1、UrinanalysisQuestion If a group of ants were attracted by urine, the urine contains ( ). Urinalysis Hingdus named the urine “honey urine”. this is the oldest urinalysis. In 1674,Thomas willis found the sugar in the urine can be detected by testing urine. Now urine sugar can be examined by urinalysis
2、 system. Formation of urine Glomerular filtration Tubular reabsorption Tubular secretion Normal: Clean-catch urine 1000-2000ml/24hThe function of urine maintain water balance; remove waste products; maintain normal blood chemistry. Clinical significance of urine analysis Routine urinalysis are perfo
3、rmed for several reasons: general health screening to detect renal and metabolic diseases diagnosis of diseases or disorders of the kidneys or urinary tracts monitoring of patients with diabetes临床上尿液可以进行哪些项临床上尿液可以进行哪些项目的测定？目的测定？你认为什么最重要？你认为什么最重要？A Complete urinalysis has 4 partsGross examinationSpec
4、ific gravityBiochemical analysisSediment Examination目前使用全自动仪器进行尿液分析，大大提高目前使用全自动仪器进行尿液分析，大大提高了工作效率了工作效率尿干化学分析仪尿干化学分析仪尿有形成分分析仪尿有形成分分析仪 干化学分析试剂条干化学分析试剂条PHSGPRO GLUKETBILUROBLDLEUNITWhat information can urinalysis give us? Routine tests SG PH Pro Glu Bil UBO WBC RBC NIT KETSpecific testsMicroprotein(Alb
5、,2MG，1MG,IgG,TRF)Light chainEnzymeUrine electrophoresis Urine sediment RBC WBC cast crystal bacteria fungi Sample collectionRandom specimen This is urine that has been spontaneously voided within a 24-h period. It often originates in patients with an acute disease. It is not known for how long the u
6、rine was present in the bladder. The interpretation of the findings is difficult.First morning(8-h specimen) urine The bladder is emptied immediately prior to bedtime and the first morning urine is collected. This urine represents the resting state. It rules out orthostatically induces proteinuria.
7、The cell concentration is high since the urine is acidic though preserving cells and casts from destruction and lysis. The bacteria content is high which lead to an improvement in the bacteriological diagnosis.(midstream)Second morning urine This urine is used in outpatients who take longer to trave
8、l to the medical facility and it used for special examinations, e.g. the classification of proteinuria, cytological examinations of the bladder mucosa or the determination of dysmorphic erythrocytes.24-h urine Urine collected over a 24-h period It is mostly employed for the determination of proteinu
9、ria as part of the diagnosis of renal disorder.Sample storage and transport The transport of urine to the clinical laboratory should be done as fast as possible. 1.After 2 h the pH may have risen and autolysis of the particulate material(cells, casts) may have occurred.2. cooling is not recommended
10、because of the precipitation of amorphous urates of phosphate crystal. The urates interfer with the microscopic examination.3.the specimen must be deepfrozen or stabilized by the chemical addictives.尿液标本的保存尿液标本的保存 冷藏法：不能超过冷藏法：不能超过8小时。小时。 化学防腐法：化学防腐法： 防腐剂防腐剂 实用范围实用范围 甲苯甲苯 化学检查化学检查 福尔马林福尔马林 显微镜检查显微镜检查
11、 浓盐酸浓盐酸 17-羟类固醇，儿茶酚胺等激素羟类固醇，儿茶酚胺等激素 麝香草酚麝香草酚 结核杆菌结核杆菌Goal of diagnostic evaluations using urinalysis To rule out increased urinary excretion(cells, proteins) To differentiate between benign and pathological situations To distinguish between different causes To quantify(xx) in order to assess disease
12、 activity.Gross Examination Color appearance Odordiabetes insipidus Biochemical analysisUrinary proteins Increased excretion of proteins in the urine, i.e. proteinuria(120mg/24h), is the hallmark of the almost any kind of kidney disease. Simple and inexpensive. Dipsticks detect protein by production
13、 of color with an indicator dye, Bromphenol blue, which is most sensitive to albumin but detects globulins and Bence-Jones protein poorly. Precipitation by heat is a better semiquantitative method, but overall, it is not a highly sensitive test. The sulfosalicylic acid test is a more sensitive preci
14、pitation test. It can detect albumin, globulins, and Bence-Jones protein at low concentrations. In rough terms, trace positive results (which represent a slightly hazy appearance in urine) are equivalent to 10 mg/100 ml or about 150 mg/24 hours (the upper limit of normal). 1+ corresponds to about 20
15、0-500 mg/24 hours, a 2+ to 0.5-1.5 gm/24 hours, a 3+ to 2-5 gm/24 hours, and a 4+ represents 7 gm/24 hours or greater. Mechanism of Proteinuria Increased glomerular filtration. The protein must pass through the glomerular capillary wall. a.Nephrotic Syndrome- minimal change disease and focal glomeru
16、losclerosis b.Glomerulonephritis c.Drugs The reason of proteinuriaglomerular the size-selective barrier leaks large protein molecules the charge-selective barrier fails to retain lower mol wt proteins. The reason of proteinuriaApproximate size cutoff of substances for filtration is 70kDa. substances
17、 smaller than this are often retained,either due to charge effects(albumin) or because they are tightly bound to other proteins to give them a larger effective sizeDecreased tubular reabsorption. Most filtered protein is reabsorbed proximally. With tubular damage, there will be increased protein in
18、the urine a. Transport defects- Fanconis Syndrome, Cystinosis b. Toxins- Penicillins, Heavy metals, Aminoglycosides氨基糖甙类氨基糖甙类, tetracycline四环素四环素c.Ischemic injury- shock, ATN急性肾小管坏死急性肾小管坏死, Endotoxemia d. Obstructive uropathy, Polycystic disease Increased secretion- normally some protein is secreted
19、 but may increase with exercise, acute renal failure, transplant rejection, and stones. chain haemoglobin myoglobin How to differentiate proteinuia from each otherRoutine tests(proteinuria).The amounts of small molecules increased more than the ability of tubular reabsorption. 1.Multipomyeloma light
20、 chain,electrophoresis or immunoassay 2.intravascular hemorrhage Hb ，OB+，TB ，IB ，UBO+ 3.urine routine test:protein negative or traceTypes of proteinuria（pathologic） Renal proteinuria:glomerula, tubular; the sytemic and generalized diseases (SLE, diabetes) . Prerenal causes: excretion of Ig light cha
21、in intravascular hemolysis(血管内溶血) Postrenal causes:hemorrhage and exudation within the lower urinary tract.Non-pathological causes of proteinuria 1. Exercise- should recheck after a few days of inactivity 2. Fever- recheck when the child is afebrile 3. Postural(体位性）体位性） or orthostatic proteinuria- v
22、ery common especially in adolescence. Picked up on routine screen and patient is asymptomatic, the physical examination including BP is normal, and there is no red blood cells in the urine.Types of proteins and marker proteinsSelective glomerula proteinuria Increased glomerular permeability for mids
23、ized anionic ,50-70KD(mostlky Alb and TRF),0.03-0.3g/24h. Nonselective glomerula proteinuria Increased glomerular permeability for highmolecular mass proteins ,50-150KD,Alb and IgG, 1.5-20g/24h.Types of proteins and marker proteinsTubular proteinuriaDecreased tubular reabsorption of low-molecular ma
24、ss proteins,10-70KD,0.15-15,1MG,2MG,retinol-binding protein,cystatin C,-NAG.Mixed proteinuriaIncreased glomerular permeability for highmolecular mass proteins with secondary damage or saturation(overflow proteinuria) of tubular reabsorption.Types of proteins and marker proteinsPrerenal proteinuria I
25、ncreased plasmatic release of low-molecular mass proteins,tubular overflow;increased total protein with normal albumin Hemoglobin Myoglobin BJ-protein 0.1-5g/24h.Types of proteins and marker proteinsPostrenal proteinuria Hemorrhage or exudation within the lower urinary tract. The main contents: Tamm
26、 Horsfall protein, IgA, plasma proteins, the quantities are variable,the marker protein:2MG,apoAI What is the definition of hematuria?Hematuria Positive test indicates either Hematuria, haemoglobinuria or myoglobulinuria. Free haemoglobin or myoglobin cause field change; intact red blood cells (RBC)
27、 are broken down on contact with the reagent pad and release local haemoglobin, producing a dot. These coalesce when 250 RBCs/ml. Hematuria False positive readings are most often due to contamination with menstrual blood. Incidence of false positives can be increased by dehydration which concentrate
28、s the number of RBCs produced and exercise. Haematuria is defined as 3 RBC/high power field (hpf) of centrifuged sediment under microscope. Other causes of dark urine include beets, blackberries, pyridium, rifampin, urate crystals, Myoglobinuria may be seen after burns, crush injuries, myositis, and
29、 prolonged generalized seizures. Hemoglobinuria is most commonly associated with hemolytic anemias. How to confirm the real hematuria? 1.urine dipstick 2.urine sediment3.TB,DB4.myoglobin How to analyze the results of urinalysis?WBC positive probable urinary tract infection; urinary proteins not asse
30、ssable; urine Repeat examination after treatment culture of infection. if negative Hemoglobin/myoglobin positive hematuria,hemeglobinuria,myoglobinuria; differentiate between renal/postrenal origin by means of Alb/2MG ratio. ratio0.02 The ratio0.02 ,Alb positive Renal proteinuria; Differentiation be
31、tween selective glomerular, nonselective glomerular, tubular proteinuria by SDS-PAGE or quantitative determination of IgG and 1MG. Monitoring by means of total protein or selected marker proteins.Alb(-) Hb(-) Leu(-) Probably no pathological proteinuria; However:purely tubular proteinuria and B-J pro
32、teinuria are not detected by the test strip; In case of clinical suspicion total protein should be analyzed using a method with higher analytical sensitivity.Urine sediment Whats urine sediment？ refers to the formed elements of the urine in a centrifuged specimen. These include red blood cells, whit
33、e blood cells, epithelial cells,casts, crystals, bacterial, and fungiNormal Clean-catch urine,light yellow Less than 3 red blood cells/hp Less than 5 white blood cells/hp A few epithelial cells,occasional hyaline casts, occasional crystal, and no bacteria or fungihematuria More than 3 red blood cell
34、s/hpPyuria More than 10 white blood cells/hp Indicate renal or genitourinary inflammation unless there is contamination of the specimen Plus NIT and(or) urine culture(65% Escherichia coli大肠杆菌大肠杆菌,NIT positive)CastsFormed in the distal tubules and the collecting ducts.Can be classified into: cell-fre
35、e casts,e.g.hyaline casts,granular casts,waxy casts,fatty casts; Cell casts,e.g.epithelia casts,red blood cell casts,white blood cell casts,and bacteria casts. Casts Hyaline casts:found in healthy people as well as in patients with renal disease. Granular casts:excreted both by healthy people as wel
36、l as by patients with renal disease,especially in the presence of proteinuria. Waxy casts:occur in in chronic renal insufficiency and during the polyuric phase of acute renal failure.Casts Fatty casts:produced by degenerated tubular cells.observed in patients with nephrotic syndrome an in those with
37、 severe proteinuria. RBC casts:a reliable indicator of renal oarenchymatous disease and usually suggest the presence of glomerulopathy. WBC cast:found in patients with inflammatory renal disease.颗粒管型颗粒管型蜡样管型蜡样管型Questions1.What factors can influence the results of urinalysis?2. Please tell us the app
38、lications of urine OB test and uses the tests you have studied to differ OB positive situations from each other. 13-year-old boy,with bloody urine of one days duration. He had been well until 1 week before admission when he developed a sore throat with fever that lasted for 2 or 3 days. The fever an
39、d the throat symptoms disappeared without treatment. However, he continued to feel generally fatigued. The day before admission, his urine became smoky brown; the morning of admission his mother noticed facial puffiness, pallor and noisy breathing. PE T 37.8, P 90/min, R 20/min, BP 150/95 mm Hg. HEE
40、NT: Slight swelling of the eyelids and periorbital edema were present. Fundi were normal. Throat and eardrums were normal. Chest: Rales were heard at both lung bases.Cardiac: The jugular veins were not distended. The point of maximal impulse was displaced slightly laterally. An S3 was heard. There w
41、ere no murmurs. Abdomen: There were no masses or abdominal tenderness. The kidneys could not be felt. Neurologic, rectal: Normal. Lab findings Blood routine: hematocrit 35%, WBC normal. Urinalysis protein 2+, RBC100 /hpf, WBC20/hpf, BUN 25 mg/dl. Creatinine 1.6mg/dl. Electrolytes normal. Questions1.
42、Whats the diagnosis and whats your evidences?2.Which other diseases will you consider to differentiate?3.In order to confirm your diagnosis, which tests will you do and why? Glomerular diseases may be primary or secondary to systemic disease. The major pathogenic categories are inflammatory (nephrit
43、ic syndrome) and hemodynamic (nephrotic syndrome). and laboratory findings due to increased glomerular capillary wall permeability. The classic nephritic syndrome includes hematuria, hypertension, renal insufficiency, and edema. Frequently, individual components of the syndrome are absent. Nephritic
44、 syndrome may be acute and transient (eg, postinfectious GN), fulminant with rapid renal failure (eg, rapidly progressive glomerulonephritis RPGN), or indolent (eg, IgA nephropathy). Pathologic changes, and therefore clinical manifestations, often vary over time. Protein 0.5 to 2 g/m2/day may be exc
45、reted; random urinary protein/creatinine ratio may be 2 g/m2/day or a random urinary protein/creatinine ratio 2), but hypoalbuminemia ( 3 g/dL), generalized edema, lipiduria, and lipemia are also common The urine sediment usually contains hyaline, granular, fatty, waxy, and epithelial cell casts. Lipiduria is determined by performing Sudan staining of casts containing lipid granules
