A˜er studying thi s chapter, the student should be able to

D e˜ne and expl ain t he imp or t anc e of qu a lit y ass essment

in t he lab orator y.
Ident if y and expl ain pre ana lytic a l, ana lyt ic al, and p ost
ana lyt ic a l comp onents of qu a lit y ass essment .
Q u a lity ass essm ent (QA)
is a system designe d to ensure t he
qu a lity of a lab orator y™s ser v ic es (i.e., test resu lts). A ll l ab o
rator y p ers onnel must b e aware of t he e˚e cts that t heir test
resu lts and s er vic es have on t he di ag nosis and t re at ment
(1) ensuring t hat t wo unique p at ient ident i˜ers (e.g., name,
d ate of birt h, me dic a l re c ord numb er) are on t he re quest slip
and on t he spe cimen and t hat t hey cor rel ate; (2) e va lu ation of
el apse d t ime bet we en colle c t ion and re c eipt of the sp e cimen
in t he lab orator y ; (3) t he suitabilit y of sp ecimen pres er vat ion,
Ana lyt ic al c omp onents are t hos e var i ables that are dire ct ly
involve d in sp e cimen test ing . ˛e y include re agents and sup
plies, instr ument at ion, analyt ic a l metho ds, t he monitor ing of
ana lyt ic a l met ho ds, and t he lab orator y pers onnel™s te chnica l
sk i lls. Be c aus e e ach c omponent is c ap able of a˚e ct ing test
Reli able ana lyt ica l resu lts obt aine d in t he ur ina lysis l abora
tor y re quire t he use of qu a lit y re agents. ˛e l ab orator y must
have an ade qu ate supply of dist il le d water, deioniz e d water,
or clinic a l l ab orator y re agent water (CLRW ), for merly c a l led
Typ e I water. E ach ur inalysis pro c edure shou ld sp e cif y t he
manu a l ly, it is ver y imp or t ant to monitor
te chni c a l c om
. Uniformit y of te chnique by a l l pers onnel is nec es
s ar y and c an b e achie ve d t hroug h (1) prop er t raining, (2)
ad herenc e to est ablishe d proto cols, and (3) p er for manc e of
p erforms on ly t he manua l qu ant it at ive pro c e dures, w here as
t he chemist r y s e ct ion p er for ms t hos e proc e dures t hat are
automate d. R egard less, a br ief dis cussion of t he Q C mate
r i a ls us e d for quantit at ive urine metho ds is prov ide d. ˛e
va lue assigne d to c ommerci al or homemade Q C mater i a ls is
spre ad of infe c t ion in a l l are as of t he hospit a l to ensure p at ient
and employee s afet y. B e c aus e clinic a l l ab orator y employe es are
exp ose d to numerous workplac e hazards in var ious formsŠ
biologic a l, chemic a l, elec t r ic a l, r ad io ac t ive, c ompress e d
gas es, ˜res, and s o onŠs afet y p olicies are an inte g ral part of
anci l lar y he a lt h-c are st a˚ such as c usto di a l and fo o d s er vic e
employe es, as wel l as he a lt h-c are volunte ers. It is a respon
sibi lit y of e ach he a lt h-c are dep ar t ment to e duc ate, imple
ment , do c ument , and monitor c omplianc e w it h St andard
Pre c autions. In addit ion, w r itten s afety and infec t ion c ont rol
In addit ion, t he y shou ld b e wor n at a l l t imes in the lab o
rator y w here c ounter tops, chairs, and ot her surf ac es are
exp ose d to t hes e sp ecimens. If l ab orator y p ers onnel are
dire ct ly involved wit h pat ients, g loves shou ld b e changed
and hands washed or s anitiz e d a˙er e ach p atient c ont act .
When spi lls o c c ur, dec ont aminants are us e d to neut ra liz e
t he biolog ic a l hazard and to f aci lit ate its remova l. B e c aus e
de c ont aminants are less e˚e c t ive in t he pres enc e of l arge
amounts of protein, a b o dy ˝uid spil l shou ld b e abs or b e d ˜rst
w it h a s olid abs or b ent p owder (e.g ., Z orbit rol) or disp os able
An OSHA Hazard Communication St andard label sample. (From
The nine OSHA Hazard Communication St andard pictograms for use on chemical labels.
l ab oratory should have avai l able a chemic a l spi ll k it t hat
includes abs or b ent , appropr i ate prote c t ive b ar r iers (e.g .,
g loves, gog g les), cle anup pans, abs or b ent towels or pil
lows, and disp os a l b ags. Fre quent ly, liquids are c ont aine d
by abs or ption using a spi ll c omp ound (abs or b ent) such as
US D epar t ment of He a lt h and Human Serv ic es: Medic are,
Me dic aid, and CLIA prog rams: regu l at ions implement ing
t he C linic a l L aborator y Improvement Amendments of 1988
(CLIA). Fina l r u le, Fe dera l R eg ister 57 FR 7002 (Febr uary 18,
1992). C odi˜e d as 42 CFR par t 493, Oc tob er 1, 1996, Co di˜e d
C linica l and L ab oratory St and ards Inst itute (CLSI): Training
and c ompetenc e ass essment: approve d guideline, 3rd e d.,
CLSI Do c ument QMS03-A3, CLSI, Way ne, PA, 2009 CLSI
C ol le ge of Amer ic an Pat holog ists: C linic a l Micros copy Sur ve y
Kit Inst ruc t ions, CMP 2016. Nor t h˜eld, IL: Col le ge of
Te chnica l c ompetenc e is displayed w hen a lab orator y
pr a ct it i on e r
do c uments rep or ts in a le g ible manner.
re c ogniz es dis crepant test resu lts.
indep endent ly re duc es t he time nee de d to p erfor m a
Both a large hospit al and its outpatient clinic have a laborator y
area for the performance of routine urinalyses. Each labora
tor y performs daily QA checks on reagents, equipment, and
procedures. Because the control material used does not have
sediment components, each laborator y sends a completed uri
A˜er studying thi s chapter, the student should be able to
St ate at least t hre e clinic a l re as ons for p er for ming a rou
D es crib e t hre e typ es of ur ine sp ecimens, and st ate at le ast
one di agnost ic us e for each t yp e.
E xpl ain the import anc e of acc urate timing and c omplete
RNA (e.g ., ch l amydi a, t r ichomonas), or a rout ine ur inalysisŠ
w hich prov ides a re a l-t ime fisnapshotfl of a p ers on™s ur inar y
t ract and met ab olic st atus.
˛e most c ommon ly p er for me d ur ine test is a rout ine ur i
na lysis test . It is e c onomic a l and prov ides va lu able p atient hea lt h
To c ol le c t a
˜rst m or ning sp e cim en
, t he p at ient voids
b efore going to b e d and imme di ately on r ising f rom sleep
c ol le c ts a ur ine sp e cimen. B e c aus e t his ur ine sp e cimen has
t he ur inar y excret ion of s ome ana lytes. When t his in˚uenc e
is k now n to b e signi˜c ant , t he p at ient ne e ds to be properly
inst ruc te d to avoid t hes e subst anc es. Wr itten instr uc t ions
shou ld include t he test name, t he pres er vat ive re quire d, and
any sp e ci a l instr uc t ions or pre c aut ions. ˛e most c ommon
washings (e.g ., nor ma l b acter i a l ˚ora of t he dist a l uret hra)
into t he toi let and a l lows c ol le c t ion of a sp e cimen t hat rep
res ents elements and ana lytes f rom t he bl adder, ureters,
and k idne ys. B e c aus e an informe d p at ient c an obt ain t hes e
us ef u l sp e cimens w it h minimal e˝or t , t he midst re am cle an
v isibly c ontaminate d w it h fe ca l mater i al or debr is (e.g .,
Rout ine urina lysis proto cols t ypic a l ly re quire 10 mL to 15
of ur ine, but colle c tion of a l arger volume is enc ourage d to
ensure suˇcient ur ine for addit iona l or repe at test ing . Sma l ler
12 mL) hinder per for mance of the micro
Oxidation or reduction of solutes (e.g ., urobilinogen, bilirubin)
Cr yst al precipit ation; bacterial proliferation
Bacterial conversion of urea to ammonia (and bacterial
Bacterial conversion of urea to ammonia; loss of CO
Photo-oxidation to biliverdin by light exposure
t hat must be t ransp or te d long dist anc es, c ommerci a l t ransp ort
tub es w it h a pres er vat ive are avai l able (
Timed sp e cimens, p art ic u l arly 12-hour and 24-hour c ol le c
t ions, may re quire t he addit ion of a chemica l preser vat ive to
maint ain the inte g rit y of t he analyte of interest . R e gard less of
t han in ot her b o dy ˚uids. Note t hat in ur ine f rom he a lthy
indiv idu a ls, no protein or g luc os e is usu a lly pres ent . In c on
t rast , ot her b o dy ˚uids such as amniotic ˚uid or pl asma exu
d ates cont ain g luc os e and are hig h in protein.
C linica l and L ab oratory St and ards Inst itute (CLSI): Ur ina lysis:
If ref rigerat ion is use d to pres erve a ur ine sp e cimen,
w hich of the fol low ing may oc c ur?
llular or bac ter ial g lycolysis will b e enhanced
For med elements w il l b e destroye d
A m orp h o u s c ryst a l s m ay pre c ipit at e
Ren a l Anatomy, 2 9
Ren a l Circu l ati on, 31
Ren a l Phy s i o l o g y, 3 3
Ur ine For mat ion, 33
Tubu l ar Funct ion, 38
are b e an-shap e d and are lo cate d on the
ab domina l wa l l in t he are a k now n as t he
re t rop e r iton e um
). An adult human k idney has a mass of approxi
mately 150 g and me asures roug h ly 12.5 cm in length, 6 cm in
150˝mL of ur ine ac cumu l ates, a ner ve re˚ex is initi ate d. Un less
a p ers on over r ides t he urge to urinate (i.e., t he mic tur ition
re˚ex), simu lt ane ous c ontrac t ion of t he bl adder muscles and
rel axation of t he ur inar y sphinc ter w i l l resu lt in t he p ass age
of urine t hroug h t he uret hra. ˛e uret hra, a c ana l c onne c t ing
enter ing t he me dul l a to b e c ome t he
lo op of Hen le has anatomic a lly dist inct are as: t hin des c end
ing and asc ending limbs t hat include a shar p hair pin tur n,
and t hick des c ending and asc ending limbs t hat are actu a l ly
st raight p or t ions of t he proximal and dist a l tubu les (
The vascular circulation of a cortical and juxt amedullary nephron. (Modi˜ed from
Patton KT, Thibodeau GA:
, ed 9, St. Louis, 2016, Mosby.)
˜ lt rat ion as wel l. ˛e outc ome of t hes e t hre e pressure diˆer
enc es is a net ˜ lt rat ion pressure of 10 mm Hg , w hich f avors
t he format ion of a pl asma u lt ra˜ ltrate in B ow man™s sp ac e
p ole is a ls o t he site of t he
juxtag l omer u l ar app aratus
mor pholog ic a l ly dist inc t st r uctures t hat comp os e t he juxt a
g lomeru l ar app aratus are p or tions of t he aˆerent and eˆer
ent ar ter ioles, t he ext rag lomer u l ar mes angi a l c el ls (w hich are
c ont inuous w ith t he extrag lomer u lar mes ang ium of t he jux
t ag lomeru l ar app aratus.
˛e c apil l ar y endot helia l c el ls of t he g lomeru lus ma ke up
t he ˜rst c omponent of t he ac tu a l ˜ lt ration b ar r ier. ˛e endo
t helium is fenest rate dŠt hat is, it has l arge op en p ores 50 to
membrane c onsistent ly c ours es b elow t he epit helium of
B ow man™s sp ac e and is abs ent b et ween t he c api l lary endot he
lium and t he supp ort ing mes ang ium. As ment ione d pre v i
ously, t his tr i l ayer st r ucture is not t he basement membrane
of t he glomer u l ar c api ll ar ies; rat her, it c ont ributes sp e ci˜ca l ly
overc ome t he negat ive charge pres ent on t he endot helium
and must be able to p ass t hroug h t he endot heli a l p ores, w hich
are 50 to 100 nm in di ameter.
shi el d of n e g ati vity
t he endot helium suc c essf u l ly repels most pl asma proteins,
Hen le. ˛es e epit heli a l c el ls, a lt houg h remaining ˚ at , exten
sively interdig it ate w it h one anot her. ˛e interdig it at ing epi
t helium found at the hairpin tur n c ontinues t hroug hout t he
t hin asc ending limb of the lo op of Hen le.
˛e t hick as c ending limb of t he loop of Henle (or t he
). As the c ol lec t ing duc t appro aches a papi l lary
t ip, t he epit helium changes again to c el ls t hat are t al ler and
m ore c o lu m n a r.
˛e f ac t t hat on ly 1% (approximately 1200 mL) of t he or ig ina l
pl asma u lt ra˜ lt rate pres ente d to t he rena l tubu les is excreted
Each s olute has a sp eci˜c t ransp or t system. C el lul ar
protein-binding sites may b e unique for a p ar t icu l ar s olute,
t ransp or t ing on ly t hat s olute across t he membrane, or t he y
may t ransp or t s e vera l s olutes, o˙en exhibit ing preferen
t i a l t ransp or t of one ana lyte over anot her. In addit ion, t he
, bi c a r b onat e ion s (HC O
), w hich re adi ly p ass
t he g lomer u l ar ˜ lt rat ion b ar r ier, re ac t w it h t he s e creted H
for m c ar b onic acid (H
) in t he tubu l ar lumen. ˛is c ar
monob asic phosphates. Note t hat hydrogen ions combine d
w it h ot her s olutes are not me asure d by t his tit rat ion.
As a dire c t result of t hes e phosphates in t he u lt ra˜ ltrate,
acid is remove d f rom t he b o dy and t he ur ine is acidi˜e d; in
addit ion, s o dium and bic ar b onate ions are retur ne d to t he
ion s e cretion to re c over bicar b onate; (2) H
t ion to y ield ur ine t it rat able acids (e.g ., monoso dium phos
s e cret ion to y ield ammonium
s a lts (e.g ., ammonium ch lor ide, ammonium su lf ate). By e ach
of thes e mechanisms, hydrogen ion s ecret ion (i.e., t he loss of
and t he dire c t ion of movementŠw hether into or out of t he
tubu l ar lumenŠis immateri a l.
In c ont rast , s ome solutes are not limite d in t he amount
t hat c an be re abs orb e d (e.g ., s o dium) or se crete d (e.g ., p ot as
sium). For t hes e subst anc es, ot her f ac tors in˚uenc e t heir rate
is t he movement of water across a membrane
f rom a s olut ion of low osmol a lit y to one of hig her osmol a lit y.
˛e c el l membrane is s emip er me able, a l low ing s ome but not
a l l s olutes to cross it . An osmol alit y gradient (i.e., t wo areas
diˆer ing in the numb er of s olute p ar ticles pres ent p er volume
The countercurrent multiplier mechanism and the urea cycle maint ain the
hypertonicit y of the medulla. (A) In the loop of Henle, note that the ˚uid leaving
the loop
is slightly hypo-osmotic (10 0) compared with the ˚uid entering the loop (30 0).
Numbers indicate osmolality in milliosmoles per kilogram (mOsm/kg) H
mechanisms in an entire nephron. As H
O leaves the collecting duct (under antidiuretic hormone [ADH] regulation), the
solutes become concentrated in the remaining ˜ltrate
and osmolalit y increases.At the same time, a urea concentration gradient causes it
to passively diffuse from the collecting duct into the interstitial ˚uid (IF) of
the medulla.
in a dilute (hyp otonic or hypo-osmot ic) ur ine. C onvers ely,
w hen a de cre as e in blo od pressure is s ens e d by b arorec ep
tors, ADH rele as e is incre ase d. Under ADH st imu l ation, the
c ol lec t ing tubu le epit helium changes and incre as e d water
re abs or ption o c curs as a resu lt of t he hig h me du l lary osmo
c ol lec t ing tubu les, water is re abs or b ed in t he pres enc e of
ADH, w hereas ure a is not . Any water reabs or pt ion s erves to
c onc entrate f ur t her t he amount of ure a pres ent in t he lumen
˚uid. When t he lumen ˚uid re aches t he me du l lary c ol lec t ing
tubu les, water (under ADH in˚uenc e) and urea re adi ly diˆ us e
Which of the fol low ing is not a vas c u l ar charac ter ist ic of
˛e aˆerent arter iole has a nar rower lumen t han t he
˛e ar teries are pr imar ily end ar ter ies, supply ing
sp e ci˜c are as of t issue, and t he y do not interc onne c t .
˛e ar terioles sub div ide into a capi l lar y net work,
Which of the fol low ing subst ances is s e crete d into t he
tubu l ar lumen to eliminate hydrogen ions?
Ur ine tit rat able acids can for m w hen the u lt ra˜lt rate
bi c a rb on at e .
ph o s ph at e .
C a lcu l ate osmolar cle aranc e and fre e-water clearanc e
resu lts using d at a prov ided.
C omp are and cont rast t he cre at inine clearanc e test and
t he inulin cle aranc e test for ass essment of g lomeru l ar
D es crib e a proto col for a cre at inine cle arance
anur i a (als o c a l l e d
a nu r e s i s
c ol li g ative prop er ty
cre atinin e cl ear an c e test
f re e-water cl ear an c e (als o c a l l e d
A ˜owchart for the evaluation of polyuria.
, urine-to-serum osmolalit y ratio. (Redrawn
A guide to diagnostic clinical chemistr y
ur ine. Oligur i a c an oc c ur in c ondit ions charac ter iz ed by
e dema or c onditions w here pl asma protein is lost and water
Components in an Average 24-Hour Urine
Average 24-hour urine volume with a glomerular ˚ltration rate of
c omp ares t he amounts and mass es of t he pr in
cip a l ur ine c omp onents. Note t hat t he amount of a c omp o
nent in mi l limoles rel ates to t he numb er of p ar t icles pres ent ,
(mmol) of par t icles fi in s olution.fl B e c aus e osmol a lit y is
dire ct ly rel ate d to p ar t icle numb er, a s olute that diss o ci ates
in s olut ion w il l pro duc e a higher osmol a lit y t han a s olute
t hat do es not diss o ci ate. For example, glucos e (MW 180) in
s olut ion do es not diss o ci ate; henc e 1 mmol of g lucose (180
(A) Production of hypotonic urine. Hypotonic urine is produced by a nephron by the
mechanism shown here. The isotonic
(30 0 mOsm) tubule ˜uid that enters the Henle loop becomes hypotonic (10 0 mOsm) by
the time it enters the dist al convoluted tubule.
The tubule ˜uid remains hypotonic as it is passes through remaining portions of the
nephron, where the walls of the distal tubule
and collecting duct are impermeable to H
. Values are expressed in milliosmoles. (B) Production of hypertonic urine.
˝e spe cimen, ur ine or s er um, in a s ample chamber is
pl ac ed into the osmometer. ˝e inst rument b eg ins t he c o ol
ing s e quenc e depic te d in
. ˝e init i a l superco oling
pro c ess (s eg ment AB,
Comparison of Speci˜c Gravities of Different Solutions
t he urine (e.g ., so dium, urea). In ot her words, t he mass of thes e
s olutes pres ent is sig ni˜c ant and a˛e c ts the ur ine SG by ref rac
tomet r y, but t heir numb er is to o smal l to signi˜c ant ly a˛ec t
t he ur ine osmola lit y. ˝es e ur ine sp e cimens are c onsidere d
A comparison of urine speci˚c gravit y and urine osmolalit y. Speci˚c gravity
measurements were determined by a
direct method (falling drop) and an indirect method (refractometry). The straight
lines represent the speci˚c gravit y and osmolal
it y results obt ained with solutions of varying sodium chloride concentrations.
(A)A comparison of urines obt ained from healthy
medical students. (B) A comparison of urines obt ained from patients on renal ser
vice. (From Holmes JH:
, Chicago, 1962,American Society of Clinical Pathologists. Used with permission.)
nig httime volume and by a nightt ime ur ine SG t hat is 1.020
o r g r e a t e r.
Just as simu lt ane ous me asurement of s er um and urine osmo
l a lit y c an aid a clinici an in t he di˛erent i a l di ag noses of dis
e as e (e.g ., neurogenic di ab etes insipidus versus nephrogenic
t he t ime d inter va l, and C is t he rena l cle aranc e of t he sub
st anc e (mL/min). Note t hat t he units for t he urine and pl asma
c o n cent r at i o n s
mu st be the s ame
to c anc el e ach ot her out in
The formation of creatinine from creatine and phosphocreatine.
w here SA is the b o dy sur f ac e are a in s qu are meters, W is t he
p at ient™s weig ht (mass) in k i lograms, and H is t he p at ient™s
Nor ma lizat ion of t he cre at inine cle aranc e test enables t he
c omp aris on of cle aranc e resu lts (i.e., GFR) w it h t hos e of ot her
c an dire c t ly a˛e ct t he cre at inine clearanc e resu lt obt aine d.
D espite t hes e shor tcomings, t he creat inine cle arance c ont in
ues to prov ide hea lt hc are prov iders w it h a us ef u l me asure
ment of t he GFR. Be c aus e cre at inine metho ds have b e en
extensively res e arche d and have proven reli abi lit y, t he per i
It is re c ommende d t hat lab orator ies c a lc u late t he eGFR
w hene ver a s er um cre at inine test is p er for med on p at ients
age d 18 ye ars and older. ˝e eGFR is a simple and e˛e c
t ive to ol that c an b e us e d to assist he a lt hc are prov iders in
dete c t ing chronic k idne y dis e as e, p ar t icu l arly in hig h-r isk
A te chnic a l ly rel ated dis advant age of
is its susc ept ibi lity to de g rad at ion in acidic env ironments.
A lt hough t his is not a problem w it h s er um sp e cimens, de g
rad at ion is an issue w hen ur ine sp ecimens are col le c ted.
Pre c autions must b e t a ken w hen c ol le ct ing and proc essing
a ls o b e en us e d. Me asurements of se cretor y f unc t ion and RPF
are not rout inely p er for me d b e c ause t hey require int ravenous
i nf usion of an exogenous substanc e.
˝e most c ommon test us e d to me asure RPF is t he
-aminohippurate cle aranc e test .
t he ammonium conc ent rat ion is c alc u l ated as t he di˛erenc e
b etween t he tot a l acidit y of t he ur ine and t he acids pres ent as
In c onclusion, a lt hough me asurements of lo ca liz e d f unc
t ions of t he nephron are possible, t he y are not p er for me d
rout inely in a clinic a l s ett ing . Inste ad, t he most c ommon and
˝e d aily volume of urine excrete d norma l ly ranges from
Anot her name for exc essive t hirst is
p olyd ip s i a .
˝e excretion of l arge volumes of ur ine (
g luc osu r i a .
In a p at ient w it h chronic rena l dis e as e, in w hom t he
k idne ys can no longer adjust urine c onc entrat ion, t he
ur ine sp e ci˜c grav it y wou ld be
Which of the fol low ing fe atures is
a c olligat ive proper t y?
˝e fol low ing dat a are obt aine d from a 60-ye ar-old
t a ll and weig hs 88
Pl asma cre at inine: 1.2
Ur ine cre at inine: 500
C a lcu l ate t he cre at inine cle aranc e.
A 24-year-old man who had previously sust ained a severe head
injury in a car accident is seen by his physician. He complains
of polydipsia and polyuria. Neurogenic diabetes insipidus is sus
pected, and tests are performed to rule out compulsive water
ingestion.The following routine urinalysis is obt ained.
C o l o r, 71
O d o r, 7 6
Ta s t e , 7 7
Vo lu m e, 7 7
C on c en t r at i on , 7 7
˛e charac ter ist ic yellow color of norma l ur ine is pr incip a l ly
due to t he pig ment
u ro c h rom e
A pro duc t of endogenous
metab olism, uro chrome is a lipid-s oluble pig ment t hat is pres
Urine Color Terms and Common Causes
Fluid ingestion; polyuria due to diabetes mellitus or diabetes insipidus
Due to the normal pigment, urochrome (as well as uroer ythrin and
Limited ˜uid int akeŠdehydration, strenuous exercise, ˚rst morning
specimen, fever; excessive conversion of urobilinogen to urobilin
From Ben-Ezra J, McPherson RA: Basic examination of urine. In
, ed 22, Philadelphia, 2011, Saunders.
View through a clear cont ainerŠplastic or glass.
Evaluate a consistent depth or volume of the specimen.
View using room lighting that is adequate and consistent.
ur ine c olor and refers to the transp arenc y of t he spe cimen.
O˝en c a l led tur bidity, cl arit y des crib es t he cloudiness of t he
ur ine caus e d by susp ended p ar t ic ul ate matter t hat sc atters
lig ht. ˛e cr iteri a out line d in
for ass essing ur ine c olor
a fema le. R e gard less of t heir or igin, thes e organisms are
rout inely repor te d w hen obs er ve d dur ing t he micros copic
examinat ion of a ur ine sp ecimen.
In summar y, cle ar ur ine is not ne c ess ari ly norma l.
Abnor ma l amounts of g luc os e, protein, lys e d re d blo od
c ondit ions and t he volume of ur ine excrete d, and (3) t he
ter minology us e d to des cr ib e volume var i at ions.
Anot her physica l charac ter ist ic of ur ine is c onc entrat ionŠ
t hat is, t he qu ant it y of s olutes pres ent in t he volume of water
excreted. As dis c uss ed in
such as gluc os e, protein, and radiog raphic me dia has clinic a l
va lue. It enables ass essment of t he ‚c onc ent rat ing abi lit y™ of the
k idne ys despite t he pres ence of t hes e large-mole c ul ar-weig ht
s olutes. As dis c uss ed in
C h ap t e r 4
A manual refractometer with the pathway of light
In summar y, ref rac tometr y c omp ares t he velocit y or ang le
of ref rac t ion of lig ht in a s olut ion versus t hat of light in air.
In a s olution, as t he numb er of s olutes incre as es, t he velo cit y
of light de cre as es and t he ang le of light refrac t ion de cre as es.
w here as protein o˝en indic ates a rena l c ondit ion such as a
change in t he glomer u l ar ˜ lt ration b ar r ier (g lomeru lonephr i
t is, nephrot ic sy ndrome). No ot her SG met ho d is able to elim
inate t he e˚ec ts of nonionic l arge-mole cu l ar-weig ht s olutes
on SG resu lts. ˛erefore re agent st r ip SG resu lts are uniquely
of radiographic medi a, approximately 8
hours is ne e de d for
c omplete eliminat ion of t he imag ing agent .
In summar y, t he pres enc e of (1) l arge qu ant ities of gluc os e
or protein, or (2) sma l l amounts of mannitol or radiog raphic
A ur ine t hat pro duces a l arge amount of w hite fo am w hen
mixed shou ld b e susp e c te d to c ont ain incre as e d amounts of
Which of the fol low ing subst ances c an change the color
of a urine and its fo am?
˛e cl arit y of a wel l-mixe d urine sp ecimen t hat has v is
A routine urinalysis on a urine specimen collected from a hos
pit alized patient revealed a speci˚c gravit y greater than 1.050
with the use of refractometr y.
The best explanation for this speci˚c gravity result is that the
is concentrated because the patient is ill and dehydrated.
A commercial reagent strip or dipstick consists of
reagent-impregnated test pads that are ˜xed to an inert plas
tic strip. After the strip has been appropriately wetted in a
urine sample, chemical reactions cause the reaction pads
to change color. At the appropriate firead time,fl results are
b e fol lowed. Each manuf ac turer prov ides a
pro duct ins er t t hat out lines t he chemica l pr inciples,
re agents, storage, us e, sensit iv it y, sp e ci˜cit y, and limit at ions
of its re agent st rips. A l l re agent st rips must b e prote cte d f rom
moisture, chemic als, he at , and lig ht . Any st rips show ing e v i
Commercia l t ablet tests (e.g ., Ic totest , C linitest , Ac etest [a l l
f rom Siemens He a lt hc are Di ag nost ics Inc.]) must be hand le d
and store d ac c ording to t he ins erts prov ide d by t he manuf ac
turers. ˙es e pro duc ts are sus c ept ible to deter iorat ion f rom
exp osure to light , he at , and moisture. ˙erefore t he y shou ld
and shou ld b e disregarded. When re agent st r ips are re ad by
automate d inst r uments, t he t iming inter va ls are set by t he
f ac tor y. ˙e advant age of automate d inst r uments in re ading
re agent st r ips is t heir c onsistenc y in timing and c olor inter pre
t at ion regard less of ro om lig ht ing or test ing pers onnel. S ome
Diet: high protein, cranberr y ingestion
Met abolic acidosis (e.g ., ketoacidosis,
st ar vation, severe diarrhea, uremia, poisonsŠ
Respirator y acidosis (e.g ., emphysema, chronic
Urinar y system disorders: UTI with acid-
u lt ra˜lt rate, and 95% to 99% of a l l ˜ ltere d protein is re ab
s or b ed. Hig h-mole cu l ar-weig ht proteins (
unable to p enet rate a he a lt hy g lomer u l ar ˜ lt rat ion b ar rier.
˙e end resu lt is t hat t he proteins in norma l ur ine c onsist of
ab out one-third a lbumin and t wo-t hirds globu lins. Among
Infectious disease (malaria, hepatitis B, bacterial
Drugs (penicillamine, lithium) and toxins (heav y
Toxins and poisons (heav y metals)
Jones protein. Tod ay, immunoass ays and ele c t rophoretic
te chniques are avai l able to sp eci˜c a l ly ident if y and qu ant it ate
t hes e light chain proteins.
Rena l proteinur i a c an pres ent w it h a g lomeru l ar p atter n, a
tubu l ar p atter n, or a mixe d p atter n. Dis e as e c an c aus e changes
When tubu l ar proteinuri a is susp e c te d, a quantit at ive
ur ine tot a l protein met ho d shou ld b e employe d, or a protein
pre cipitat ion metho d s ensit ive to al l proteins c an b e us e d for
s cre ening (e.g., SSA pre cipit at ion test). Tubu lar proteinur ia,
or ig inal ly dis c overed in workers exp os e d to c admium dust
w hich are nor ma l ly not pres ent , c omp ete for re abs orpt ion.
Henc e t he re agent st r ip dete ct ion of a lbumin is o˝en c apable
of dete ct ing most inst anc es of proteinur i a.
I dent i ˜c at ion and management
of p at ients at r isk for k idney dis e ase are en hance d g re at ly by
coated blue latex particles; saturated and
isolated and differentiated by migration on
strip; intensit y comparison of two blue bands
complex migrates to detection pad, where
bound enzyme converts substrate on pad to
re d ga l ac toside) in t he re ac t ion z one to pro duc e a re d dye.
Timing and te chnique are cruci a l; t herefore, t he manuf ac
turer™s inst r uc t ions must b e fol lowed to ensure ac curate test
resu lts. ˙e Micra l Test met ho d is c ap able of dete ct ing as
litt le as 15 to 20
atom. Note, however, t hat subst anc es ot her t han hemog lobin
a ls o c ont ain a heme moiet y such as myog lobin and c yto
chromes. Of par t ic u lar interest is myog lobin (MW 17,000),
an intrac el lu lar protein of mus cle t hat w il l b e incre as ed in
t he blo o dst re am w hen mus cle t issue is d amage d by t rauma
˙e fol low ing appro ach to di˛erent i ating bet we en hemo
g lobin and myog lobin is simil ar to a protoc ol re c ommende d
by Shi habi, Hami lton, and Hopk ins in 1989 for development
of a firhab domyolysis / hemolysis pro˜ le.fl
Nor ma l ly, myog lo
Pseudoperoxidase activity of the heme moiety
The chromogen reacts with a peroxide in the
presence of hemoglobin or myoglobin to
become oxidized and produce a color change
Equally speci˜c for hemoglobin and myoglobin
as c or bic acid to caus e a f als e-ne gat ive blo o d re agent st r ip test
emphasiz es t he ne ed to include a micros copic examinat ion
w hene ver scre ening for hematur i a.
Fa ls e-posit ive resu lts for ur inar y blo od c an b e obt aine d
w hen menst ru a l or hemor rhoid a l blo o d c ont aminates t he
oxa lic acid c annot exist but diss o ci ates and is pres ent exclu
sively as its sa ltŠoxa l ate. Howe ver, if acidif y ing agents are
adde d to a ur ine sp ecimen a˝er c olle c t ion to re duc e t he pH
to 4.4 or lower, oxa late c an be c onver te d (re duc ed) to oxa lic
acid. If this acidi˜e d ur ine is tested, a f a ls ely low or ne gative
c onversion of nit rate to nit r ite. To appropr i ately s creen for
nit r ite, the ur ine sp e cimen of choic e is a ˜rst mor ning void
or a sp e cimen c ol le c te d a˝er t he ur ine has b een ret aine d in
t he bl adder for at le ast 4
hours. ˙is l atter re quirement c an b e
nit rate-re ducing b acter i a. ˙e test is a s creening test on ly and
is limite d by various f actors, including micro organism char
ac terist ics, dietar y f actors, bladder retent ion t ime, and sp eci
men storage. D espite t hes e dis advant ages, the test remains an
imp or t ant p ar t of a rout ine ur inalysis.
A schematic diagram comparing the ˜ltration and reabsorption of glucose by proximal
tubular cells normally and in condi
tions of hyperglycemia and renal tubular disease.
Wit h rarer enzy me de˜ciencies ga lac t itol is for me d, which
c aus es c at arac t for mat ion in ne wb or ns. If t hes e c ondit ions
are re c og niz ed e arly, ga l ac tos e c an b e eliminate d f rom t he
adjuste d to avoid dete ct ion of t hes e sma ll amounts of
summariz es t he g luc os e re ac t ion pr inciple, s ensi
t iv it y, and sp e ci˜cit y of sele c te d re agent st r ip brands. Sp e ci˜c
g rav it y and temp erature c an mo dify t he s ensit iv it y of t he
re agent str ip for gluc os e. As t he ur ine sp e ci˜c g rav it y incre as es
p erio d, ver y hig h g lucos e c oncent rat ions must b e pres ent . If
t he re ac tion mixture is not obs er ved during test ing and the
15-s ec ond t ime perio d is exc ee de d, t he c olor obs er ve d (a˝er
t he p ass t hroug h) may no longer indic ate t he hig h g luc os e
c onc entrat ion, and f a ls ely low resu lts may b e rep or te d. Note
keton e b o di es
ident i f y t hre e i nter
me di ate pro ducts of fatt y acid met ab olism: ac eto acet ate,
-hydroxy but y rate, and ac etone (
). Nor ma l ly, t he end
clinica l present at ion is s e en in pat ients w it h uncont rol le d
di ab etes mellitus. In t hese pat ients the b ody is unable to us e
c ar b ohydrates and f at met ab olism increas es dramatic a l ly. As a
resu lt , keto acids (ketones) ac c umu l ate in t he p atient™s plasma,
c ausing t he pl asma pH and bic ar b onate to de cre ase. To elimi
A rapid and e asy me ans of dete c t ing a f a lse-p osit ive
re ac tion c aus e d by a f re e su l˘ydr y lŒcont aining dr ug w hen
p erforming t he reagent st rip test or t he t ablet test (Ac etest , to
b e dis c uss ed) is p ossible. In hig h concent rat ions, t hes e dr ugs
c aus e t he ketone re ac t ion p ad to b e c ome immedi ately posi
bi lirubin, c onjugate d bilir ubin, or b ot h may b e pro duc e d in
abnor ma l ly incre as e d amounts, resu lt ing in hyper bi lir ubine
b i lir ub inur i a
In he a lt hy indiv idu als, on ly t rac e amounts of bi lir ubin
mg/dL) are excrete d, and its pres enc e is nor mal ly unde
Diagnostic Utility of Urine Bilirubin, Urobilinogen, and Fecal Color
˙e t hird mechanism of a ltere d bi lirubin met ab olism
involves p ost hep at ic obst r uc t ion of t he bi le duc t or biliar y sys
tem. In t hes e c ondit ions, t he liver f unct ions nor ma lly ; howe ver,
c onjugate d bi lir ubin t hat is t ransp or te d to t he bi li ar y system is
to pro duc e a p osit ive Ictotest result despite a negat ive re
agent st r ip test result . When sp e ci˜c re quests are made for
deter minat ion of ur ine bi lir ubin or w hen bi lirubin is sus
p e cte d f rom t he physic al examinat ion but t he re agent st r ip
resu lt is ne gat ive, t he Ic totest met ho d shou ld be p er for med.
t ypic al fia lka line t idefl (a lkaline pH) obs er ve d in t he ur ine
a˝er me a ls. Q u antit at ive urobi linogen pro c edures are rarely
Urobi linogen is l abi le in acid ur ine and e asi ly photo-
oxidiz es to urobi lin. B e c aus e urobi lin is nonre ac t ive in t hes e
tests, ur ine colle c t ion and hand ling proc e dures must b e fol
en hanc er, and an acid bu˛er. As urobi linogen re ac ts w it h
E hrlich™s re agent to for m a red chromophore, t he re agent p ad
changes f rom light pin k to d ark pin k (
E qu at ion 6.16, E hrlich™s
R ea c t i on
t hat c an sig ni˜c ant ly incre as e t he amount of as cor bic acid
excreted in ur ine. Wit h a t ypica l Wester n diet
ment at ion, urine excret ion of as c or bic acid ranges f rom 2 to
Howe ver, w ith v it amin C supplement at ion (e.g .,
ora l v it amins, f r uit and juic e ingest ion), t he ur inar y excretion
numb ers of RB Cs but t he re agent st r ip test for bloo d is
ne gat ive. ˙e e˛e c t of as c or bic acid on de cre asing gluc os e
resu lts by re agent st r ip is not obv ious and may b e susp e c ted
on ly in ext reme c as es w hen ketones are p ositive and g luc os e
ne gat ive. Note t hat as c or bic acid inter ferenc e in bi lir ubin and
manu al ly. ˙e p otent i a l for sp e cimen mix-up is pr imar i ly due
to t he c ent r ifugat ion require d for prep aration of t he urine
s e diment for micros copic re v ie w.
examination results and p ossible ˜ndings in the microsc opic
examination t hat cor rel ate. When resu lts do not c or relate
Which of the fol low ing is not che cke d by qua lit y c ontrol
mate r i a ls ?
˙e te chnic a l sk il ls of t he pers onnel per for ming
t h e te s t
˙e integ r it y of the sp e cimen, t hat is, t hat the
Which of the fol low ing aids in the di˛erent iat ion of
hemog lobinuri a and hematuri a?
L eu ko c yte esterase test
Mic ros c opic ex ami nat ion
S ele ct t he c or re c t st atement(s).
Which of the fol low ing subst ances if pres ent in t he urine
resu lts in a ne gat ive C linitest?
˙e g luc os e re agent str ip test is more s ensit ive and
sp e ci˜c for g lucos e t han t he Clinitest met ho d b e c ause it
ot her re ducing subst anc es and hig her c oncent rat ions
Which of the fol low ing st atements ab out urobi linogen
Urobi linogen is not nor ma lly pres ent in urine.
Urobi linogen excret ion usu a lly is de cre as e d a˝er a me al.
Urobi linogen excret ion is an indic ator of rena l
Urobi linogen is l abi le and readi ly photo-oxidiz es to
An 82-year-old woman was admitted to the hospit al with back
and left rib pain. Radiographic examination revealed lytic lesions
of the lumbar vertebrae and ribs, and sheets of plasma cells
were present on bone marrow biopsy. A diagnosis of multiple
myeloma is made. The result of a 24-hour urine tot al protein
A 26-year-old man is seen by his physician and reports sud
den weight loss, polydipsia, and polyuria. A routine urinalysis
and plasma glucose level are obtained. The patient was fasting
Circle any abnormal or discrepant urinalysis ˜ndings.
Explain the pass-through effect exhibited by the Clinitest
Stan d ardizati on of S e dim ent Pre p arati on, 125
C ent rif ugat ion, 126
S e diment C onc ent ration, 127
Volume of Se diment Viewe d, 127
R epor t ing Formats, 128
˛e st and ardiz e d qu ant it at ive microscopic examinat ion of
ur ine s e diment made its clinic a l l ab orator y debut in 1926. At
t hat t ime, ˛omas Addis de velope d a pro ce dure to qu ant if y
for me d elements in a 12-hour over night ur ine c ol le ct ion. ˛e
pur p os e of t his test , t he Addis c ount , was to fol low t he prog
me asurement (Fig . 7.1). ˛e tub es are cle ar, al low ing for ass ess
ment of urine c olor and cl ar ity, and c onic a l, which f aci lit ates
s e diment c onc ent rat ion dur ing c entr if ugat ion. ˛e c ent r if uge
tub es of each c ommerci al system are unique. ˛e Ur iSystem
tub e (Fisher He a lt hCare, Houston, T X) is desig ne d such t hat
In t his e qu at ion, the radius in cent imeters refers to the dis
t anc e f rom t he c enter of the rotor to t he outer most p oint of t he
c up, tub e, or tr unnion w hen t he rotor is in mot ion (Fig . 7.2).
It is imp or t ant t hat t he c ent rif uge brake is not us e d be c aus e
t his w i l l caus e t he s e diment to resusp end, resu lt ing in errone
˛is te chnique f aci litates unifor m dist r ibut ion of the for me d
elements throug hout t he vie w ing are a of the slide.
Gl ass micros cope slides and coverslips are not re com
mende d b e c ause t hey do not y ield st andardize d, repro ducible
If gl ass slides are us e d, t he lab orator i an should a lways
Conversion of the Number of Formed Elements Present in a Microscopic Field to
the Number of Formed Elements Present in a Volume of Urine
Calculate the areas of the low-power (LPF) and high-power
(HPF) ˜elds of view for your microscope using the formula:
0.5 mm (ocular ˜eld number 20)
White blood cells (neutrophils) st ained with 0.5%
Oval fat body st ained with Sudan III st ain. Note the
characteristic orange-red coloration of neutral fat (triglyceride)
Visualization Techniques to Aid in the Microscopic Examination of Urine Sediment
A supravital st ain that characteristically stains cellular structures and other
formed elements
Hans el st ain (met hy lene blue and eosin-Y in methanol)
is us e d in t he ur inalysis l ab orator y spe ci˜c a lly to ident if y
e osinophils in t he urine (Fig. 7.9). Where as Wr ig ht™s st ain
or Giems a st ain a ls o distinguishes eosinophi ls, Hans el st ain
i s p re f e r re d .
C holesterol droplets are birefr ingent (i.e., the y refrac t lig ht in
t wo dire c t ions) and, simi l ar to t heir c ounter p ar t tr ig lyc er ides,
t he y c an be found as f re e-˚o at ing droplets or in c el ls (ova l fat
b o dies) and casts. In droplet for mŠw it hin c el ls, f re e ˚o at ing ,
or in c astsŠcholesterol pro duc es a charac ter ist ic
has b e en mo di˜e d for mo du l at ion cont rast micros copy, it c an
e asi ly b e us ed for br ig ht ˜eld, p ol ar izing, and ot her te chniques
by simply remov ing t he sp eci a liz e d slit ap er ture from t he
Cy to c entr i f u g ati on
is a te chnique us e d to produce
ur ina lysis.) Nor ma l ly, a fe w RB Cs, WB Cs, epit helia l c el ls, and
hya line c asts are obs er ve d in the ur ine s e diment f rom nor ma l,
he a lthy indiv idu als. ˛eir actu a l numb er var ies dep ending
on t he s e diment prep arat ion protoc ol and t he st and ardiz e d
slide system us ed for t he micros c opic examinat ion.
Forms of Red Blood Cells in Urine
Biconcave disk form of normal size
Cell with evenly spaced projections or spicules over cell
surface; thisfireversiblefl shape change progresses from a
Cell with thin membrane and without hemoglobin
in ur ine or iginate f rom t he vas c u l ar system. ˛e inte g rit y
of t he nor ma l vasc u l ar b ar r ier in t he k idne ys or t he ur inar y
t ract can b e d amage d by injur y or dise as e, c ausing le a kage of
RB Cs into any p art of t he ur inar y t rac t . Incre as ed numbers
of RB Cs a long w it h re d RBC casts indicate renal ble eding ,
fore any condit ion t hat resu lts in in˚ ammat ion or t hat
c ompromis es t he inte g rit y of t he vasc u l ar system t hrough
out t he ur inar y t rac t c an resu lt in hematur i a. Ke ep in mind
t hat sp e cimens c ont aminate d wit h blo o d f rom vag ina l s e cre
t ions or hemor rhoid a l blo o d c an fa ls ely imply hematuri a.
Anot her de generative change is t he development of
numerous ˜nger-li ke or wor m-like proj ec t ions protr uding
f rom t he c ell sur f ace (Fig . 7.20). ˛es e long ˜ laments, terme d
my elin f o r m s
, resu lt f rom t he bre akdown of the c el l mem
owing to excess hydration or when
dist inguish f rom leu ko c ytes. A 2% ac et ic acid s olut ion or,
b etter yet, a 0.5% toluidine blue st ain helps re ve a l t he nucle
ar det ai ls of t he cel ls pres ent , w hich in turn enables prop er
c el l identi ˜c ation. ˛e l arge, dens e nuclei of c ol le ct i ng duc t
in a cytospin of urine sediment;
Macrophages and several other white blood cells. (A) Bright˜eld,
c ont rast, ly mpho c ytes pre dominate in urine f rom p at ients
exp eriencing rena l t ranspl ant rej ec t ion. B ec aus e ly mphoc ytes
do not c ont ain LE s, t he y w i l l not pro duc e a posit ive LE test
obs er ved, such as unusu a l siz e, shap e, inclusions, or nucle ar
chromat in p atter n, addit iona l c ytologic studies are ne c ess ar y.
˛es e c el ls may indic ate ne opl asi a in t he genitour inary t ract or
c an resu lt from t reat ments, such as chemot herapy or radi at ion.
Basica l ly thre e typ es of epit heli al c ells are obs er ved in urine
Epithelial Cells: Microscopic Features and Clinical Signi˜cance
Approximately the size of a red blood cell or a white blood cell.
Over time, cells in urine absorb water to become swollen, and the ˚at edge may not
be as noticeable.
Two squamous epithelial cells. The cell on the left
is presenting a side view, demonstrating how ˚at these cells
are. The upper edge of the cell on the right is curled, produc
ing an unusual form. Phase contrast,
(A) A single squamous epithelial cell, a fragment of
De coy c ells are t ransit iona l or rena l tubu l ar epit heli a l c ells
t hat are infe cte d w it h p olyomav irus of t he BK v ir us (BKV )
or ig inate d b e caus e of t he resembl anc e
and p otent i a l misidenti˜c at ion of thes e c el ls in ur ine as ma lig
nant cel ls. ˛es e infe c te d epit helia l cel ls have en l arge d nuclei
Be caus e t he c ytopl asm of
c onvolute d tubu l ar c ells is co ars ely g ranu l ar, t heir nuclei are
not re adily v isible w hen phas e c ont rast micros c opy is us ed, and
t hese cel ls c an res emble g ranu lar casts. Using br ig ht ˜eld mi
cros copy and st aining t he ur ine s e diment g re at ly en hanc e v isu
Renal collecting duct epithelial cells. (A) Two cells with an int act edge and
eccentric nuclei.
40 0. (B) Six renal tubular epithelial cells. Based on their cuboidal
shape and nucleus-to-cytoplasm ratio, these cells are from a small collecting duct.
Bright˜eld,
(A) Fragment of renal epithelial cells from a large collecting duct. Bright˜eld,
Fragment of renal collecting duct epithelial cells in fispindlefl form, indicative of
regeneration of
op ening on t he ab domen (stoma), w here it is c ol lec te d in an
exter na l drainable p ouch. When a
c o nt in e nt ur in ary div ersi o n
is p er for med, an inter na l p ouch is made from intest ine and it
is c onne c te d to t he ab domina l surf ac e at an op ening c a lle d a
c ast b eing for me d. ˛e ˜rst (nar rower) cast b ec omes c om
press e d to for m a c ast t hat appe ars c onvoluted (Fig . 7.38).
B e caus e c asts c an be ret aine d in t he tubule for var y ing lengths
of t ime, t he substanc es enmeshe d in t heir matr ic es c an disin
te g rate. In addit ion, t he cast mat rix itself c an undergo changes
˛e imp or t anc e of a p at ient histor y including t he di ag nosis
and a list of me dic at ions c annot b e overemphasiz e d. A pat ient
histor y prov ides infor mat ion t hat c an supp or t or acc ount for
t he numb ers and t yp es of for me d elements obs er ved. Note
t hat physic a l exercis e and emot iona l st ress c an a˙e ct t he
Granules from renal cell metabolic byproducts
trapped cellular debris, and met abolic
Not associated with any speci˜c disease
A rare cast may be obser ved after cont act
(e.g ., bacterial or viral pyelonephritis)
10 0. See Fig . 7.12 for an interference contrast image of this same
Cast, part granular and part waxy. Note the differ
ence in cast diameter at one end compared with the other.
This indicates initial cast formation in a narrow tubular lumen
followed by st asis in a tubule with a wider lumen and further
If ur ine st asis is suˆcient , er yt hro c yte c asts de generate
into pig mente d, g ranu l ar casts c a l le d
(Fig. 7.48). ˛es e re d to golden-brow n g ranu l ar
c asts c ont ain no dist inct RB Cs in t heir matr ix be c aus e t he
c el ls have lys e d and undergone de generat ion. ˛is pro c ess
˛e pres enc e of WB C c asts indicates rena l in˚ ammat ion
or infec t ion and re quires f urt her clinica l invest igat ion. ˛e
or ig in of t he WB Cs, g lomer u lar or tubu l ar, can be diˆc u lt
to deter mine. If g lomer u lar (e.g ., g lomeru lonephr it is), RBC
c asts w i l l a ls o be present and in g re ater numb ers t han WB C
g ranu l at ion is not clinic al ly signi˜c ant . Easi ly v ie wed w it h br ig ht
˜eld micros c opy b ec aus e of t heir high refrac t ive index, g ranu l ar
c asts o˝en app e ar c olorless to shades of yel low. Granul ar c asts
c an app e ar in a l l shap es and siz es, and bro ad g ranu l ar c asts are
c onsidere d to b e an indic ator of p o or prognosis.
tubu l ar epit helium as wel l as c aus e tubu l ar obst r uc tion. As
a resu lt , var y ing amounts of hematuri a usu a lly ac c ompany
cr yst a lline c asts in the ur ine s e diment.
Pig mente d c asts, usu a l ly of a hya
line mat r ix w it h distinc t c olorat ion, are charac ter iz e d by in
c olor to ur ine, do es not c olor t he for me d elements of t he s e di
ment . Hig hly pig mente d drugs, such as phenaz opy r idine, c an
a ls o charac ter ist ic a l ly color s e diment elements.
Bro ad c asts indic ate c ast for mat ion in di l ate d tubu les
or in t he l arge col le c t ing ducts (Fig . 7.59). B ec aus e s e veral
Cr yst a ls such as amor phous urates and phosphates c an
ag g re gate together or along a muc us t hre ad to simu l ate a c ast .
Wit h p ol ar izing micros c opy, t heir biref r ingenc e ident i˜es
t hem as cr yst a l line entit ies, and t he l ack of a dist inc t mat r ix
di˙erent iates t hem from a tr ue cast .
m). Ye asts do not diss olve in acid and usu a l ly
do not st ain w it h suprav it a l st ains; t hes e t wo charac ter istics
c an aid in di˙erent iat ing t hem f rom er yt hro c ytes. In addit ion,
ye ast are resist ant to KOHŠpl ac e a drop of urine s e diment on
a micros c op e slide, add a drop of KOH and a c overslip, and
may b e found phago c ytiz e d w it hin WB Cs (Fig. 7.64). In
i mmu nosuppress e d p at ient s , systemic
c ommon, and ye asts have a pre dile c t ion for t he k idne ys. Note
t hat dur ing t he micros copic examinat ion, on ly t he pres ence of
ye ast c an be determine d; ident i˜c at ion of t he spe cies pres ent
and inter ference c ontrast micros c opy p er mit en hance d imaging
and v isu a lizat ion of t he ˚ agel l a and undu l at ing membranes of
t r ichomonads; howe ver, t heir charac ter ist ic movement is sti l l
re quire d to sp e ci˜c a lly ident if y t hem.
Squ amous epit helia l cel ls from t he vag ina l muc os a w it h large
Muc us, a ˜br i ll ar protein, c ommon ly app e ars in ur ine
s e diment and has no clinic a l sig ni˜canc e. In unst aine d ur ine
s e diment wit h br ig ht ˜eld microsc opy, muc us c an b e diˆc u lt
to obs er ve b ec aus e of its low ref ract ive index. Howe ver,
w hen phas e cont rast or inter ference c ont rast micros copy is
Mucus. (A) Several mucus threads and t wo hyaline
10 0. (B) A mass of mucus surround
ing a ˜ber (cont aminant). Bright˜eld,
Chemical structures of triglyceride (triacylglycerol or
neutral fat), cholesterol, and cholesterol esters.
fiCr yst a lsfl l ater in t his chapter for more dis cussion of t he
unique features of cholesterol cryst a ls.
L ipi du r i a
is a lways clinic a l ly sig ni˜c ant , a lt houg h its
pres enc e do es not pinp oint a sp e ci˜c di ag nosis. L ipidur i a is
t he pres enc e of sp er m in ur ine from fema les b ec aus e it c ou ld
p otent ia l ly ident if y s exu a l abus e in underage vulnerable
indiv idu a ls and thos e w ith intel le c tu a l or de velopment a l
dis abi lities. ˛is infor mat ion enables t he he a lthc are prov ider
to appropr iately inter vene if ne c ess ary.
Se vera l f ac tors in˚uence cr yst a l for mat ion, including (1) the
c onc entrat ion of t he solute in t he ur ine, (2) t he urine pH, and
(3) t he ˚ow of urine t hroug h t he tubu les. As t he g lomer u lar
u lt ra˜ lt rate p ass es t hroug h t he tubu les, s olutes w it hin t he
lumen ˚uid are c onc ent rate d. If an incre ase d amount of a
Crystals of Normal Urine SolutesArrangedAccording to pH
inf ants. Monos odium urate cr yst a ls can b e pres ent w hen t he
ur ine pH is acid and diss olve at 60°C. ˛e y have no clinica l
sig ni˜c anc e and usu al ly are rep orte d as fiurate cryst a ls.fl
Ur ic acid cryst a ls o c c ur in many forms; t he
most c ommon are rhombic or di amond shap es (Figs. 7.80
c yst ine cr yst a ls. When t hes e hexagons are elongated (Fig.
7.85), t he y must b e di˙erent i ate d f rom a simi l ar at ypic a l
for m of ca lcium oxa l ate monohydrate cr yst a ls, w hich can
b e done using c olor, pH, and s olubi lit y character ist ics (s e e
Ur ic acid cr yst a ls are yel low to golden-brow n, and t he
Calcium oxalate dihydrate cr yst als (
Three uncommon dodecahedral (12-sided) crystals. Bright
Calcium oxalate cr yst als. Three dihydrate bi-pyrami
dal forms and one monohydrate ovoid form
ur ine of any pH. C a lcium and oxa l ate are s olutes nor ma lly
Calcium oxalate cr yst als. Small ovoid monohydrate (whewellite) cr yst als that
resem
ble erythrocytes, and t wo large t ypical envelope forms of dihydrate (weddellite)
crystals.
40 0. The strong birefringence of the small ovoid
monohydrate cr yst als helps distinguish them from erythrocytes. Note that the
dihydrate cr yst als
Calcium oxalate cr yst als. At ypical ovoid form that
for m of dib asic c alcium phosphate cr yst a ls are t hin, long ne e
d les arrange d in bundles or she aves (Fig . 7.96). In c ont rast,
monob asic c a lcium phosphate cr yst a ls usu a l ly app ear micro
s c opica l ly as ir re gu l ar granu l ar she ets (Fig . 7.97) or ˚ at pl ates
t hat c an b e l arge and may even b e notic e d ˚o at ing on t he top
shap e. Under p ol ar izing micros copy, t he y are st rong ly bire
f r ingent , w hich aids in di˙erent i at ing t hem f rom b ac ter ia t hat
are not biref r ingent . C a lcium car b onate cryst a ls are usu a l ly
found in p airs, g iv ing t hem a dumbbel l shap e, or as tetrads.
˛e y may a ls o b e enc ountere d as ag gre gate mass es t hat are
t hes e condit ions, t he conc ent rat ion of t y rosine and leucine
in the blo o d is hig h (amino acidemi a), resu lt ing in incre as e d
rena l excret ion. A lt hough rare, t hes e cr yst als have a ls o b e en
obs er ve d in the ur ine of p at ients w it h s evere liver dis e as e.
Calcium carbonate. (A) Numerous single cr yst als. Bright˜eld,
t y rosine or leucine b efore t he y are rep or te d. Techniques avai l
able to sp e ci˜c al ly ident if y them include chromatog raphic
met ho ds, FTIR and ult rav iolet sp ec t romet ry.
Cholesterol cr yst a ls app e ar as cle ar, t hin
p ara llelog ram-shape d pl ates (Fig. 7.105). ˛eir shap e and siz e
Cholesterol cryst a l for mation o c c urs in v it ro, t hat is, t he
cr yst a ls are induc ed out of s olut ion by t he c o oling of ur ine
a˝er c ol le c tion and storage. ˛erefore in s ome inst itut ions,
t hes e cr yst a ls are not rep or ted. Inste ad, lipiduri a or chyluri a is
do c umente d in t he urina lysis report by t he enumerat ion and
(A) View of urine sediment with a cholesterol cr yst al, free-˚oating fat, and oval
fat bodies. Bright˜eld,
20 0. (B) Cholesterol cryst al. Phase contrast,
Cholesterol cr yst als show weak birefringence
under polarizing microscopy. Note that birefringence will
increase with cr yst al thickness. Polarizing microscopy with
cr yst als; but form pseudo-
s o dium (c at ion) or a mixture of t hes e two c at ions. ˛e y
are k nown by numerous pro duc t names such as di at r iz o ate
(Hypaque, R enogra˜n, Cystog ra˜n), met riz o ate (Isop aque),
and iotha l amate (C onray). Note that in t he Unite d St ates, t hes e
o c cur at a less opt ima l pH w hen the c oncent rat ion of t he s olute
is ver y hig h. It is a ls o imp or t ant to note t hat s ome dr ugs (na˝ i
drof ry l oxa l ate [a vas o di l ator], orlistat [ora l in hibitor of lip as e])
as wel l as s ome i atrogenic subst ances (et hylene g lyc ol, toluene
in ha lants) c an c aus e a cr yst a l luri aŠnot of t he dr ug itself but
most o˝en obs er ve d in neut ra l to al ka line (pH
Su l fon a m i d e s .
Su lfonamide dr ug cr yst a ls appe ar in acid
6). ˛e y c an t a ke various for ms dep ending on t he p ar
t icu l ar dr ug pres cr ib e d. Histor ic a lly, sulfonamide prep arations
c an aid in c or re c tly ident if y ing t hem. Note t hat it is equ a l ly
imp erat ive t hat a micros c opist is able to ident if y c ont am
inants and ar t if ac ts t hat shou ld be disre garde d as it is t hat
t he y can properly ident if y elements of clinic a l imp or t anc e.
Note t hat addit iona l images of c ont aminants c an a ls o b e
s ourc es, ˜bers have a var iet y of appe aranc es. ˛e y c an b e long
or shor t, w ide or t hin, smo oth, w r in k led, t w isted or f raye d.
One c ommon fe ature is t heir st rong biref r ingence under p o
l ar izing micros c opy.
Fib ers from clot hing , gauz e dressings, or hair are usu a l ly
not have w rin k les (s e e Fig. 7.60 and Ur ine S e diment Image
G a l lery, Fig. 7). ˛e strong biref r ingenc e of ˜b ers a ls o dif
ferent i ates t hem f rom mat r ix of c asts, w hich are not biref r in
gent (c omp are Fig . 7.60 [˜b er] to Figs. 7.54B and 7.56B [c ast
Any cream, lot ion, detergent , or
have a fe w epit heli a l c ells, a rare RBC, and fe w WB Cs (s e e
Table 7.4). A fe w hyaline c asts or an o cc asiona l ˜nely g ranu lar
c ast may a lso b e obs er ved, but b e c ause t he ur inar y t ract is
ster i le, micro organisms such as b ac teri a and ye ast should not
b e pres ent . Note t hat hya line c asts are not listed in t his t able
Courtesy Michel Daudon, Laboratoire des Lithiasis, APHP, HopitalTenon, Paris,
France.
, ed 3, Milan, Italy, 2010, Elsevier Srl.
Courtesy Hrafnhildur Runolfsdottir, Runolfur Palsson, andV. Edvardsson,APRT
De˜ciency Research Program, Landspitali,The National
University Hospit al in Reykjavik, Iceland.
Cr yst als in each section are listed in order of prevalence, i.e., the most
frequently seen are listed ˜rst.
Which of t he fol low ing are not st andardiz e d w hen
c ommerci a l systems are us ed for t he pro c essing and
microsc opic examinat ion of ur ine s e diment?
Micros c opic var i ables, such as t he numb er of foc a l pl anes
˛e c oncent rat ion and volume of t he ur ine s e diment
˛e mic ros c opic ident i ˜c at ion of hemosider i n is
en hanc e d when t he ur ine s e diment is st aine d w ith
When t he lab orator i an per for ms t he micros c opic exami
nat ion of urine s e diment , w hich of the fol low ing are
enumerated using low-power mag ni˜c ation?
Ur inar y casts are for med in
e dist a l and c ol le ct ing tubu les.
t he dist al tubu les and t he lo ops of Hen le.
t he proxima l and dist a l tubu les.
t he proxima l tubu les and the lo ops of Henle.
D ur ing t he micros copic examinat ion of a ur ine
s e diment , c yst ine cryst a ls are found. ˛e lab orator ian
shou ld per for m w hich of t he fol low ing before rep ort ing
t he presenc e of t hese cr yst a ls?
or m a con˜r mator y chemic a l test
A 22-year-old woman is seen in the emergency department.
She complains of a painful burning sensation (dysuria) when
urinating. She also st ates that she feels as if she has fito gofl all
the time. A midstream clean catch urine specimen is collected
for a routine urinalysis and culture.
A 36-year-old man with a histor y of diabetes mellitus is admit
ted to the hospit al with the following complaints: decreased
frequency of urination, const ant fibloatedfl feeling, weight gain,
puffy eyes in the morning , and scrot al swelling. Mild edema of
the ankles, abdomen, and eyes is also noted. Routine chemis
A 30-year-old man is admitted to the hospit al with headache,
anorexia, and passing red-colored urine. Examination reveals
mild edema of the eyes and mild hypertension. Medical his
tor y reveals that the patient™s daughter had strep throat about
a month ago and was treated successfully. Subsequently, he
A 19-year-old female college athlete visits the campus health
clinic for a mandatory sports physical. She claims no health
problems and is taking no medications. A clean catch urine
specimen is collected for a routine urinalysis, and the following
Cr yst als/hpf: few uric acid
A 37-year-old man was found unconscious outside a homeless
shelter. From the individuals that called the ˜rst responders, it
was reported that he abuses alcohol. He was t aken to the local
emergency room and found to be in severe met abolic acidosis
with signs of renal failureŠhyperkalemia, high plasma creati
a c ute i nter s t it i a l n e p h rit i s
a c ute p oststrepto c o c c a l gl omer u l onephritis
a c ute p y e l on e p h r it i s
a c ute ki dn e y injur y (AKI)
a c ute tubul ar n e cro sis (ATN)
t he on ly organ involve d.
P r i m ar y
g lomer u l ar d is orders , c ol
, c onsist of se vera l dif
Four dist inct mor pholog ic changes of g lomer uli are re c og
injur y, and t he rapidit y of dis e as e ons et . A cl assic example of
a c ondit ion charac ter iz ed by a l l t he fe atures of a
is acute p ostst repto c o c ca l g lomer u lonephr it is. In
c ontr a s t , som e f orm s of gl om e r ul on e p h rit i s a re a s y mp t
om
at ic and are dete cte d on ly w hen rout ine s cre ening re ve a ls
Nephrot ic sy ndrome o c curs in pat ients w it h minima l
change dis e as e (MCD; lip oid nephrosis), membranous g lo
mer ulonephr it is (MGN), fo ca l s e g ment a l g lomer u losclerosis,
and MPGN. ˘es e g lomer u l ar dis e ases acc ount for ab out 90%
of a l l nephrot ic sy ndrome c as es in chi ldren and ab out 75%
B e caus e t his dis e ase is immune-me di ate d, any bloo d or ur ine
c u ltures for infec t ious agents are negat ive. Blo o d tests re ve a l
an ele vate d ant ist reptolysin O t iter, a de crease in s er um c om
plement , and t he presenc e of cryog lobu lins. In addit ion, t he
cre at inine cle aranc e is de cre ase d and t he rat io of blo o d ure a
FSGS can o c cur (1) as a pr imar y g lomeru l ar dis eas e;
(2) in ass o ciat ion wit h anot her g lomer u lar dis e as e, such as
IgA nephrop at hy ; or (3) s e condar y to ot her dis orders. Heroin
abus e, ac quire d immuno de˛cienc y sy ndrome (AIDS), re˚ux
nephrop at hy, and analgesic abus e nephrop at hy are s ome c on
Di ab e tes m el litus
is anot her systemic d is order t hat
f re quent ly resu lts in k idne y dis e as e. ˘e most c ommon rena l
c ondit ions in di abet ic pat ients pres ent as a g lomeru l ar sy n
drome. Howe ver, ot her rena l dis eas es o c c ur and include vas
c epha losp or ins, amphotericin B, indinav ir, ac yclov ir, fos c ar net),
anest het ics (en˚urane, met hoxy ˚urane), radiog raphic cont rast
me di a, chemot herap eut ic dr ugs (c yclosp orine), re cre at iona l
dr ugs (heroin, c o c aine), and indust r i a l chemica ls such as he av y
met a ls (merc ur y, le ad), organic s olvents (c ar b on tet rach lor ide,
f unc tion. B e c aus e rena l tubu lar dis orders do not a˜e ct g lo
mer ul ar f unc t ion, the GFR is usu a lly nor ma l. ˘is s ec t ion
dis c uss es c ommon ly encountere d tubu lar dysf unct ions, and
out lines t he t ypic al ur ina lysis ˛ndings ass o ciate d
us e d to charac ter ize any c ondit ion t hat presents w it h a gen
Pat ients w it h t yp e III RTA express charac terist ics of t yp e I
and t ype II RTA. Type IV RTA is charac ter iz ed by an imp aire d
abi lit y to exchange s o dium for pot assium and hydrogen in t he
Numerous c ondit ions c an g ive r is e to ac quire d RTA.
Approximately 30% of p at ients w it h ac quire d RTA t yp e I
U TIs are c ommon and a˜e c t females approximately 10 t imes
more oˇen t han ma les. ˘is predisp osit ion in fema les is due
to s e vera l f ac tors: a shor t uret hra w it h clos e proximity to t he
vag ina and re ctum; hor mones t hat en hanc e b ac ter i al ad her
enc e to muc os a; t he abs enc e of prost at ic ˚uid and its anti
tubu lointerst it i a l dis eas e; howe ver, most do not involve
t he rena l c a lyces and p elv is. ˘e most common caus es of
chronic pyelonephrit is are re˚ux nephrop athies, such as VUR
and int rarena l re˚ux, and chronic ur inary t rac t obst r uc
t ion. VUR was dis cuss e d pre v iously (s e e subs ec t ion Ac ute
If t his c ondit ion l asts long enoug h, t issue is chemia results. In
f ac t , is chemic ATN is t he most c ommon c aus e of AKI. O t her
c ondit ions that caus e a sudden re duc t ion in blo o d volume
and t hat are ass oci ate d w it h t his t yp e of AKI include hemor
rhages, burns, and surg ic al pro c e dures, as wel l as acute di ar
ot her urine proteins. Simi l arly, lipids of t he mat r ix include
cholesterol, t r i g lyc er ides , phosphol ipids , and gang l iosides .
Underly ing met ab olic or endo cr ine disorders, as wel l as
infe c tions and is ohydr i a (˛xe d ur inar y pH), c an c aus e or
en hanc e c a lcu lus for mat ion. When t he ur ine b e c omes super
excret ion or to bind ca lcium, resp ec t ively. Me dic at ions c an
a ls o b e us e d to c onvert a s olute to a more s oluble for m.
-p enicil l amine re duc es cyst ine for mat ion
t hroug h t he comp et it ive product ion of a s oluble s a lt , w here as
a l lopurinol re duc es uric acid for mat ion by a ltering purine
Glut aric acidemia t ype I
Glut aric acidemia t ype II
Carnitine upt ake or transfer defect
Glycogen storage disease t ype III (Pompe)
Spinal muscular atrophy due to deletion of
Amino acidur i as c an o c cur as a pr imar y or a s e c ond ary
dis e as e. ˘e pr imary dis e as es are a ls o know n as
inb or n e r rors
of m e tab o li s m
and resu lt f rom an in her ite d defe ct . Two t yp es
Major and minor pathways of phenylalanine met abolism.
pheny l a lanine is c onver te d to t y rosine by t he maj or met a
b olic p athway depic te d in
. Howe ver, in cl assic PKU,
t he enzy me pheny l a l anine hydroxy l as e is de˛cient or defe c
c ar t il age and ot her c onne ct ive tissues to c aus e an abnor ma l
d ark blue or bl ack t issue pig ment ation and t he de velopment
of de generat ive ar t hr it is. Al kaptonur i a is not usua l ly di ag
nos e d unt il midd le age (30Œ40 ye ars old), w hen art hr it is of
t he spine and l arge j oints develops and pig ment at ion in t he
Mel anin is pro duc e d f rom t y rosine by mel ano c ytes and
is t he pig ment resp onsible for t he c olor of hair, sk in, and
e yes. When in her ite d defe c ts resu lt in defe c t ive mel anin
pro duc tion, hyp omel anosis or a lbinism resu lts. Incre as e d
pro duc tion of mel anin and its c olorless pre curs ors (e.g .,
blo o d or ur ine. L ac tose, a dis ac char ide c omp os e d of g luc os e
and ga l ac tos e, is t he pr incip a l diet ar y s ourc e. G a l ac tosemi a
is ass o ciate d most oˇen w it h t hre e rare
in her ite d autos omal re c essive dis orders t hat c aus e an enzy me
in t he gal ac tos e met ab olic p at hway to be defe ct ive or de˛
pres ent , t his pat hway is ret arded or in hibite d such t hat on ly
t rac e amounts of t he p or phy r in prec urs ors are for me dŠAL A
1.4 mg/dL) and p orphobi linogen (
w hen su#cient heme is l acking , t he p at hway is st imu l ated
to incre as e its for mat ion. In dis orders in w hich an enzy me
and me dic at ions have be en ru le d out , porphy r i a shou ld be
Por phy ri as c an b e cl assi˛ed as hep atic or er yt hrop oiet ic
b as ed on t he site of the met ab olic abnor ma lit y; howe ver, cl as
si˛c at ion b as ed on clinic a l pres ent at ion is oˇen more pract ic a l
and us ef u l (
. 5t h ed. Ne w York: Churchi l l
Di ab etes C ont rol and C omplic at ions Tr ia l R es earch Group.
˘e e˜e ct of intensive tre at ment of diab etes on the de velop
ment and progression of long-term c omplic at ions of insu lin-
dep endent diab etes mel litus.
E ig ht y p erc ent of pat ients who de velop chronic
g lomeru lonephr it is pre v iously had s ome typ e of
g lomeru l ar dis ease. Which of t he follow ing dis orders
is implic ate d most fre quent ly in the de velopment of
c h ron ic g l om e ru l on e ph r it i s ?
Which of t he fol low ing dis e as es c an resu lt in s e vere ment a l
ret ard at ion if not dete c te d and t re ate d in t he inf ant?
Maple syr up ur ine dis e as e
A l k ap t o nu r i a
2, and 3 are cor re c t .
A 30-year-old woman is seen by her physician. She has a tem
perature of 101°F and reports nausea and headache, with ˚ank
(below ribs and above iliac crest) tenderness and pain. When
asked, she st ates that urination is sometimes painful, that she
must urinate much more frequently than usual, and that she
A 14-day-old baby girl is admitted to the hospit al with lethargy,
diarrhea, vomiting , and dif˜culty in feeding. Physical examina
tion reveals jaundice, an enlarged liver, and neurologic abnor
malities (e.g., increased muscular tonus). No blood group
incompatibility is found. She has lost 1.8
A 6-year-old boy is brought to the hospit al emergency depart
ment by his mother. This morning after his bath, she noticed
that his scrotum appeared swollen. In addition, for the past sev
eral days her son has been has been tiredŠthat is, de˜nitely
not his active selfŠand has been complaining of a headache.
Two days previous, a 26-year-old woman saw her primar y care
physician and it was determined that she had a urinary tract
infection. A conventional 10-day regimen of ampicillin was pre
scribed. Today, she returns to the clinic with a fever and urti
carial rash on her chest, back, face, and hands. The following
A 23-year-old woman is seen in the emergency room with
acute abdominal pain, nausea, and hypertension. She had a pre
vious admission 1 year ago for intestinal problems and neuro
logic symptoms (depression). At that time, gastrointestinal and
neurologic examinations were negative. She recently st arted
A˜er studying thi s chapter, the student should be able to
D es crib e t he format ion of c erebrospina l ˜uid (CSF ) and
st ate at le ast t hre e func t ions t hat the CSF p er forms.
D es crib e t he pro c e dure for lumb ar puncture and t he
prop er c ol le ct ion technique for CSF.
C erebro spin a l ˜ui d
(CSF ) b at hes t he brain and spina l c ord.
CSF is pro duc ed pr imar ily (70%) f rom s ecret ions into t he
ventr i c l e s
of the brain by t he hig h ly vasc u l ar
words, a l l subst anc es t hat enter or le ave the CSF must p ass
t hroug h t he membranes and c ytoplasm of t he c api l lar y endo
t heli al cel ls. ˝is mo du l at ing inter fac e b et we en t he blo o d and
t he CSF is c a l led t he
bl o o d-brain b ar r i er
t he c el lu l ar c omp onents, and teste d for t he pres enc e of
ant i gens . ˝es e cytolog ic, mic robiolog ic al, and i mmu nolog ic
studies can prov ide va lu able di ag nost ic infor mat ion. For CSF
referenc e inter va ls, s ee
Cerebrospina l ˜uid sp e cimens are c olle c te d sp e ci˛c a l ly for
a su˘cient volume of t he sp ecimen is t ransfer red to anot her
c ont ainer for c el l c ounts and any chemica l or immunolog ic
te s t s re qu e s ted.
˝e examinat ion and test ing of CSF shou ld t a ke pl ac e as
s o on as p ossible a˙er col le c tion. ˝erefore in most institu
1 and tub e 3 (or 4) w i ll show a sig ni˛c ant di˚erenc e (de cre as e).
In c ont rast , a hemor rhage resu lts in a homogene ous dist ribu
t ion of RBCs t hroug hout al l c ol lec t ion tubes.
Se c ond, a˙er c ent rif ugat ion of CSF, w hen t he sup er nate is
c olorless, it p oints to a t raumat ic t ap. In c ontrast , a xant ho
a l l of t he RB Cs pres ent resu lt f rom contaminat ion, and have
litt le clinic al us e. ˝erefore t his chapter does not des crib e
t hes e c orre c t ions in det ai l; re aders are refer re d to the bibliog
raphy for additiona l infor mat ion.
As w it h t he tot a l c el l c ount , wel l-mixe d, undi luted CSF
Cell Types and Causes of Cerebrospinal Fluid Pleocytosis
Intrathecal treatment (e.g ., drugs, myelography)
Response to RBCs or lipids inCSF resulting from:
Blood cont amination after lumbar puncture
Met ast atic tumors (e.g ., lung, breast,
sing le c ate gor y.
lists ot her c ondit ions demonst rat ing
CSF-ly mphoc yt ic ple oc ytosis.
In he a lt h, pl asma c el ls are not in CSF; t here
fore w hen pres ent , t he y should a lways b e note d. Ly mpho c ytes
found a˙er hemor rhage and var ious ot her c onditions b e caus e
of t heir act ive phago c ytic abi lit y. CNS proc e dures such as
myelography and pneumo encepha log raphy can stimu l ate an
incre as e in mono c ytes and macrophages in t he CSF t hat c an
p ersist for 2Œ3 we eks a˙er t he pro c e dure. Macrophages are c a
Macrophage with engulfed (intracellular) red blood
cells; can also be called an
, ed 3, St. Louis, 20 08, Saunders.)
granules that appear blue-black in its cytoplasm. Cerebrospinal
Siderophage with intracellular hematin cr yst als.
f rom ma lignant c el ls or ar tif ac tu a l clusters of ly mpho c ytes or
Ot her c el ls such as s qu amous epit heli a l cel ls, chondro cytes
(c ar ti l age cel ls), c ells or ig inating f rom bone mar row c ont ami
nat ion (e.g., nucle ate d RB Cs), spind le-shape d c el ls, neurons,
and ast ro cytes c an als o b e obs erve d in CSF. Li ke w is e, brain
ly mphoma, can a ls o resu lt in t he pres enc e of malig nant c ells
in t he CSF. In p at ients w it h lymphoma and ac ute ly mphobl as
t ic leu kemi a w it h meninge a l in˛ lt rat ion, incre as e d numb ers
of ly mphobl asts are pres ent (
ly mphoma ly mphobl asts are character ist ic a l ly unifor m in
proteins in t he blo o d pl asma c omp are d to CSF (
a t raumat ic t ap c an resu lt in sig ni˛c ant f a ls e elevation of
t he CSF tot a l protein. For mu l as to c or re c t for t he c ont r i
but ion of pl asma protein to CSF a˙er a t raumat ic t ap us e
t he RB C c ount obt aine d f rom t he s ame c ol le c t ion tub e.
Myelin, a primar i ly lipid subst anc e (70%), sur rounds t he
axons of ner ves and is ne cess ar y for prop er ner ve c onduc t ion.
˝e remaining 30% of myelin is made up of proteins, one of
w hich is myelin b asic protein. Wit h mu ltiple s clerosis and
ot her demyelinat ing dise as es, t he myelin sheaths undergo
f rom v ira l meningit is. In v iral meningit is, t he lac t ate level
rarely exc e e ds 25 to 30 mg/dL; in c ontrast , other for ms of
mening itis usu a l ly pro duc e CSF l ac t ate le vels g re ater t han 35
mg/dL. It is interest ing to note t hat incre as e d CSF l ac t ate le v
els are clos ely ass o ci ated w it h low CSF g luc os e levels and t hat
and vir us es c an b e c aus at ive agents. Aerobic cu ltur ing of CSF
enables t he is ol at ion of c ommon t yp es of b acter i a in 80% to
90% of c as es. However, if ant ibiot ic t herapy pre ce des CSF
c ol lec t ion, re c over y of b ac ter i al isolates f rom the spe cimen
c an b e sig ni˛c ant ly re duc e d. In susp e cte d c as es of tub erc u
Grant GH, Si lver man LM, C hristens on RH. Amino acids and
proteins. In: Tiet z NW, e d.
Fun d am e ntal s of C lini c al C h e mi s t r y
Phi l adelphi a: WB S aunders; 1987.
Nor mas ell DE, St ac y EK, Bo oker CF, et#al. D etec t ion of b eta-2
A l l of the fol low ing proteins are nor ma lly pres ent in the
˛br i no ge n .
Which of the fol low ing events do es not result in an
incre as ed CSF tot a l protein?
A t raumat ic punc ture pro c e dure
A 4-year-old girl is brought to the emergency room by her par
ents. She is lethargic, reports that her head hurts, and shows
signs of stiffness in her neck. Her mother st ates that she has
had fia temperaturefl for the past 2 days; her current tempera
ture is determined to be 104°C. She is admitted to the hospi
A˜er studying thi s chapter, the student should be able to:
D es crib e t he func t ion of serous membranes as the y
rel ate to t he for mat ion and abs or pt ion of serous ˜uid.
D es crib e four pat holog ic changes that le ad to t he
f or m ati on of a n e ˚ u s i on .
howe ver, t he opp osing surf ac es of t he membraneŠdespite
clos e c ont ac tŠare not att ache d to e ach ot her. Inste ad, t he
sp ac e b et we en t he opp osing sur f aces (i.e., b et we en the v is
c era l and pariet a l membranes) is ˝ lle d w it h a smal l amount
of ˜uid t hat s er ves as a lubr ic ant b et ween t he membranes,
A pleura l, p er ic ardia l, or p er itonea l e˚ usion is di agnose d
by a physic a l examinat ion of t he p atient and on the b asis
of radiog raphic , u lt ras ound, or echo c ardiog raphic imag
ing studies. ˛e col le c tion and clinica l test ing of pleura l,
p eric ardi a l, and p er itonea l ˜uids pl ay an impor t ant role in
p otent ia l chemic al changes, cel lu l ar de g rad at ion, and b ac te
r i a l proliferat ion. Note t hat refr igerat ion (4Œ8°C) advers ely
a˚e c ts t he v i abi lit y of micro organisms and shou ld not b e us e d
for s erous ˜uid sp e cimens. Howe ver, s erous ˜uid s amples
intende d for c ytolog y examinat ion are an exc ept ion and can
resu lt f rom p at holog ic changes of t he p ar iet a l membrane
(e.g ., b e c aus e of infec t ion or d amage) t hat c aus e an incre as e
in c api l lar y per me abilit y ; henc e t he maj or it y of p er ic ardi a l
e˚ usions c ou ld b e c onsidere d ex ud ates .
R eferenc e va lues for t he characterist ics of nor ma l s erous ˜uid
˛e micros c opic examinat ion of pleural, p eric ardi a l, and
p eritone a l ˜uids may include a tot a l c el l c ount of er yt hro c ytes
(re d blo o d c el ls, RB Cs) and leu ko cytes (w hite blo od c el ls,
WB Cs), a nucle ate d c ell di˚erent i a l count , c ytolog y studies,
and, at t imes, ident i˝cat ion of cr yst a ls. Note t hat in c ont rast
A di˚erent i a l nucle ate d c el l count is p er for med using a high-
p ower oi l immersion obj e c t ive (i.e., 50
t yp es t hat c an be pres ent in pleura l, p er ic ardia l, and p er ito
ne a l ˜uids include g ranu loc ytes (i.e., neutrophi ls, e osino
phi ls, b as ophi ls), ly mpho c ytes, pl asma c el ls, mononucle ar
in pleura l and p er ic ardi a l ˜uids, t hey are more o˙en s e en in
t he c erebrospina l ˜uid (s e e
) and sy nov i a l ˜uids.
In a macrophage, s e veral vacuoles c an merge toget her to
for m a sing le l arge vacuole. When t his o cc urs, t he nucleus
sig n e t r ing
shou ld not b e us e d w hen rep or ting macro
A det ai led disc ussion of t he for mat ion of t hes e var ious
macrophages is prov ide d in
C h ap t e r 9
t hat it is diˆc u lt to s e e t he nucleus. ˛ere is a g reater den
sit y of t hes e g ranu les in a mast c el l c omp ared w ith a b as ophi l.
˛e p eritonea l ˜uid in
shows a mast c el l b as ed on
its round, ec c ent r ic nucleus. It is unusu a l to se e bas ophi ls or
var ious inter me di ate c el l t ypes are for me d: re ac tive ly mpho
c ytes, pl asmac ytoid ly mpho cytes, and immunobl asts. When
mature, a pl asma c el l is 8 to 20
m in di ameter and has an
e c cent r ic round or ova l nucleus w it h no nucle oli and c o ars e
Clinical Value of the Nucleated Cell Differential
˛e clinic a l value of a nucle ate d c el l di˚erent i a l var ies w ith
t he or ig in of t he p arac entesis ˜uid. In
p l e ura l ˛ui d
phi ls pre dominate in ab out 90% of e˚ usions cause d by acute
a chy lous e˚ usion, w here as a t rig lyc er ide value of less t han
mg/dL r u les it out . If t he tr ig lycer ide le vel is b etwe en 50
mg/dL, lip oprotein ele c trophoresis c an be p er for me d;
t he pres enc e of chy lomic rons ident i ˝es a chylous e˚ usion ,
w hereas t he abs enc e of chylomicrons indic ates a pseudo chy
C linica l and L ab oratory St and ards Inst itute (CLSI). Bo dy F luid
Ana lysis for Cel lu l ar C omp osit ion: Approve d Guideline. CLSI
D o cument C49-A. Way ne, PA: CLSI; 2006.
Karcher DS, McPhers on R A. Cerebrospina l, sy nov i a l, s erous b o dy
˜uids, and a lter nat ive sp ecimens. In: McPhers on R A, Pincus
Which of the fol low ing fe atures is not a charac ter ist ic of
Ir re gu l ar nucle ar membr ane
Une ven nucle ar chromat in distr ibut ion
L ess than nor ma l nucleus-to-c ytopl asm rat io
Mu lt iple prominent nucle oli wit h ir regu l ar
A 48-year-old woman has ascites and pleural effusion. Blood is drawn and a
peritoneal ˚uid specimen is obt ained by paracentesis and
sent to the laborator y for evaluation.
Calculate the ˚uid-to-serum tot al protein ratio.
Calculate the ˚uid-to-serum lact ate dehydrogenase ratio.
Classify this peritoneal ˚uid specimen as a transudate or an exudate, and st ate t
wo physiologic mechanisms that can cause this
D e˜nitions are prov ide d in the chapter and gloss ary.
In are as of t he skeleton w here f r ic t ion c ou ld de velop, such as
t he j oints, burs ae, and tendon she at hs, v is c ous sy nov i a l ˚uid is
pres ent . Wit hin ar t icu l ate d di ar t hro di a l j oints (e.g., t he k ne e),
t he ends of apposing bones are c overe d w it h ar t ic u l ar c ar t il age,
in t he sy nov i a l membrane. ˛e most pre va lent t yp e is act ively
phago c yt ic and sy nthesiz es deg rad at ive enzymes (e.g ., col
l agenas es). ˛e s e c ond t ype of sy nov io cyte sy nt hesiz es hya l
uronate, a muc op olys ac char ide linked w it h approximately 2%
protein. ˛e sy nov io c ytes are lo os ely organiz e d in t he sy nov i a l
c ate gor ies: nonin˚ammator y, in˚ ammator y, s ept ic , or hem
or rhag ic. ˛es e general cl assi˜c at ions aid in di˝erent i al di ag
nosis of j oint dis e ase and are summar ize d in
imp or t ant note is that (1) t hes e c ate gor ies p art i a l ly overl ap,
(2) s e vera l c ondit ions can o c cur in t he joint at the s ame t ime,
studies. Be c aus e t he volume of synov i a l ˚uid pres ent c an var y
sig ni˜c ant ly, the amount c ollec te d and dist r ibute d into e ach
collec tion tub e will als o var y.
Note t hat using l arger volumes of sy nov i al ˚uid for cu ltures
c an en hanc e t he re c over y of microbi a l organisms; simi l arly,
tur bidit y are usu a l ly ident i˜e d by microsc opic examinat ion.
S ome subst anc es are e v ident up on gross v isu a l examinat ion
of sy nov i a l ˚uid. R ice b odies are w hite, f re e-˚o ating p art i
cles made up of c ol l agen c overe d by ˜br inous t issue.
res emble p olished, shiny grains of ric e and can var y g reat ly in
t he di˝erent ia l, including sy nov io c ytes, t he lining c ells of the
s y nov i al me mbr ane.
Sy nov io cytes c an b e diˆc u lt to di˝erent iate f rom mono
c ytes and t he y clos ely res emble mesot heli a l cel ls t hat are
found in pleura l and p eritone a l ˚uids (c ompare
examinat ion is ne c ess ary b e c aus e (1) t he number of cr ys
t a ls pres ent c an var y sig ni˜c ant ly w it h dis e as e (i.e., on ly a
fe w sma ll cr yst a ls may b e pres ent); (2) the di˝erent i at ion of
cr yst a ls is diˆc u lt b e caus e di˝erent t ypes of cr yst a ls clos ely
res emble e ach ot her; (3) free cryst a ls c an b e come enmeshe d
Note t hat cholesterol cr yst a ls are best ident i˜e d using a wet
prep or an fiunst aine dfl c ytospin slide b e c aus e Wr ig ht-Giems a
st aining c an c aus e cholesterol cr yst a ls to diss olve. C holesterol
cr yst a ls usu a lly app ear as ˚ at , re c t angu l ar pl ates w it h notche d
c orn e r s (
mor pholog ic a l ly and exhibit simil ar ne gat ive biref r ingenc e.
C or t ic osteroid cr yst a ls have no clinic al sig ni˜canc e ot her
t han indic at ing pre v ious inj e c t ion of t he drug into t he j oint .
Ca lcium oxa late di hydrate (
) and c a lcium oxal ate
exp er ienc ed micros c opist is able to di˝erent iate ar t if ac ts
b as e d on t heir ir re gu l ar or indist inc t mor pholog ic app e ar
anc e comp are d to cryst a ls. Note that ant ic o agu l ant-ass o ci a t ed
cr yst a ls (e.g ., c alcium oxa l ate, p owdere d EDTA) c an a ls o
b e phago c ytos e d by WB Cs a˙er c ol le c tion and storage.
involve d; approximately 75% of p at ients wit h st aphyloc o c c al
infe c tion (Gram-posit ive co c ci), 50% of p at ients w it h Gram-
ne gat ive organisms, and 40% of p at ients w ith gonoc o c c al
infe c tion (Gram-negat ive c o cci) are ident i˜e d as p osit ive by
Staphy lococcu s aure u s
C ohen AS, G oldenberg D.
Sy n ov i a l ˚uid
L ab orator y di ag n o s t i c
p ro c e dure s in t h e rh e um at i c di s e a se s
. Ne w York: Gr une &
˛e microsc opic examination of sy nov i a l ˚uid for cr ys
t a ls can b e diˆcu lt b e c ause
numerous art if ac ts are als o biref r ingent .
fe w cryst a ls may b e pres ent .
f re e-˚o at ing cryst a ls c an b ec ome enmeshe d or hid
A 51-year-old man has painful swelling in both knees. He is
hospit alized and an arthrocentesis is scheduled for the next
morning . In the morning, a fasting blood sample is drawn for
routine chemistr y tests. Synovial ˜uid is aspirated from the
right knee and submitted to the laborator y.
A 25-year-old professional football player is in an automobile
accident. His recover y is complete except for persistent swell
ing in his left knee. This same knee had been a chronic
before the accident, and he had received a corticosteroid
intraarticular injection 6 months earlier. An arthrocentesis is
A˜er studying thi s chapter, the student should be able to:
Dis c uss the c omposit ion of s emina l ˜uid and br ie˜y
des crib e t he f unc t ion of e ach of t he fol low ing st r uc tures
in s emina l ˜uid for mation:
Interst iti a l c ells of L e ydig
, or s emen, is a c omplex b o dy ˜uid us e d
or sp er matoz o a. It is ana lyz e d rout inely
to e va lu ate infer t i lit y and to fol low up a˝er a
v a s e c t o my
ensure its e˙e c t iveness. O ther re as ons for ana lysis include the
c el ls (sp er matogoni a) cont inuously undergo mitot ic div i
sion to produc e more germ c el ls. At t he s ame t ime, s ome of
t hem move slow ly toward the tubu lar lumen, chang ing in siz e
and undergoing meiotic (re duc t ion) div ision unt i l t he y for m
sp e r mat i ds .
ej ac u l ate, w here as t he prote olyt ic enzy mes are resp onsible for
its liquef act ion. Z inc is pr imar i ly added to s emen by t he pros
t ate g l and; howe ver, t he testes and sperm a ls o c ont r ibute zinc .
S emen zinc le vels c an b e us e d to evalu ate prost ate f unc tion; a
de cre as e d le vel is ass o ci ate d w it h prost ate g l and dis orders.
A˝er c omplete liquef ac t ion, t he
of t he s emen is
e va luate d using a Pasteur pip ette and obs er ving the drop
lets t hat form w hen t he ˜uid is a l lowed to f a l l by g rav ity. A
nor ma l sp e cimen is water y and for ms into discrete droplets.
Be c ause sp er m mot i lit y is a˙e c ted advers ely by tem
p erature, s ome l aborator ies cont rol t he temperature of
t he micros cop e slide at 37°C using an air c ur t ain incub a
O t hers per for m t he ana lysis at ro om temperature
Init i al ly, e ach wet mount is s creene d to ensure unifor mit y
sp er matoz o on is e videnc e of an unsucc essf u l vas e ctomy (i.e.,
re c ana lizat ion of t he vas deferens has o c c ur red), w here as low
numb ers of fi immot i lefl sp er m c an p ersist for mont hs in s ome
Sp erm mor pholog y, li ke mot i lit y, is rout inely ass ess ed sub
j e ct ively, henc e t his qu a lit at ive deter minat ion is subj e ct to
of t he sp er matoz o on and c an a˙e c t its siz e or shap e, or b ot h.
In addition, numerous sp er m var i at ions are found w it hin a
sing le ej ac u l ate. A lt houg h s ome mor pholog ic abnor ma lit ies
have b e en ass o ciate d w it h p ar t icu l ar dis orders (e.g ., t ap ered
he ads w ith var ic o c ele), most abnor malit ies are nonspe ci˚c .
sp er m are obs er ved, t his eva lu at ion deter mines whet her t he
sp er m are immot ile b e c aus e t he y are dead or b ec aus e of a
st r uctura l abnor ma lit y (e.g ., defe c t ive t ai l).
Eosin a lone or an eosin-nig rosin (a mo di˚cat ion of Blom™s
te chnique) combinat ion is f re quent ly us e d to deter mine
˛e determinat ion of fr uc tos e in s emen is a c ommon ly
p er for med chemica l test. B ec aus e f r uc tos e is pro duc e d
and s ecrete d by the s eminal vesicles, its pres ence in semen
re˜e cts t he s e cretor y f unc t ion of t his g l and and t he f unc
t iona l inte gr it y of t he ej ac u l ator y duc ts and vas deferens.
S emina l ˜uid ana lysis is rout inely p er for med to e va luate
w hich of the fol low ing?
Pro s t at e c an c e r
Po st v a s e c tomy st atu s
Pe n i le i mp l a nt st at u s
Which of the fol low ing st atements re garding sp er m
mor pholog y is t r ue ?
Sp er m mor pholog y is usua l ly e valu ate d using a per
St aine d sme ars of f resh s emen c an be us e d to eva lu
ate sp er m mor pholog y.
A˜er studying thi s chapter, the student should be able to:
Dis c uss the c ol lec t ion and prop er handling of vag inal
s e cret ion sp e cimens.
D es crib e t he per for manc e of e ach of t he fol low ing tests
and dis c uss the clinic al ly sig ni˜c ant ent it ies:
micros copist . ˚is f ac t shou ld not b e minimiz e d. If p ersonnel
w it h t he ne c ess ar y te chnic a l ski l ls and exper t is e are unavai l
able, test ing shou ld be refer red to a lab orator y w it h qu a li˜e d
p e rson n e l.
˚e C linica l L ab orator y Improvement Act has classi˜e d
p at ient™s menst r u a l st atus, exp osure to s exu a l ly t ransmitte d
dis e as es, and us e of vagina l lubr ic ants, cre ams, and douches.
Tests on vag ina l s e cret ion sp e cimens shou ld b e performe d
as s o on as p ossible. If a del ay in t ranspor t or ana lysis is unavoid
able, t hes e sp e cimens shou ld b e kept at ro om temp erature.
˜eld of v ie w. ˚is var iat ion is o˙en ass o ciate d w it h a woman™s
menst ru a l c ycle, w it h increas e d w hite blo o d c ells pres ent dur
ing ovu l at ion and mens es.
In c ont rast , re d blo o d c el ls usu a l ly
are not pres ent un less t he sp ecimen was c ol le cte d around or
nucleus-to-c ytopl asm rat io of 1:2. ˚e pres enc e of b asa l c el ls
in t he wet mount is abnor ma l. ˚es e c el ls are usu a l ly ac com
p anie d by numerous w hite blo o d c el ls in vag ina l s e cretion
sp e cimens f rom women w it h des qu amat ive in˝ ammatory
Tr ichomonads are ˝ agell ate d protoz oans t hat infec t and c aus e
prov ide propu lsion w hi le t he c onst ant wave-li ke mot ion of t he
undu l at ing membrane imp ar ts a rotar y mot ion to t he organism
). A single p oster ior axost y le is a ls o pres ent
and is b elie ve d to pl ay a role in t he att achment of t he organ
ism to t he vagina l muc os a and henc e is a p otent i a l c aus e of
t he l ac tob aci l li present in he alt h are repl ac e d by an over
G . v ag in a li s
and a f ac u lt at ive anaerob e, such as
Mob i lun c u s
M . c ur t i s ii
c ost ly and t ime c onsuming , t he y are reli able and have g re ater
clinica l s ensit iv it y and sp e ci˜cit y.
Topic a l antimyc ot ic agents f rom the f ami ly of imid az ole
der ivat ives pre dominate, such as mic onaz ole, clotr imaz ole,
buto c onaz ole, and terc onaz ole. Ora l agents appe ar to b e
Fibrone c t in is a c omplex and multif unc t iona l g lyc opro
tein found on c el l sur f ac es t hroug hout t he b o dy, as well
as in pl asma and amniot ic ˝uid. It is involve d in numer
ous imp or t ant f unc t ions including c el l-to-c el l ad hesion,
c el l-to-b as ement membrane att achment , clot st abi lizat ion,
Pl ac ent a l a lpha microg lobu lin-1 (PAMG-1) is a pl acent a l g ly
c oprotein t hat is a go o d marker for premature r upture of t he
amnion in pre g nant women (i.e., premature r upture of mem
branes [PROM]). PAMG-1 is pres ent at a hig h c onc ent rat ion
ng/mL) in amniot ic ˝uid, at a low c onc ent ra
S ob el JD. Vag init is.
Koneman EW, Al len SD, Jand a WM, etˆal.
book of diag nostic mic robiolo g y
. e d 5 Phi l adelphi a: Lippinc ott-
Hi l l GB. ˚e microbiolog y of bac ter i al vag inosis.
Which of the fol low ing st atements b est descr ib es the
microbi a l ˝ora of a he alt hy vag ina?
L arge Gram-posit ive rods pre dominate.
L arge Gram-posit ive co c ci predominate.
Sma l l Gram-ne gat ive ro ds pre dominate.
A 49-year-old perimenopausal female is seen by her gyne
cologist for a routine annual Pap smear. Before the examina
tion, the health care provider asked if she had any concerns,
to which the patient st ated that she has been noticing a foul
vaginal odor, particularly after intercourse with her husband.A
A˜er studying thi s chapter, the student should be able to
Dis c uss amniot ic ˜uid for mat ion and t he interac t ive role
t he fetus has in t he comp osit ion of the amniot ic ˜uid.
St ate at least four indic ations for p er for ming an amnio
c entesis and t he st age in pre g nanc y b est suite d for each
sur rounds t he fetus and is ˝l le d w it h t his ˜uid. Amniot ic ˜uid
prote c ts t he fetus w hi le enabling feta l movement and pl ays
an imp or t ant role in numerous bio chemic a l pro cess es. Fet a l
c el ls and many bio chemic al comp ounds, such as ele c t rolytes,
nit rogenous c omp ounds, proteins, enzy mes, lipids, and hor
Tests c an deter mine t he matur it y of t he fet a l pu lmonar y
system by ana lyzing sur f ac t ants in t he amniot ic ˜uid. If resu lts
indic ate an immature fet al pulmonar y system, ele c t ive deliver y
c an b e postp one d and cor t ic osteroids (b et amethas one) that
promote lung de velopment c an b e given, or ot her attempts
is pres ent and t he ˜uid is not ver y tur bid. As pre g nanc y pro
g resses, incre as ed amounts of feta l c ells, hair, and vernix are
sloug hed and remain susp ende d in t he amniot ic ˜uid. Two
te chniques t hat c an b e us ed to remove t he par t ic u late matter
c ausing the tur bidit y are cent r if ugat ion and ˝ lt rat ion.
amniot ic ˜uid shou ld not b e us e d. A lt hough le cit hin and
sphingomyelin are not present in me c onium, t he L/S rat io
obt aine d w hen me c onium-cont aminate d sp e cimens are
us e d is unreli able and must be interprete d w ith c aut ion,
˛e L/S rat io is a better predic tor of t he maturit y of feta l
R esu lts are rep or ted as ne gat ive (immature) or as low posi
t ive (mature) or hig h p osit ive (mature) b as e d on the siz e of
ag g lutinates and t he deg re e of backg round cle aranc e. ˛e
ag g lutinat ion test is simple to p er form and t a kes a minima l
minutes) c ompare d w it h t he more l ab or-
t he mater na l circu l at ion. B ec aus e t he fetus has an immature
liver, w hen a hemolyt ic dis eas e pro c ess c aus es incre as e d and
p ersistent hemolysis of fet al er yt hro c ytes, t he pro duct ion of
unc onjugate d bi lir ubin increases sig ni˝c antly. As a result , an
incre as ed amount of unc onjugate d bilir ubin enters t he amni
Howe ver, if s eri a l deter minations indic ate t hat va lues are in
z one II and are incre asing , t hen marke d hemolysis is t a king
pl ac e. Va lues in t he upp er most re g ion, z one III, indic ate t hat
t he fetus is exper iencing s e vere hemolysis and w il l die w it h
out i nter vent ion .
Di lena BA, Ku F, D oy le I, etˇal. Six alter nat ive metho ds to t he
le cit hin/sphingomyelin rat io in amniot ic ˜uid for ass essing
fet a l lung matur it y.
Ann C lin Bi o ch em
Ne erhof MG, D ohna l JC, Ashwo od ER , etˇal. L amel l ar
Which of the fol low ing condit ions c an c ause er yt hro
Immaturit y of t he feta l liver
D e cre as e d amounts of amniot ic ˜uid
Inade qu ate fet a l pu lmonar y sur f act ants
Mater na l immunizat ion by fet a l ant igens
A˜er studying thi s chapter, the student should be able to:
D es crib e t he comp osit ion and for mat ion of nor ma l
D es crib e t he e˜e c t of abnorma l intest ina l water
re abs or ption on t he c onsistenc y of fe ces.
E xpl ain the t hre e physiologic me chanisms that c aus e
C h emi ca l E xamin ati on, 342
Fe c al Blo o d, 342
Fet a l Hemog lobin in Fe c es (Apt Test), 344
Q u ant itat ive Fe c al Fat , 345
Fe c al C ar b ohydrates, 345
If the osmot ic gap (i.e., di˜erenc e b et ween t he me asure d
and c a lc u l ate d fe c a l osmol a lit y) exce e ds 20
p at ient is exp er iencing osmot ic di ar rhe a. If me asure d and
c a lcu l ate d fec a l osmol alit ies ag ree w it hin 10 to 20
t he pat ient is exper iencing se cretor y di arrhe a.
An Overview ofAcute Diarrhea: Nonin˜ammatory and In˜ammatory
Large volume of stool; nausea and vomiting (varies with pathogen)
Predominantly malabsorption (osmotic) and secretor y diarrhea; intestinal
Šdair y, meats, cream pies, mayonnaise-cont aining foods
Person-to-person contact; predominantly infants (day-care centers) or elderly
When di ar rhe a p ersists despite f ast ing , t he me chanism is
s e cretor y. ˆe volume of fec es excrete d d ai ly is sig ni˛c ant ly
incre as ed (2Œ3 t imes more), and p at ients compl ain t hat t he y
ne e d to get up during t he nig ht to defe cate. Various hor
mones and hor mone-se cret ing tumors are c aus es, as wel l as
Condit ions pro ducing ste ator rhe a can o c c ur simu ltane
ously w it h di ar rhe a. For appropr i ate p at ient management to
b e gin, t he c aus e of t he diar rhe a, ste ator rhe a, or b ot h must b e
ident i˛e d. Usu a lly, t his is achie ve d by fol lowing an a lgor it hm
simi lar to t hat in
and it is postul ate d to b e at le ast p art i a l ly resp onsible for
t he high nonc ompli anc e rate (50%Œ90%) in c ol le c t ing fec a l
sp e cimens for oc c u lt blo o d testing obs er ve d in studies of
c olore c t a l canc er.
In lig ht of t hes e f acts, p atient e duc at ion
dramat ic al ly, a change in fe ca l o dor may b e notic e d. For
example, ste ator rhe a resu lts in dist inc t ively foul-smel ling
fe c es b e c aus e of the b ac ter ia l bre a kdow n of undigeste d lipids.
Micros c opic examinat ion of t he fe ces is p er for me d on a p or t ion
of a sto ol susp ension and c an aid in di˜erent iat ing t he c aus e
Nor ma lly, neut rophi ls are not pres ent in fe c es, henc e t he
pres ence of e ven a sma l l numb er (one to thre e per hig h-p ower
˛eld) indic ates an invasive and in˚ ammator y condit ion. In
c ont rast , nonin˚ammator y diar rhe a l c ondit ions do not have
neut rophi ls in t heir fe c es. C eli ac spr ue and micros copic c olitis
of tot al f at (on t he s e c ond slide) indic ates intest inal ma l ab
s or pt ion. In ot her words, t he incre as e d f at pres ent c onsists of
pr imari ly f atty acids and s o aps t hat were not abs orb e d by t he
sma l l intest ine. In contrast , an incre as e d amount of neut ra l
f at on the ˛rst slide sug gests ma ldigest ion.
using t hes e slide-b as e d tests, t he c ol le ct ion of t hre e fe c a l
s amples is st and ard prac t ic e to maximiz e test s ensit iv it y.
Pat ients are inst r uc te d to s ample s e vera l p or t ions of a sing le
sto ol sp ecimen or, ide a lly, to c ol le c t fe c a l materi a l f rom sto ol
s amples on three di˜erent d ays. ˆe pat ient op ens t he fifrontfl
and have t he p otent i al to c aus e f a ls e-ne gat ive resu lts. Fa ls e-
ne gat ive resu lts c an a ls o b e produc e d w hen (1) t he p eroxide
de velop er is expire d, (2) slides are defec t ive (e.g ., expire d),
or (3) t he fe c a l sp e cimen or prep are d slide is store d for an
extende d per io d b efore test ing (e.g .,
A qu ant it at ive deter mination of fe c a l f at is t he de˛nitive test
for ste ator rhe a. A lt hough t his chemic a l test con˛r ms t hat
abnor ma l quant it ies of diet ar y lipids are b eing eliminate d,
it do es not ident if y t he c aus e of t he incre as e d excret ion.
For 3 d ays b efore sp e cimen c ol le ct ion, as well as dur ing
c ar b ohydrate ma l abs orpt ion f rom c ar b ohydrate maldiges
t ion, a xy los e abs or pt ion test is per for me d. Xy los e is a pentos e
t hat do es not depend on liver or p ancre at ic f unct ion for diges
t ion and is re adi ly abs or b e d in the sma l l intest ine. Nor ma l ly,
xy los e is not present at sig ni˛c ant le vels in t he blo o d, and t he
Which of the fol low ing tests is us e d to diag nos e steator
Fe c al c ar b ohydrates
Which of the fol low ing st atements ab out fec es is
ˆe nor mal c olor of fec es is primar i ly due to urobi
ˆe amount of fe c es produce d in 24
Which of the fol low ing st atements re garding the test for
fet a l hemog lobin in fec es (t he Apt test) is
Any adu lt hemog lobin pres ent shou ld resist a lka li
t r e atm e nt .
ˆe Apt test is us e d to di˜erent i ate var ious hemog lo
A 23-year-old woman sees her physician and reports headache,
nausea, fever, and diarrhea for the past week. She ˚rst experi
enced the diarrhea shortly after a summer picnic. She currently
has ˚ve to six bowel movements each day. The stool does not
appear bloody. A stool specimen is collected and the following
A˜er studying thi s chapter, the student should be able to:
D es crib e t he pr inciple of re˜e c t anc e photometr y.
Dis c uss and di˚erent i ate bet we en semi automate d and
f u l ly automate d ur ine chemist r y ana lyz ers.
St ate advant ages gaine d by p erfor ming automated ur ine
Automation of Urine and Body Fluid Analysis
de velop ed. A l l re agent st r ip re ading inst r uments, re gard less
of manufac turer, us e re˜e ct ance photomet ry to inter pret the
c olor for me d on e ach test pad. ˛es e
s e m i au t o m at e d
Automation of Urine and Body Fluid Analysis
f u l ly autom ate d
urine chemist ry ana lyz er, t he
us er simply pl ac es l ab eled tub es of ur ine into a s ample rack
or c arous el. Test ing is initi ate d by pressing a button on t he
Automation of Urine and Body Fluid Analysis
or ient ing t he p ar t icles in t he ur ine. ˛e ˜ow p at h is at a sp e
ci˝c dept h of fo c us t hat enables pre cis e micros c opic v ie w
ing . ˛e FOV of t he microsc op e is c ouple d to a dig it a l v ide o
c amera, and st rob os c opic i l luminat ion f re e z es the par t icles
Automation of Urine and Body Fluid Analysis
Sub cl assi˝c at ion is us e d to indic ate the sp e ci˝c typ es of cr ys
t a ls, c asts, and nons quamous epit heli a l c el ls pres ent, as wel l
as to ident if y ps eudohyphae, t r ichomonads, or f at (
Addit iona l f re e text c omments c an b e adde d to rep or ts as
Automation of Urine and Body Fluid Analysis
sma l l round c el ls (i.e., t ransit iona l or rena l c el ls), or sp er m.
D eter mining t he sp e ci˝c ident it y of elements in fi˜agge dfl
sp e cimens re quires a manu a l microsc opic re v ie w of t he ur ine
by t he us er or, in t he c as e of t he UF-5000, it c an b e linke d w it h
Automation of Urine and Body Fluid Analysis
for c ar r y-over bet we en sp ecimens.
˛e lo aded c uvette is
automat ic a lly ins er te d into a unique on-b o ard mini-c ent r i
f uge t hat c ent rif uges t he s ample at 260
Automation of Urine and Body Fluid Analysis
UriSed 2Autoclassi˜cation and Subclassi˜cation Categories for Urine Sediment
Cr yst als (CRY) and pathologic casts (PAT) can be reported as such, or the user
can speci˜cally subclassify by t ype.
Nonsquamous epithelial cells (NEC) can be reported as such, or the user can
speci˜cally subclassify as transitional or renal.
A Selection of FullyAutomated Urinalysis Systems
Automation of Urine and Body Fluid Analysis
ag re ement t he Ur iSe d 2 micros copy ana lyz er is p art of s e v
era l f u lly automate d ur inalysis systems in Europ e and Asia.
As e v ident in t he USA se c t ion of
c or porate ag re ements and c ombinat ions of urine chemist r y
Automation of Urine and Body Fluid Analysis
WB C di˚erent ia l is prov ide dŠmononucle ar
c el ls (MNCs; ly mpho c ytes and mono c ytes) and p oly mor
phonucle ar c el ls (PMNs; neut rophi ls, e osinophi ls, b as ophi ls).
Macrophages and mes ot helia l cel ls are c ounte d but are
Automation of Urine and Body Fluid Analysis
S el e ct t he
st atement re gard i ng re˜e c t anc e
˛e amount of light t hat is abs or b e d is dete c ted and
m e a s u red.
A˜er studying thi s chapter, the student should be able to:
St ate four fac tors t hat advers ely a˜e c t manua l c el l counts
p erforme d using a hemac ytometer.
Dis c uss advant ages and dis advant ages of e ach di luent
us e d to per for m bo dy ˚uid c ell c ounts.
of WB Cs in ˚uids ot her t han sy nov i a l ˚uid, t he ˚uid c an b e
fiexp ose dfl to g l aci al ac etic acid (
blo o dy ˚uids c an b e di lute d using di luents t hat (1) lyse RB Cs
and (2) en hance v isu a lizat ion of nucle ate d cel ls.
O˛en is otonic , part icle-f ree c ommerci a l di luents us ed by
c el ls in t he hemac ytometer. A ls o w hen prepar ing di lut ions
of unt re ate d sy nov i a l ˚uid, a posit ive displ ac ement pip ette
is re quire d to acc urately prep are di lut ions of t he ˚uid. An
a lter nat ive is to pret re at sy nov ia l ˚uid using t he enzy me
hya luronid as e. ˙is enzy me eliminates t he ˚uids™ v is c osit y
˙ere are t wo appro aches to using t his for mu l a, and
b ot h w i l l pro duc e the s ame resu lt . One appro ach is to c ount
b ot h chamb ers of t he hemac ytometer, c omp are t he c ounts
to ensure t hat pre cision criteri a are met, average t he c ount
(if ac cept able), and t hen us e the for mu l a to c a lc u l ate t he
Note t hat t he c ounts f rom b ot h chamb ers agre e w it hin pre ci
sion criter i a of less t han or e qua l to 20%, w hich indicates t hat
t he ˚uid was well mixe d and e quiva lent ly disp ens e d in b oth
chamb ers. ˙e di˜erenc e in cel l numb er b et we en side 1 and
side 2 (18 Π15) is 3 c el ls, w hich is less t han 20% (3.6 c el ls
Example C: Sperm Count Using Diluted Semen
A s emen sp ecimen was pret re ate d 1:2 using a bromelain
enzy me prep arat ion to get it to liquef y. For t he sp erm count ,
t he ˚uid is di lute d 1:20,
in du p lic at e
E ach ass embly is pl ac e d onto t he rotor of t he c yto c ent r i
f uge, and w hen t he instr ument is ac t ivate d, c ent r if uga l forc e
pu l ls t he b o dy ˚uid f rom t he s ample chamb er to t he micro
s c op e slide. ˙e c el ls ad here to t he gl ass slide w hi le t he liquid
is abs or b e d by t he sur rounding absor b ent ˝ lter p ap er. D ur ing
an older sp e cimen is us e d (i.e., not f resh).
To re duc e t hes e
ar t ifac ts, l ab oratories shou ld deter mine t he opt ima l sp e e d
and t ime of c yto cent r if ugat ion for t heir instr ument , us e f resh
sp e cimens, and prepare appropri ate di lut ions of ˚uids w it h
Br i g ht˜ eld Mi cro s c op e, 370
Me chanic a l St age, 372
C ondens er, 3 7 2
O bj e ct ives, 374
O c u l ar Fi el d Numb er, 375
A hig h-qu a lit y br ight ˜eld micros c op e is re quire d for t he
micros copic examinat ion of ur ine and ot her b o dy ˚uids. One
must g ive c onsiderable c are to its s ele c t ion b e caus e its us e is
an inte g ral p ar t of lab orator y work, and microsc op es w ith
qu a lity obj e c t ive lens es are c ost ly. B e c aus e some br ig ht˜eld
w here M is t he mag ni˜c at ion of the obj ec t ive and any addi
˛is sum do es not include t he e yepiec e
For example, an e yepiec e w it h a ˜eld numb er of 18 has a
1 obj e c t ive is us e d, a di ameter
10 obj e c t ive is us e d, and a di ameter of
sp e cimen, and (4) an il luminat ion s ourc e. E ach c omp onent
and its unique fe atures are disc uss e d next.
Where as s ome micros c op es have on ly one e yepie c e (mon
o c ul ar), t hos e us e d in most clinic al lab orator ies have t wo
e yepiec es (binoc u l ar). Howe ver, w hen using a mono c u lar
˛e pur p os e of t he ap er ture di aphrag m is to c ont rol t he angle
of t he i l luminat ion lig ht presente d to t he sp e cimen and t he
obj e c tive lens. When t he user prop erly adjusts t he ap er ture
di aphragm, he or she achie ves maxima l res olut ion, contrast ,
and de˜nit ion of t he sp e cimen. One of t he most c ommon mis
obj e c ti ve s
are t he most imp or t ant optic a l c omp onents
of the micros c ope b ec aus e t he y pro duc e t he pr imary image
mag ni˜cat ion. ˛e obj e ct ives are lo cate d on a rot at able nos e
pie c e; on ly one obj e c tive is us e d at a t ime. O bj e c tives are
obj e c tives are c or re c ted spher ic a l ly for g reen light , w here as
ap o chromats are c or re c ted spher ic al ly for g re en and blue
Ot her abbre v i at ions may b e eng rave d on the obje c t ive
to indic ate sp eci˜c lens t yp es. For example, fiPl anfl indicates
t hat t he lens is a pl an achromat , achromat ic a lly cor re c te d and
to achieve Köhler i l luminat ion.
g ives a b asic pro c e
dure for adjust ment of a t ypic a l bino c u l ar micros c ope w it h a
Köh ler i l luminat ion system. Where as init ia l ly t hes e steps may
fe el c umb ers ome, w it h us e t he y b ec ome rout ine. When using
Al l typ es of microsc opy (w it h t he exc ept ion of elec t ron
micros copy) us e t he s ame b asic magni˜c at ion pr inciples us e d
in t he c omp ound br ig ht ˜eld micros c op e. Diˇerent typ es of
micros copyŠphas e-c ont rast, pol ar izing , interferenc e c on
t rast , d ark ˜eld, and ˚uores c enc eŠare achie ve d by chang ing
p enetrat ing t he spe cimen. ˛e obj ec t ive us e d must b e ˜tte d
w it h a phas e-shi˙ing element, a ls o depic te d in
Note t hat t he phas e-shi˙ ing element a ls o res embles a t arget .
Howe ver, its c entra l r ing ret ards lig ht by one-qu ar ter of a
wavelengt h, pro ducing a d ark annu lus or r ing. ˛e lig ht and
Comparison of light ray orient ation in (A) regular
light (vibrating in all directions) and (B) polarized light (vibrating
Light entering a birefringent (biaxial) cr yst al is
refracted into t wo raysŠa slow ray and a fast rayŠthat
move in a perpendicular direction to each other. By conven
e yepiec e, usu a l ly in a sp eci a l fisliderfl lo c ated ab ove t he re volv
ing nos epie c e. Note t hat t he ana lyz er™s axis of t ransmission
is ˜xe d (ins crib e d on t he ana lyz er housing) and on ly al lows
lig ht vibrat ing on a sp e ci˜c pl ane to p ass. In
diˇerent housing st yles of p ol ar iz ers and ana lyz ers avai l able
(550-nm re g ion) such t hat t he g re en wavelengt hs cannot p ass
t hroug h t he ana lyz er. As such, t he FOV is no longer bl ack but
is re d-violet , henc e t he name
re d c omp e n s ator
chang ing t he b ackg round c olor, b e c aus e t he re d c omp ens ator
Appearances of Cholesterol and Starch Using Bright˜eld and Polarizing
St arch granule (a cont aminant)
Note that cholesterol droplets may also show a Maltese cross pattern with
quadrants. Usually when in clusters or within cells or casts.
For optimal viewing , the microscope should ˜rst be adjusted
i nte r fe re n c e c ont r a s t m i c ro sc op y
u l at ion cont rast (Hof f man) and different i al interferenc e
c ontrast (Nomarsk i). In inter ferenc e c ont rast micros c opy,
t he micros c op e conver ts dif ferenc es in t he opt ic a l p ath
t hrough t he sp ecimen to intensit y dif ferences in t he sp eci
as b eam splitters. One pr ism pl ace d b efore t he sp ecimen
pl ane splits t he i lluminat ion light into two be ams, w here as
t he s e c ond prism pl ace d a˙er t he obj e c tive re c ombines t hem.
˛e split b e ams fol low diˇerent light pat hs through t he sp e ci
men pl ane. ˛e y are rej oined b efore t he e yepie ce to pro duc e
that are p erp endic u l ar and do not inter fere with e ach ot her)
enter t he ana lyz er. ˛e ana lyz er pro duces t he inter ferenc e
image obs er ve d by chang ing t he dire c t ion of v ibrat ion of the
re c ombine d rays s o t hat t he y inter fere w it h e ach ot her. In
re a lit y, t wo images are for me d, but human e yes are unable
en hanc ed v isu al ly by the incre ase d cont rast . If no spe cimen
is pres ent , t he FOV app e ars black b e c aus e no lig ht is enter ing
t he obj e c t ive lens.
Dark ˜eld micros c opy is an inexp ensive me ans of obt ain
ing incre as e d cont rast to f acilit ate v isu a lizat ion of sp ecimen
(Modi˜ed from Hoffman Modulation Contrast System, Modulation Optics, Inc.,
Greenvale, NY.)
Not applicable; technique requires st aining with a ˚uorescent dye or the presence
of a naturally occurring ˚uorophore.
Contrast is optimal in thin sections, where structures are ˚at and differences in
the refractive index are small.
Not applicable; technique used only to obser ve unst ained specimens.
St ained with a ˚uorescent dye.
In a br ig ht ˜eld micros c op e, w hich lens pro duc es t he pri
mar y image mag ni˜c ation?
Eyepie c e (oc u lar)
Nu mer ic a l ap er tu re
A micros c op e has a
When v iew ing a fo cus e d sp e cimen in t he micros c op e,
t he us er s e es a sp e ck in the ˜eld of vie w. ˛e sp eck
remains in v ie w w hen t he obj e c t ive is change d and w hen
t he spe cimen is move d. ˛e sp eck is most likely lo c ated
e y e pi e c e .
Comparison of Reagent Strip Principles, Sensitivit y,And Speci˜city
Summary of Reagent Strip Sensitivity and Speci˜city
Drug-induced color changes, such as phenazopyridine, indican-
Improper storage or light exposure, which oxidizes or
hydrolyzes bilirubin to nonreactive biliverdin and free bilirubin
A. 42 mL/min (Note t hat t he pl asma and urine cre at inine
resu lts must ˜rst be c onver te d to t he s ame units.)
Sur f ac e are a: 1.80
Nor ma lize d cre at inine cle aranc e: 55 (54.7) mL/min
B e c aus e of damage to t he hypothal amus or t he p oster ior
Physic a l examinat ionŠl arge amount of w hite fo am
C hemic a l ex ami nat ion Š g luc os e, blo o d, protei n
˚e changes in t he g lomeru l ar ˜ lt rat ion b arr ier t hat are
now a llow ing increas e d qu antit ies of pl asma proteins to
p ass w ith t he u lt ra˜ lt rate into t he tubules are a ls o enabling
c ausing t issue hyp oxi a. ˚e d amage d mus cle t issue rele as es
myog lobin into t he blo o dst re am, w hich is subs e quent ly
cle are d from t he pl asma by t he k idne ys.
O dor and chemic a l examinationŠg luc os e, ketone
Dis crepant resu lts: Sp eci˜c g rav ity by re agent st r ip and
Fre e hemoglobin passes t he ˜ lt ration barr ier and is reab
s or b ed pr imar i ly by t he proxima l rena l tubu le (and to a
less er de g ree by t he dist a l tubules). ˚e tubu lar c ells c at ab
oliz e t he hemog lobin to fer r itin and subs e quent ly dena
ture it to for m hemosider in. When t hes e rena l cel ls are
D ysmorphic re d blo o d cel ls and re d bloo d c el l casts
Systemic lupus er yt hematosus is an autoimmune dis
order. Henc e a p ossible s cenar io for t he de velopment of
ac ute g lomer ulonephr it is in t his p at ient is t hat immune
c omplexes (ant ib odies against g lomer u l ar t issue antigens)
E xud ates resu lt f rom in˝ ammator y pro c ess es t hat incre as e
t he p er me abi lit y of t he c api ll ar y endot helium in t he p ar i
et a l membrane or de cre as e t he abs orpt ion of s erous ˝uid
by t he ly mphat ic system .
F luid-to-ser um tot al protein rat io: 0.45
B ac ter i a l vag inosis
O verg rowt h of anaerobic b ac teri a caus es incre as e d pro
duc t ion of se vera l met ab olic bypro duc ts, including p oly
amines, w hich vol ati liz e in an a l ka line env ironment to
pro duc e the fou l-smel ling t r imet hy l amine.
˚e s ensit iv it y of t he re agent st r ip urobi linogen test is
limited. ˚es e tests are not able to ac c urately detec t t he
abs enc e of or de cre ase d amounts of urobilinogen.
Fe c al abnor ma l ˜ndings: c onsistenc y ; leu ko c ytes;
S alm on el l a
dramat ic al ly and quick ly outdate. Howe ver, t he intent is to
prov ide an underst anding of t he ana lyt ic principles us ed
in automated inst r uments. In t his re gard, t he b asic ana lytic
pr inciples for ur ine chemic a l (re˚ec t anc e photomet r y) analy
sis have sto o d t he test of t ime and c ont inue to endure. ˛e
Urine Specimen Types, Collection, and Preservation
Pleural, Pericardial, and Peritoneal Fluid Analysis
Automation of Urine and Body Fluid Analysis
Body Fluid Analysis: Manual Hemacytometer Counts and Differential Slide Preparation
Appendix A: Reagent Strip Color Charts, 390
A. 42 mL/min (Note t hat t he pl asma and urine cre at inine
resu lts must ˜rst be c onver te d to t he s ame units.)
Sur f ac e are a: 1.80
Nor ma lize d cre at inine cle aranc e: 55 (54.7) mL/min
B e c aus e of damage to t he hypothal amus or t he p oster ior
Physic a l examinat ionŠl arge amount of w hite fo am
C hemic a l ex ami nat ion Š g luc os e, blo o d, protei n
˚e changes in t he g lomeru l ar ˜ lt rat ion b arr ier t hat are
now a llow ing increas e d qu antit ies of pl asma proteins to
p ass w ith t he u lt ra˜ lt rate into t he tubules are a ls o enabling
c ausing t issue hyp oxi a. ˚e d amage d mus cle t issue rele as es
myog lobin into t he blo o dst re am, w hich is subs e quent ly
cle are d from t he pl asma by t he k idne ys.
O dor and chemic a l examinationŠg luc os e, ketone
Dis crepant resu lts: Sp eci˜c g rav ity by re agent st r ip and
Physic a l ex ami nat ion Š cloudy
C hemica l examinat ionŠbloo d t rac e, protein t race
Micros c opic examinationŠWB Cs, 10 to 25; b ac ter i a,
Two to ˜ve hya line c asts is not clinica l ly sig ni˜c ant .
In a urine sp e cimen f rom a woman, a l arge number of
Fre e hemoglobin passes t he ˜ lt ration barr ier and is reab
s or b ed pr imar i ly by t he proxima l rena l tubu le (and to a
less er de g ree by t he dist a l tubules). ˚e tubu lar c ells c at ab
oliz e t he hemog lobin to fer r itin and subs e quent ly dena
ture it to for m hemosider in. When t hes e rena l cel ls are
Two di˛erent me chanisms: movement of b ac ter i a from t he
lower urinar y t ract to t he k idne ys (as c ending infe c t ion), or
b ac ter i a in t he blo o d lo c a lizing in t he kidne ys (hematog
Lysis of re d blo o d cel ls has o c cur re d; this pro cess is
en hanc e d in hyp otonic and a lka line ur ine.
D ysmorphic re d blo o d cel ls and re d bloo d c el l casts
Systemic lupus er yt hematosus is an autoimmune dis
order. Henc e a p ossible s cenar io for t he de velopment of
ac ute g lomer ulonephr it is in t his p at ient is t hat immune
c omplexes (ant ib odies against g lomer u l ar t issue antigens)
E xud ates resu lt f rom in˝ ammator y pro c ess es t hat incre as e
t he p er me abi lit y of t he c api ll ar y endot helium in t he p ar i
et a l membrane or de cre as e t he abs orpt ion of s erous ˝uid
by t he ly mphat ic system .
F luid-to-ser um tot al protein rat io: 0.45
B ac ter i a l vag inosis
O verg rowt h of anaerobic b ac teri a caus es incre as e d pro
duc t ion of se vera l met ab olic bypro duc ts, including p oly
amines, w hich vol ati liz e in an a l ka line env ironment to
pro duc e the fou l-smel ling t r imet hy l amine.
˚e s ensit iv it y of t he re agent st r ip urobi linogen test is
limited. ˚es e tests are not able to ac c urately detec t t he
abs enc e of or de cre ase d amounts of urobilinogen.
Fe c al abnor ma l ˜ndings: c onsistenc y ; leu ko c ytes;
S alm on el l a