Laboratory Interpretation
Made Easy
Diana Tamondong-Lachica, MD, FPCP
OUTLINE
l Urinalysis
l Renal Function Tests
l Complete Blood Count
INFORMATION THAT CAN BE
OBTAINED BY SIMPLE URINALYSIS
Appearance
Specific gravity
Chemical tests
pH, Protein, Glucose, Ketones,
Blood, Urobilinogen, Bilirubin,
Nitrites, Leukocyte esterase
Cells
Casts
Crystals
URINE COLOR CAUSES
Faint yellow Normal
White Pus, Chyle, Phosphate crystals
Pink / red / brown Red blood cells, Hemoglobin,
( tea colored ) Myoglobin, Beets, Senna,
Methyldopa, Metronidazole,
Food coloring
Yellow / Orange Bilirubin, B complex, Rifampicin,
Iron, Nitrofurantoin, Phenytoin
Brown / black Methemoglobin, melanin
Blue / green Pseudomonas, Dye, Chlorophyll
PHYSICAL CHARACTERISTICS
Normal Clinical Value
Values
Specific 1.003 – 1.000-1.005 Diabetes insipidus
gravity 1.030
>1.030 Dehydration, contrast
dyes, glucose,
mannitol
Turbidity Clear Infection, crystals.
Chyluria (milky white)
CHEMICAL CHARACTERISTICS
Normal values Comments
Urine 4.5 - 6 Alkaline urine - vegetarian diet,
pH UTI, Renal Tubular Acidosis
Acidic urine – uric acid
crystals
Urine negative Regular Dipsticks detects only
protein (Total protein albumin> 300 mg / L
<150mg/24hrs)
(Albumin <30mg/
24hrs)
WAYS TO QUANTIFY PROTEINURIA
24 hr urine collection – cumbersome, prone to
collection error
Albumin / creatinine ratio is a simple and accurate
method of quantifying proteinuria
Ex. A/C ratio of 200 mg protein/Gm crea equivalent
to urine protein of 200mg/24h
Urine Electrophoresis – to determine type of protein
MICROALBUMINURIA
• Marker of silent DM nephropathy
• Significant predictor or overt nephropathy
• First manifestation of injury to the
glomerular filtration barrier
TYPES OF PROTEINURIA
• ORTHOSTATIC or POSTURAL
• FUNCTIONAL
- High fever, exercise, heat stroke, CHF
• GLOMERULAR
• TUBULAR
• OVERFLOW
- Hyperglobulinemic states
URINE MICROSCOPY
Crystals
Urates, calcium, oxalate, triple
phosphates, cystine, drugs
Cells Red blood cells, white blood cells,
tubular cells, fat bodies, squamous
cells
Casts
Hyaline, granular, RBC, WBC, broad,
waxy
Organisms Bacteria, yeasts, trichomonas
Miscellaneous Spermatozoa, mucus treads
URINE MICROSCOPY
CELLS AND NORMAL PATHOLOGY
CASTS
Leucocytes 1-4 /HPF UTI, interstitial nephritis
Erythrocytes 0-2 /HPF Stones, obstruction, UTI,
glomerular
Tubular cells FEW Renal failure
Hyaline casts FEW Dehydration
Course granular NONE CKD
casts
Muddy brown cast NONE Acute tubular necrosis
WBC casts NONE Pyelonephritis
RBC cast NONE Glomerulonephritis
HEMATURIA
May originate anywhere from the glomerulus to the
urethral meatus
Normal: RBC in the urine is between 0 – 2 / HPF
Abnormal: > 3 RBC / HPF
Shape of RBC is important:
Normal shape RBC – originate from collecting system
Dysmorphic RBC - originate from glomerulus
CAUSES OF HEMATURIA AND
URINALYSIS FINDINGS
Hematuria with Proteinuria , RBC Glomerular pathology
casts
Hematuria coincident with URTI, IgA nephropathy
occasional proteinuria
Hematuria days or weeks after Acute post-streptococcal
URTI glomerulonephritis
Hematuria with Pyuria UTI, Glomerulonephritis
Hematuria, Crystals Stone disease
OTHER CELLS
Eosinophils – seen in allergic interstitial nephritis,
atheroembolism
Epithelial cells
squamous cells – contaminant
transitional cells – from pelvis to urethral lining
renal tubular cells - large amount seen in ATN
OTHER CAUSES OF PYURIA
Contamination during collection
Vaginal secretions
Foreskin secretions
Non-infectious causes
VesicoUreteral Reflux Hypercalcemic nephropathy
Analgesic Nephropathy Lithium toxicity
Uric acid nephropathy Hyperoxalosis
Polycystic kidney Heavy metal toxicity
ATN Carcinoma of Urinary tract
Transplant rejection Renal calculi
Allergic interstitial nephritis Sickle cell disease
Sarcoidosis Idiopathic interstitial cystitis
Radiation nephritis Glomerulonephritis
Infectious diseases
TB, chlamydial / gonococcal urethritis, Leptospirosis, Viral cystitis
Infections adjacent to urinary tract
Appendicitis, diverticulitis
CLINICAL SYNDROMES OF
RENAL DISEASE
SITE OF URINALYSIS EXAMPLES
INJURY FINDINGS
GLOMERULUS Hematuria Nephritic syndrome
(dysmorphic) Nephrotic syndrome
Pyuria IgA nephropathy
Proteinuria
Cells, casts
TUBULES Abnormal urine Urinary tract infection
INTERSTITIUM specific gravity, pH Urinary tract
Proteinuria obstruction
Hyaline casts Renal tubular acidosis
Hematuria, pyuria (RTA)
VASCULAR Bland sediments Hypertension
(no cells, hyaline casts
Differentiation between nephrotic and
nephritic syndromes
Features Nephrotic Nephritic
ONSET insidious abrupt
EDEMA ++++ ++
BP normal raised
JVP norma/low raised
PROTEINURIA ++++ ++
HEMATURIA may/may not occur +++
RBC CASTS absent Present
ALBUMIN low Normal/sl. decreased
Serum Creatinine
l Mainly derived from metabolism of creatine/creatine
phosphokinase from skeletal muscle cells
l Produced in almost constant rate
l Steady state concentration dependent on renal
excretion w/c mainly reflects of GFR
Cockcroft-Gault Formula*
(140 – Age ) X Wt in kgs
______________________
72 X Cr in mg/dl
*Multiply result by 0.85 for female
CrCl normal values = 90 – 120 ml/min
Normal decline rate 1 ml/min/yr after age 40
SERUM CREATININE ALONE IS NOT A GOOD
INDICATOR OF ESTIMATED GFR
Creatinine Clearance
l Widely used method to estimate GFR
l CrCl = (Ucr)(V) / Pcr
(Timed urine collection)
l Quick estimation of creatinine clearance use
Cockcroft-Gault formula and MDRD formula
Factors that can affect BUN levels
Increase levels – high protein intake, hyperalimentation
GI bleeding, Catabolic states, Steroids
Tetracyclines, volume depletion
Decrease levels – liver disease, pregnancy
BUN to Creatinine ratio
Normal = 10 – 20 : 1
Volume depletion ( Prerenal ) = > 20 : 1
Factors Affecting Markers of
Kidney Function
RIFLE classification of
Acute Kidney Injury
UO < 0.3 ml/kg/h x24h or
Outcome
Differentiating Acute vs
Chronic Renal Failure
Points favoring CRF:
1) History
Prior history of DM, HPN, Renal or GU disease
Review of old medical records
Onset of nocturia
2) PE
Pallor, Skin changes
3) Lab
Severe anemia, elevated PTH and phosphorus,
low serum calcium
4) Radiology
Bilateral small kidneys, osteodystrophy (bone changes)
Note: Acute injury on top of chronic kidney is common
EXERCISES
25
y/o,
female
pa4ent
with
Urinalysis
result
showing:
Protein
=
+++
RBC
=
15
–
20
/
hpf
WBC
=
10
–
15
/
hpf
Which
part
of
the
kidney
is
most
likely
injured
?
A.
Glomerular
area
B.
Tubulo-‐inters44al
area
C.
Vascular
area
POST
-‐
TEST:
25
y/o,
female
pa4ent
with
Urinalysis
result
showing:
Protein
=
+++
RBC
=
15
–
20
/
hpf
WBC
=
10
–
15
/
hpf
Which
part
of
the
kidney
is
most
likely
injured
?
A.
Glomerular
area
B.
Tubulo-‐inters44al
area
C.
Vascular
area
50
y/o,
male,
with
recent
treatment
for
Herpes
Zoster,
No
genitourinary
symptoms,
had
urinalysis
result
of:
Specific
Gravity
=
1.010
Protein
=
trace
Glucose
=
+1
RBC
=
0
-‐
2
/
hpf
WBC
=
25
–
30
/
hpf
Urine
C/S
=
nega4ve
The
pa4ent
most
likely
has:
A.
Urinary
tract
infec4on
B.
Glomerulonephri4s
C.
Tubulo-‐Inters44al
nephri4s
50
y/o,
male,
with
recent
treatment
for
Herpes
Zoster,
No
genitourinary
symptoms,
had
urinalysis
result
of:
Specific
Gravity
=
1.010
Protein
=
trace
Glucose
=
+1
RBC
=
0
-‐
2
/
hpf
WBC
=
25
–
30
/
hpf
Urine
C/S
=
nega4ve
The
pa4ent
most
likely
has:
A.
Urinary
tract
infec4on
B.
Glomerulonephri4s
C.
Tubulo-‐Inters44al
nephri4s
sCr 120 µmol/L 120 µmol/L
Question:
Both of them have equivalent renal function
True
False
sCr 120 µmol/L 120 µmol/L
Question:
Both of them have equivalent renal function
True
False
Given a 70 y/o, male, diabetic patient,
with body wt = 72 kg
Serum Creatinine of 1 mg/dl
What is the Creatinine Clearance of the patient ?
A. CrCl of 100 ml/min
B. CrCl of 70 ml/min
C. CrCl of 50 ml/min
To which Stage of Chronic Kidney Disease
should the patient be classified ?
A. CKD Stage 1
B. CKD Stage 2
C. CKD Stage 3
Given a 70 y/o, male, diabetic patient,
with body wt = 72 kg
Serum Creatinine of 1 mg/dl
What is the Creatinine Clearance of the patient ?
A. CrCl of 100 ml/min
B. CrCl of 70 ml/min
C. CrCl of 50 ml/min
To which Stage of Chronic Kidney Disease
should the patient be classified ?
A. CKD Stage 1
B. CKD Stage 2
C. CKD Stage 3
Complete Blood Count
PARAMETER NORMAL REMARKS
VALUES
Hemoglobin M: 133 - 162 g/L Consider transfusion if with acute
F: 120 - 158 g/L blood loss, symptomatic chronic
anemia
Caution with hemolysis
Hematocrit M: 0.38 - 0.46
F: 0.35 - 0.44
Mean corpuscular 79-93.3 fL Decreased in iron deficiency,
volume (MCV) thalassemia
Increased in megaloblastic anemia,
structural hemoglobinopathies
Mean corpuscular 26.7 - 31.9 pg Same as MCV
hemoglobin (MCH)
Mean corpuscular 323-359 g/L Increased in hereditary spherocytosis
hemoglobin
concentration (MCHC)
Complete Blood Count
White blood 4.0-11.0 x 109/ Increased in leukemia/
cell count L leukemoid reaction
Platelet count 150-450 x 109/ Increased in iron
L deficiency, CML
Reticulocyte 0.8-2.3% Increased in hemolysis
count/ < 14.5% Decreased in bone marrow
Red cell failure states
distribution
width (RDW)
Complete blood count
l Different labs have different normal values
l Correlate with findings with your patient
l Any abnormalities in two cell lineages -->
bone marrow aspiration (exclude nutritional
anemia, sepsis)
Common Hematologic
Diseases
Disease CBC Finding Clinical Profile
Iron deficiency Microcytic, hypochromic Females in reproductive age
anemia (IDA) anemia group
Thrombocytosis Persons with chronic blood
loss, CKD
IDA in elderly male: colon CA
Megaloblastic Big RBCs (high MCV) Alcoholics, vegetarians
anemia Gastric bypass surgery
Hemolysis Low hemoglobin, high Pallor, jaundice
RDW/retic ct, high serum Signs of sepsis
indirect bilirubin
Anemia of Normocytic, normochromic CKD, CLD, malignancy
chronic anemia (may proceed to
disease hypo, micro)
When Should You Transfuse?
Indications Cutoffs/Details Remarks
Acute blood loss > 40% blood If 30-40%, may transfuse if elderly,
volume with pre-existing anemia or
comorbids
Hemoglobin levels < 60 mg/L If Hgb 60-100, may transfuse if with
symptoms, ongoing bleeding or
elderly
Chronic anemia < 60 mg/L May transfuse if Hgb < 70, if with
ongoing blood loss, cardiac/pulmo/
cerebrovascular risk factors
Peri-operative If Hgb < 70 and asymptomatic, may transfuse if with
scheduled surgery is expected to produce significant
blood loss or if anesthetic risk is high
New York State Council on Human Blood and Transfusion Services Guidelines 2004
When Should You Transfuse?
l Transfuse whole blood or pRBC + FFP +
cryosupernate for significant blood loss
l FFP transfusion - hemophiliacs*, HUS/TTP, dengue
hemorrhagic fever
l Platelet transfusion
l Platelet count < 10 x 109/L
l Platelet count < 50 x 109/L if with bleeding or for surgery
* Better to transfuse cryoprecipitate (Hemophilia A),
cryosupernate (Hemophilia B) or specific factor components
Hazards of Blood Transfusion
l HIV, HBV, HCV
l Volume overload
l Transfusion reactions
l Hypocalcemia, hyperkalemia, hypothermia
l Be careful!
Questions?
