AUBF (LEC) [title]

AY 2022-2023 Urinalysis and Body Fluids

BSMT2F Sixth Edition

6 Microscopic Examination of Urine

2
3
4
5

VI. MICROSCOPIC EXAMINATION OF URINE

Specimen Preparation
Figure 28. Immunodip reagent strip pad
● First, you really have to check for the urine volume and clarity.
● The process of urinalysis in the laboratory: Macroscopic
● Proteins or albumin in urine should only have <10 mg/dL or 100
examination → chemical examination → microscopic
mg/24 hrs.
examination
● Albuminuria - presence of albumin in urine which reaches about
● Specimen should be examined while fresh or adequately
>200 mg/L.
preserved.
● Microalbuminuria - the amount of albumin excreted in urine is
● Refrigeration: Precipitation of amorphous urates, phosphates,
only 20-200 mg/L.
and other non-pathologic crystals
● There are monoclonal antibodies embedded in reagent strip
● The temperature of refrigeration: 2-8°C
pads that are highly specific for human albumin.
● Amorphous urates are found in acidic urine and become pink
● Albumin concentration of an average urine specimen should not
because of uroerythrin.
exceed between 15-20 mg/L.
● Amorphous phosphates are found in alkaline urine and
● Disorders:
become white.
→ Clinical Diabetic Nephropathy - a person has
● If the specimen is refrigerated, make it to room temperature
microalbuminuria which excretes >20 mg/L for at least two of
before examination.
the three morning urine samples.
● Warming at 37°C: May dissolved some crystals
● The urine sample must be examined within 2 hours of
collection. If not, preserve the sample by refrigeration or
application of preservatives.

Specimen Volume
● Standard amount of urine: Usually 10 and 15 mL
● 10-15 mL - standard amount of urine for analysis.
● 50-60 mL - standard amount of urine for submission.
● Excess amount of urine is needed for repeat testing.
● 12 mL - is frequently used.
● Note to the report: If the urine volume is not adequate
● In cases of the patient having oliguria (decreased urine output) or
anuria (no urine output), or pediatric or geriatric patients, you
have to note in the report about the urine volume.
● QNS (Quantity Not Sufficient) - the reported note.
● Patients with oliguria or anuria will be catheterized for their urine.

Centrifugation
● 5 minutes @ 400 RCF
● Centrifugation is done after chemical examination.
● RPM - is used in the Philippines instead of RCF.

Sediment Preparation
● Volumes of 0.5 mL and 1 mL are frequently used (uniform
amount of urine and sediment).

Volume of Sediment Examined

FINALS OUTLINE

BSMT2F Raze, Jett, Omen, Skye, Cute 14 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

● Conventional Glass Slide Method: Recommended volume is ▪ Under a polarizing microscope, you will observe maltese
20 µL (0.02 mL) covered by 22 x 22 glass cover slip. cross formation of cholesterol crystals.

Examining the Sediment

● LPO: Detects casts, ascertain the general composition of
sediment.
● HPO: Identification of urinary sediments.
● Conventional Glass Slide Method: Casts have a tendency to
locate near the edges of the cover slip (Low power scanning of
the coverslip perimeter is recommended).
● Point of Reference: Epithelial cells Figure 29. Maltese cross formation
● Remember: Casts are often found on the edges of the cover slip. → Identify free fat droplets and lipid-containing cells and casts
● Gram Stain - identification of bacterial casts which can be
Reporting the Microscopic Examination confused from granular casts.
● Average number per LPF: Casts → Components: Crystal violet (10 stain), Iodine (mordant),
● Average number per 10 HPF: RBCs and WBCs Alcohol (decolorizer), Safranin (Counterstain)
● Semiquantitative (Rare, few, moderate, many / 1+, 2+, 3+, 4+): → Gram-positive Bacteria = purple / violet
Epithelial cells, crystals, and other sediments → Gram-negative Bacteria = red
→ Even numbers: Packed field (PF) → E. Coli - the most common bacterial contaminant that came
from the patient itself; Gram-negative bacteria.
Qualitative Terms and Descriptions for Fields of Views → Components: VIAS
(FOVs) ▪ V = Crystal Violet
Term Description ▪ I = Gram’s Iodine
Rare 1+ Present, but hard to find ▪ A = Alcohol
One (or more) present in almost ▪ S = Safranin
Few 1+ → Crystal Violet - primary stain in Gram stain method.
every FOV
Easy to find, number present in FOV → Safranin - secondary stain.
Moderate 2+ varies; “more than few, less than
many” Gram (+) Gram (-)
Prominent, large number present in 1st Stain Crystal Violet Violet Violet
Many 3+
all FOVs Mordant Gram’s Iodine Violet Violet
FOV is crowded by or overwhelmed Decolorizer 95% Alcohol Violet Colorless
Packed 4+
with the elements 2nd Stain Safranin Violet Red / Pink

A. SEDIMENT EXAMINATION TECHNIQUE ● Hansel Stain - preferred stain for urinary eosinophils (in case of
drug-induced allergic reaction producing inflammation of the
Sediment Stains renal interstitium).
● Sternheimer-Malbin Stain - most frequently used stain in → Components: Methylene Blue and Eosin Y
urinalysis. ● Prussian Blue Stain - stains structures containing iron.
→ Components: Crystal violet and Safranin O → Identifies yellow-brown granules of hemosiderin in cells and
→ Commercially-available: Sedi Stain, KOVA Stain casts.
→ Delineates structure and contrasting colors of the nucleus and
cytoplasm. Microscopy
→ Crystal violet = purple color ● Bright-Field Microscopy - objects appear dark against a light
→ Safranin O = red color background; most frequently used in the clinical laboratory.
→ Acidic (nucleus) - takes up the Crystal violet (purple). ● Dark-Field Microscopy - aids in the identification of Treponema
▪ Crystal violet is a basic stain, so it takes up the acidic pallidum.
nucleus. → Treponema pallidum - causative agent of Syphilis.
→ Basic - takes up the Safranin O (red). ● Phase-Contrast Microscopy - enhances visualization of
● Lipid Stains: Oil Red and Sudan III elements with low refractive indices such as hyaline casts, mixed
→ Polarizing microscope cellular casts, mucous threads, and Trichomonas.
→ Stain triglycerides and neutral fats orange-red ● Polarizing Microscopy - aids in identification of cholesterol in
→ Do not stain cholesterol (capable of polarization) oval fat bodies, fatty casts, and crystals.

BSMT2F Raze, Jett, Omen, Skye, Cute 15 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Used to confirm the presence of cholesterol globules by their → Hyposthenuric (diluted) - Ghost Cells (due to absorption of
characteristic Maltese cross pattern. water).
→ Aids in the identification of crystals. ▪ Hyposthenuric has SG of less than 1.010.
→ Assists in differentiating “look-alike” components ▪ After absorbing a lot of water, cells swelled then became
lysed (sasabog).
Do Not Polarize Light Do Polarize Light ▪ Ghost cells have no laman lol.
Monohydrate Calcium Oxalate → Dysmorphic (Cellular protrusions, fragmented) - Glomerular
RBCs Bleeding
Crystals
Fibers (Cloting, Diapers), ● Clinical Significance:
Casts, Mucus → Associated with damage to the glomerular membrane or
Plastic fragments
Amorphous crystals (Urates: vascular injury within the genitourinary tract.
Bacteria Strongly; Phosphates: Very → The number of cells present is indicative of the extent of the
Weakly) damage or injury.
Cholesterol globules, Starch → Macroscopic Hematuria - urine appears cloudy with a red to
Cells, Cellular Debris
(Membrane Phospholipids) granules brown color.
▪ Frequently associated with advanced glomerular damage
but is also seen with damage to the vascular integrity of the
● Fluorescence Microscopy - allows visualization of naturally
urinary tract caused by trauma, acute infection or
fluorescent microorganisms or those stained by a fluorescent
inflammation, and coagulation (bleeding tendencies)
dye including labeled antigens and antibodies.
disorders.
● Interference Contrast - produces a three-dimensional
→ Microscopic Hematuria - can be critical to the early
microscopy image and layer by-layer imaging of a specimen.
diagnosis of glomerular disorders and malignancy of the
● Cytodiagnostic Urine Testing
urinary tract and to confirm the presence of renal calculi aka
→ Frequently performed independently of routine urinalysis for
kidney stones.
detection of malignancies of the lower urinary tract.
▪ It has normal yellow urine color, but it has a lot of RBCs in
→ Preparation of permanent slides using cytocentrifugation
the microscope.
(specialized centrifuge) followed by staining with
Papanicolaou stain.
→ Papanicolaou stain (Pap’s stain) - provides an additional
method for detecting and monitoring renal disease.
▪ Components: OG6 (Orange G6), EA50 (Eosin Azure 50),
Harris Hematoxylin

B. URINARY SEDIMENTS

● Formed Elements in Urine Sediment

→ Originates throughout the urinary tract: from the glomerulus to
the urethra or can result from contamination like:
▪ Menstrual blood (urine should be collected 3-5 days after the
last day of menstruation to avoid contamination) Figure 30. Glomerular membrane
▪ Spermatozoa (do not report if female; may come from sexual
intercourse or masturbation)
− Retrograde ejaculation - is the case where
spermatozoa is expelled in the urinary bladder instead of
urethra; infertility.
▪ Fibers (diapers, pantyliners)
▪ Starch granules (talcum powder)

Red Blood Cells (RBC)

● Appearance: Smooth, non-nucleated, biconcave disks (7 mm)
→ Hypersthenuric (concentrated) - Crenated (due to loss of Figure 31. Normal RBCs
water).
▪ Hypersthenuric has SG of greater than 1.010.

BSMT2F Raze, Jett, Omen, Skye, Cute 16 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

▪ Histiocytes - old name of macrophage; same with

monocytes.
→ Primary concern in identification of WBC in urine:
Differentiation of mononuclear cells and disintegrating
neutrophils from round renal tubular epithelial (RTE) cells
(usually larger than WBCs with an eccentrically located
nucleus)
→ Supravital staining / Addition of Acetic Acid - used to
enhance nuclear detail.

Figure 32. Microcytic and crenated RBCs

Figure 33. Ghost cells

White Blood Cell (WBC)

● WBCs are also called pus cells.
● Pyuria - increased in urinary WBC which indicates the presence
of an infection or inflammation in the genitourinary system.
● 5 White Blood Cells
→ Neutrophil
→ Eosinophil Figure 34. White blood cells
→ Basophil
→ Lymphocyte Epithelial Cell
→ Monocyte ● Three Types of Epithelial Cells:
● Neutrophil: Predominant → Squamous Epithelial Cell
→ Most abundant → Transitional Epithelial Cell
→ Multilobed → Renal Tubular Epithelial Cell
→ Contains granules ● Squamous EC - normal, sloughing off.
→ aka PMN or Polymorphonuclear Cell → They are the largest cells found in urine sediment.
● Hypotonic (absorbs water and swell) - granules exhibit Brownian → They represent normal cellular sloughing and have no
Movement (sumasayaw), appear as "Glitter Cells" (kumikintab). pathologic significance.
● Eosinophil - associated with Drug-induced Interstitial Nephritis,
UTI, renal transplant rejection.
→ Hansel stain - specific for the detection of urinary eosinophil.
● Clinical Significance
→ Mononuclear Cells:
▪ Lymphocytes - seen in increased numbers in the early
stages of renal transplant rejection.
− Resembles RBC, because they are similar in size
− Smallest WBC.
▪ Monocytes - large cells that can appear vacuolated (butas
butas yung cytoplasm) or may contain inclusion (may
Figure 35. Clump of squamous epithelial cells
nakasabit sa cytoplasm).
● Transitional EC - aka Urothelial Cell.
▪ Macrophages - same with monocytes.
→ Smaller than squamous cells and appear in several forms,
including spherical, polyhedral, and caudate.

BSMT2F Raze, Jett, Omen, Skye, Cute 17 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ These differences are caused by the ability of transitional EC

to absorb large amounts of water.
→ Originate from the lining of the renal pelvis, calyces, ureters,
and bladder, and from the upper portion of the male urethra.

Figure 38. Oval fat body

→ Bubble cells - RTE cells containing non-lipid filled vacuoles
(acute tubular necrosis).

Figure 36. Transitional EC

● RTE Cell - PCT, DCT, CD - most significant
→ Renal fragments - if they appear in groups of 3.
→ Size and shape depending on the area of the renal tubules
from which they originate.

Figure 39. Bubble cells

● Clinical Significance:
→ Clue Cells - squamous EC covered with Gardnerella
coccobacillus (bacterial vaginosis).

Figure 40. Clue cells

Bacteria
● NOT normally present in urine.
Figure 37. RTE cells
→ Cocci - spherical-shaped
→ RTE Cell Origin:
→ Bacilli - rod-shaped
▪ PCT - larger than any RTE cells.
● ENTEROBACTERIACEAE (Gram-Negative Rods) - most
− Rectangular in shape; thus, referred to as columnar or
frequently associated with UTI.
convoluted cells; resembles a cast.
→ Escherichia coli (E. coli)
▪ DCT - smaller, round or oval
● Significant UTI - bacteria should be accompanied by WBC.
− Can be mistaken for WBC or spherical transitional EC.
→ Positive Leukocyte Esterase and Nitrite
▪ CD - cuboidal and are never round.
▪ Possible presence of WBC and bacteria in urine.
− If they appear in groups of three or more, they are called
renal fragments.
▪ Pathologic significance: Indication of tissue destruction or
necrosis
▪ >2 RTE per hpf: Tubular injury
▪ Golden brown, yellow brown - presence of Hemosiderin
granules.
− Indication of destruction of RBC.
→ Oval fat bodies - lipid-containing RTE cells.

BSMT2F Raze, Jett, Omen, Skye, Cute 18 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ It has “jerky motility”.

→ Described as a “hot-burning sensation”.

Figure 43. Trichomonas vaginalis

● Schistosoma haematobium - bladder parasite (ova).

Figure 44. Schistosoma haematobium

Figure 41. Bacteria
● Enterobius vermicularis - most common fecal contaminant.
→ Resides in the perianal area.
Yeast
→ Pruritus ani - intense itching.
● Small refractile oval structure (may or may not contain bud)
● Candida albicans: DM, Vaginal Moniliasis,
Immunocompromised individual

Figure 45. Enterobius vermicularis

Spermatozoa
● Routine UA: Do not report, only if requested
● Significant: Male infertility, Retrograde Ejaculation (sperm is
expelled into bladder instead of urethra).

Figure 42. Yeast

Parasites
● Trichomonas vaginalis - most frequent parasite encountered in
the urine.
→ Transferred via sexual intercourse (STD)
→ Associated with vaginal inflammation Figure 46. Spermatozoa
→ Found in the urethra / prostate in males, but they are
asymptomatic. Mucus

BSMT2F Raze, Jett, Omen, Skye, Cute 19 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

● Uromodulin - major constituent.

● Thread-like structures (Low Refractive Index)
● Frequently seen in FEMALES.

Figure 49. Hyaline cast 2

● RBC Casts
→ aka Blood cast / Muddy Brown casts
→ RBC casts degenerate into pigment, granular cast → Greater
stasis of urine
→ Indication: Bleeding within the nephron
→ Glomerular damage (glomerulonephritis) is associated with
proteinuria and dysmorphic erythrocytes.
→ In the SM stain, it turns orange-red color.
Figure 47. Mucus

Urinary Casts
● Only elements found only in urine, unique to the kidney.
● Cylinduria - presence of urinary cast.
● The width of the cast depends on the size of the tubule in which
it is formed.
● Urinary casts are formed at DCT and collecting ducts. Figure 50. RBC cast
● Tamm Horsfall Protein (Uromodulin) - the core matrix,
component of our casts.
● Cylindroids - incomplete casts which result from incomplete cast
formation, cast disintegration and depend where it was formed.
● Hyaline Casts
→ Most frequently seen.
→ Normally increased in:
▪ Strenuous exercise
▪ Dehydration
Figure 51. RBC cast
▪ Heat exposure ● WBC Casts
▪ Emotional stress → Leukocyte embedded in hyaline cast matrix.
→ Pathologically increased in: → Non-bacterial inflammation: Acute Interstitial Nephritis
▪ Acute Glomerulonephritis ▪ WBC + WBC casts
▪ Pyelonephritis → Bacterial Inflammation: Pyelonephritis
▪ Chronic Renal Disease ▪ WBC + Bacteria
▪ Congestive Heart Failure (CHF) → Signifies infection or inflammation within the nephron.
→ 0-2 per lpf → Associated with pyelonephritis and are a primary marker for
→ In the Sternheimer-Malbin stain, it turns pink. distinguishing pyelonephritis (upper UTI) from cystitis (lower
UTI).
→ Cystitis - wala kang mahahanap na WBC casts.

Figure 48. Hyaline cast

BSMT2F Raze, Jett, Omen, Skye, Cute 20 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Appearance: Fragmented with jagged ends and have notches

on sides
→ Indication: Extreme Urine Stasis (Chronic Renal failure)
→ Represent an advanced stage of other casts (e.g., hyaline,
granular, cellular) that are transformed during urinary stasis.
→ In Supravital staining, waxy casts turn homogenous dark pink.
● Broad Casts
→ Renal Failure casts
Figure 52. WBC cast
→ Indication: Destruction “widening” of the tubular walls
→ Bile Stained Broad Waxy cast - indication of tubular necrosis
caused by viral hepatitis.

C. CRYSTALS

● Appearance: True geometrically structure or amorphous

materials
● Several factors influence crystal formation:
Figure 53. WBC cast → The concentration of the solute in the urine
● Bacterial Casts → The urine pH
→ Bacterial Inflammation: Pyelonephritis → The flow of urine through the tubules
→ Bacterial casts containing bacilli both within and bound to the ● “Regardless of the crystal type, crystal formation within the
protein matrix are seen in pyelonephritis. nephrons can cause significant tubular damage.”
→ Pure bacterial cast or mixed with WBCs.
→ May resemble a granular cast. NORMAL URINARY CRYSTALS (UAACCTAC)
→ Confirmation: Gram stain
● Uric Acid
→ Urine pH: Acid
→ Appearance: Rhombic, Four sided flat plates (whetstones)
wedges, rosettes
→ HIGHLY BIREFRINGENT: distinguishing feature from
CYSTINE CRYSTALS
→ Significantly Increased in: Gout, Lesch-Nyhan Syndrome

● Amorphous Urates (Ca, Mg, Na, K)

Figure 54. Bacterial cast
● Epithelial Cell Casts → Urine pH: Acid
→ Significant cast containing RTE cells. → Appearance: Colorless to Yellow-brown granules
→ Indication: Advance Tubular Obstruction → Refrigerated: Pink Sediment
● Fatty Casts → Macroscopic Appearance: Orange-pink precipitate
→ Lipiduria - fatty casts + oval fat bodies + free fat droplets (“brick-dust”)
→ Frequently associated with nephrotic syndrome. → Convert to URIC ACID with concentrated HCl
● Mixed Cellular Casts
→ Casts containing multiple cell types. ● Amorphous Phosphates
→ Glomerulonephritis: RBC + WBC Casts / WBC + RTE Cells → Urine pH: Alkaline
Casts → Appearance: Similar to Amorphous Urates (distinguished by
→ Pyelonephritis: WBC + Bacterial Cells Casts URINE pH)
● Granular Casts → Refrigeration: White Sediment
→ Result of cellular disintegration. → Macroscopic Appearance: White to beige precipitate
→ Increased cellular metabolism occurring during periods of
strenuous exercise accounts for the transient increase of ● Calcium Oxalate
granular casts that accompany the increased hyaline casts. → Urine pH: Acid/Neutral/Alkaline
● Waxy Casts → Dihydrate (most common form): Colorless, octahedral
envelope or as two pyramids joined at their base

BSMT2F Raze, Jett, Omen, Skye, Cute 21 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Monohydrate: Oval or dumbbell shaped (Ethylene Glycol → Appearance: Colorless to yellow-brown, needles, rhombics,
“Antifreeze” Poisoning whetstones, “sheaves of wheat”, and rosettes
→ Majority of renal calculi is composed of “CaOx” → Distinguished from calcium phosphate.
→ Does not dissolve upon addition of dilute acetic acid.
● Calcium Phosphate → Primary Common Cause: Inadequate patient hydration
→ Urine pH: Alkaline
→ Appearance: Colorless, flat rectangular plates, thin prisms in ● Ampicillin
rosette form → Appearance: Colorless, needles (tend to form bundles
→ Confused with: Sulfonamide Crystals (when urine pH is in following refrigeration)
neutral range) → Indication: Precipitation of antibiotics following massive
→ Distinguished by addition of DILUTE ACETIC ACID: Calcium dosage of this penicillin compound without adequate hydration
Phosphate (Dissolves): Sulfonamide (DOES NOT
DISSOLVED) ● Leucine
→ Appearance: Yellow-brown spheres (concentric circles with
● Triple Phosphate radial striations)
→ Urine pH: Alkaline → Should be accompanied by tyrosine crystals.
→ A.K.A.: Ammonium Magnesium Phosphate → Liver Disorder
→ Appearance: Prism Shape, resembles “COFFIN-LID”
→ “FERN-LIKE” form can be induced by addition of AMMONIA ● Tyrosine
● Ammonium Biurate → Appearance: Fine, colorless to yellow needles (in clumps or
→ Urine pH: Alkaline rosettes)
→ Appearance: “THORNY APPLES” → Seen in conjunction with leucine crystals & positive chemical
- spicule covered sphere test for bilirubin.
→ Dissolves at 60 degree celsius → Liver Disorder
→ Convert into URIC ACID CRYSTALS when GLACIAL ACETIC
ACID/ CONC. HCl is added ● Bilirubin
→ Most often encountered in: OLD SPECIMEN → Appearance: Yellow, clump needles or granules
● Calcium Carbonate → (+) bilirubin in urine
→ Urine pH: Alkaline → Liver Disorder
→ Appearance: Small, colorless, dumbbell of spherical shapes
→ Resemble AMORPHOUS MATERIAL - distinguished by D. ARTIFACTS
addition of ACETIC ACID (FORMATION OF GAS)
● Starch - highly refractile sphere with dimple center.
ABNORMAL URINE CRYSTALS ● Oil droplets
● Air bubbles
● Cystine ● Pollen grains - appear as spheres with a cell wall and
→ Appearance: Colorless, hexagonal plates (thick or thin) occasional concentric circles.
→ Distinguished from uric acid crystals (highly birefringent). ● Fibers / hair - may resemble casts however fibers polarized
→ Confirmation: Cyanide-Nitroprusside Test while casts do not.
→ Cystinuria - metabolic disorder that prevents reabsorption of ● Fecal contamination - appears as plant and meat fiber or as
cysteine by renal tubules. brown amorphous material.

● Cholesterol
→ Appearance: Rectangular plates with notch on one or more
corners
→ Can be seen in nephrotic syndrome in conjunction with fatty
casts and oval fat bodies.

● Radiographic Dye / Radiographic Contrast Media

→ Appearance: Colorless, flat plates, similar to cholesterol
crystals
→ Specific Gravity: Markedly Elevated

● Sulfonamide VII. RENAL DISEASES

BSMT2F Raze, Jett, Omen, Skye, Cute 22 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Henoch-Schӧnlein Purpura
● Renal Diseases are classified into 4 types (based on ▪ Occurs primarily in children after upper respiratory infections.
morphologic component initially affected): ▪ Initial Symptoms: Appearance of raised, red patches on the
→ Glomerular - immune mediated skin
→ Tubular - results from infectious or toxic substances. ▪ Blood vessel walls are affected.
→ Interstitial - results from infectious or toxic substances. ▪ Petechiae, purpura, and ecchymosis are all characterized by
→ Vascular - renal perfusion (?). red patches and dots. The difference between the three is
→ If you have a kidney disease, your circulatory system is also their sizes.
affected. ▪ Petechiae - < 3 mm
→ People with liver diseases suffer from hypertension or ▪ Purpura - 3 mm - 1 cm
hypotension. ▪ Ecchymosis - > 1 cm
→ Membranous Glomerulonephritis
Renal Disease: Glomerular Disease ▪ Aka Membranous Glomerulosclerosis
● Non-Immunologic Causes of Glomerular Damage: ▪ Predominant Characteristics: Pronounced thickening of
→ Exposure to chemicals and toxins affects the tubules. the glomerular basement membrane resulting from the
→ Disruption of the electrical membrane charges as occurs in deposition of immunoglobulin G (igG) immune complexes
nephrotic syndrome (NS). → Membranoproliferative Glomerulonephritis (MPGN)
→ Deposition of amyloid material from systemic disorders that ▪ Marked by two different alterations in the cellularity of the
may involve chronic inflammation and acute-phase reactants. glomerulus and peripheral capillaries.
→ Thickening of the basement membrane associated with ▪ Cellularity = makikita sa microscope/ microscopic
diabetic nephropathy. ▪ Type 1 - displays increased cellularity in the subendothelial
● Glomerulonephritis - refers to a sterile, inflammatory process cells of the mesangium (interstitial area of Bowman’s
that affects the glomerulus and is associated with the finding of capsule), causing thickening of the capillary walls.
blood, protein, and casts in the urine. ▪ Type 2 - displays extremely dense deposits in the glomerular
→ Acute Poststreptococcal Glomerulonephritis (AGN) basement membrane.
▪ Disease marked by the sudden onset of symptoms ▪ Hypocellularity - malalaking cells, may spaces
consistent with damage to the glomerular membrane. ▪ Hypercellularity - punong-puno ng cells
▪ Fever, edema (noticeably around eyes), fatigue, nausea, → Chronic Glomerulonephritis
hypertension, oliguria, proteinuria, and hematuria. ▪ Onset: Slow and silent
▪ Caused by: Group A ꞵ-hemolytic Streptococci ▪ Gradual progression of glomerular damage (may even lead
→ Rapidly Progressive (Crescentic) Glomerulonephritis to end-stage renal disease)
▪ More serious form of acute glomerular disease. → Immunoglobulin A (IgA) Nephropathy
▪ Poorer prognosis ▪ Aka Berger’s Disease
▪ Symptoms: Initiated by deposition of immune complexes in ▪ IgA Immune Complexes - are deposited on the glomerular
the glomerulus. membrane, is the most common cause of
▪ Deposition of an antibody called Immunoglobulin. glomerulonephritis.
▪ Often as a complication of another form of ▪ Increased serum level of IgA
glomerulonephritis or an immune systemic disorder such as ▪ Present with an episode of macroscopic hematuria after
systemic lupus erythematosus (SLE). infection or strenuous exercise.
→ Goodpasture Syndrome ▪ Asymptomatic for 20yrs or more
▪ Morphologic changes in glomeruli (resembling rapidly ▪ Gradual to chronic nd ESRD
progressive glomerulonephritis) + cytotoxic auto-antibody
(ANTI-GLOMERULAR BASEMENT MEMBRANE ● Nephrotic Syndrome - non-immunologic cause of glomerular
ANTIBODY) damage (exposure to chemicals and toxins)
▪ AGBM Antibody - “marker”, attaches to the basement → Increased permeability of the glomerular membrane (damage
membrane of the glomeruli. to the shield of negativhbg! No
→ Wegener Granulomatosis → ity & podocytes)
▪ Causes a granuloma-producing inflammation of the small → PODOCYTES produces a less tightly connected barrier
blood vessels primarily of the kidney and respiratory system. → Marked by massive proteinuria (greater than 3.5g/day), low
▪ Autoantibodies present: Antineutrophilic Cytoplasmic levels of serum albumin, high levels of serum lipids, and
Antibody (ANCA) pronounced edema.
▪ ANCA binds to the neutrophils located in the vascular walls → You can observe fatty casts and oval fat bodies in the urine.
(initiates immune response and resulting granuloma → Increased permeability of the glomeruli to the passage of
formation). plasma proteins (albumin).

BSMT2F Raze, Jett, Omen, Skye, Cute 23 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Heavy proteinuria (3.5 g/day) → Cellular Proliferation of the MESANGIUM along with
▪ Normally, our urine produces <10 mg/day of protein. LEUKOCYTE INFILTRATION & THICKENING OF THE
→ Hypoproteinemia - plasma albumin usually <3 g/dL GLOMERULAR BASEMENT MEMBRANE
▪ Liver synthesis unable to compensate for the large amount ● IgA NEPHROPATHY
of protein excreted in the urine. → Most prevalent type of glomerulonephritis world wide
▪ Hyperlipidemia - increased plasma levels of triglycerides, → Deposition of IgA in the GLOMERULAR MESANGIUM
cholesterol, phospholipids, and VLDL. ● CHRONIC GLOMERULONEPHRITIS
→ Development: Slow and Silent
→ 80% have previously some forms of glomerulonephritis
→ 20% form of glomerulonephritis that has been unrecognized
→ Silent Killer

TUBULAR DISEASE: TUBULAR DISORDERS

● Acute Tubular Necrosis
→ Primary disorder associated with damage to the renal tubules
→ Ischemia - lack of oxygen presentation to the tubules (leads
to damage to the RTE cells)
→ Exposure to NEPHROTOXIC AGENTS - e.g. aminoglycoside,
antibiotics, antifungal agent, etc. (can damage & affect the
function of RTE cells)
→ Aminoglycoside - medication used of
antimicrobial/antibacterial agents
Figure 55. Microscopic view of glomerulus
● Minimal Change Disease
→ aka: LIPID NEPHROSIS
→ Etiology: Unknown
→ Associated with: allergic reactions, recent immunization, &
possession of the human leukocyte antigen-B12 (HLA - B12)
antigen ← marker (also responsible for immune response)
● Focal Segmental Glomerulosclerosis
→ Affects only certain numbers and areas of glomeruli, and the
others remain normal
→ Immune deposits: IgM & C3
→ Associated with: abuse of HEROIN, ANALGESICS, & AIDS
TUBULAR DISEASE: HEREDITARY & METABOLIC
TUBULAR DISORDERS
GLOMERULAR DISEASE: TYPES OF ● Fanconi Syndrome
→ Disorder most frequently associated with tubular dysfunction
GLOMERULONEPHRITIS
→ Generalized failure of tubular reabsorption in the PCT
● ACUTE GLOMERULONEPHRITIS
→ Affected Substances: Glucose, AA, Phosphorous, Na, K,
→ One cause: Post-Streptococcal Infection → known as: ACUTE
HCO3– , H2O
POSTSTREPTOCOCCAL GLOMERULONEPHRITIS (Group
● Alport Syndrome
A 𝛃-hemolytic Streptococci - those with M PROTEIN in their
→ Inherited disorder of collagen production affecting the
cell wall induces this type of nephritis) ← virulence factor
glomerular basement membrane
→ Blood: ELEVATED ASO(anti-streptolysin O) Titer - specific for
→ MOI: Sex-linked or Autosomal Genetic Disorder
group a streptococci
→ Glomerular basement membrane has a lamellated
→ NON- AGN: non-streptococcal agent (bacteria: pneumococci,
appearance with areas of thinning (lack/lost of elasticity)
viruses: mumps, Hepa B, parasitic infection: malaria
→ MOI - Mode of Inheritance
→ Virulence factor - pinaka nagcacause ng disease
● Uromodulin-Associated Kidney Disease
● FOCAL SEGMENTAL GLOMERULONEPHRITIS
→ MOI: Autosomal mutation in the gene that produces
→ SCLEROSIS of the GLOMERULI
UROMODULIN (UMOD Gene located at C 16p 11.2-12)
→ FOCAL (Occurring in some glomeruli); SEGMENTAL(Affecting
● Diabetic Nephropathy
a specific area of the glomerulus)
→ Currently the most common cause of end-stage renal disease
→ Predominant Feature: PROTEINURIA
● MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

BSMT2F Raze, Jett, Omen, Skye, Cute 24 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Caused by: Glomerular membrane thickening, increased → Cystinuria(Cystine and Dibasic AA) & Hartnup
proliferation of mesangial cells and increased deposition of Diseases(monoamino-monocarboxylic AA) - impaired ability
cellular and noncellular material within the glomerular matrix to reabsorb specific amino acids
→ Associated with: deposition of glycosylated proteins(HbA1C) → Bartter’s Syndrome - impaired ability to reabsorb sodium
resulting from poorly controlled blood glucose levels → Renal Tubular Necrosis Type II - impaired ability to reabsorb
● Nephrogenic Diabetes Insipidus bicarbonate
→ Non-functional ADH (Antidiuretic Hormone/Vasopressin) - → Idiopathic Hypercalciuria - impaired ability to reabsorb
water retention calcium
▪ Leading to Polyuria → Hypocalciuric Familial Hypercalcemia - excessive
→ MOI: Sex-linked Recessive Gene or ACQUIRED from reabsorption of calcium, low calcium levels in urine but high in
medications (amphotericin B & lithium) blood
→ Complication of: Polycystic Kidney Disease & Sickle Cell → Gordon’s Syndrome - excessive reabsorption of sodium
Anemia → Pseudohypoparathyroidism - excessive reabsorption of
● Renal Glycosuria phosphate
→ Impaired reabsorption of glucose → Fanconi Syndrome - generalized loss of proximal tubular
→ Glycosuria(reducing sugars) function
▪ Glucosuria (appearance of glucose in urine, the most ▪ not reabsorbed from the ultrafiltrate & excreted in the
frequent type of glycosuria) urine:(AA, glucose, water, phosphorous, potassium, and
calcium)
● Acute Tubular Necrosis (ATN) ● Tubular Dysfunction- Distal Tubular Dysfunction (DCT is
→ Destruction of renal tubular epithelial cells affected)
→ 2 Distinct types: → Familial Hypophosphatemia (Vitamin D Resistant
▪ Ischemic ATN - follows a HYPOTENSIVE event that result Rickets)- Impaired ability to REABSORB PHOSPHATE
in decreased perfusion of the kidneys followed by renal → Idiopathic Hypercalciuria - Impaired ability to REABSORB
tissue ischemia CALCIUM
− 3 Principal cause: → Renal Tubular Acidosis, Types I and II - Impaired ability to
o Sepsis ACIDIFY URINE
o Shock → Renal Salt-Losing Disorder - Impaired ability to RETAIN
o Trauma SODIUM
▪ Toxic ATN - results from exposure to NEPHROTOXIC → Nephrogenic Diabetes - Impaired ability to CONCENTRATE
AGENTS URINE
− Caused by a variety of agents separated into 2 → Liddle's Syndrome - Excessive reabsorption of SODIUM
categories → Renal Phosphaturia - Inability to REABSORB INORGANIC
− A. Endogenous Nephrotoxin - normal solutes or PHOSPHATES
substances that become toxic when their concentration
in the bloodstream is excessive: TUBULOINTERSTITIAL DISEASE & URINARY TRACT
o Hemoglobin - hemoglobnuria - severe hemolytic INFECTIONS
events ● Lower UTI
o myoglobin - myoglobinuria - rhadomyolysis → urethra(urethritis)
o uric acid → Bladder(cystitis)
o immunoglobulin light chain ▪ Painful Urination(Dysuria)
− B. Excogenous Nephrotoxin - substances ingested or ▪ Burning sensation
absorbed ▪ frequent urge to urinate
o therapeutic agents ● Upper UTI
o anesthetics → Renal Pelvis Alone(Pyelitis)
o radiographic contrast media → Renal Pelvis including Interstition(Pyelonephritis)
o chemotherapeutic drugs ● Acute Pyelonephritis - bacterial infection that involves the renal
o recreational drugs tubules, interstitium, & renal pelvis
o industrial chemicals → Mechanism:
● Tubular Dysfunction- Single Defect in proximal tubular ▪ Movement of bacteria from the lower urinary tract to the
dysfunction (PCT is affected) kidney
→ Renal Glycosuria - impaired ability to reabsorb glucose ▪ Localization of the bacteria from the bloodstream in the
kidneys (hematogenous infection)

BSMT2F Raze, Jett, Omen, Skye, Cute 25 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

● Chronic Pyelonephritis - develops when permanent ▪ Large Staghorn Calculi - resembling the shape of the renal
inflammation of renal tissue causes permanent scarring that pelvis and smooth, round bladder stones with diameters of 2
involves the renal calyces and pelvis or more inches.
● Acute interstitial Nephritis - allergic response to the interstitium − removed by surgical procedure or lithotripsy
of the kidney ▪ Small Calculi - may be passed in the urine
→ Most common cause: acute allograft rejection of a → LITHOTRIPSY - procedure using high-energy shock waves,
transplanted kidney can be used to break stones located in the upper urinary tract
into pieces that can then be passed in the urine. Stones can
also be removed surgically.
● Yeast Infections
→ Candida species (e.g. Candida albicans) - normal flora of GIT METABOLIC DISORDERS:
& vagina but becomes pathogenic with increase in number
and if it reaches the kidneys
● Newborn screening
→ Proliferation of yeasts due to: changes in pH, adversely
- RA no. 9288
disrupted by antibiotics
- after 24 hours of infant’s life but not later than 3 days
→ Anti-fungal should be used which is why it is important to
- after 24 hours to respect the first hours of his/her life
know the cause of the infection because giving anti-microbial
- Philippine Set up:
to fungal infections will just damage the kidney more
1. CH -Congenital Hypothyroidism
2. CPH - Congenital Adrenal hyperplasia
VASCULAR DISEASE 3. PKU - phenylketonuria
● Acute Renal Failure 4. MSUD - maple syrup urine disease
→ Clinically, sudden: 5. Galactosemia
1. DECREASE of GFR - glomerular filtration rate 6. G6PDD - glucose-6-phosphate dehydrogenase deficiency
2. Azotemia - presence of urea or high urea in urine
3. Oliguria (Urine Output < 400mL) ● Qualitative test: Screening of metabolic disorders
→ Mechanisms: → Ferric Chloride Test
1. Pre-Renal - result from decrease renal blood flow (25% of ▪ Alkaptonuria (Homogentesic Acid)
cases)[Urine sodium concentration is low - increased amount ▪ MSUD
of sodium being reabsorbed] ▪ Melanoma (Melanin)
2. Renal - (Approx. 65% of cases) renal damage, can result ▪ PKU
from glomerular, tubular or vascular disease process → Ammoniacal Silver Nitrite
[INCRASES URINARY EXCRETION OF SODIUM] ▪ Alkaptonuria (Homogentesic Acid)
3. Post-Renal - (Approx. 10% of cases) obstruction in the → Benedict's Test
urine flow ▪ Alkaptonuria (Homogentesic Acid)
● Chronic Renal Failure → Nitrosonaphthol Test
→ Progressive LOSS of RENAL FUNCTION caused by: ▪ Tyrosinuria
▪ IRREVERSIBLE & INTRINSIC RENAL DISEASE → Hoesch Test
→ Decreasing GFR slowly but continuously DECREASES ▪ Porphyria (Porphobilinogen)
→ "END-STAGE RENAL DISEASE"/ "END-STAGE KIDNEYS" - → Watson-Schwartz Test
CRF that progresses to advanced renal disease ▪ Porphyria (Porphobilinogen)
● Calculi (Renal Lithiasis)
METABOLIC DISORDERS: AMINO ACIDS DISORDERS

● Liver and Kidney

→ Actively involved in the metabolism of Amino Acids
→ TRANSAMINATION: Interconversion of AA
→ DEAMINATION: Degradation of AA
→ AA→ results in formation of AMMONIUM IONS→ this Al is
used to form→ UREA (subsequently eliminated from the body
by the KIDNEYS)
→
● Aminoaciduria
→ Calculi vary in size from barely visible to large A. Overflow Aminoaciduria:

BSMT2F Raze, Jett, Omen, Skye, Cute 26 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Cause: INCREASE in the plasma levels of AA → MOI: Autosomal Recessive

→ Renal Threshold for AA reabsorption: → Accumulation of branched-chain AA (leucine, isoleucine,
→ EXCEEDED - additional AA are valine) and their corresponding a-keto acids in BLOOD,
→ EXCRETED in the URINE URINE & CSF
B. No- Threshold Aminoaciduria: → Deficient Enzyme: Branched-Chain a-Keto Acid
→ AA of reabsorption by tubules Dehydrogenase (BCKD)
→ INCREASE in blood = INCREASE in urine (PIC should be attached)
C. Renal Aminoaciduria: ● Phenylketonuria
→ Plasma levels of AA are normal. → MOI: Autosomal Recessive
→ Cause: Defect in tubules (congenital acquired) → INCREASED urinary excretion of PHENYLPYRUVIC ACID (a
→ NOT Reabsorbed by the tubules = INCREASE amount in ketone) and its metabolites
URINE → Deficient Enzyme: PHENYLALANINE HYDROXYLASE
→ Urine, Sweet & Breath: Characteristic MOUSTY/MUSTY
● Primary Aminoaciduria ODOR -> caused by -> PHENYLACETIC ACID
→ a.k.a. “inborn errors of metabolism” (PIC should be attached)
→ Result from: INHERITED DEFECT ● Alkaptonuria
2 Types of Defects: → MOI: Autosomal Recessive
→ 1. Enzyme is DEFECTIVE (DEFICIENT) in the SPECIFIC AA → Excretion of large amount of HOMOGENTISIC ACID (HGA) in
metabolic pathway the urine
→ 2. Tubular Reabsorption Dysfunction → Unusual darkening of the urine when ALKALI is ADDED
→ EXCEEDED - additional AA are → Deficient Enzyme: HOMOGENTISIC ACID OXIDASE
(PIC should be attached) (PIC should be attached)
● Tynosinuria
● Cystinuria → Increased amount of TYROSINE in the urine -> occurs when
→ MOI: Autosomal Recessive -> tyrosine levels in PLASMA is abnormally high
→ Due to: NEPHRONS (pTC = UNABLE to REABSORBED AA (PIC should be attached)
(cysteine, dibasic AA e.g, arganine, lysine, ornithine) ● Melanuria
(PIC should be attached) → Melanin:Color of hair, eyes & skin
→ Hypomelanosis/ Albinism: Defective melanin production
● Cystinosis → Melanuria (Increased excretion of urinary melanin) =
→ MOI: Autosomal Recessive INCREASED production of MELANIN & its colorless
→ Lysosomal Storage Disease - results in -> DEPOSITION OF precursors (e.g. 5,6-dihydroxyindole
CYSTINE in the LYSOSOMES of cells throughout the body ● Diabetes mellitus
(Kidneys, Eyes, Bone Marrow & Spleen) → “Diabetes” -> copious amounts of urine (POLYURIA) that this
(PIC should be attached) disorder produces
3 DISTINCT TYPES → “mellitus” -> means “sweet”
1. Nephropathic Cystinosis → Polyuris with presence of glucose in the urine
→ Most common and severe form of cystinosis. → HIGH: SG
→ Accumulated CYSTINE CRYSTALLIZES within the ● Diabetes insipidus
PROXIMAL TUBULAR CELLS of the NEPHRONS -> causing → “Diabetes” -> copious amounts of urine (POLYURIA) that this
-> GENERALIZED TUBULAR DYSFUNCTION -> disorder produces
development of FANCONI SYNDROME → “insipidus” -> refers to “bland taste”
→ Evident: FIRST YEAR OF LIFE → of urine produced
→ LOW: SG
2. Intermediate Cystinosis ● Galactosemia
→ RARE FORM Enzymes Responsible for Galactosemia:
→ Clinical Features: SAME with Nephropathic Cystinosis → 1. Galactose 1-phosphate uridylyltransferase (GALT)
→ Evident: ADOLESCENCE → 2. Galactokinase (GALK)
3. Ocular Cystinosis → 3. Uridine diphosphate galactose 4-epimerase (GALE)
→ RARE FORM
→ CYSTINE DEPOSITION in the CORNEA -> Ocular
Impairment
(PIC should be attached)
● Maple Syrup Urine Disease

BSMT2F Raze, Jett, Omen, Skye, Cute 27 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ If possible, the 4th tube may be withdrawn for the

VIII. OTHER BODY FLUIDS microbiology section.
→ TUBE #3
A. CEREBROSPINAL FLUID - less contaminated
- for cell counting
● Third major body fluid.
● First recognized by Catugno in 1764. Tube # Section Storage Note
● It is not an ultrafiltrate of plasma. Chemistry / Frozen Tests are least
● Functions: Serology affected by
1
→ Supply nutrients to nervous tissue. blood or
→ Remove metabolic waste. bacteria
→ Cushion the brain & spinal cord against trauma. Microbiology Room H. influenza, N.
2&4
● CSF Volume: temperature meningitidis
→ Adults: 140-170 mL Hematology Refrigerated Least likely to
3
→ Neonates: 10-60 mL contain cells
● Ventricular Shunt
→ Purpose: Reduce the amount of CSF in the brain by draining → Frozen temperature: -24°C
it to the abdomen or directly into the chambers of the heart. → Room temperature: 20-24°C
→ Shunting of CSF - helps reduce the pressure on the brain to → Refrigerated temperature: 2-8°C
prevent brain injury.
● Shunt Appearance
→ Hollow plastic tube that is placed in the ventricles of the brain. Crystal Clear Normal
→ Tube is attached to the valve and is threaded under the skin Cloudy, milky, turbid Protein, lipid, WBC
from the brain to the abdomen (peritoneum) or heart (atrium). Bloody Intracranial hemorrhage, traumatic tap
→ V-P Shunt: Ventricular-Peritoneal Shunt Xanthochromic Hemoglobin, bilirubin, carotene, ↑
▪ If the excess CSF is being drained from the abdomen. (Pink, orange, protein, melanin
→ V-A Shunt: Ventricular-Atrial Shunt yellow)
▪ If the excess CSF is being drained from the chambers of the Clotting factors introduced by traumatic
Clotted
heart. tap
Tubercular meningitis, seen after
Pellicle
FORMATION AND PHYSIOLOGY overnight of refrigeration
● Meninges - lines the brain and the spinal cord. Oily Radiographic contrast media
→ Three Layers:
▪ Dura Mater - outermost layer of the meninges. Traumatic Tap vs. Intracranial Hemorrhage
▪ Arachnoid - middle layer / web-like structure. Traumatic Tap Intracranial Hemorrhage
− Subarachnoid space - between the arachnoid and pia Uneven distribution of blood Even distribution of blood
mater where CSF flows. Clot formation (activation of No clot formation
▪ Pia Mater - innermost layer. coagulation pathways,
● Choroid Plexus - capillary networks that form the CSF. activation of clotting factors)
→ Blood-Brain-Barrier (BBB): light-fitting endothelial cells. Supernatant: Xanthochromic
▪ It protects your CSF. (pink, blue, orange, yellow
Supernatant: Not color)
→ Produces: 20 mL/hr of fluid. xanthochromic (pink, blue,
Additional:
orange, yellow color)
SPECIMEN COLLECTION Erythrophagocytosis, (+)
D-Dimer
● Procedure: Lumbar Tap / Lumbar Puncture: 3rd, 4th, & 5th
Lumbar Vertebrae
● Fibrinolysis - dissolution of clot
→ They should be either in a lying or sitting position.
→ It happens when there is a (+) D-Dimer.
● Before aspirating: Opening Pressure is measured FIRST.
● Xanthochromic Colors:
● Ideally: Tests are performed on STAT basis
→ Pink - presence of oxyhemoglobin.
→ Palaging inuuna, wow sana all.
→ Yellow - presence of bilirubin.
→ Physicians ang kumukuha ng CSF, hindi MedTech.
→ Orange - combination of oxyhemoglobin and bilirubin.
● Collection Tubes
→ 3 sterile tubes: Numbered in ORDER they are withdrawn.

BSMT2F Raze, Jett, Omen, Skye, Cute 28 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

● Must LYSE RBC prior to WBC Count

CELL COUNT AND DIFFERENTIAL COUNT - 3% Glacial Acetic Acid: Diluent
● Should be performed ASAP. - May add Methylene Blue to the DIluting Fluid
● RBC: disintegrate within 1 hour - If dilution is not necessary: rinse pipette with the diluting
● Decrease by 40% in WBC: after 2 hours fluid prior to aspiration
● Pleocytosis - increase of WBC in CSF. Corrections for Contamination
Normal Values: - Calculations made to correct for WBCs introduced in the
→ Adult: 0-5 cells/uL → predominant cells: LYMPHOCYTES CSF because of traumatic tap
→ Neonates: 0-30 cells/uL → predominant cells: MONOCYTES - Correction for Contamination:
Methods:
→ Manual: Neubauer Counting Chamber
→ Automated: Automated Cell Counters
Quality Control:
● Correct WBC Count = Actual wbc count - WBC added
- Results of MANUAL COUNT should agree with the
● If the peripheral WBC and RBC: Normal
AUTOMATED COUNT by +-25%
- Subtract 1 WBC for every 700 RBCs present
Calculation of CSF cells
in the CSF. (eg. 1,400 RBC/uL and 100 WBC/uL
- follows the standard calculation formula used for blood cell
= 98 WBC/uL)
counts.
- Counting of Cells: 4 LARGER CORNER SQUARES &
LARGE CENTER SQUARE CSF ELECTROPHORESIS
●
● Primary Purpose: Detection of OLIGOCLONAL Bands
● Can determine if a fluid is indeed CSF
Procedure:
1. Protein separated through electrophoresis
2. Cellulose Acetate strips with anti-serum is placed over
3. Wash
4. Strips are stained
Most Common Method
● Agarose Gel Electrophoresis
● Coomassie Brilliant Blue Staining
Oligoclonal Bands
- Indicates Immunoglobulin production
- Bands are located in the GAMMA region of the protein
electrophoresis
● INTERPRETATION: Oligoclonal Bands in CSF ONLY
- Multiple Sclerosis
Volume = Area (1mm^2) x Depth (0.1mm)
- Other: Neurologic Disorder, Encephalitis,
0.1mm^3 = 1uL
Neurosyphilis, Guillain-Barre Syndrome
● INTERPRETATION: Oligoclonal Bands in CSF and
Serum
- HIV Infection: gP120/160, gP41, p24 (2 out of 3
are present matic may HIV)
● INTERPRETATION: Oligoclonal Bands in Serum ONLY
- Leukemia, Lymphoma, Viral Infections
- May produce CSF banding because of BBB
leakage or blood contamination during lumbar
tap
Total Cell Count
● Clear Specimens may be counted UNDILUTED MYELIN BASIC PROTEIN
- NSS: used as Diluent - Indicates recent destruction of the myelin sheath that
- Should use calibrated, automatic pipettes protects the axon of the neurons (demyelination)
- Cells may be counted in 4 CORNER SQUARES and the - Measurement can be used to monitor the course of
CENTER SQUARE multiple Sclerosis

BSMT2F Raze, Jett, Omen, Skye, Cute 29 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

➢ Theorized that the inflammatory response in MS - Microorganism must be recovered by growing it on the
is triggered by Molecular Mimicry appropriate culture medium
- EBV, Measles, HSV, VZV, Rubella, Influenza C, HHV-6 ● 24 hours in bacterial meningitis
- It may also provide a valuable measure of the ● 6 weeks for tubercular meningitis
effectiveness of current and future treatments. - Specimen Concentration: CSF centrifuged @1500 rpm for
15 mins - sediment used for slides and culture
CSF GLUCOSE - CSF Culture: Confirmatory RATHER than Diagnostic
- Value: 60-70% of plasma glucose Procedure
● Plasma Glucose: 100 mg/dL - Microbiology laboratory test for a preliminary diagnosis:
● CSF Glucose: 65 mg/dL (lower than plasma ● Gram Stain - G=/G-/ fungal
glucose) ● Acid Fast Stain - MTB/ Acid fast microorganisms
- Blood glucose should be drawn 2 HOURS prior to ● India Ink Preperation - C. neoformans
Lumbar Tap (CSF) ● Latex Agglutination Test - Bacterial Antigen
- Clinical Significance: Can be used to determine the cause
of meningitis Major Laboratory Result for the Differential Diagnosis of
● Inc. levels: always a result of plasma elevation Meningitis
● Dec. levels: caused by alteration in transport in
BBB and inc. used by brain cells.
(hindi ito bababa kapag di mo ginamit brain cells mo)

LACTATE
- Destruction of tissue within the CNS due to hypoxia
causes the production of inc. CSF Lactate
GRAM STAIN
(Pag mataas ang CSF Lactate, mababa ang oxygen concentration)
● Routinely performed on CSF from all suspected cases of
- Aid in the diagnosis and management of meningitis cases
meningitis
● Elevation is consistent with: Bacterial, Tubercular
● Value lies in the detection of Bacterial and Fungal
and Fungal Meningitis
Organism.
● Level declines rapidly when treatment is
● Use of Cytocentrifuge: provides highly concentrated
successful
specimens
- used to monitor severe head injuries
- Falsely Elevated: Obtained from Xanthochromic or
Hemolyzed Samples COMMON CAUSES OF BACTERIAL MENINGITIS

CSF GLUTAMINE INFANTS S. agalactiae

- indirect measure of CSF Ammonia
E. coli K1 Stain, L. monocytogenes
- Preferred over DIRECT measurement of CSF AMMONIA:
AMMONIA is Volatile
ADOLESCENTS N. meningitides
- Normal Value: 8-18 mg/dL /ADULTS
➢ Elevated levels: associated withLIVER H. influenza type B, S. pneumoniae
DISORDER that result in inc. Blood and CSF
Ammonia ELDERLY S. pneumoniae
- Glutamine produced from Ammonia & a-ketoglutarate by
the brain cells N. meningitides, L. monocytogenes
- AMMONIA IS TOXIC TO YOUR CNS TISSUE!!
- Frequently requested procedure for patients with
TESTS FOR FUNGAL MENINGITIS
coma of unknown origin
Cryptococcus neoformans
➢ Inc. in approx. 75% of children with REYE/’s
● Cryptococcal meningitis (one of the frequently
SYNDROME
occurring complications of AIDS)
Lab findings:
MICROBIOLOGY TEST ❖ INDIA INK: THICK ENCAPSULATED organism
- Identification of causative agent in Meningitis

BSMT2F Raze, Jett, Omen, Skye, Cute 30 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

24 h (BACTERIAL) Streptococcus India ink

pneumoniae
6 weeks (gram pos. cocci) Gram’s stain
(TUBERCULAR)
Haemophilus
influenzae
(pleomorphic
gram-neg. rods)
❖ GRAM STAIN: Starburst pattern (may be seen more
often than a positive India ink Escherichia coli
(gram neg. rods)

Neisseria
meningitidis
(gram neg. cocci)

Cryptococcus
neoformans (star
burst pattern)
❖ Associated with: Inc. Eosinophils

LIMULUS LYSATE TEST B. SYNOVIAL FLUID

● Diagnosis of meningitis caused by Gram (-) bacteria
○ Limulus amebocyte reacts with bacteria ● Synovial Fluid - located in the cavities between the moveable
endotoxin of Gram (-) bacteria joints.
● Reagent from blood cells of horseshoe crab (Limulus ● Synovlocytes - secrete hyaluronic acid, a large molecule that
polyphemus) produces the viscosity of the fluid.
● (+) Result: Coagulation within 1 hour of incubation @ 37 ● Damage to the joints produces arthritis.
C.
Classification of Arthritis
RAPID TEST Class Pathology Laboratory Results
● Latex Agglutination Clear, yellow, good viscosity
Non-inflammat
● ELISA Method Osteoarthritis WBCs <1000/mL,
ory
● Bacterial Antigen Test neutrophils <30%
[ALL ARE FOR DETECTION OF BACTERIAL ANTIGEN] Cloudy, yellow, poor
Inflammatory / Autoimmune viscosity
SEROLOGIC TESTING immunologic disorders WBCs 2000-75,000/mL,
● Performed to detect the presence of Neurosyphilis (CA: neutrophils <75%
Treponema pallidum) Clear or milky, low viscosity
● Venereal Disease Research Laboratories (VDRL) Inflammatory / Gout,
WBCs up to 100,000/mL,
○ Procedure recommended by the CDC to crystals pseudogout
neutrophils <75%
diagnose Neurosyphilis Cloudy, yellow-green, low
● Fluorescent Treponemal Antibody-Absorption viscosity
(FTA-ABS Test) Septic Infection
WBCs 50,000-100,000/mL,
○ More sensitive than VDRL neutrophils >75%
○ Prevent contamination with blood because the
Trauma, Cloudy, red, low viscosity
FTA-ABS remains positive in the serum of
Hemorrhagic coagulation WBCs and neutrophils =
treated cases of syphilis
disorders blood values

MICROBIOLOGICAL TEST ● Laboratory Testing: Color

→ Normal is colorless to pale yellow.
CULTURE GRAM STAIN TEST FOR ● Laboratory Testing: Viscosity
(Confirmatory) FUNGAL → The “ropes” or “mucin clot” test detects and measures the
MENINGITIS
hyaluronic acid.
→ Normal: 4-6 cm

BSMT2F Raze, Jett, Omen, Skye, Cute 31 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Addition of acetic acid to normal synovial fluid will form a firm

mucin clot surrounded by clear liquid; clots become less firm ● Serous Fluid - located between the parietal and visceral
as the viscosity decreases. membranes that line the closed body cavities, mesothelial cells
→ Addition of acetic acid to a questionable fluid identifies it as line the membranes.
synovial fluid. → Cavities: Pleural, pericardial, and peritoneal
● Laboratory Testing: Cell Counts → It is normally produced and reabsorbed at a constant rate;
→ Do not use normal WBC diluting fluid (acetic acid), use disruption of this process produces an effusion.
normal saline.
→ Normal WBC count is < 200 cells/mL. TRANSUDATES AND EXUDATES
● Laboratory Testing: Differential Cell Counts ● Effusions caused by systemic disorders are transudates.
→ Incubate fluid with hyaluronidase before slide preparation. ● Effusions caused by membrane disorders are exudates.
→ Primary cells are monocytes and macrophages, followed by
neutrophils at less than 25% and lymphocytes at less than Differentiation between Transudates and Exudates
15% and occasional synoviocytes. Test Transudates Exudates
● Laboratory Testing: Crystal Identification
Appearance Clear Cloudy
→ Primary crystals are monosodium urate seen in gout, and
Fluid-to-serum protein ratio <0.5 >0.5
calcium pyrophosphate dihydrate seen in pseudogout.
Fluid-to-serum LD ratio <0.6 >0.6
→ Identify using polarized and compensated polarized light.
WBC count <1000/uL >1000/uL
→ Monosodium Urate Crystals - needle-shaped, strongly
birefringent under polarized light. Spontaneous clotting No Yes

SEROUS FLUID: PLEURAL FLUID

● Collected by thoracentesis.
● Appearance:
→ Milky: Thoracic duct leakage (chylous effusion), chronic
infection (pseudochylous effusion).
→ Bloody: Hemothorax, hemorrhagic effusion (embolus,
tuberculosis, malignancy).
▪ Yellow when aligned with the slow vibration of compensated
→ Viscous: Malignant mesothelioma producing hyaluronic acid.
polarized light and blue when vertical to the slow vibration.
● Hematology: Differential Count
▪ Elevated serum uric acid levels aid in the identification.
→ Neutrophils: Pneumonia, pancreatitis
▪ Gout → increase in BUA + presence of uric acid crystals in
→ Lymphocytes: Tuberculosis, viral infections
urine.
→ Eosinophils: Pneumothorax
→ Calcium Pyrophosphate Dihydrate Crystals - rhombic,
→ Mesothelial cells: Normal, decreased with tuberculosis
often seen intracellularly in neutrophil vacuoles (phagocytized
→ Plasma cells: Tuberculosis
monosodium urate crystals puncture the cell membrane).
→ Malignant cells: Small cell and adenocarcinoma, metastatic
carcinoma cells.
● Chemistry
→ pH <7.0 = need for chest tube drainage
→ pH <6.0 = esophageal rupture
→ Pleural fluid cholesterol: equal to or less than 45-60 mg/dL
(transudate), higher (exudate).
→ Pleural Fluid: Serum cholesterol ratio
▪ Blue when aligned with the slow vibration of compensated ▪ Less than 0.3 (transudate), higher (exudate).
polarized light and yellow when vertical to the slow vibration. → Pleural Fluid: Serum bilirubin ratio
● Laboratory Testing: Microbiology ▪ Less than 0.6 (transudate), higher (exudate).
→ Gram stains and cultures are routinely run on synovial fluid ● Microbiology
specimens. → Acid-Fast stains - detection / determination of acid-fast
→ Cultures require enriched agar (chocolate) for detection of microorganisms.
possible Haemophilus sp. and Neisseria gonorrhea.
▪ Enriched agar (chocolate) is what we call CAP. This is our SEROUS FLUID: PERICARDIAL FLUID
oxidized blood. ● Collected by pericardiocentesis.
● Appearance:
C. SEROUS FLUID → Cloudy, blood-streaked: Infection, malignancy

BSMT2F Raze, Jett, Omen, Skye, Cute 32 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ Grossly bloody: Cardiac puncture, anticoagulant medications → Provide protective cushion for the fetus
HEMATOLOGY → allow fetal movement
● Increased neutrophils are seen in bacterial endocarditis. → stabilize the tempreature to protect the fetus from extreme
● Refer metastatic malignant cells for cytologic examination temperature changes
MICROBIOLOGY → permit proper lung development
● Gram stains and cultures are performed on concentrated ● Volume
specimens. → is regulated by a balance between:
● Acid-Fast stains for tuberculosis are associated with acquired ▪ Production of fetal urine and lung fluid
immunodeficiency syndrome. ▪ Adsorption from fetal swalling and intramembranous flow
→ @ 3rd trimester - approximately 800 - 1200 mL (gradually
SEROUS FLUID: PERITONEAL FLUID decrease prior to delivery)
→ Collected by PARACENTESIS.
→ Often called ascitic fluid, effusion is ascites 2 Phases of Amniotic Fluid
→ Effusions are caused by liver disorders (cirrhosis), intestinal ● Polyhydramnois - amniotic fluid > 1200 mL
infection (peritonitis), and malignancy. → Due to: failure of the fetal lung to begin swallowing
TRANSUDATES AND EXUDATES → Secondary associated with: fetal structural anomalies, cardiac
● The serum-ascites albumin gradient is the recommended method arrhythmias, congenital infections, chromosomal abnormalities
for differentiation. ● Oligohydramnois - Amniotic fluid < 800 mL
● Measure serum and ascites albumin levels. → Due to: ↑ fetal lung swallowing, urinary tract deformities,
● Serum albumin - fluid albumin = 1.1 or higher is a transudate. membrane leakage
● Serum albumin - fluid albumin = 1.1 or lover is an exudate.
APPEARANCE Composition of Amniotic Fluid
● Turbid: Infection ● 1st Trimester
● Green: Gallbladder or pancreas disorder → Volume of approximately 35mL
● Blood-streaked: Trauma, infection, malignancy → Composition similar to maternal plasma
● Milky: Lymphatic trauma or blockage → Contains small amount of sloughed fetal cells
HEMATOLOGY ▪ Basis for Cytogenetic Analysis
● Normal WBC count: Less than 350/mL. ● 3rd Trimester
● Absolute neutrophil count distinguishes between cirrhosis and → Volume reaches a peak of 1L - gradually decreases prior to
peritonitis. delivery
● More than 250 neutrophils/mL or 50% of the differential indicates → Major Volume Contributor in Fetal Urine
peritonitis. ▪ ↑ Creatinine, Urea, Uric Acid
DIFFERENTIAL COUNT ▪ >2mg/dL Creatinine = Fetus >36 weeks
● Additional cells seen include abundant mesothelial cells, ▪ AF Creatinine does not exceed 3.5mg/dL & Urea 30mg/dL
lipophages, yeast, Toxoplasma gondii, and malignant colon, ▪ ↓ Glucose & Protein
prostate, and ovarian cells.
CHEMISTRY Differentiation maternal urine from AF
● Glucose: Decreased in infection and malignancy. Maternal Urine AF
● Amylase: Elevated in pancreatitis and gastrointestinal (GI) Creatinine High (up to 10mg/dL) Lower(<3.5mg/dL)
perforations. Urea High (up to 300mg/dL) Lower(<30mg/dL)
● Alkaline phosphatase: Elevated in intestinal perforation. Glucose & Negative(normally) Present
● BUN and creatinine: Bladder rupture or puncture. Protein
● Tumor markers: Carcinoembryonic Antigen and CA125 Fern Test Negative Positve
MICROBIOLOGY
● Gram stains and cultures for both aerobic and anaerobic ● Fern Test - used to evaluate premature rupture of the
organisms. membranes.
● Blood cultures aid in the detection of anaerobic organisms. → Vaginal Fluid specimen is spread on the glass slide
→ Allow to completely dry at room temperature
D. AMNIOTIC FLUID → Observed microscopically:
▪ + Screen for AMNIOTIC FLUID: presence of "FERN-LIKE"
PHYSIOLOGY: crystals (due to protein & sodium chloride)
● Amnion - membranous sac that surrounds the fetus Collection of Amniotic Fluid
● Amniotic Fluid - is the fluid inside this sac ● Amniocentesis
● Primary functions: → ultrasound guided

BSMT2F Raze, Jett, Omen, Skye, Cute 33 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

→ AF is obtained by needle aspiration into the amniotic sac ● Neural Tube Defects (NTD)
→ Maximum of 30mL collected in sterile syringe → Most common birth defects in the US
→ 1st 2-3mL collected → DISCARDED → Can be detected by: Maternal Serum Alpha-fetoprotein
→ Safe if performed after 14th week gestation (MSAFP), High Resolution Ultrasound & Amniocentesis
▪ Chromosome Analysis: Fluid collected @ 16th week → ↑ AFP (both maternal circulation & AF): Indicative of NTD (e.g.
gestation Anencephaly & Spina Bifida)
▪ Fetal Distress & Maturity Test: Performed later in the 3rd → Alpha-fetoprotein(AFP) - major protein producedby the fetal
Trimester liver during early gestation (prior to 18 weeks)
→ 2 Procedure for amniocentesis: → Amniotic Acetylcholinesterase(AChE) - more specific than
▪ Transadominal amniocentesis - most frequently performed AFP
▪ Vaginal amniocentesis- great risk of infection ▪ not to be performed in bloody specimen because blood
Specimen Handling & Storage contains AChE
● Bilirubin Testing
→ Protected from light Tests for Fetal Maturity
→ Place in amber colored tubes or black plastic cover for ● Respiratory Distress Syndrome (RDS) - ↓ lung surfactant
container → Most frequent complication of early delivery
→ for detection of hemolytic disease of the newborn → 7th most common cause of morbidity & mortality in premature
● Fluid for Chemical Testing infant
→ ✓ Separated from cellular element and debris → Cause by insufficiency of Lung Surfactant production &
● Cytogenetic Studies structural immaturity of the fetal lungs
→ Stored at RT or Body Temperature (37°C) → Surfactant:
● FLM (Fetal Lung Maturity) ▪ normally appears in mature lungs and allows the alveoli (air
→ Low speed centrifugation not >5 minutes sacs of the lung) to remain open throughout the normal cycle
→ Filtration recommended prior to testing of inhalation and exhalation
→ Delivered in ICE ▪ keeps the alveoli from collapsing by decreasing surface
→ Refrigerated prior to testing (Tested within 72 hours) tension and allows them to inflate with air more easily
Color and Appearance ▪ ↓ Surfactant = Collapsed of Alveoli = RDS
→ Colorless ● Lecithin-Sphyngomyelin Ration
→ Transparency - slight to moderate turbidity (from cellular → L/S Ratio: reference method for Fetal Lung Maturity
debris, particularly in later stages of fetal development) → Lecithin: primary component of the surfactants (phospholipids,
neutral lipids & proteins)
Color Significance ▪ Produced at a relatively low & constant rate until the 35th
Colorless Normal week of gestation
Blood-streaked Traumatic Tap, Abdominal trauma, → Sphingomyelin: lipid that is produced at a constant rate after
intra-amniotic hemorrhage about 26th week of gestation
Yellow HDN(bilirubin)
Dark Green Meconium (NB 1st bowel movement) L/S Ratio
Dark Red-Brown Fetal Death Prior to 35 weeks’ usually <1.6
gestation
Tests for Fetal Distress after 35 weeks’ 2.0 or higher
● Hemolytic Disease of the Newborn (HDN) gestation
→ Oldest routinely performed laboratory test on amniotic fluid Therefore: hen L/S ratio reaches 2.0 - PRETERM delivery is
evaluates the severity of the fetal anemia produced by HDN usually considered to be relatively a safe procedure
→ Rh-Negative Mother→ Rh-Positive Newborn Falsely elevated L/S Ratio - AF contaminated ith blood or meconium
▪ Initial exposure to foreign red cell antigen occurs during: ● Phospatidyl Glycerol
(STIMULATES the mother to produce antibodies against the → Lung surface lipid
antigen) → can be detected after 35 weeks’ gestation
→ tests for: Gestation → production of PG normally - parallel with lecithin
→ Delivery of the placenta ▪ production is delayed in cases of maternal diabetes
→ Previous pregnancy (when fetal RBCs enter the maternal → Foam Stability index
circulation) ▪ “Foam” or “Shake” test
→ Presence of (red blood cell degradation product): ▪ Mechanical Screening test
Unconjugated Bilirubin (Amniotic Fluid) due to destruction of ▪ Measure the individual Lung-Surface lipid concentrations
fetal red blood cells ▪ Procedure:

BSMT2F Raze, Jett, Omen, Skye, Cute 34 of

35
 AUBF (LEC) [title]
AY 2022-2023 Urinalysis and Body Fluids
BSMT2F Sixth Edition

1. Amniotic Fluid + 95% Ethanol

2. Shake for 15 seconds
3. Allowed to sit undisturbed for 15 minutes
4. The surface of the fluid is observed for: PRESENCE OF
CONTINUOUS LINE OF BUBBLES AROUND THE
OUTSIDE EDGE.
✓ Presence of the Bubbles: Indicates a sufficient amount
of phospholipids
❖ Falsely Mature Index Result: AF contaminated with
blood or meconium

● Lamelar Bodies:
→ densely packed layers of phospholipids that represent a
storage form of pulmonary surfactant
→ secreted by the type II pneumocytes of the fetal lung at about
24 weeks of gestation
→ absorbed into the alveolar spaces to provide surfactant
→ Enters the AF at about 26th-week gestation
→ Increase in concentration from 50,000- 200,000/mL by the end
of 3rd Trimester
→ Fetal Lung Mature = ↑ Lamellar Body Production = ↑ Amniotic
Fluid Phospholipids & L/S Ratio
→
● s
E. FECAL ANALYSIS
2nd vid @ 34:00

BSMT2F Raze, Jett, Omen, Skye, Cute 35 of

35