Bodily Fluids Quiz 1

Introduction to Urinalysis

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Analyzing

• Physical

  • Color, clarity, odor

• Chemical

  • Dipstick and/or tables

• Microscopic

  • Cells, casts, crystals, etc

Composition

• Water (95%)

• Urea

  • Produced in the liver

  • Breakdown of protein and amino acids

  • Half of total dissolved solids in urine

• Other organic substances

  • Creatine

  • Uric acid

Composition Pt 2

• Inorganic Substances

  • Chloride

  • Sodium

  • Potassium

  • Calcium

  • Magnesium

  • Phosphates

  • Sulfates

  • Ammonia

• Other Substances

  • Vitamins

  • Hormones

Volume

• Average: 1200-1500mL in 24 hours

• Oliguria

  • Decrease in urine output (dehydration)

• Anuria

  • Cessation of urine flow

Volume Pt 2

• Nocturia

  • Increase in the nocturnal excretion of urine

• Polyuria

  • Increase in daily urine volume

    • Diabetes mellitus: excretion of increased amounts of water to remove glucose

    • Diabetes insipidus: decrease in the production or function of ADH

Specimen Collection

• Specimen handling

  • Container: clean, dry, leak-proof, sterile

  • Proper label: Name, MRN, Date, Time collected, Info on the container not the lid!!

  • Delivery to lab within one hour at room temperature

Changes in Unpreserved Urine

1. Color

2. Clarity

3. Odor

4. pH

5. Glucose

6. Ketones

1. Modified or darkened due to oxidation/reduction of metabolites

2. Decreased due to bacterial growth and precipitation of amorphous material

3. Bacterial multiplication causing breakdown of urea to ammonia

4. Breakdown of urea to ammonia by urease-producing bacteria/loss of CO2

5. Glycolysis and bacterial use

6. Volatilization and bacterial metabolism

7. Bilirubin

8. Urobilinogen

9. Nitrite

10. Red and White Blood Cells and Casts

11. Bacteria

12. Trichomonas

7. Decreased due to exposure to light/photooxidation to biliverdin

8. Oxidation to urobilin

9. Multiplication of nitrate-reducing bacteria

10. Disintegration in dilute alkaline urine

11. Multiplication

12. Loss of motility, death

Urine Preservatives Advantages and Disadvantages

• Refrigeration

  • Does not interfere with chemical tests (A)

  • Precipitates amorphous phosphates/urates (D)

• Boric Acid

  • Prevents bacterial growth and metabolism (A)

  • Interferes with drug and hormone analyses

Urine Preservatives Advantages and Disadvantages Pt 2

• Formalin (Formaldehyde)

  • Excellent sediment preservative (A)

  • Acts as a reducing agent, interfering with chemical tests for glucose, blood, leukocyte esterase, and copper reduction (D)

• Sodium Fluoride

  • Good preservative for drug analysis (A)

  • Inhibits reagent strip tests for glucose, blood, and leukocytes (D)

Urine Preservatives Advantages and Disadvantages Pt 3

• Commercial preservative tablets

  • Convenient when refrigeration not possible have controlled concentration to minimize interference (A)

  • Check tablet composition to determine possible effects on desired tests (D)

• Urine Collection Kits

  • Contains collection cup, transfer straw, culture, and sensitivity preservative tube, or UA tube (A)

Urine Preservatives Advantages and Disadvantages Pt 4

• Light Gray and Gray C&S Tube

  • Sample stable at room temp for 48 hours, prevents bacterial growth and metabolism (A)

  • Do not use if urine is below the minimal fill line (D)

• Yellow UA Plus Tube

  • Use on automated instruments (A)

  • Must refrigerate within 2 hours (D)

Urine Preservatives Advantages and Disadvantages Pt 5

• Cherry red/yellow Preservative Plus Tube

  • Stable for 72 hours at room temperature, instrument compatible (A)

  • Must be filled to minimum fill line. Bilirubin and urobilinogen may be decreased if specimen is exposed to light and left at room temperature

Specimens Collected

• Random: routine

• First morning

  • Routine, pregnancy, orthostatic protein (increasing protein in urine when walking)

• Fasting

  • Second voided specimen after a fast→ used in glucose monitoring

• 2 hour postprandial→ diabetes

Specimens Collected Pt 2

• Catheterized→ bacterial culture

• 24 hour specimen→ quantitative chemical tests

• Midstream clean catch

  • Routine screening, bacterial culture

• Suprapubic aspiration

  • Bladder urine for bacterial culture, also cytology

Kidney Function

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Functions of the Kidney

• Excretory: Clears the body of:

  • Undesirable end products of metabolism

  • Excess inorganic substances ingested in the diet

• Regulatory → Homeostasis

  • Volume and composition of body fluid through reabsorption and secretion

• Acid base balance

• Endocrine: production of renin, erythropoietin, vitamin D

Anatomy

• Two kidneys, two ureters, bladder, and urethra

• Nephron

  • Glomerulus

  • Bowman’s capsule

  • Proximal tubule

  • Loop of Henle

  • Distal tubule

  • Collecting tubules

Nephron

• Functional unit of the kidney

• Responsible for:

  • Renal blood flow

  • Glomerular filtration

  • Tubular reabsorption

  • Tubular secretion

Nephron Pt 2

• Renal blood flow through the kidney

  • Enter the afferent arteriole

  • Into the glomerulus

  • Efferent arteriole

  • Peritubular capillaries (back to the blood stream)

Glomerular Filtration

• Blood enters the glomerulus via the afferent arteriole

• Glomerular filtrate

• Plasma and small particles filter through the glomerular capsule to the loops

  • Water, salts, HCO3, H+, Urea, glucose, amino acids, drugs

• Large particles are carried out through the efferent arteriole

  • Proteins and RBCs

Proximal Tubules

Reabsorbed

• Amino acids, glucose, phosphates, sulfate

• Urates, electrolytes, bicarbonate, 8-% of water

Secreted

• Ammonia (NH3), potassium, hydrogen, uric acid

• Some organic bases, some drugs

Loop of Henle

• Descending: Water is reabsorbed (passive)

• Ascending: sodium and chloride reabsorbed (active)

Distal Convoluted Tubule

Reabsorbed

• Salt (A), water (P), bicarbonate (A)

Secreted

• Hydrogen (A)

Collecting Duct Pathway

NaCl is reabsorbed (A) and urea is reabsorbed (P)

• Filtrate

• Collecting duct

• Renal pelvis

• Out of the kidney via ureters

• Bladder to be released

Renal Threshold

• Substances are reabsorbed according to the body’s needs

• When plasma concentration is high, reabsorption is no longer possible

• The nutrient is then spilled into the urine

  • Glucose renal threshold= 160mg/dL

Clearance

• Rate at which the kidney can clear a substance from the body

• Must be one that is not secreted or reabsorbed by the tubules

• Stable substance

• Creatinine is most common substance

Renal Clearance Test

• Creatinine clearance

Urine creatinine level (mg/dL) x urine volume (mL/min)/ plasma creatinine level (mg/dL)

• x (1.73)/body surface area (m)

If surface area not stated assume it is 1.73

Creatinine Clearance Reference Ranges

• Male: 97-137 mL/min

• Female: 88-128 mL/min

Osmolarity

• Measures renal concentrating ability

  • Measurement of the number of moles of particles per kilogram of water

  • An early indicator of chronic renal disease if concentrating ability is reduced

• Equation:

  1.86 x Na + (glucose/18) + (BUN/2.8) + 9

Proteinuria

• Normal urine protein is <150mg/24 hrs

• Renal disease associated with glomerulus almost always results in an increase in protein

• Primary protein excreted = albumin

• Pre-albumin is an indicator of early kidney damage

• Increase protein in urine = rise of interstitial fluid and edema

Nephrotic Syndrome

• Edema

• Hypoalbuminemia

• Albuminuria

• Increase in lipids with fatty casts, oval fat bodies

Nephrotic Syndrome Pt 2

• Causes

  • Circulatory disruptions that result in decrease in blood flow to the kidney

  • Complication of glomerulonephritis

• Disease associations

  • Diabetes mellitus, amyloidosis, systemic lupus erythematosus

Glomerulonephritis: Acute

• Sudden onset, frequently seen in children and young adults

• Circulating immune complexes deposit in glomeruli

• Hyaline and granular casts, increased BUN, increased creatinine, anemia, oliguria, Na+ and water retention

• May be seen 1-4 weeks following Group A strep infection

Glomerulonephritis: Chronic

• Continual or permanent damage to glomerulus

• Edema, hypertension, anemia, metabolic acidosis, oliguria to anuria

• Blood, protein, and variety of casts in urine, specific gravity of 1.010

Glomerulonephritis: Other Diseases

• Renal failure

  • Hypotension due to traumatic or surgical shock, burns, or intravascular hemolysis

• Pyelonephritis

  • Infection of the kidney

• Cystitis

  • Infection of the bladder

• Acute Interstitial nephritis

  • Allergic reaction without bacteria, eosinophils present

Pleural, Pericardial, and Peritoneal Fluids

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Anatomy and Pathophysiology

• Pleural cavity encloses the lungs

• Pericardial cavity encloses the heart

• Peritoneal cavity encloses the abdominal origin and are lined by two membranes referred to as serous membranes

Parietal membrane lines the cavity wall and visceral membrane covers the organs within the cavity

Serous Fluid

The fluid that accumulates between the membranes

• It serves as cushion, lubricant, and transport media between the visceral and peritoneal membranes

• Accumulation of serous fluid within the cavities is called an effusion

Serous Fluid Pt 2

• Normally a small amount of serous fluid is present since production and reabsorption take place at a constant rate

• Accumulation of serous fluid within the cavities is called effusion

Bronchioalveolar lavage (BAL)

May be performed by inserting a bronchoscope through the mouth/nose into the lungs to dispense a small amount of fluid which is recollected for analysis

Formation

Pleural Fluid Effusion

• Normal amount of pleural fluid is 3-20mL

• Aspiration is called thoracentesis

  • Aids in diagnosis

  • Therapeutic benefit in the relief of pressure

Formation Pt 2

• Formed though ultrafiltration of the plasma in the parietal membranes and absorption by the visceral membranes; this is a continuous process

• As ultrafiltrate of the blood, the composition of the fluid reflects that of the serum

Formation Pt 3

• Protein enter pleural space from both pleural surfaces and leaves via the lymphatic vessels

• Normal appearance is clear and pale yellow

• Abnormal appearance may be milky which indicates an increase in chylous material from lymph fluid seen in obstruction of the thoracic duct

If Milky

• Abnormal: Chylous

  • Lipid concentration can aid in differentiating between chylous and pseudochylous

• Triglycerides

  • >100mg/dL is chylous effusion

  • <50mg/dL pseudochylous effusion

• Cholesterol ratio (fluid:serum)

  • <1.0 is chylous effusion

  • >1.0 pesudochylous effusion

If Bloody

• Most common cause of hemorrhagic pleural effusion is malignancy (usually lung cancer)

• True hemothorax as my be seen in chest injuries, is associated with pure blood in the pleural cavity

• Pure blood in cavity increased blood with normal fluid (high hematocrit)

If Bloody Pt 2

• A hematocrit reading is helpful in differentiating true hemothorax and hemorrhagic effusions

• In true hemothorax, hematocrit of the fluid will be similar to that of the peripheral blood

• In hemorrhagic effusion there is an increase of both fluid and blood, thus low hematocrit

Cells Seen In Pleural Fluid

1. Neutrophils

2. Lymphocytes

3. Mesothelial cells

4. Plasma Cells

5. Malignant cells

1. Pneumonia, pulmonary infections

2. TB, viral infections, autoimmune disorders, malignancy

3. Normal and reactive forms have no clinical significance, decreased is associated with TB

4. TB

5. Primary adenocarcinoma and small-cell carcinoma

Mesothelial Cells

• Cavity lining cells

• Proliferative and hyperplastic: clusters of mesothelial cells usually with moderate to scant cytoplasm and hyperchromatic nuclei

Mesothelial Cells Pt 2

• Reactive: mesothelial cells with slightly irregular nuclei and prominent nucleoli

• Atypical: mesothelial cells that closely resemble malignant cells and malignancy cannot be excluded

Pleural Chemical Testing

• Glucose

  • Decreased in rheumatoid inflammation and bacterial infection

• Lactate

  • Increased in bacterial infections

• Triglycerides

  • Increased in chylous effusions

• Cholesterol

  • Increased in pseudochylous effusions

Pleural Chemical Testing

• pH

  • Decreased in pneumonia not responding to antibiotics

  • Markedly decreased with esophageal rupture; the placement of a drainage tube may be required in addition to antibiotics

• Amylase

  • Increased in pancreatitis, esophageal rupture, malignancy

Pericardial Fluid Effusion

• Normal amount of pericardial fluid is 10-15mL

• Aspiration is celled pericardiocentesis

• Increases most frequently caused by damage to lining of pericardial cavity with increase in capillary permeability

Causes of Pericardial Effusions

• Infections

• Cardiovascular disease

• Renal failure and uremia

• Neoplastic disease

• Trauma

• Misuse of anticoagulant therapy

• Collagen vascular disease

Pericardial Fluid Effusion Pt 2

• Normal appearance is clear and pale yellow

• Abnormal

  • Milky: indicates damage to lymphatics

  • Turbid: may indicate infection

  • Blood streaked: TB or tumors

  • Bloody: indicates puncture

Pericardial Testing

• Differential (increased neutrophil and malignant cells)

  • Tests for bacterial infections and metastatic carcinoma

• Carcinoembryonic antigen (CEA)

  • Metastatic carcinoma

• Gram stain and culture

  • Bacterial infection

• Acid fast stain

  • Tubercular effusion

Peritoneal fluid effusions (Ascites Fluid)

• Aspiration of the peritoneal cavity is called paracentesis

• Lavage

  • Saline wash of cavity

  • Detects abdominal injuries

• Major cause: Infections

• Peritonitis: inflammation of abdominal lung

Normal vs Abnormal Peritoneal Effusion

• Clear, pale yellow: normal

• Turbid: Microbial infection

• Green: gallbladder, pancreatic disorders

• Blood-streaked: trauma, injection or malignancy

• Milky: lymphatic trauma and blockage; cirrhosis

Peritoneal Testing

• Differential

  • Peritonitis, malignancy

• CEA

  • Malignancy of the GI

• CA125

  • Malignancy of GI

• Peritoneal lavage

  • > 1 million RBC/uL = blunt trauma

• WBC Count

  • <500 cells is normal

  • >500 cells is peritonitis

Peritoneal Testing Pt 2

• Glucose

  • Decreased in malignancy

• Amylase/lipase

  • Increased in peritonitis and GI perforation

• ALP

  • Increased in GI perforation

• BUN/Creatine

  • Ruptured/punctured bladder

• Gram stain/culture

  • Peritonitis

General Classifications

• Transudates and exudates: differentiating fluid into these categories can be significant in diagnosis

• Transudates

  • Indicate that fluid has been accumulated because of systemic disease. A common disorder with transudates is congestive heart failure

    • Non-inflammatory response, clear fluid containing few cells and little protein

General Classifications Pt 2

• Exudates

  • Usually produced by conditions that directly involve membranes of the particular cavity including infections, malignancies, and inflammation

  • Results of inflammatory process, directly involves membranes of cavity, fluid is rich in protein and cellular elements

Test Results: Transudate

1. Clarity

2. Color

3. Specific gravity

4. Cell count

5. Differential

6. Glucose

1. Clear

2. Pale yellow

3. </= 1.015

4. <300

5. mononuclear cells

6. equal to serum

Test Results Transudate Pt 2

7. Total Protein

8. LD level

9. Fluid: serum protein ratio

10. Fluid: Serum LD ratio

7. <3g/dL

8. <60% of serum level

9. <0.5

10. <0.6

Test Results: Exudate

1. Clarity

2. Color

3. Specific gravity

4. Cell count

5. Differential

6. Glucose

1. usually cloudy

2. Yellow, green, pink, red

3. >1.015

4. >1000/uL

5. neutrophils early, mononuclear cells later

6. 30mg or more < serum

Test Results Exudate Pt 2

7. Total Protein

8. LD level

9. Fluid: serum protein ratio

10. Fluid: Serum LD ratio

7. >3g/dL

8. >60% of serum level

9. >0.5

10. >0.6

Specimen Collection and Processing

• Specimens are obtained by sterilely introducing a needle into body cavity containing fluid of interest

• Must be processed quickly to ensure minimum amount of artifacts

• Collection in EDTA for cell count and differential

• Collection in heparin for microbial stain and culture, flow cytometry, or cytogenic analysis

Specimen Collection and Processing Pt 2

• Serous fluids should be transported at room temperature and tested immediately to prevent cellular degradation, chemical changes, and bacterial growth

  • 40% of lysis of neutrophils after 2hrs at room temperature

  • Lymphocytes and monocytes are not affected until after 3hrs

  • If delay in transportation of specimen, should be refrigerated 2-8C

  • All specimens should be processed within 48hrs of collection

Cytocentrifuge Principles

• Cytocentrifuge: a low-speed, low acceleration centrifuge used to separate cells without causing damage to cellular components

• Some use a closed system to prevent aerosolization of specimens

• Some deposit the cellular material directly onto the microscope slides

Microscopic Examination

• A WBC differential is performed on cytospun stain slide with Wright-Giemsa stain

• Cells that may be encountered in serous fluids are:

  • Granulocytes

    • These may appear more or less identical to those in blood

    • Elevated neutrophils (>25%) may indicate bacterial infection

Microscope Exam: Lymphocytes

• Usually deep blue cytoplasm with prominent nuclei

• May vary in size

• May exhibit reactive changes

• Immature lymphs: may suggest lymphatic leukemia or lymphoma

• In TB fluid characteristics shows lymphocytosis

• Elevated lymphocytes in fluid may be indicative of infection

Microscope Exam: Mononuclear Cells

• Usually seen in variable numbers, large cells, blue/gray cytoplasm, vacuolated, with small round dark blue nucleus

• Macrophages are large vacuolated cells that show evidence of phagocytosis

• A macrophage may form into a “signet ring”, the vacuoles fuse together, forming a large vacuole that flattens the nucleus against the side of the cell membrane

Microscope Exam: Mononuclear Cells Pt 2

• The “signet ring” is a descriptive term and may be seen in benign or malignant s

• The number of macrophages varies n benign and malignant fluids and usually increases as the process becomes chronic

Microscope Exam: Mesothelial Cells

• Form lining of cavities

• Sometimes mistaken for malignant cells

• During inflammatory process they often go into serous fluid

• Large cells with “fried egg” appearance, nucleus round, chromatin is dark purple

Microscope Exam: Mesothelial Cells Pt 2

• May be binucleated

• Sometimes resemble large plasma cells

• Sometimes mistaken for tumor cells but mesothelial are more uniform and have a regular arrangement

Microscope Exam: Malignant Cells

• Cells usually bizarre

• Large cells sometimes with abnormal nuclei and cytoplasm

• Cells usually clump together

• These are sent to a pathologist

Synovial Fluid

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Anatomy and Physiology

• Synovial Cells (synovialcytes) line the synovial membrane

  • Synthesize protein

  • Phagocytize bacterial

• Synovial membrane secretes a small amount of muco-polysaccharide containing hyaluronic acid and protein into the fluid contributing to its viscosity

Anatomy and Physiology Pt 2

• Synovial fluid

  • Formed as an ultrafiltrate of plasma across the synovial membrane

  • “Joint” fluid

  • Supplies nutrients to the cartilage

  • Lubricant to the surface of the joints

Categories of Joint Disorders

• Noninflammatory: degenerative joint disease

• Inflammatory: rheumatoid arthritis and systemic lupus erythematosus, crystal induced, gout, and pseudogout

  • Septic→ microbial infection

  • Hemorrhagic→ trauma, coagulation deficiencies

Collection

• Arthrocentesis: needle aspirate, normal amount of fluid <4mL

• Types of collection tubes

  • Microbiology: sterile, heparinized

  • Hematology: EDTA

  • Non-anticoagulant tube to compare glucose

Clarity

• Normal: clear

• Inflammatory: hazy/cloudy/turbid

• Rice bodies seen in patients with RA

• Ochronotic shards seen in patients with alkaptonura (black urine disease)

Color

• Normal: colorless, pale yellow

• Inflammation: deeper yellow, white

• Hemorrhagic: homogeneously bloody

• Traumatic collection: pink or red

• Septic: yellow-green

• Xanthochromia (yellow): blood has been in fluid for a long time, becomes yellow after centrifugation

Turbidity (Presence of WBCs)

• Transparent

• Translucent

• Opaque

• Milky when crystals are present

Viscosity

• String test→ normal measures 4-6cm

  • RA: decreased viscosity

  • Inflammation, sepsis, crystal-induced hemorrhage: viscosity absent

• Mucin clot test

  • Adding drops of acetic acid to synovial fluid to promote clot formation

  • Poor clot formation is in inflammatory conditions like RA

Cell Count

• Normal: <200 cells/uL

• Differential: Primary Celss

  • Lymphocytes: <15%

    • Increase indicates non-septic inflammation

  • Monocytes and macrophages 60%

  • Neutrophils <25%

    • Increase indicates infection/septic conditions

• Synovial tissue cells

Crystal Identifications

• Polarized light

  • Crystal bending light

  • Light hits crystal in one plane

  • Crystals bed the light are able to pass through the other perpendicular plane, resulting in the crystal being white against a black background

Crystal Identification Pt 2

• Bifringence

• The ability to break light into 2 beams, detected with compensated polarized light

• Red compensator is placed between specimen and the analyzer

• Slow and fast moving light due to red compensator

Crystal Identification Pt 3

• Positive means that parallel is blue

• Negative means that parallel is yellow

Crystals: Sodium urate

• Negative birefringence= yellow

• Needlelike

• Increased uric acid

• Causes gout

• Intra/extracellular cells

• Tophus: nodular mass of sodium urate crystals

Calcium Pyrophosphates

• Positive birefringence= blue

• Rhombic in shape

• Causes pseudogout

• Intra/extracellular

Other Crystals

• Cholesterol

  • Notched rhombic plates

  • Negative birefringence

  • Extracellular of cells

• Corticosteroid

  • Flat, variable shaped plates

  • Positive and negative birefringence

  • Primarily intracellular of cells

  • Results from injection

Other Tests on Synovial Fluids

• Microbiology: gram stain, culture, and sensitivity

  • Staphylococcus: in older adults, infected joint replacement

  • Streptococcus

  • Haemophilus

    • All cause arthritis in young children

  • Neisseria: 75% of septic arthritic cases in young/middle aged adults

Chemistry

• Glucose: marked decreased in inflammatory or septic disorders

  • Normal synovial glucose levels are less than 10mg/dL lower than serum levels

• Total Protein

  • Normal <3g/dL

  • Increased levels found in inflammatory and hemorrhagic disorders

• Uric acid: gout, mirrors plasma concentration

Amniotic Fluid, Vaginal Secretions, Fecal, and Sweat Analysis

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Amniotic Fluid Formed From:

• Metabolism of fetal cells

• The transfer of water across the placental membrane

• Fetal urine (later stages in development)

Amniotic Fluid

• Volume

  • 12 weeks: 25-50mL

  • 37 weeks: 800-1200mL

• Replenishes every 2-3 hours

• Oligohydramnios: low (<800mL): intrauterine infection

• Polyhydraminos: high (>1200mL): decreased fetal swallowing

Amniocentesis

• Procedure to obtain fluid for analysis by needle aspiration into the amniotic sac

• Ultrasound examination is essential to assist the obstetrician in accurately directing the needle

• The amount of fluid takes out varies from 10-20mL No more than 30mL should be removed to prevent premature labor or spontaneous rupture of membranes

• Specimen should be protected from light and promptly delivered to the lab

Amniocentesis Pt 2

• Gross appearance should be noted

  • Colorless with some turbidity

  • Blood streaked: traumatic tap, abdominal trauma, intra-amniotic hemorrhage

  • Dark green: meconium, fetal distress

  • Yellow: bilirubin, HDFN

  • Dark red-brown: fetal death

  • Clarity decreases as gestation progresses