AUBF
AUBF
RENAL FUNCTION
Kidneys
• The kidneys selectively clear waste products from the blood & simultaneously maintain the body’s
essential water & electrolyte balances.
• Each kidney contains 1 to 1.5 million functional units called NEPHRONS
2. UNFILTERAD BLOOD
ACTUAL
2.
FILTRATON
6. RENAL VEIN
BACK TO THE PERIPHERAL
ENTRY BLOOD CIRCULATION
RENAI I
Brop H.
PERITBUM
ARIES
LEXCHANGE
FoN
OFSUBSTMEN BULES
M
2. Glomerular Filtration
• Glomerulus is consists of a coil of approximately eight capillary lobes, the walls of which
are referred to as the glomerular filtration barrier. It is located within Bowman’s capsule.
• Responsible for non-selective filtration of substances in plasma
▪ Filtered substances – MW of less than 70,000 da > 70,00: I 2 3
· NOT FILTERAD CO2 NO BIG
MONITORSHIEPRESSURE
VOUm TR
↑ra
↓ Blood Pressure AFFECTS THE GLOMERULAR PRESSURE
PHYSIO LOGIC EFFECTS:
EX: MASSIVE BLEEDING PROMOTING A BLOOD FLOW
SOURCE: JUX TAGLOMERULAR
↓ Glomerular Pressure I. VASODICATION OF AFFERENT ARTERIOLES
OF HO & SODIUM
IN THE PROXIMAL CONSULATED
RIMMOREENY
on
2.
ACE IANGIOTENSIN_CONVERTING ENZYME) TUBULE_. CORRECTS BLOOD VOLUME
SOURCE: LUNGS
3. STIMULATES RELEASE OF 2 HORMoWEs
& polEnion minim
Angiotensinogen SUBSTRATE
Angiotensin I Angiotensin II RESULT: CORRECTS
THE PROBLEM INSIDE
BLOOD-BORNE
3. Tubular Reabsorption
• Essential substances and water are reabsorbed back to circulation (PCT→ Blood capillaries)
• Mechanisms:
▪ Active transport
O
o substance to be reabsorbed must combine with a carrier protein
2
L
PARTNER
WALLS ARE
IMPERMEABLE O- NaCl
7 T
WATER
*
&
I NFLUENCED
↓ BY ADH
HERINEELINE
IN
> HCOG WILL BE ELIMINARD
URINE
Lo LEAD TO METABOLK
ACIOspH, HCOR
• Elimination of unfiltered waste products;
LEVEL
*
EX: MEDICATIONS
9 901 CHOULD BE
E AB SOR BED
BUFIEE
->
SECRETION OF HYDROGEN IONS BUT
& NOT ELIMINATED
REABSORBES
> ESSENTAL
Clearance Test
• standard test for the filtering capacity of glomerulus
• measures the rate by which the kidneys are able to remove a filterable substance from the blood
• Substance must be one that is NEITHER reabsorbed nor secreted by the tubules
• Improperly-Timed Specimens = GREATEST SOURCE OF ERROR in any clearance procedure
1. Urea
USED IN
AE PAST
• earliest glomerular filtration test
• 40% of filtered urea is reabsorbed
• REPLACED by newer methods
2. Inulin
• Original REFERENCE METHOD
• polymer of fructose; extremely stable; used in the past
• EXOGENOUS procedure
24-AR URINE
4. Cystatin C ↑= ↓GFR
• MW: 13,359 – produced at a constant rate by all nucleated cells
• readily filtered by the glomerulus and reabsorbed and broken down by the renal tubular cells.
• No cystatin C is secreted by the tubules, and serum concentration can be directly related to the GFR
• Advantage: Independent of Muscle Mass ↑SERUM LEVEL CAN DIRECTLY REFLECT THE OFR
5. Beta2 microglobulin
• MW: 11,800 – dissociates from HLA at a constant rate and is rapidly filtered by glomerulus
• Advantage: more sensitive indicator of decreased GFR than creatinine clearance
• Disadvantage: not reliable in patients w/ history of immunologic disorders / malignancy
6. Radionucleotides
• enables visualization of the filtration in one or both kidneys FIRST FUNCTION
TUBULAR
AFFECTED IN RENAL DISEASE:
REABSORPTON
• EXOGENOUS procedure (125I-iothalamate)
1.
KIDNEY FAILURE
mL/min
mL/min.
Urine Creatinine Clearance: 120 mL / min omd.comor:
# 1.055
b
WHOLE DAY-INCLUDED
MEASURES
* THE TOTAL VOLUME
ALIQUOT OF 24-HR URINE: REPRESENTATIVE SAMPLE
*
Other Formula:
1. COCKCROFT & GAULT Formula
• Predicts creatinine clearance
• Historical and not used clinically nowadays
• will likely result to 10-20% higher than current methods
2 ERROR
RENAL Concentration Tests - tests to determine the ability of the tubules to reabsorb essential salts & H2O
↑INCONVENIENT
1. FISHBERG METHOD = patients were deprived of fluids for 24 hrs. prior to measuring sp. gr.
2. MOSENTHAL METHOD = compares the volume & sp. gr. of day and night urine samples
FIRST MORNING: 4URINE
SO
NURMAL
b Specific Gravity = affected by number of particles present and its densities USEFUL AS SCREENING PROCEDURE FOR URINE CONCENTRATON
REN AL CONCENTRAT.
BlUtY
A Osmolality = affected only by number of particles present
REABSORB
c ABILITY TO &PROVIDES MORE ACCURATE EVALUARON OF DENAL CONCENTRATING ABILIT
• measuring FREEZING POINT DEPRESSION was the first principle utilized by clinical osmometers
• clinical osmometers uses solutions of known NaCl conc. as their reference standard
T
AMBULAR SECREMON
-P-AMINOHIPPURIC
SPAH TESTS
ACID EST
• after controlled fluid intake/restriction, it should reach 3:1 INDICATES NORMAL RCA CRENAL CONCENTRATING ABILITY
INTRODUCTION TO URINALYSIS
Urine Composition
95% Water
5% Solutes
• MAJOR Organic Component: ________
UREA
Urine Volume ↑
AFFECTED BY BODY HYDRATION STANS
EXCRI)
CLARGE AMOUNT OF HIO
↑(GLYCOSURIA)
Diabetes mellitus
↓
SC
Diabetes insipidus
ODOR
URINE PRESERVATION
- CAUSES MORE CRYSTALS
REFRIGERATION - most routinely used method (2-8C) up to 24 hrs; precipitates amorphous urates, phosphates
1. __________ INHIBITS BACTERIAL MULTIPULATION
3. Formalin – excellent sediment preservative (Addis count); but acts as reducing agent
4. Sodium fluoride – good preservative for drug analysis; inhibits rgt strips for glucose, blood, leukocytes
5. Phenol – does not interfere w/ chemical tests; causes an odor change
6. _____________
SACUMANNO'S - used for CYTOLOGY; made up of 50% ethanol & 2% carbowax
FIXATIVE
7. Light Gray and Gray C&S tube – sample is stable at room temp for 48 hrs; has boric acid
8. Yellow UA Plus tube – used in automated instruments; must refrigerate within 2 hrs
9. Cherry Red/Yellow Preservative Plus tube – stable for 72 hrs at room temp; instrument-compatible
FIRST MORNING URINE IDEAL specimen; useful for Pregnancy test and Orthostatic proteinuria
> MOST CONCENTRATED
OR
FASTING URINE SAMPLE
Recommended for glucose monitoring (for DM)
2 HOUR
- ↑USTPRANDIAL URINE
safer, less traumatic method for obtaining urine for bacterial culture and
COLLECTION
MIDSTREAM
routine urinalysis; less contaminated by epithelial cells and bacteria
↑HREE-CLASS COLLECTION
PORTION OF URINE IS COLLECTED
TECHNIQUE
Useful to determine PROSTATIC INFECTION
FIRST: FIRST
THIRD:
PROSTATIC MASSAGE--..........
REMAINING PORTION OF URINE 2nd bottle (midstream urine) = serves as “control” for bladder infection
~ WIC COUNT
CES
• Required volume: 30 – 45 mL
-
(OC/MS -CONFIRMATORY
COLOR
• roughly indicates the degree of hydration & should CORRELATE WITH URINE SP. GR.
• Normal Urine Color: _______________________
IDIFFERENT SHADES TELLOW OF
• Urine Pigments:
o UROCHROME
▪ MAJOR urine pigment; yellow color; amount is dependent on metabolic state
▪ named by Thudichum in 1864; product of endogenous metabolism
▪ increased production in ___________________________
StARVAMONIFASTING, FEVER, THROTOXICOSIS (PTHY ROID HURMONES
o
o Uroerythrin
▪ pink color; most evident in refrigerated specimen (ppt of urates)
▪ attaches to the urates, producing pink color to the sediment
o
o Urobilin
▪ oxidation product of normal urinary constituent, urinobilinogen OMM
URINE ODOR
1. Aromatic Normal
2. Ammoniacal Bacterial decomposition; UTI
3. Fruity/sweet Ketones (DM, starvation, vomiting)
4. Maple syrup/burnt sugar MSUD
5. Mousy A Phenylketonuria
6. Rancid butter Tyrosinemia
7. Sweaty feet Isovaleric acidemia
8. Cabbage/Hops Methionine malabsorption
9. Rotting fish A Trimethylaminuria
10. Sulfur Cystine disorder
Specific Gravity
• density of a solution compared w/ the density of a similar volume of distilled water at similar temp.
• influenced by number & density of particles in solution
• Normal random specimen: 1.002 – 1.035
• 1.010 = isosthenuric; < 1.010 = hyposthenuric; > 1.010 = hypersthenuric
• Dilutions = just multiply the decimal portion of the urine specific gravity by the dilution factor
INSTRUMENT
Reagent Strips
• chemical-impregnated absorbent pads attached to a plastic strip. A color-producing chemical reaction
takes place when the absorbent pad comes in contact with the urine.
• Usually composed of 10 pads; if there is 11th rgt pad – intended for detecting ascorbic acid
• To ensure against run-over, blotting the edge of the strip on absorbent paper and holding the strip
horizontally while comparing it with the color chart is recommended.
• Storage:
o Reagent strips are packaged in opaque containers w/ desiccant to protect from light & moisture
o Stored at room temperature below 30°C but never refrigerated
• Reagent strips must be checked with both (+) and (-) controls a minimum of once every 24 hours, when
a new bottle is opened, or questionable results are obtained.
• Manufacturers:
o MULTISTIX – Siemens Healthcare Diagnostics
o CHEMSTRIP – Roche Diagnostics
56
pKa change of a Bromthymol blue 1.000-1.030 Blue (1.000)
45 sec polyelectrolyte Yellow (1.030)
A tetrabromphenol blue /
Protein error of
PROTEIN tetrachlorophenol 15-30 mg/dL Green / Blue
1 min indicators
tetrabromosulfophthalein
pH
Double indicator
1 min pH Methyl red / bromthymol blue pH 5-9 Yellow (4-6)
system
Blue (6-9)
5-20
Pseudoperoxidase
1 min BLOOD Tetramethylbenzidine RBCs/mL Green/ Blue
activity of Hgb
Other Tests:
Clinitest
• Purpose: Non-specific test for reducing sugars:
o (+) Glucose
o (+) Galactose, lactose, fructose, maltose, pentoses
o Interference: (+) ascorbic acid, drug metabolites, and antibiotics ex. (Cephalosporins)
• Principle: Copper reduction (copper sulfate to cuprous oxide)
• Color results: CLINITEST TABLETS
USES
o (-) Blue
o (+) Orange-red
• Pass-through phenomenon
o Occurs when there is high urine glucose levels 2g(d( -
Microalbuminuria
• Useful in predicting early renal complications brought by DM
• Uses an immunochemical assay for detection of low albumin levels in urine (0-10 mg/dL)
• D Micral-Test reagent strips contain a gold-labeled antihuman albumin antibody-enzyme conjugate (ELISA)
• The amount of color produced represents the amount of albumin present in the urine.
• Early methods require 24-hour urine collection: REPORTING UNIT OF
o results were reported in mg of albumin/24 hours or as the albumin excretion (AER) in μg/min.
o Significant result: 30 to 300 mg of albumin is excreted in 24 hours or AER is ____________.
20-200 ng/min.
Acetest CONFIRMATORY
• Tablet test used to confirm questionable results in urine ketone rgt strip test
- -
Ictotest
• Tablet test used to confirm results in urine bilirubin rgt strip test
• Content: p-nitrobenzenediazonium, SSA, sodium carbonate, boric acid
• (+) result: Blue / Purple
OTHER INFORMATION:
1. pH
• pH of normal random samples: 4.5 to 8.0
• pH of 9 = unpreserved urine
ENHANCES THE EXCRERON OF UROBILINOGN
↑
ACID URINE ALKALINE URINE
Emphysema Hyperventilation
DM Vomiting
Starvation, dehydration, diarrhea Renal tubular acidosis
Acid-producing bacteria (E. coli) Vegetarian diet
High protein diet Old specimens
Cranberry juice (remedy for minor UTI) Alkaline tide 2PM -
4PM
Pre-renal Post-renal
Renal Proteinuria
Proteinuria Proteinuria
(Glomerular Disorders) (Tubular Disorders)
intravascular hemolysis (Hb) immune complex disorder Fanconi’s syndrome lower UTI
RE-ECLAMPSIA, DEFY DRATON
↑
*Bence Jones protein - monoclonal Ig light chains associated with multiple myeloma : (-) REAGENT STRIP; N 8 DISSONES 100°
*Orthostatic proteinuria - occurs following periods spent in a vertical posture and disappears
when a horizontal position is assumed.
3. Glucose
PLASMA CONCENTRATON
BY WHICH
SUBSTANCE
• most frequently performed chemical analysis on urine
OF A
• Renal threshold: 160 – 180 mg/dL
REABSORPION MBULAR
OF
TRANSPORT EFECTIVE RENAL 1
ACTIVE
SLOPS p
REABSORPRON
• Glycosuria in the absence of hyperglycemia is frequently referred to as “renal glycosuria” and is seen in
end-stage renal disease, cystinosis, and Fanconi syndrome.
SPECIFIC ONLY FOR GUCUSE
REAGENT STRIP
Glucose Oxidase Clinitest Interpretation
1+ Negative Only small amount of glucose is present
4+ Negative Possible oxidizing agent interference on rgt strip
Negative Positive FOR NON-
Non-glucose reducing substance present;
-> NON-SPECIFIC
REDUCING SUGAR
Possible interfering substance for rgt strip
t f EXPECTED RESULT IN SLUCOSE IN URINE) GLYCOSURIA)
4. Ketones
• results from increased fat metabolism due to compromised carbohydrate utilization
• 3 ketone compounds:
o 78% beta-hydroxybutyric acid
o 20% acetoacetic acid
o 2% acetone
• Reagent strip primarily detects _______________________________
ACETOACEMC ACID (DIACERC ACID), ACETONE
*
• Clinical significance
YPE DM
of ketonuria:
↑
5. Blood -
NO INTACT RBCS
I I
PROTOPHRINOXYGENASES BRIVERDINGMEOXINDIRECT
HOB
6. Bilirubin t
H2O INSOLUBLE
SALLBLAPDiCEIZIA oorCto
TRANSFERASE
-
EBOY'Ruc
- CONJUGATAD
-
POST-HEPATC
H2O
POLAR
SOLUBLE
50% IS
- CHOVEBILIRUBIN
Liver damage + or – ++
↑ IN DISEASE
LEVELS LIVER DISEASE & HEMOHRC
URINE
7. Urobilinogen UROBILINOGAN LEVELS/ ABSENT:
↓
BILE DUCT OBSTRUCTION CERAYACHOUC STAL colon)
• Increased urine urobilinogen (greater than 1 mg/dL) is seen in liver disease and hemolytic disorders.
• Although it cannot be determined by reagent strip, the absence of urobilinogen in the urine and feces is
also diagnostically significant and represents an obstruction of the bile ducts.
EXTRACTION
BUTANOL
EXTRACTION
9. Leukocyte
• advantage of chemical test for this parameter is that it will detect the presence of leukocytes that have
been lysed, particularly in dilute, alkaline urine LYMPIOCYT- NEGATI
-nonreductase-containing bacteria
improperly preserved specimen -insufficient contact time between bacteria
(multiplication of bacteria) & urinary nitrate
-large quantities of bacteria further
Nitrite
highly pigmented urines converting nitrite to nitrogen
-lack of urinary nitrate
-presence of antibiotics
-high ascorbic acid
-high sp. gr.
Oxidizing agents
Formalin -High conc. of protein, glucose,
Leukocyte Highly pigmented urines oxalic acid, ascorbic acid
Nitrofurantoin -Gentamicin, cephalosporins, tetracyclines
I. Numerical Ranges (sample reporting: 0-2, 2-5, 5-10, 10-25, 25-50, 50-100, > 100)
a. Casts / LPF
b. RBCs, WBCs / HPF
c. RTE cells / HPF MOST CLINICALLY SIGNIFICANT E.C
·
II. Descriptive
SQUAMOUS
None Rare Few Moderate Many
Epithelial cells / LPF 0 0-5 5-20 20-100 >100
NORMAL
Crystals / HPF 0 0-2 2-5 5-20 >20
Bacteria / HPF 0 0-10 10-50 50-200 >200
Mucus threads LPF 0-1 1-3 3-10 >10
SEDIMENT STAINS
1. Sternheimer-Malbin
SAFRANIN
• ____________
CRYSTAL
and ______________
VIOLET
2. Toluidine blue
• used as 0.5% solution; a metachromatic stain
• enhances NUCLEAR detail
• differentiates ____________
WBC (3-5COBULES) and ______________
RTECREWAL TUBULAREC)
&
PROTEINURIA
3. Lipid stains: Oil Red O & Sudan III EX: NEPHRORC XLIPIDURIA SYNDROME
5. Hansel stain
• ____________ and ______________ ALLERGIC REACTION MEDICATIONS
EOSIN Y TO
METHLENEBLUE ↑
• performed independently of urinalysis for detection of MALIGNANCIES of the lower urinary tract
• Specimen required is ____________________
FIRST MORNING URINE
• also provides information in transplant rejection; viral, fungal, parasitic infections; cellular inclusions;
pathologic casts; inflammatory conditions
MICROSCOPIC TECHNIQUES
1. Bright-Field Microscopy
• objects appear dark against a light background
• used for routine urinalysis; sediments w/ a low refractive index may be overlooked
• sediments must be examined using decreased light controlled by adjusting the rheostat on the light source
2. Phase-Contrast Microscopy
• Light passes to the specimen through the clear circle in the phase ring in the condenser, forming a halo of
light around the specimen.
• enhances visualization of elements w/ low refractive indices, such as hyaline casts, mixed cellular casts,
mucous threads, Trichomonas
3. Polarizing Microscopy
• aids in the identification of crystals and lipids
o crystals – characteristic colors
o lipids – MALTESE CROSS formation
• “Birefringent”
o a property indicating that the element can refract light in two dimensions at 90° to each other
o Positive Birefringence - rotates the plane of polarized light 90 degree in a clockwise direction
o Negative Birefringence - rotates the plane on a counterclockwise direction
4. Dark-field microscopy
• object appears light against the black background
• often used for unstained specimens, and in particular, to identify the spirochete Treponema pallidum
5. Fluorescence microscopy
• Used in visualization of structures stained by a fluorescent dye including labeled antigens and antibodies
6. Interference-Contrast Microscopy
• provides a three-dimensional image showing very fine structural detail by splitting the light ray so that
the beams pass through different areas of the specimen.
• The advantage is that an object appears bright against a dark background but without the diffraction halo
• Two types:
o modulation contrast (Hoffman)
o differential interference contrast (Nomarski)
SEDIMENT CONSTITUENTS
Normal: Strenuous Exercise:
0 – 2 or 0 – 3 RBC / hpf - RBCs or RBC cast
0 – 5 or 0 – 8 WBC / hpf - Hyaline casts
0 – 2 hyaline cast / lpf - Granular casts
HEMATURIA ->
_______________
CRENATED RBCS in hypertonic urine (cells shrink due to loss of water)
_______________
6HOST CELLS in hypotonic urine (cells swell, absorb water, & lyse rapidly)
_______________ primarily associated w/ glomerular bleeding
DYSMORPHIC RBCS
WBCs
• larger than RBCs (12 um)
• increased WBCs in urine is termed as: _________________
PYURIA
PoCONERnt
o Bacterial infections - Pyelonephritis, cystitis, prostatitis, urethritis
o Non-bacterial d/o – Glomerulonephritis, SLE, tumors, interstitial nephritis
& INFECTION OF RENAL INTERSTUM (UPPER UAT
Neutrophil
• predominant WBC (granulated, multi-lobed nuclei)
• ________________
GLITTER CELLS in hypotonic urine (neutrophils absorb water & exhibit Brownian movement)
Eosinophil
• primarily associated with Acute/Drug-induced interstitial nephritis
• also seen in UTI & renal transplant rejection
• preferred stain is Hansel’s stain (Wright’s stain can also be used)
• > 1 % is considered significant
Mononuclear cells
• lymphocytes – seen in early stages of renal transplant rejection
• monocytes, macrophages, histiocytes – may appear vacuolated (inclusions)
EPITHELIAL CELLS
• derived from the linings of the genitourinary system
• represent normal sloughing of old cells
BACTERIA ASCENDING UT
YEASTS
• appear as small, refractile oval structures (may contain a bud)
• in severe infections, they may appear as branched, mycelial forms
• the acidic, glucose-containing urine of px w/ DM provides an ideal medium for their growth
• a true yeast infection should be accompanied by WBCs
• reported as few, moderate, or many per hpf
PARASITES
• most frequent parasite encountered in urine: T. vaginalis
• Trichomonas trophozoite
o pearl-shaped w/ undulating membrane; rapid darting motility
o when not moving, Trichomonas may resemble a WBC, transitional, or RTE cell
o Use of phase microscopy may enhance visualization of the flagella or undulating membrane
o reported as few, moderate, or many per hpf
• bladder parasite ova that can be found in urine: S. haematobium
• most common fecal ova contaminant: E. vermicularis
MUCUS
• protein material produced by the glands & ECs of the lower genitourinary tract
• ____________________________________________________
UROMODULIN
CASTS
• CYLINDRURIA – presence of urinary casts
• formed within the lumens of the DCT & collecting ductsA
• their shape is representative of the tubular lumen
• in conventional glass-slide analysis, perform along the edges of coverslip
• has LOW REFRACTIVE INDEX – use subdued light
• cast matrix dissolves quickly in DILUTE, ALKALINE URINE
• reported as the average number per 10 lpfs
1. Hyaline casts
• most frequently seen cast
• consists almost entirely of Tamm-Horsfall protein
• NV: 0 – 2 hyaline cast / lpf
• Pathologically, they are increased in:
o acute glomerulonephritis
o pyelonephritis
o chronic renal disease
o CHF
• appear colorless in unstained sediment
• have a refractive index similar that of urine
• stains light pink w/ Sternheimer-Malbin
2. RBC casts
• presence indicates ________________________
GLOMERULONEPHRITIS
• RBC casts associated w/ glomerular damage are usually accompanied by proteinuria & dysmorphic
RBCs
• detected by their orange-red color
• more fragile & may exist as fragments
• in massive hemoglobinuria = granular, dirty, red-brown casts
3. WBC casts
• mostly associated w/ ________________________
P-ELONEPHRITS
4. Bacterial casts
• seen in pyelonephritis
• presence should be considered when many free WBCs & WBC casts are seen
6. Fatty casts
• seen in conjunction w/ oval fat bodies & free fat droplets
• frequently associated with:
o Nephrotic syndrome
o toxic tubular necrosis, DM, crush injuries
• fatty casts are HIGHLY REFRACTILE
• triglycerides & neutral fats = orange-red in fat stains
• cholesterol = Maltese cross formation under polarized light
• Fats do NOT stain w/ Sternheimer-Malbin
8. Granular casts
• non-pathologic cause:
o origin appears to be in lysosomes excreted by RTE cells during metabolism
o increased cellular metabolism: strenuous exercise
o accompanies the hyaline casts in strenuous exercise
• pathologic cause:
o represent disintegration of cellular casts or protein aggregation filtered by the glomerulus
o urinary stasis must be present in order for the granules to result from disintegration of casts
• when granular casts remain in the tubules for extended periods, the granules further disintegrate, & the
cast matrix develops a WAXY appearance
9. Waxy casts
• FINAL DEGRADATION FORM of all types of casts
• represents “Stasis of urine flow” (chronic renal failure)
• appears brittle, HIGHLY REFRACTIVE cast matrix
• often appear fragmented w/ jagged ends & notches in their sides
URINARY CRYSTALS
• Reporting:
o Routinely reported as rare, few, moderate, or many per hpf
o Abnormal crystals may be averaged and reported per lpf
• formed by the precipitation of urine solutes (inorganic salts, organic compounds, medications)
• Solutes precipitate more readily at low temperatures (crystals are abundant in refrigerated specimens)
• first consideration when identifying crystals: URINE pH
• All abnormal crystals are found in ACID URINE
• additional aids for identification:
o Polarized microscopy
o Solubility characteristics
• Changes in temp & pH contribute to crystal formation, and REVERSAL of these changes can cause
crystals to DISSOLVE
3. Calcium phosphate
• colorless, flat rectangular plates or thin prisms in “rosette forms”
• rosette forms are confused w/ sulfonamide crystals when pH is neutral
o calcium phosphate will dissolve in dilute acetic acid
o sulfonamides will not dissolve in dilute acetic acid
• common constituent of renal calculi
4. Calcium carbonate
• small, colorless, dumbbell or spherical shapes
• resemble amorphous material
• distinguishing characteristic: formation of GAS (carbon dioxide) after the addition of acetic acid
• also BIREFRINGENT under polarized light w/c differentiates them from bacteria
5. Ammonium biurate
• exhibit yellow-brown color
• described as “THORNY APPLES” (spicule covered spheres)
• like other urates, they dissolve in 60°C
• they will be convert to uric acid crystals when glacial acetic acid is added
• found in OLD SPECIMENS
• also assoc. w/ the presence of ammonia produced by urea-splitting bacteria
5. Leucine crystals
• yellow-brown spheres w/ concentric circles & radial striations
• seen less frequently than tyrosine crystals
• if seen, it should be accompanied by tyrosine crystals
6. Bilirubin crystals
• present in hepatic disorders causing bilirubinuria
• characteristic yellow clumped needles or granules
7. Sulfonamide crystals
• primary cause: ______________________________________
INADEQUATE PATIENT HYDRATION
1. Starch granules
• most common contaminant; occasionally confused w/ RBCs
• from corn starch in powdered gloves
• usually with a DIMPLED CENTER
• resemble fat droplets – also produce Maltese cross formation
• differentiation: chemical test for blood & presence of oval fat bodies
2. Oil droplets (may also resemble RBCs)
3. Air bubbles (from coverslip)
4. Pollen grains (seasonal contaminants)
5. Fibers
• from hair fibers, clothing, and diapers
• mistaken for casts
• but they are much longer & more refractile
• will often POLARIZE, whereasC casts, other than fatty casts, do NOT -
6. Fecal contamination
I. GLOMERULAR DISORDERS
• immunologic
o B majority of the cases
o deposition of immune complexes
• non-immunologic
o exposure to chemicals
o disruption of electrical membrane charges (nephrotic syndrome)
o deposition of amyloid material
o thickening of basement membrane assoc. w/ diabetic nephropathy
• Glomerulonephritis
o sterile, inflammation that affects the glomerulus
RBC
o blood, protein, and casts are seen in the urine iRBC CAST THE URINE; DYSMORPHIC
-
IN
> INDICATES BLEEDING IN THE GLOMERULUS
INFECTION
FOR
OYO GENES
4. Vasculitis
• disorders affecting systemic vascular system can result in glomerular involvement
• Wegener’s granulomatosis -AFFECTS
KIDNEYS THE LUNGS AND
6. Membranous Glomerulonephritis
• pronounced thickening of the glomerular basement membrane resulting from deposition of IgG
immune complexes
• disorders associated: SLE, Sjogren’s syndrome, Secondary syphilis, hepatitis B. malignancy
• most common is frequent development to nephrotic syndrome in adults A
7. Membranoproliferative Glomerulonephritis
• cellular proliferation affecting capillary walls or the glomerular basement membrane, possible
immune-mediated
• Type I
o displays increased cellualrity in the subendothelial cells of the mesangium, causing
thickening of capillary walls
o could progress to nephrotic syndrome
• Type II
o displays extremely dense deposits in the glomerular membrane
o experiences symptoms of chronic glomerulonephritis
• Urine findings: hematuria & proteinuria +(3
• Lab findings: DECREASED SERUM COMPLEMENT LEVELS
8. Chronic Glomerulonephritis
• marked decrease in renal function resulting from glomerular damage precipitated by other renal
disorders CHRONIC GLOMERULONEPHRINS
RENAL FAILURE
• Lab findings: decreased GFR, increased BUN & crea (APPEAR DISEASES
>RENAL FAILURE CAST IN CHRONIC KIDNEY
9. Nephrotic Syndrome
• disruption of electrical charges that produce the tightly fitting podocyte barrier resulting in
massive loss of proteins & lipids HEAVY PROTEINURIA AND HEAVY LIPIDURIA
>FAT PROPLETS
PRESSURE
LEAKAGE OF
LONCORC
-
INTERSTITIAL DISORDERS
• disorders affecting the interstitium also affect the tubules
• “Tubulointerstitial Disease” CYSTITIS
URETHRITIS
3. Cystitis
• bacterial infection of the bladder (Lower UTI)
• seen more often in women & children
• Symptoms: urinary frequency & burning
• Urine findings: WBCs, bacteria, mild proteinuria, increased pH
CONVERSION OF UREA < AMMONIA BY BACTERIA
4. Acute Pyelonephritis
• Upper UTI involving both the tubules & interstitium E.COLL
• most frequently occurs as a result of ascending movement of bacteria from a lower UTI (untreated
cystitis) into the renal tubules & interstitium
• enhancing conditions include renal calculi, pregnancy, and “reflux” of urine from the bladder back into
the ureters (vesicoureteral reflux)
• Symptoms: urinary frequency, burning & lower back pain
• a recommended test beside urine culture is blood culture (possible bacteremia)
• Urine findings: WBCs, WBC casts, bacteria, mild proteinuria
• WBC casts = primary diagnostic value * + BACTERIAL CAST
5. Chronic Pyelonephritis
• more serious disorder that can result in permanent damage to the renal tubules
• most frequently casue by Congenital urinary structural defects producing reflux nephropathy
• often diagnosed in children (congenital origin)
• Urine findings: similar to acute pyelonephritis + increased proteinuria,
hematuria, granular, WAXY CASTS, BROAD CASTS
1. Renal Failure
• 2 forms:
o Acute Renal Failure
▪ exhibits sudden loss of renal function
▪ frequently REVERSIBLE I
▪ Primary causes:
• Prerenal – ↓ blood flow to the kidney / hemorrhage
• Renal – acute glomerular & tubular disease
• Postrenal – renal calculi, tumor obstruction
▪ Urine findings: (varied)
• RTE cells & casts – suggests tubular origin
• RBCs – indicate glomerular injury
• WBC casts – interstitial infection / inflammation
• Abnormal urothelial cells – malignancy / postrenal obstruction
DIALYSIS
o Chronic Renal Failure (END-STAGE RENAL DISEASE) IRREVERSIBLE TRANSPLANT
▪ gradual progression from the original disorder
VRBC COUNT
▪ Lab findings: RENAL FAILURE-IEPO=↓HOB
COMMON FINDINGS: •
HARB
may form in the calyces & pelvis of the kidneys, ureters, & bladder
-
MODERATELY
HEMATRIA
1.
URINECRYSTAIS
• small calculi maybe passed in the urine, large stones cannot 3. CALCIUM OXALAEE STONES
VERY HARD, DARK COLOR
2.
• Lithotripsy – uses high-energy shock waves to break stones in the upper urinary tract
-
-
ROUGH SURFACE
• conditions favoring formation of renal calculi: pH, chemical conc. & urinary stasis -
ELCON-BROWN
-SOMENHAT GREAST
URINALYSIS AUTOMATION
Automated Reagent Strip Readers*
• uses REFLECTANCE PHOTOMETRYS
o a spectrophotometric measurement of light reflection ~ CHEMICAL
o uses the principle that light reflection from the test pads decreases in proportion to the intensity of
color produced by the conc. of the test substance
• also uses a photodetector and an analog/digital converter
Automated Microscopy
• Sysmex UF-1000i Urine Cell Analyzer
o uses laser-based flow cytometry along w/ impedance detection,A
light scatter, and fluorescence to identify stained urine sediment particles
o To perform an automated microscopy, 4 mL of uncentrifuged urine is aspirated into the instrument
o Particles are identified by measuring height and width of the fluorescent and light scatter signals
o The main particles enumerated are RBCs, WBCs, epithelial cells, hyaline casts, and bacteria
o Flagged particles include pathologic casts, crystals, small round cells (RTE or transitional ECs),
sperm, mucus, and yeast-like cells, and must be confirmed by ____________________.
MANUAL MICROSCOPY
The appearance of abnormal metabolic substances in the urine can be caused by variety of disorders that
can generally be grouped into two categories: I metabolli
reted in urine
Overflow type. result from disruption of normal metabolic pathway that causes increased
plasma concentrations of the nonmetabolized substances ; 4here is missing enuyme
O Renal type caused by malfunctions in the tubular reabsorption mechanism
Disruption of enzyme function can be caused by failure to inherit the gene to produce a particular
enzyme, referred to as an inborn error of metabolism (IEM).
Tandem
mass spectrophotometry (MS/MS) is capable of screening the infant blood sample for specific
substances associated with particular IEMs.
Amino Acid Disorders
1. Phenylketonuria
first identified in Norway by Ivan Folling in 1934
most well-known of the aminoacidurias; autosomal recessive inheritance
if undetected: causes severe mental retardation
Urine Findings: 1 Keto acids, including phenylpyruvic acid
MOUSY ODOR of urine
lacks theenzyme: PHEN LALANINE HOROXLASE
Screening test:
o Guthrie's Bacterial Inhibition test : SPECIMEN: Blood
blood-impregnated disks are placed on culture media streaked w/ B. subtilis
if there is 1 phenylalanine: there will be Bacterial growth (+)
phenylalanine counteracts the action of beta-2-thienylalanine,
which is an inhibitor of B. subtilis that is present in the media
• Urine Screening test
Ferric chloride tube test: PERMANENT BLUE-GREEN
2. Tyrosyluria
there is excess tyrosine in the plasma producing urinary overflow
Causes:
inherited form (enzymes required in metabolic pathway are not produced)
metabolic form (caused by acquired severe liver disease)
Types:
Type I - deficiency of fumaryl acetoacetate hydrolase (FAH)
Type II - deficiency of tryrosine aminotransferase
° Type III - deficiency of p-hydroxyphenylpyuvic acid dioxygenase
• Urine findings:
tyrosine, or metabolites:
p-hydroxyphenylpyruvic acid
p-hydrozyphenyllactic acid
• Urine Screening test
Nitroso-naphthol test: ORANGE-RED
3. Alkaptonuria
one of the six original inborn errors of metabolism described by Garrod in 1902
Urine Findings: DARKENED URINE after becoming alkaline in room temp. CO-OR OF JRINE:
Causes brown-stained or black-stained cloth diapers Brown and Black
111
Sodium nitroprusside: RED COLOR
Ehrlich's reagent: RED COLOR
Branched-Chain Amino Acid Disorders
1. Maple syrup urine disease (MSUD) EM
2. Organic Acidemias
Three most common disorders: - TEM
o Isovaleric acidemia
"sweaty feet odor" of urine
deficiency of enzyme: isovaleryl CoA in the leucine pathway
Propionic and methylmalonic acidemias
result from errors in the metabolic pathway converting isoleucine, valine, threonine,
and methionine to succinyl coenzyme A.
Tryptophan disorders
major concern is urinary excretion of the metabolites
indican
O 5-hydroxyindoleacetic acid (5-HIAA)
caused by the INABILITY of the renal tubules to reabsorb cystine filtered by glomerulus
amino acids involved: Custine. Ornithing. Lysine, Arginine
cystine IS much less soluble than the other three amino acids
rules out inborn error of metabolism but the condition is inherited
patients have tendency to form RENAL CALCULI
URINE SCREENING TEST
Cyanide-nitroprusside test: RED-PURPLE
False (+): ketones and homocystine
Cystinosis
"Genuine inborn error of metabolism"
Categories:
Nephropathic
incomplete metabolism of cystine results in crystalline deposits of cystine in many areas
of the body, including the cornea, bone marrow, lymph nodes, and internal organs.
a major defect in renal tubular reabsorption mechanism (Fanconi syndrome) also occurs
i f untreated, will result in renal failure
O Non-nephropathic
relatively benign but may cause some ocular disorders.
Renal transplants & use of cystine-depleting medications are extending lives.
Homocystinuria
inherited disorder of the metabolism of amino acid methionine due o a deficiency of cystathionin -B-symthase
clinical signs:
cataracts
thrombosis
mental retardation
URINE SCREENING TEST
• Cyanide-nitroprusside test: RED-PURPLE
Silver-nitroprusside test: RED-PURPLE
Porphyrin disorders
Disorders of porphyrin metabolism are collectively termed porphyrias.
Forms: Problem in heme Synthesis
Inherited: absence of a particular enzyme involved in heme synthesis
Acquired: lead poisoning, excessive alcohol intake, iron deficiency, chronic liver disease
Causes PORT WINE COLOR of urine
Sanfilippo synbdrome
mental retardation ONLY
PURINE DISORDERS
LESCH-NYHAN DISEASE
disorder of purine metabolism
sex-linked recessive
lacks the enzyme: Hspoxanthine Guanine Phosphorile 1 TransFerase
causes massive excretion of urinary uric acid crystals
Clinical signs:
severe motor defects and mental retardation
tendency toward self-destruction
gout
renal calculi
CSF
• Major fluid in the body which has the ff functions:
o supply nutrients to the nervous tissue
o removes metabolic wastes
o produce a mechanical barrier to cushion the brain & spinal cord
• Meninges are membranous coverings of the brain and spinal cord and has the ff layers:
o Dura Mater OUTER -
o Neonates _____ mL
10-60
•
• LUMBARI SPINAL TAP (between 3rd, 4th or 5th vertebrae)
Mode of collection: _______________
• Considerations during CSF collection:
o Opening pressure: (using manometer)
▪ Lateral position – 90-180 mmH2O (adults)
▪ Sitting up/Obese px – slightly higher than normal
▪ Infants and Children – 10-100 mmH2O
o Amount of CSF removed
▪ up to ____
20 mL of CSF can be normally removed (w/ stable pressure)
▪ > 200 mmH2O (relaxed px) Do NOT aspirate more than 2 ml CSF
• Indications of CSF analysis:
o Infectious meningitis
o Subarachnoid hemorrhage
o Demyelinating disease MULDPLE SCLEROSIS -
PROCESS
o Malignancy 1.
MICRO
• Appearance of CSF:
o Normal CSF: _______________
CRYSTAL CLEAR
with viscosity similar to water
o Cloudy – presence of WBCs or ↑ Protein
o Oily – Radiographic contrast media
o Bloody – Hemorrhage or Traumatic tap
o Clot formation – traumatic tap, spinal block, suppurative meningitis
o Pellicle/web-like formation in CSF – Tubercular meningitis
o Xantochromic CSF
▪ pink to yellow color of CSF supernatant usually due to RBC degradation products
• Pink – slight amount of oxyhemoglobin
• Yellow – oxyhemoglobin converted to unconjugated bilirubin
• Orange – heavy hemolysis or carotenoids
NO PANOLOGIC SIGNIFICANCE
Cell Count
• should be done immediately because WBCs & RBCs will begin to lyse in 1 hour
• 40% of leukocytes will disintegrate within 2 hrs.A
• The standard Neubauer calculation formula for blood cell counts is also applied to CSF cell counts
• Clear specimens may be counted undiluted, but for turbid specimens, dilution is made with NSS.
• For WBC count, diluent is 3% Acetic acid and Methylene blue for better differentiation of WBCs.
• For Differential cell count, recommended is the Cytocentrifuge method
• RBC count is only done in case of traumatic tap
• The presence of increased numbers of normal cells is termed as _________ & indicate abnormality. PLEOCTOSIS
CSF/serum albumin index = CSF albumin (mg/dL) * An index value of < 9 represents an
Serum albumin (g/dL) an intact blood brain barrier.
CSF IgG index = CSF IgG (mg/dL) / serum IgG (g/dL) * An index value of > 0.7 indicate
CSF albumin (mg/dL) / serum albumin (g/dL) IgG synthesis within CNS
CSF Electrophoresis
• primary purpose is to detect _______________
OLIGOCLONAL BANDS in the gamma region
• To ensure that the oligoclonal bands are present as the result of neurologic inflammation, a
simultaneous serum electrophoresis must be performed
o (+) CSF and (-) serum
▪ Multiple sclerosis (2 or more bands)
FPRESENT
R
INFLAMMATON
▪ Guillain-Barré syndrome
IN THE ▪ Encephalitis, Cryptococcal meningitis
CNS
▪ Neurosyphilis, Neuroborreliosis, Trypanosomiasis
▪ Neoplastic disorders
o (+) CSF and (+) serum
▪ HIV infection
CSF Glucose
• Ref value: _________
60-70% of Plasma Glucose
• for comparison, blood glucose should be drawn 2 hours PRIOR to the spinal tap
o Elevated CSF glucose levels = due to plasma glucose elevations
o Decreased CSF glucose levels
▪ With numerous neutrophils – Bacterial meningitis
▪ With numerous lymphocytes – Tubercular meningitis (pellicle form)
o Normal glucose levels with numerous lymphocytes – Viral meningitis
CSF Lactate
• Ref value: 10 – 24 mg/dL
• destruction of tissue w/in the CNS due to oxygen deprivation causes ↑ Lactate levels
• it is also frequently measured to monitor severe head injuries
• Findings:
o Elevated CSF lactate levels (> 25 mg/dL) = cases of bacterial, tubercular, fungal meningitis
o Lower or Normal levels (< 25 mg/dL) = cases of viral meningitis
• Falsely elevated = xantochromic or hemolyzed fluid (RBCs have high conc.)
Serologic Tests
• Done mainly to detect presence of NEUROSYPHILIS
• CDC recommends _________
UDRL to detect neurosyphilis
o standard nontreponemal test: VDRL
o treponemal test: FTA-ABS
SEMEN ANALYSIS
Fractions of Semen
BULBOUREMRAL GLAND'S 5% forms a thick, alkaline mucus that helps to neutralize acidity
OR
from the prostate secretions & vaginal acidity
COWPER'S 6)AND
SPECIMEN COLLECTION
• Sexual abstinence of ________ DAYS
2 -
7
SEMEN ANALYSIS
Appearance
• Normal: Gray-white color and translucent
• ↑ White Turbidity: Presence of WBC and Infection
o > 1 million WBCs / mL = INFECTION
o Screening: Leukocyte esterase reagent strip
o WBCs must be differentiated from immature sperm (spermatids)
• Yellow Coloration:
o Urine contamination
o Prolonged abstinence
o Medications
Volume
• 2 – 5 mL
• ↓ volume: Infertility
Viscosity
• Normal: Pours in droplets
• Ratings: 0 (watery) to 4 (gel-like)
• Viscosity can also be reported as low, normal, or high.
• ↑ Viscosity can impede testing for sperm motility, sperm concentration
pH
• Normal: 7.2 – 8.0 RESPONSIBLE:
- BULBOURATHRAL GLAND
• should be measured within 1 hour of ejaculation; pH pad of a urinalysis rgt strip can be used
o ↓ pH: associated with increased prostatic fluid
o ↑ pH: indicative of infection within reproductive tract
Sperm Concentration
• Normal: ____________
20-10 million / mL (10-20 million is the borderline)
• 2 chambers:
o Neubauer Counting Chamber (counted in the same manner as CSF) >NEEDS DILUTON
o Makler counting chamber – undiluted seminal fluid; immobilized by heating
• Diluting Fluid (immobilizes the sperm): NaHCO3, formalin, saline, distilled water
• 1:20 is commonly used dilution (Positive Displacement Pipette)
• Only fully developed sperm should be counted RECOMMENDED FOR VISCOUS BODY FLUID
wo...lo
Y
• Both sides of the chamber is counted & must agree within 10%
Sperm Count
• Normal: ≥ 40 million / ejaculate
• Formula: Sperm Conc. (sperm/mL) x Volume of specimen (mL)
Sperm Motility
• Should be examined in liquefied semen within 1 hour of collection
• 10 μL of semen is placed under a 22 × 22 mm cover slip using a calibrated positive-displacement
pipette, and allow it to settle for 1 minute. Evaluate 20 HPFs
Motility Grading
Grade WHO Criteria Sperm Motility Action
4.0 a Rapid, straight-line motility
3.0 b Slower speed, some lateral movement
2.0 b Slow forward progression, noticeable lateral movement
1.0 c No forward progression MORILE ↑
0 d No movement
*Normal result: Minimum motility of 50% with a rating of 2.0 after 1 hour
Sperm Morphology
• Head: 5 um long x 3 um wide = affects ovum penetration
• Tail: 45 um long = affects motility
• Middle Piece: 7 um long and thickest part of the tail; houses the ___________
MITOCHONDRIA for flagellar motion
• Acrosomal Cap: contains __________ for ovum penetration (1/2 of the Head)
ENIYMES
• Examination:
o Thinly Smeared (10 uL) and stained slide observed using OIO
o Stained using Wright’s, Giemsa, or Papanicolau (stain of choice)
o At least 200 sperm cells should be evaluated
• Kruger’s Strict Criteria
o uses morphometry or stage micrometer for measurement & size
o not routinely performed but recommended by WHO
• Head abnormalities: giant, double, amorphous, tapered, pinhead, constricted head
• Tail abnormalities: double, coiled, bent
• Neck (middlepiece) abnormalities: sperm head bends backward
• Normal Values:
o > 30 % Normal Forms – using Routine Criteria
o > 14 % Normal Forms – using Strict Criteria
POSTVASECTOMY ANALYSIS
• routinely tested at monthly intervals
• done 2 months post vasectomy, continuing until 2 consecutive monthly specimens show no sperm
• Recommended testing includes examining a wet preparation using phase microscopy for the
presence of motile and nonmotile sperm
SYNOVIAL FLUID
Specimen Collection
• _________________
ARTHROCENTESIS
o Needle aspiration
o Can be done on an inflamed knee/joint
o Site of aspiration: Area of greatest distention
o Volume of fluid collected should be recorded
o Syringe is moistened with ______________
HEPARIN
• Fluid
o Normally does NOT clot
o Diseased joint – contain fibrinogen and will clot
o Collected in different tubes
Appearance
• Normal: __________________
CLEAR, PALE ELIOW
Viscosity
• Polymerization of the Hyaluronic Acid (proper joint lubrication)
• Measure of viscosity
o String that measures 4-6 cm = Normal
o < 3 cm = ↓ viscosity (Depolymerization of Hyaluronic Acid)
▪ Ex. Arthritis
▪ affects both production of HA and its ability to polymerize
Cell Count
• Normal WBC count = < 200 wbc/uL
• RBC count – unless evidence of traumatic tap exists
• performed < 1hr or sample should be refrigerated
• If fluid is very viscous, it is pretreated by adding 0.05% Hyaluronidase in PO4 buffer and then
incubating at 37°C for 5 mins
• Clear fluids can usually be counted undiluted, but dilutions are necessary when fluids are turbid
• Neubauer counting chamber – manual count
• WBC count OK FOR CSF COUNT
o Acetic acid as diluting fluid CANNOT be used
o use NORMAL SALINE, may add methylene blue to separate WBCs and RBCs
o use Hypotonic saline (0.3%) with Saponin to lyse RBCs
• Automated cell counts
o Fluid is highly viscous and may block the apertures
o debris and tissue cell = falsely elevated counts
Differential Count
• should be performed on cytocentrifuged preparations or on thinly smeared slides
• 65% - mononuclear cells
• < 25% - neutrophils (↑ septic condition)
• < 15% - lymphocytes (↑ non-septic inflammation)
EITER
R CELLS Vacuolated macrophage w/ ingested neutrophils Reactive arthritis / Reiter’s syn
ON
RHEUMATOID FACTOR + FC PORTION OF 196 -> ACTIVATS COMPLEMENT
Crystal formation
• frequently results in an acute, painful inflammation
• Causes:
o Metabolic disorder
o Decreased renal excretion
o Degeneration of cartilage and bones
o Injection of medication
• Crystal examination should be performed soon after fluid collection
o examined as an unstained wet preparation
o reported as being located extracellularly and intracellularly (within neutrophils)
• Primary Crystals
& IFFERENDATES THE TO
• Additional crystals
Condition associated Shape CPL
Cholesterol RA / joint inflammations notched, rhomboid plates Negative birefringence
Glucose determination
• ↓ values – inflammatory (group 2) or septic disorders (group 3)
• 8 hours fasting
• NV: 0-10 mg/dl lower than plasma glucose
Lactate
• Differentiation between inflammatory and septic arthritis
• NV: <250 mg/dl
• INCREASE: septic arthritis
Protein
• NV: Less than 3 g/dL
• INCREASE: inflammatory and hemorrhagic disorders
Uric acid
• For Gout; used to confirm Dx in the absence of crystals in fluid
• NV: Equal to blood value
OTHER TESTS:
1. Microbiologic Tests
• Gram stain & culture
• include a chocolate agar – for fastidious Haemophilus & Neisseria gonorrhoeae
CAUSES GONOCLOCAL ARARINS
2. Serologic Tests
• majority of the tests are performed on serum
• but autoantibodies of SLE & RA can also be demonstrated in synovial fluid
• Lyme Disease (B. burgdorferi) : frequent complication is Arthritis
SEROUS FLUIDS
• the fluid between Parietal membrane & Visceral membrane
• provides lubrication as the surface moves against each other
• normally, only a small amount is present and is formed as an ULTRAFILTRATE of plasma
• Fluid production and reabsorption are subject to hydrostatic pressure and
colloidal pressure (oncotic pressure) from the capillaries
• __________________
SEROUS EFFUSION = Accumulation of fluid in the body cavity
Types of Effusion
TRANSUDATE EXUDATE
Mechanism due to systemic disorder; disruption of due to conditions that directly involved
balance in fluid filtration/reabsorption the membranes of a particular cavity
↑
Fluid:Serum LDH ratio < 0.6 > 0.6 LDH
WBC count < 1000 / uL > 1000 / uL WBC COUNT
↑
PLEURAL FLUID
Associated condition
CLEAR, PALE YELLOW Normal
Turbid, white Microbial infection (e.g. tuberculosis)
Bloody -
Hemothorax or Hemorrhagic effusion CANCER, TB
->
Chemistry Tests
Glucose ↓ levels in purulent infection & rheumatoid inflammation
A
DENOSINE DEAMINASE CADAS ↑ levels in Tuberculosis (> 40 U/L)
MYLASE
A
PERICARDIAL FLUID
Appearance of fluid
Associated condition
CLEAR, PAIF YELLOW Normal
Turbid Infection or Malignancy
Blood-streaked Malignancy
Grossly bloody Cardiac puncture, anticoagulant medications
Milky Chylous or Pseudochylous effusion
PERITONEAL FLUID
Appearance of fluid
Associated condition
CLEAR, PALE YELLOW
Normal
Turbid Microbial Infection
Blood-streaked Trauma, infection, malignancy
GREEN Presence of bile; gallbladder or pancreatic disorder
Milky Chylous or Pseudochylous material
AMNIOTIC FLUID
Fluid Volume
• Increases in quantity throughout pregnancy; reaches a peak of approximately 800 to 1200 mL
during the third trimester, and then gradually decreases prior to delivery.
Polyhydramnios Oligohydramnios
Fluid Volume Increased (> 1,200 mL) Decreased (< 800 mL)
Causes Decreased fetal swallowing of urine Increased fetal swallowing of urine
Neural Tube defect Urinary Tract deformities
Fetal Distress Membrane Leakage
Specimen Collection
• AMNIOCENTESIS
o Transabdominal amniocentesis – most frequently performed
o Vaginal amniocentesis
• Usually performed AFTER ______
14 TH WEEK OF GESTATION
• Chromosome Analysis – Fluid is collected at 16th Week Gestation
• Volume collected
o Maximum of ____38 mL
o First 2 or 3 mL = Contaminated by maternal blood = Discarded
o Must be placed on ICE for delivery to Lab & refrigerated prior to testing
o Low-speed Centrifugation is required (500 – 1000) for less than 5 mins.
• Bilirubin testing – specimen must be protected from light
• Cytogenetic studies - Maintained at Room Temp. or Body Temp. to prolong the life of the cells
• Chemistry – fluid must be separated from cellular elements & debris
COLOR SIGNIFICANCE
___________
COLORLESS Normal
Meconium
• dark green, mucus-like material and is the newborn’s first bowel movement
• formed in the intestine from fetal intestinal secretions and swallowed amniotic fluid.
• It may be present in the amniotic fluid as a result of fetal distress.
AMNIOTIC MATERNAL
ANALYTE FLUID URINE
Glucose + -
Protein + -
Fern test + -
"PALM-LEAF" APPEARANCE
Result Remarks
Zone I ∆ OD: 0.025 – 0.09 Nonaffected or mildly affected fetus
Zone II ∆ OD: 0.1 – 0.2 Moderately affected fetus requiring close monitoring
Zone III ∆ OD:: 0.2 – 1.0 Severely affected fetus requiring intervention
MATERNAL
↑
*
/ SERUN
AFPL PAMNIORC
• Examples of defects are Anencephaly and Spina bifida
#
UUID
• Increased Levels of alpha-1 fetoprotein (AFP) are found in both maternal serum & Amniotic fluid
o Both serum & amniotic fluid AFP levels are reported as multiples of the median (MoM)
AChE
<MORE SPECIFIC o A value two times the median value (greater than 2 MoM) is considered abnormal
•
OF A. F
<PRESENCE
INDICATED NTD
↑ Amniotic fluid AFP levels are followed by measuring Amniotic __________________
ACETYL CHOLINESTERASE CAChE)
o more specific test but specimen should NOT be performed on a bloody specimen. (false +)
LUNG
• Respiratory Distress
o most frequent complication of early delivery
o also called “Hyaline Membrane Disease of the Newborn”
o caused by an insufficiency of lung surfactant production & structural immaturity fetal lungs
• False elevated results are found in specimen contaminated with Blood or Meconium
2. Phosphatidyl Glycerol
• another lung surface lipid is also essential for FLM
• Its production parallels that of Lecithin, but DELAYED in Diabetic Mothers.
• Amniostat-FLM uses antisera specific for phosphatidyl glycerol
o The size of the agglutinates is read macroscopically and the results are reported as
▪ Negative - indicating pulmonary immaturity
▪ Low positive or high positive - indicating pulmonary maturity
o NOT AFFECTED by specimen contamination w/ Blood and Meconium
• A modified Foam test uses 0.5 mL of amniotic fluid added to increasing amounts of 95% ethanol
o provide a semiquantitative measure of the amount of surfactant present.
o A value of 47 or higher indicates FLM.
4. Microviscosity
• The presence of phospholipids decreases the microviscosity of the AF
PRINCIPLE
• This change in microviscosity can be measured by Fluorescence Polarization:
• Albumin is used as an internal standard (remains at a constant level throughout gestation).
• Fluid should be filtered rather than centrifuged prior to examination
• A Ratio of 70 or greater predicts FLM & lower values maybe considered
ETAL FAT
#
NORMAL
I STERCOBILIN
CANTI-TB DRUG
CCLAY-COLORE/ ACHOLI SO
PEA-SOUP
RICE WATER
3
=> NEUTROPHIKS
CYSTC FIBROSIS
SUDANI
ADVANTAGE:
REAGENT
FALSE-NEGATIVE
ALSE-POSITIVE
#
FALSE-POSITIVE
REACENT
PINK
ECLOW-BROWN
↓
SUPERNATANT