

• To determine the nature of recommended therapy

• To help decide on treatment modalities

Renal biopsy
Renal biopsy
• The indications for performing a kidney biopsy:
• A biopsy is usually performed in patients with lupus nephritis to determine the
type of disease.

• In patients with the nephrotic syndrome and no evidence of systemic disease to

determine treatment.

• Acute nephritic syndrome is often caused by a systemic disease and requires a

kidney biopsy to establish the diagnosis and guide treatment.

• Among patients with unexplained acute kidney injury, a biopsy is indicated in

those settings in which the diagnosis is uncertain.
Contraindications of renal biopsy
• Absolute contraindications: • Relative contraindications:

o Uncorrectable bleeding diathesis o Uncooperative patient

o Small kidneys
o Uncontrollable severe
hypertension
o Solitary kidney

o Active renal or perirenal infection

o Multiple cysts

o Skin infection at biopsy site o Hydronephrosis