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1、Urinanalysis,Question,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 syste
2、m.,Formation of urine,Glomerular filtrationTubular reabsorptionTubular secretionNormal:Clean-catch urine 1000-2000ml/24h,The function of urine,maintain water balance;remove waste products;maintain normal blood chemistry.,Clinical significance of urine analysis,Routine urinalysis are performed for se
3、veral reasons:general health screening to detect renal and metabolic diseasesdiagnosis of diseases or disorders of the kidneys or urinary tractsmonitoring of patients with diabetes,临床上尿液可以进行哪些项目的测定？,你认为什么最重要？,A Complete urinalysis has 4 parts,Gross examinationSpecific gravityBiochemical analysisSedi
4、ment Examination,目前使用全自动仪器进行尿液分析，大大提高了工作效率,尿干化学分析仪,尿有形成分分析仪,干化学分析试剂条,PHSGPRO GLUKETBILUROBLDLEUNIT,What information can urinalysis give us?,Routine tests SG PH Pro Glu Bil UBO WBC RBC NIT KET,Specific testsMicroprotein(Alb,2MG，1MG,IgG,TRF)Light chainEnzymeUrine electrophoresis,Urine sediment RBC WBC
5、 cast crystal bacteria fungi,Sample collection,Random 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 urine was present in the bladder.The interpretation of the findings is difficult
6、.,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.The cell concentration is high since the urine is acidic though preserving cells an
7、d 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 travel to the medical facility and it used for special examinations,e.g.the classificati
8、on of proteinuria,cytological examinations of the bladder mucosa or the determination of dysmorphic erythrocytes.,24-h urine,Urine collected over a 24-h periodIt is mostly employed for the determination of proteinuria as part of the diagnosis of renal disorder.,Sample storage and transport,The trans
9、port 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 because of the precipitation of amorphous urates of phosphate crystal.The urates interfer
10、 with the microscopic examination.3.the specimen must be deepfrozen or stabilized by the chemical addictives.,尿液标本的保存,冷藏法：不能超过8小时。化学防腐法：防腐剂 实用范围甲苯 化学检查福尔马林 显微镜检查浓盐酸 17-羟类固醇，儿茶酚胺等激素麝香草酚 结核杆菌,Goal of diagnostic evaluations using urinalysis,To rule out increased urinary excretion(cells,proteins)To diff
11、erentiate between benign and pathological situationsTo distinguish between different causesTo quantify(xx)in order to assess disease activity.,Gross Examination,Colorappearance Odor,diabetes insipidus,Biochemical analysis,Urinary proteins,Increased excretion of proteins in the urine,i.e.proteinuria(
12、120mg/24h),is the hallmark of the almost any kind of kidney disease.Simple and inexpensive.,Dipsticks detect protein by production 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
13、semiquantitative method,but overall,it is not a highly sensitive test.The sulfosalicylic acid test is a more sensitive precipitation 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
14、 urine)are equivalent to 10 mg/100 ml or about 150 mg/24 hours(the upper limit of normal).1+corresponds to about 200-500 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 mus
15、t pass through the glomerular capillary wall.Nephrotic Syndrome-minimal change disease and focal glomerulosclerosis Glomerulonephritis Drugs,The reason of proteinuria,glomerularthe size-selective barrier leaks large protein molecules the charge-selective barrier fails to retain lower mol wt proteins
16、.,The reason of proteinuria,Approximate size cutoff of substances for filtration is 70kDa.substances 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 size,Decreased tubular reabsorption.Most
17、filtered protein is reabsorbed proximally.With tubular damage,there will be increased protein in the urine Transport defects-Fanconis Syndrome,Cystinosis Toxins-Penicillins,Heavy metals,Aminoglycosides氨基糖甙类,tetracycline四环素Ischemic injury-shock,ATN急性肾小管坏死,Endotoxemia Obstructive uropathy,Polycystic d
18、isease,Increased secretion-normally some protein is secreted but may increase with exercise,acute renal failure,transplant rejection,and stones.chain haemoglobin myoglobin,How to differentiate proteinuia from each other,Routine tests(proteinuria),.The amounts of small molecules increased more than t
19、he ability of tubular reabsorption.1.Multipomyeloma light chain,electrophoresis or immunoassay 2.intravascular hemorrhage Hb，OB+，TB，IB，UBO+3.urine routine test:protein negative or trace,Types of proteinuria（pathologic）,Renal proteinuria:glomerula,tubular;the sytemic and generalized diseases(SLE,diab
20、etes).Prerenal causes:excretion of Ig light chain intravascular hemolysis(血管内溶血)Postrenal causes:hemorrhage and exudation within the lower urinary tract.,Non-pathological causes of proteinuria,Exercise-should recheck after a few days of inactivity Fever-recheck when the child is afebrile Postural(体位
21、性）or orthostatic proteinuria-very 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 proteins,Selective glomerula proteinuria Increased glo
22、merular permeability for midsized 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 proteins,Tubular proteinuriaDecreased tubular reabs
23、orption of low-molecular mass 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 pro
24、teins,Prerenal proteinuria Increased 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 proteins,Postrenal proteinuria Hemorrhage or exudation within the lower urinary
25、tract.The main contents:Tamm 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;intac
26、t red blood cells(RBC)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
27、 which concentrates 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,myosi
28、tis,and prolonged generalized seizures.Hemoglobinuria is most commonly associated with hemolytic anemias.,How to confirm the real hematuria?,1.urine dipstick,2.urine sediment,3.TB,DB,4.myoglobin,How to analyze the results of urinalysis?,WBC positive probable urinary tract infection;urinary proteins
29、not assessable;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 positiveRenal proteinuria;Differentiation b
30、etween 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 protein
31、uria 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,white bloo
32、d cells,epithelial cells,casts,crystals,bacterial,and fungi,Normal,Clean-catch urine,light yellowLess than 3 red blood cells/hpLess than 5 white blood cells/hpA few epithelial cells,occasional hyaline casts,occasional crystal,and no bacteria or fungi,hematuria,More than 3 red blood cells/hp,Pyuria,M
33、ore than 10 white blood cells/hpIndicate renal or genitourinary inflammation unless there is contamination of the specimenPlus NIT and(or)urine culture(65%Escherichia coli大肠杆菌,NIT positive),Casts,Formed in the distal tubules and the collecting ducts.Can be classified into:cell-free casts,e.g.hyaline
34、 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 well as by patients with
35、 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 severe proteinuria.R
36、BC 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,蜡样管型,Questions,1.What factors can influence the results of urinalysis?2.Please tell us the applications of urine OB test a
37、nd 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 and the throat symptoms disappea
38、red 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.HEENT:Slight swelling of the eyelids and per
39、iorbital 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 were no murmurs.Abdomen:There were no masses or abd
40、ominal 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.Whats the diagnosis and whats your evidences?2.Which other diseases
41、 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(nephritic syndrome)and hemodynamic(nephrotic syndrome).and laboratory finding
42、s 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 syndrome may be acute and transient(eg,postinfectious GN),fulminant with rapid
43、 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 excreted;random urinary protein/creatinine ratio may be 2(normal,0.1 to 0.3).gross or microsc
44、opic hematuria(cola-colored,brown,smoky,or frankly bloody)The urinary sediment contains dysmorphic RBCs,WBCs,and renal tubular cells;casts containing RBCs and Hb are characteristic,and WBC casts and granular casts(protein droplets)are common.,The antibody titer against the causal infectious agent us
45、ually rises within 1 to 2 wk.The increase in antibodies to streptococcal antigenic products can be measured:antistreptolysin-O(ASO)is the best indicator of URIs,C3 and C4 usually are diminished during active disease,Nephrotic syndrome(NS),occurs at any age but is more prevalent in children than in a
46、dults;in children,it is most common between ages 1 1/2 and 4 yr.Diagnosis is suggested by the clinical features and laboratory findings and confirmed by renal biopsy.Severe proteinuria is essential to the diagnosis.,laboratory findings,The main feature is heavy proteinuria(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,
