Bodily Fluids Comp. Exam :0

Normal Urine Sediment

–0-2 RBCs/hpf

–0-5 RBCs/hpf

–0-2 Hyaline or Fine Granular Casts/lpf

–Few epithelial cells

–Slight presence of mucus (especially in female patients)

RBC in Urine

• Abnormal

• indicates glomerular damage or menstrual contamination

• ghost cells seen in alkaline urine

• can be confused with yeast or oil droplets / to differentiate add 2% acetic acid all rbc will be lysed

WBC in urine

• indicate infection or inflammation (pyuria)

• can be present in clumps

Tamm Horsfall Protein ( uromodulin)

• main component of casts that is secreted by renal tubule epithelial cells

Factors that cause cast formation

Decreased pH

  - Decreased urine output

  - Increased solute concentration (increased SG)

  - Increased protein in urine

Hyaline Cast

• most commonly seen

• made of mostly uromodulin ( transparent in appearance )

RBC Cast

• indicates bleeding in the nephron caused by glomerular dysfunction

• critical result of intrinsic renal disease (glomerulonephritis)

WBC Cast

• associated with pyelonephritis

• used to differentiate between cystitis and pyelonephritis

• in pyelonephritis the casts will be seen

• to differentiate between wbc clumps and casts look for a cast matrix

Granular Cast

–Disintegrated cellular casts

–Sometimes seen following strenuous exercise due to dehydration decreasing urine flow

Broad Waxy Cast

–Advanced stage of Hyaline, Cellular, or Granular Cast

–Indicates prolonged urinary stasis (think…stagnant urine)

–Diagnostic of Chronic/End Stage Renal Disease

–Also called “Renal Failure Casts”

–Possesses distinct “notches”

–Form in Collecting Ducts that have become dilated due to damage (BAD SIGN!!!)

Fatty Cast

–Made from breakdown of epithelial cell casts that contain Oval Fat Bodies

–Seen in Nephrotic Syndrome

Squamous Epithelial Cell

•Largest cell, BUT LEAST significant (frequently seen, especially in urine specimen from females)

•Has abundant irregular cytoplasm

•Has a central nucleus (about the size of a RBC)

Transitional Epithelial Cell

•Round or pear shaped (Round can be confused with RTE)

•Has central nucleus

•Can absorb water and swell to 3X its normal size

•Present in Renal Carcinoma

•Lines bladder and upper urethra

•Increased presence in patients with catheters

Renal Tubule Epithelial Cell

•MOST significant

•Round eccentric nucleus

•Larger in size than a WBC

•Lines renal tubules

•Indicates Tubular Necrosis

Oval Fat Body

•RTE cells that absorb fat deposits in certain fat-producing disorders

•Highly refractile

•Present in Nephrotic Syndrome

•Possesses distinct “Maltese Cross” when polarized

•Can stain with Sudan III or Oil Red O

Amorphous Urates

• pink sediment with yellow-brown granules

• in normal urine

Uric Acid

• typically in rhomboid shape

• indicator of Lesh-Nyhan Syndrome

• (Lesh-Nyhan :incomplete metabolism of dietary purines )

Calcium Oxalate

• envelope shape or distinct “X”

• seen in children with antifreeze poisoning

Normal crystals in alkaline urine

–Amorphous Phosphates: white sediment with yellow-brown granules

–Triple Phosphate: “coffin lid”

–Ammonium Biurate: “thorny apple”

–Calcium Carbonate: “dumbbell”

Amorphous Phosphate

Triple Phosphate

Ammonium Biurate

Calcium Carbonate

Bilirubin

small clusters of yellow-brown fine needles

Cystine

colorless hexagonal plates

Cholesterol

rectangular plates with notched corners

•Birefringent: exhibits two colors under polarized light

•Commonly seen in urine with 4+ Protein (ex: Nephrotic Syndrome)

Leucine

yellow-brown spheres with concentric circles or radial striations

Tyrosine

–fine, delicate needles

•When found together with Leucine = Liver Disease!!!

•Commonly found in urine POS for Bilirubin

Sulfonamide

needles or brown spheres from sulfonamide drugs

Radiographic dyes

plates or may appear as needles

Bacteria

•“Rod Shaped” is most commonly found form

•MOST significant with POS Leukocyte Esterase result (WBC’s)

Yeast

•Often represent vaginal infection

•Simple “budding” or hyphae yeast can be present

Must correlate with clinical findings (ex: POS Glucose)

Paracites

•Trichomonas Vaginalis: parasite transmitted through sexual intercourse

–Look for “whipping” motility…moves in circles

Sperm

may be seen in both male and female patients

Mucous

•More common in female specimens, but can be seen in both

•Has no clinical significance

Clue cells

•Squamous epithelial cells with “rod shaped” bacteria clustered on borders

•Presence indicates Bacterial Vaginosis (BV)

Glitter Cells

•In urine with LOW SG (Hypotonic), WBC’s absorb water and swell causing granules to exhibit Brownian Movement.

Artifacts

components that are not clinically significant, but can sometimes contaminate urine. Should be ignored during microscopic examination

Powder

•Can be confused with crystals

•“Maltese Cross” can be seen when viewed with polarized light, BUT NOT ROUND like Cholesterol. Has “dimpled center.”

Fat

•Triglycerides will stain positive with fat stains (Sudan III and Oil Red O)

•Cholesterol will NOT stain with fat stains

Hair

•May be confused with casts

Fiber

•Also may be confused with casts

•Polarizes light, while casts do NOT

Phenylketonuria

caused by failure to produce phenylalanine hydroxylase

mousy odor

guthrie test

Tyrosinuria

• the accumulation of excess tyrosine

• rancid odor

• caused by 2 reactions p-hydroxyphenylpyruvic acid and p-hydroxyphenyllactic acid

• underdeveloped liver

• metabolic disorder

alkaptonuria

• failure to produce the enzyme homogentisic acid oxidase

• build up in homogentisic acid

• urine darkens at room temp.

• metabolic disoder

melanuria

• caused by malignant melanoma

• build up of melanin

• urine darkens on exposure to air

• metabolic disorder

Maple Syrup Disease

• autosomal recessive trait

• build up of leucine, valine, and isoleucine

• ketoacids in the blood and urine

• urine will have maple syrup smell

• metabolic disorder

indicanuria

• causes by obstruction or abnormal bacteria

• build up of indica

• blue urine when exposed to air

• hartnup disease

• tryptophan disorder

5-Hydroxyindoleacetic acid (5-HIAA)

• Tryptophan disorder

• Caused by tumor that involves argentaffin cells

• build up of serotonin

• 5-HIAA in the urine

Cystinuria

• inability of renal tubules to reabsorb cystine

• cystine crystals in urine

• sulfur odor

Cystinosis

• incomplete metabolism of cystine

• build up of cystine

• cystine deposits throughout the body

• polyuria

• aminoacid uria

• positive clinitest

• lack of urinary concentration

• sulfur odor

Uroporphyrin, Coproporphyrin, protophyrin

• precursor is porphobilinogen

• can be due to lead poisoning, excessive alcohol intake, iron deficiency, renal disease, and liver disease

• Ehrlich Reaction tests for aminolevulinic acid (ALA) and porphobilinogen

• urine has a portwine color

Lesh-Nyhan Disease

• purine disorder

• sex-linked recessive disorder

• build up of uric acid

• uric acid crystals in urine

• crystals in joints, tendons, and organs

The 3 layers of meninges

Dura mater- outer

Arachnoid mater- middle web-like

Pia mater- soft inner

CSF Fluid

• flows between the middle and inner layer

• secreted from the choroid plexus

3 Functions of CSF Fluid

1. mechanical support or cushion to the brain against trauma

2. removes metabolic waste products from the brain

3. supplies nutrients to the tissues and nerves of the CNS

Blood-Brain Barrier

bi-directional active transport between the blood, CSF, and brain

lumbar puncture

done between the 3&4 or 4&5 lumbar vertebrae

tube collection

tube 1 : chemistry

tube 2: microbiology

tube 3: hematology

Traumatic tap

blood in all 4 tube

xanthochromic

supernatant with a yellow pink or orange color

indicates a subarachnoid hemorrhage

is always pathological

3 visual examination to determine traumatic tap

• uneven distribution of blood

• clot/ pellicle

• clear supernatant

what causes cloudy CSF

• bacterial or viral infection (meningitis)

• traumatic tap (fibrinogen)

cell count in CSF

• RBC and WBC must be counted within 1 hr of collection

• may use saline or 3% acetic acid

• hemocytometer is used to count

pleocytosis

increased cellularity in bodily fluids

Normal WBC in CSF

Adults: 0-5/ul

Babies: 0-30/ul

B-2 Micorglobulin

• increased levels of B-2 microglobulin indicate reduced GFR

• not specific for GFR

Blood Test Strip

• detects RBC, hemoglobin, and myoglobin

• rxn principle: 1. peroxide + O2 / 2. O2 + indicator = color change

• aid in detection of hematuria, hemoglobinuria, myoglobinuria

• bleach and other oxidizing agents cause a false positive

Protein Test Strip

• tests for the presence of albumin( and globulin)

• rxn principle: protein error of indicators

• interfering substances: highly alkaline urine which causes a false positive

• indicates presence of renal abnormalities with glomerular involvement

Glucose Test Strip

• detects glucose ONLY

• rxn principle: Glucose Oxidase Method glucose → gluconic acid & hydrogen peroxide → peroxidase catalyzes oxidation of chromagen

• used for diagnosis of diabetes

• interfering substances: oxidizing agents cause a false positive

Osmolality Gap

2x (sodium) + 1.5(glucose/18) + (urea/2.8)

Microalbumin Strip Test

• used for early detection of diabetic nephropathy

• indicated decreased glomerular function

• rxn principle: immunochemical rxn

Yellow-Green Urine

bilirubin

Green Urine

pseudomonas infection

Brown Urine

melanin/ phenol derivatives

Pink Urine

blood, beets, rhubarb

What affects urine color?

• urochorme,uroerythrin, porphyrins

• food, drugs, disease

Abnormal Urine Appearance

• Turbid, cloudy, opaque

• pink, red, brown, black, green

Normal Urine Appearance

• clear or hazy

• colorless, pale yellow, amber

Pyelonephritis

Cause: advanced UTI

Microscope finding: WBC casts and bacteria

Cystitis

Cause: UTI

Microscope finding: WBC, bacteria, possible RBC

Acute Interstitial Nephritis

Cause: allergic reaction causing inflammation of renal tubules

Microscope findings: eosinophil count

Acute Pyelonephritis

Lab Findings

• turbid specimen

• nitrite positive

• leukocyte esterase positive

• WBC casts

• bacteria

Nephrotic Syndrome

Lab Findings

• fat droplets

• oval fat bodies

• fatty casts

Acute Glomerulonephritis

Lab Findings

• gross hematuria

• turbid specimen

• RBC casts

• dysmorphic RBC

• proteinuria

possible cause: goodpasture’s syndrome

Non-immune causes of Glomerular Damage

1. exposure to chemicals/ toxins

2. disruption of electrical membrane changes

3. deposition of amyloid material from systematic disorders

4. basement membrane thickening associated with diabetic nephropathy

Type of Renal Disease

• glomerular

• tubular

• interstitial

• vascular

Acute Tubular Necrosis

Damage to the renal tubules

Causes: shock, trauma, crushing injury, surgical procedure

UA:

• mild proteinuria

• microscopic hematuria

• RTE cells and casts

Tubular Disorders

disruption of tubular function

may be caused metabolic or hereditary

The Medulla Contains

• loop of Henle

• Collection tubules

The Cortex Contains

• Glomerulus

• Bowman’s capsule

• Proximal portion of tubules

Function of the Kidneys

1. waste elimination

2. acid/base balance

3. regulate volume of body fluids

4. maintain BP and erythropoisis

Criteria for Glomerular Filtration Testing

1. Neither excreted or reabsorbed by tubules

2. Is produced at a constant rate and not influenced by the body’s state of hydration

(creatinine)

Ascending Loop of Henle

sodium

passive transport

GFR

measures the rate at which the kidneys are able to remove a filterable substance from the blood

Ultrafiltrate contains

• water

• glucose

• electrolytes

• amino acids

• uria

• creatinine

• ammonia

Proximal Convoluted tubule and Ascending Loop of Henle

urea

passive transport

Loop of Henle (except ascending)

water

passive transport

Distal Convoluted Tubule

sodium

active transport

Ascending Loop of Henle

chloride

active transport