vis dis urine

signs and symptoms to order a UA

low back pain, painful urination (dysuria), hematuria, suprapubic pain, urethral or vaginal discharge (get that cultured too), frequent urination, anuria, polydipsia (excessive water intake), polyphagia, physicals and wellness screening

kidneys

have the ability to select and retain essential substances and excrete end products of metabolism and excess substances from the diet - important role in water balance, acid-base balance, and electrolyte balance - glomerular filtrate becomes urine after is leaves the distal convoluted tubule

how much cardiac output perfuses to the kidneys every minute?

25%

what else are the kidneys involved in?

production of erythropoietin (RBC stimulation hormone), and renin (BP controlling enzyme)

what does a routine UA consist of?

physical properties, chemical properties, microscopic properties

principle solutes of urine

urea, sodium, chloride, potassium, creatinine, uric acid, and ammonia - body excretes ~60 grams of dissolved material/24 hours, with one half being urea

urine formation

result of glomerular filtration, tubular reabsorption, and tubular secretion - composed of 95% water and 5% dissolved solids - average daily volume is 1200-1500mL with normal being between 600-2000

polyuria

>2000 mL/24 hours - could be due to diabetes mellitus, diabetes insipidus, large fluid intake, diuretic usage

oliguria

<500 mL/24 hours - could be due to renal tubule dysfunction, end stage renal disease, obstruction, edema, dehydration, diarrhea, vomiting, shock

anuria

absence of urine - due to renal failure, obstruction, heart attack

when is it best to collect a urine specimen?

early morning - want a midstream clean catch on first rising (as the urine has been in the bladder for hours and is most concentrated) - decomposition begind within 30 minutes at room temperature and within 4 hours if refrigerated

changes in unpreserved urine

color becomes darker, turbidity increases, odor is more foul smelling, pH increases, glucose, ketones, bilirubin and urobilinogen decrease, nitrites and bacteria increase, RBCs lyse, WBCs and casts disintegrate

what indicates degree of hydration inurine?

color

what is considered normal color for urine?

straw to amber (light yellow to dark yellow) - early morning urine is darker and more concentrated

orange urine

found with dehydration from fever, vomiting, certain foods (rhubarb, vit C, carrots), medications

bright yellow urine

found with excessive B vitamins

black urine

found with alkaptonuria, melanin problems like malignant melanoma - urine turns black after a bit of time

colorless urine

found with diabetes insipidus or over hydration associated with low SpG, diabetes insipidus associated with decreased pituitary ADH (which could happen with head trauma)

brownich-yellow/green combination urine

found with liver problems - so check bilirubin and urobilinogen - could also be referred to as dark yellow - may see jaundice of skin and sclera and other findings possible for hepatitis/liver disease (SGOT, SGPT, RUQ pain)

milky urine

associated with hyperlipidemia (risk factor for heart disease)

urine turbidity

urine is held up to light, need to microscopically look at urinary sediment as that contributes to turbidity

clear urine turbidity

normal

hazy or cloudy urine turbidity

either will be infection (pus, bacteria, RBCs, spermatozoa) or can be insignificant if it’s associated with crystals

milky turbidity of urine

may indicate hyperlipidemia

frothy urine turbidity

associated with proteinuria - if it’s white froth, then protein, if it’s yellow froth, then bilirubin

urine specific gravity

evaluates the kidney's ability to concentrate urine - inability to concentrate urine can be an early sign of renal disease - weight of urine compared to distilled water - equipment used to measure this is urinometer/refractometer or dipstick

what is the normal range for urine specific gravity for an adult?

1.015-1.035

hyposthenuria

low specific gravity of urine

hypersthenuria

high specific gravity for urine (could be due to sugar and/or proteins because those are heavy molecules)

isothenuria

fixed specific gravity at 1.010 (same as protein free plasma and signifies the end stage of renal failure) - requires multiple readings/tests/, can’t say this with only one test

increased specific gravity

indicates a concentrated urine, like proteinuria or glucosuria - dehydration (fever, vomiting, diarrhea) - decreased renal blood flow (heart failure, renal artery stenosis)

decreased specific gravity

indicates a dilute urine, so decreased concentration - could be from overhydration (polyuria) - also from glomerulonephritis (hematuria, blood casts), pyelonephritis, diabetes insipidus, or renal failure but these would have other signs

foul or fishy smelling urine indicates

UTI

fruit, sweet smelling urine indicates

diabetes mellitus/ketosis

feces odor from urine indicates

asparagus, enterobladder fistula

chemical characteristics of urinalysis

substances present in excess amounts are filtered through the kidney and appear in the urine - dipsticks (reagent strips - plastic strip with pads impregnated with various chemicals) are utilized - stick in the urine and match findings to chart - several tests are done simultaneously - precise timing is essential

what is urine pH often an indicator of?

renal or lung disease

normal pH range for urine

4.5-7.5 (acidic <7, neutral = 7, alkaline >7)

urine pH

urine becomes alkaline as it stands due to bacterial growth and breakdown of urea - changes in pH may appear first in urine - maintain normal pH primarily through reabsorption of sodium and secretion of hydrogen and ammonium ions

what kind of diet typically produces more acidic urine?

diet high in animal products

what kind of diet typically produces more alkaline/basic urine?

diet high in citrus fruits and vegetables

acidic pH urine

values under 7 - causes could be respiratory acidosis (emphysema), metabolic acidosis (sugars, diabetic ketoacidosis), diabetes mellitus, large amounts of meats and cranberries

alkaline pH urine

values over 7 - causes could be respiratory alkalosis (hyperventilation), metabolic alkalosis, UTIs (recommendation is to increase fluids likel blueberry and cranberry juices to make more acidic to fight more basic infection like E coli and bacillus proteus)

pH can help identify crystals in urine

acidic urine associated with xanthine, cysteine, uric acid stones and should be kept alkaline - alkaline urine associated with calcium carbonate, calcium and magnesium phosphate stones and should be kept acidic

protein/albumin in urine

1/3 of urine is albumin (dipstick is mainly sensitive to albumin) - albuminuria is used synonymously with proteinuria - reported as normal/negative (nonmeasurable), trace, 1+, 2+, 3+, 4+ - normally the glomerulus prevents proteins entering the glomerular filtrate - always investigate proteinuria since it may be primary indicator of renal disease - screening test is dipstick, positive test needs to be confirmed with SSA - glomerular filter is leaking proteins

proteinuria testing

centrifuge the urine, heavy stuff (like WBCs, RBCs) settles to bottom and proteins in fluid remain suspended above - protein/albumin is in the fluid (supernatant) - SSA is sulfosalicylic acid test detects all proteins - tech checks for amount of turbidity - confirmatory tests from SSA are used to confirm the results obtained from the dipstick - proteins can indicate a sign of stress or dysfunction - proteinuria may be physiological or pathological

proteinuria because of kidney disease usually indicates what?

an upper UTI, diabetes, glomerulonephritis, nephrotic syndrome, preeclampsia, trauma

reasons for physiological proteinuria

strenuous exercise, stress, cold exposure (shivering makes blood go to muscles more than kidneys), large abdomen from pregnancy, dehydration, febrile illness

orthostatic proteinuria

positive proteinuria tests when patient is upright but not when supine/lying down - lie down for one hour and recheck urine - may be associated with exaggerated lumbar lordosis —> renal congestion - more common in adolescents and etiology unknown and likely altered hemodynamics from activity

preeclampsia

toxemia associated with pregnancy especially 3rd trimester - proteinuria and increased BP are associated signs if mild - may become severe with headache, visual changes, liver enlargement, severe proteinuria, intrauterine growth retardation, convulsions, coma etc

proteinuria causes

heart conditions (MI) (+2 protein, chest pain, and cardiac enzymes are present), CNS lesions (brain and cord tumors), blood disorders (leukemia), drug therapy, systemic disorders (diabetes), collagen disease (systemic lupus, scleroderma), septicemia (microorganisms in blood)

nephrotic syndrome

massive proteinuria showing as +4 protein, losing large amounts of protein (several grams a day), urine may appear frothy (white), severe edema, especially around the eyes - associated with toxins, bee stings, severe infections, and polycystic kidney disease

bence jones protein

this test should be run on all patient’s with a +4 protein and be considered when the following are suspected multiple myeloma (50-80% of cases have these), chief complaint of back pain and may have lytic changes, rain drop skull, pathological fractures

multiple myeloma

malignant proliferation of plasma cells, which make immunoglobulins, which come from B cells - older people get this

immunoglobulins

2 long/heavy chains and 2 short/light chains - kidneys sometimes excrete pieces of the M protein into the urine which will be the light chain (also known as bence jones protein)

what are the tests called to find monoclonal immunoglobulin in urine?

urine protein electrophoresis and urine immunofixation

will a routine urinalysis detect bence jones proteins?

no - it just measures albumin levels

what must be done in a test for bence jones proteins to be detected? (so what are the definitive tests)

boiling, using chemicals, electrophoresis, or immnoelectrophoresis

common findings in multiple myeloma patients

lytic bone lesions, chest infections like pneumonia, fractures, proteinuria, bence jones protein, kidney problems, anemia (bruise easily and may have raynauds), purpuria

other findings in those with multiple myeloma

nausea, confusion, polyuria (hypercalcemia renal insufficiency), fatigue (anemia, renal insufficiency), bone pain (bone lysis and pathological fractures), bleeding (thrombocytopenia), infections (immune deficiency), neurological complaints (pathological fracture), confusion, dizziness, blurred vision (hyperviscosity)

what does a positive sulfosalicylic acid SSA test suggest when a dipstick test is negative?

urinary excretion of increased amounts of kappa or lambda light chains (bence jones proteins) - a positive SSA indicates the potential presence of globulins and further testing is necessary

CRAB mnemonic for MM

calcium (elevated), renal failure/dysfunction, anemia, bone lesions

what medical scan is NOT indicated with MM?

bone scan - the sensitivity of detecting lesions is less than that of plain film - variability in osteoblastic activity

what test is usually ordered when the protein electrophoresis test shows the presence of an abnormal protein band that may be an immunoglobulin?

immunofixation electrophoresis

diagnostic criteria for MGUS

serum M protein < 3 g/dL, bone marrow plasma cells <10%, co CRAB - just blood tests for rest of life to see if it evolves into MM

smoldering MM diagnostic criteria

serum M protein >3 g/dL, bone marrow plasma cells >10%, no CRAB

multiple myeloma diagnostic criteria

serum M protein >3 g/dL, bone marrow plasma cells >10%, CRAB present

sugar/glucose characteristics of UA

normal is negative - dispstick test is qualitative for glucose, bit clinitest is confirmation test (quantitative) test for an yreducing sugar glucose, fructose, galactose

what to di if clinitest is positive

fasting blood sugar FBS and correlate to history (family history, over weight, >20, polyuria, polydipsia, etc)

glucose in renal system info

glucose filtered by glomeruli and reabsorbed in proximal tubules - renal threshold value RTV (aka blood threshold value BTV) beyond the threshold glucose spills over in the urine (glycosuria or glucosuria), 140-180 mg/dL is RTV - diabetics may demonstrate a higher than normal RTV like 220-240

what is the classic association with glucosuria?

diabetes

when is glycosuria not abnormal?

right after eating a high carbohydrate meal

glycosuria

may be seen with kidney disease affecting the renal tubules which may lower RTV (aka renal glycosuria)

reasons for hyperglycemia and glucosuria

diabetes mellitus, endocrine disorders (acromegaly), pancreatic problems (tumor, pancreatitis), adrenal disorders (cushings syndrome), hyperthyroidism (oily hair.skin, increased BO hyperactivity, increased metabolism), pregnancy (gestational diabetes), stress, CNS disorders tumor hemorrhage stroke, disturbances of metabolism like burns, infections, MI, obesity, liver disease, exercise, certain drugs

ketones

due to lack of available sugar getting to the cells due to lack of insulin - these are a byproduct of fat metabolism - reported as negative (normal) , trace, small, moderate, or large amounts with +1, +2, +3, +4 - types include acetone, beta hydroxybutric acid, acetoacetic acid - usually associated with poorly controlled diabetes mellitus and may warn of impending diabetic coma

when you’ll see a lot of ketones

electrolyte imbalance, alcoholism, babies and children with fever, inadequately controlled disease in diabetics, reduced carbohydrate metabolism and excessive fat metabolism in nondiabetic patient

bilirubin characteristics in UA

most bilirubin is formed in the recticuloendothelial system (spleen, liver, marrow) as a breakdown product of RBC hemoglobin released from senescent RBCs (prehepatic/indirect/unconjugated bilirubin)

why can’t bilirubin pass the glomerular filter?

it’s not water soluble

bilirubin process

RES releases bilirubin into the blood stream, binds with albumin to transport it to the liver and gets conjugated with glucuronic acid to become direct/conjugated bilirubin (which is water soluble) - liver excretes conjugated bilirubin into the bile that ultimately goes to the small intestine - acted on by bacteria to become urobilinogen, which is reduced to stercobilinogen which gives color to feces - conjugated bilirubin in urine would indicate that there is an obstruction of flow of bile from the liver (gallstones, tumor, pancreatic cancer, liver inflammation/infection)

bilirubinia

urine is dark and may have yellow foam (especially when shaken) - associated with elevated serum conjugated bilirubin which is an indicator of liver dysfunction or biliary obstruction = jaundice and pale colored feces

abnormal pre-hepatic bilirubin values indicate

unconjugated bilirubin does not appear in urine - anemia’s (hemolytic) or excessive breakdown of RBC

abnormal hepatic bilirubin values may indicate (liver disease)

hepatitis, cirrhosis, obstruction of biliary duct, toxic liver damage

abnormal post-hepatic bilirubin values indicate

biliary tree obstruction

urobilinogen characteristics of UA

normal is 0.1-1.0 mg/dL - a by-product of hemoglobin metabolism with bilirubin breakdown in the intestine - abnormal levels of this suggest pre-liver problems

urobilinogen

contributes to the yellow urine color and the brown color of feces - serum and urine urobilinogen increases with increased bilirubin production - liver disease and hemolytic conditions - with liver disease urobilinogen is not re-excreted in the bile and increased levels are in the urine

what happens with hemolytic disorders occur?

the amount of unconjugated bilirubin that is present in the blood increases causing an increase in hepatic excretion of conjugated bilirubin, resulting in increased amounts of urobilinogen that in turn causes an increase in reabsorption, recirculation, and renal excretion

increased values of urobilinogen may indicate

overburdening of the liver, excessive RBC breakdown, increased urobilinogen production, re-absorption (from like a large hematoma), restricted liver function, hepatic infection, poisoning, liver cirrhosis l

low values of urobilinogen may indicate

failure of bile production, obstruction of bile passage (most common reason for obstruction is gallstones)

typical liver/biliary tract disease report

dark yellow/brown/green colored urine, bilirubin +, urobilinogen +, RUQ discomfort and midback pain, jaundice of skin and sclera, gallstones are the main cause of biliary obstruction (cholecystitis) decreased pigment leads to gray/white stools, increased liver enzymes

gallstone follow up

expectant management of asymptomatic gallstones says risk of surgical and nonsurgical treatments outweigh the benefits so we do a wait-and-see approach - if symptomatic then we look into surgical and nonsurgical removals of the gallbladder

occult blood characteristics of UA

normal is negative, smoky colored urine implies blood, cloudy urine needs to be looked at microscopically - need to figure out what is causing the hematuria (elevated intact RBCs), hemoglobinuria, or myoglobinuria (Hgb and Myb have no elevated RBCs, found microscopically)

hematuria may indicate (in reference to occult blood)

kidney and bladder calculi, damage to kidney or urinary tract - most common reason for this is due to menses

hemoglobinuria may indicate (in reference to occult blood)

breakdown of red blood cells

myoglobinuria may indicate (in reference to occult blood)

myocardial infarct and/or muscle damage

occult blood hematuria

urine is light red yellow to fairly dark red, smoky - blood or RBCs in urine - may be an early indicator of renal disease - in kids, 1/3 of hematuria is idiopathic - may be due to malignancy, infection, stones, menses, trauma, exercise