Lp urina

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Lucrari practice

Aparat renal 1

Dr. Radu Braga

Catedra de Fiziologie “NC Paulescu”

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Cuprins

• Functiile rinichiului

• Sumarul de urina

• Proba de concentrare/dilutie (Volhard)• Colectare urina /24h

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Sumarul de urina

• Colectarea sumarului

• Examenul macroscopic

• Examenul proprietatilor fizico-chimice• Examenul microscopic

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Colectarea Sumarului de urina

• Colectarea aleatorie recoltata in orice moment al zilei, fara precautii de contaminare.

Proba poate fi diluata, izotonica, sau hipertonica si poate contine celule, bacterii si

epitelii scuamoase drept contaminanti. La femei, specimenul poate continecontaminanti vaginali precum trichomonas, fungi, si la menstra, hematii.

• Recoltarea matinala a probei, inaintea ingestiei oricarui. Proba este uzual hipertonica

si reflecta abilitatea rinichiului de concentrare a urinei in timpul deshidratarii nocturne.

Daca aportul hidric a fost evitat de la ora 18 a zilei precedente, densitatea specifica

uzual depaseste 1.022 la persoane sanatoase.

• Colectarea curata, la jumatatea jetului specimenului de urina dupa igienizarea

meatului uretral extern. Un tampon de vata imbibat in hidroclorura de benzalconiu este

util si non-iritant in acest scop. In timpul urinarii, dupa ce jumatate din VU a fost

evacuata se incepe colectarea in borcanul colector, a restului de urina ramas. Pirma

jumatate a jetului spala celulele contaminante sau microbii de pe uretra distala inainte

de colectare.

• Sondarea vezicala transuretrala colecteaza urina in conditii particulare, de ex., la

pacient comatos sau sondat cf. indicatiei diagnostice. Procedura risca introducerea degermeni sau traumatizarea uretrei sau a VU, putand cauza infectii sau hematurie

iatrogena.

• Aspirarea vezicala cu ac pe cale suprapubiana transabdominala. Efectuata in conditii

ideale, furnizeaza cel mai pur esantion de urina vezicala. Este o metoda utila la nou-

nascuti si copii mici.

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Analiza macroscopica

• Primul pas al analizei este observarea directa. Urina normal,

proaspata este clara si are culoare.

• Volumul normal de urina este de 750 - 2000 ml/24hr.

• Turbiditatea poate fi cauzata de materii celulare excesive sau

proteine in urina sau poate rezulta in urma cristalizarii sau

precipitarii sarurilor prin depozitarea probei la temperatura

camerei sau in frigider. Obtinerea claritatii specimenului prin

adaugarea unei mici cantitati de acid indica faptul ca

precipitarea sarurilor este cauza probabila a turbiditatii.

• Culoarea rosu-brun (anormala) poate fi datorata colorantiloralimentari, sfeclei rosii proaspete, medicamentelor, sau

prezentei hemoglobinei sau mioglobinei. Daca proba contine

hematii multe, va fi si tulbure in afara de rosie.

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Red blood cells in urine

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Rosu, tulbure Rosu, clar Galben, tulbure

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Turbiditatea probei este data de numeroase cristale de struvit care au precipitat la

racirea specimenului la temperatura camerei

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Substante care

modifica culoarea urinii

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A li hi i SU i ti i i

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Analiza chimica a SU prin sticuri urinare

(DIPSTICK)

pH – Filtratul glomerular al plasmei sangvine este acidifiat in mod normal in tubii renali (tubi

distali contorti) si in ductele colectoare de la pH 7.4 la pH de 6 in urina finala. In functie deEAB, pHul urinar poate varia intre 4.5 si 8.0.

Densitate specifica (ρ), este direct proportionala osmolaritatii urinare care masoara

concentratia solutilor, reflecta densitatea urinara, sau abilitatea rinichiului de a concentra

sau dilua urina fata de plasma sangvina. Sticurile urinare masoara densitatea cu

aproximatie. Poate fi masurata si cu ajutorul unui refractometru sau al unui urodensimetru.

• Densitatea intre 1.002 si 1.035 din probe aleatorii poate fi considerata normala daca functiarenala este normala. Intrucat densitatea filtratului glomerular in spatiul caps. Bowman are

valoarea 1.007 - 1.010, orice valoare inferioara reflecta relativa hiperhidratare si orice

valoare superioara – relativa deshidratare.

• Daca densitatea nu e > 1.022 dupa 12 ore fara aport hidric su alimentar, functia renala de

concentrare este afectata iar pacientul are fie afectare generala renala fie diabet insipid

nefrogen.

• In IR stadiu terminal, densitate devine 1.007 -1.010 (fara influenta tubulara).

• Orice urina cu densitate > 1.035 este fie contaminata, fie are niveluri mari de glucoza, sau

pacientul a primit subst. de contrast radio-opace recent iv. pentru investigatii radiologice

sau solutii de dextrani cu masa moleculara redusa. Scadeti 0.004 pentru fiecare 1%

glucoza pt a determina concentratia solutilor non-glucidici.

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Glucose - Less than 0.1% of glucose normally filtered by the glomerulus appears

in urine (< 130 mg/24 hr). Glycosuria (excess sugar in urine) generally means

diabetes mellitus. Dipsticks employing the glucose oxidase reaction forscreening are specific for glucose but can miss other reducing sugars such as

galactose and fructose. For this reason, most newborn and infant urines are

routinely screened for reducing sugars by methods other than glucose oxidase

(such as the Clinitest, a modified Benedict's copper reduction test).

Ketones (acetone, acetoacetic acid, beta-hydroxybutyric acid) resulting from either

diabetic ketosis or some other form of calorie deprivation (starvation), are easily

detected using either dipsticks or test tablets containing sodium nitroprusside.

Nitrite - a positive nitrite test indicates that bacteria may be present in significant

numbers in urine. Gram negative rods such as E. coli are more likely to give a

positive test.

Leukocyte Esterase - a positive leukocyte esterase test results from the presenceof white blood cells either as whole cells or as lysed cells. Pyuria can be

detected even if the urine sample contains damaged or lysed WBC's. A negative

leukocyte esterase test means that an infection is unlikely and that, without

additional evidence of urinary tract infection, microscopic exam and/or urine

culture need not be done to rule out significant bacteriuria.

URINE DIPSTICK CHEMICAL ANALYSIS

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Protein - Dipstick screening for protein is done on whole urine, but semi-quantitative

tests for urine protein should be performed on the supernatant of centrifuged urine

since the cells suspended in normal urine can produce a falsely high estimation ofprotein. Normally, only small plasma proteins filtered at the glomerulus are

reabsorbed by the renal tubule. However, a small amount of filtered plasma

proteins and protein secreted by the nephron (Tamm-Horsfall protein) can be

found in normal urine. Normal total protein excretion does not usually exceed 150

mg/24 hours or 10 mg/100 ml in any single specimen. More than 150 mg/day is

defined as proteinuria. Proteinuria > 3.5 gm/24 hours is severe and known asnephrotic syndrome.

Dipsticks detect protein by production of color with an indicator dye, Bromphenol blue,

which is most sensitive to albumin but detects globulins and Bence-Jones protein

poorly. Precipitation by heat is a better semiquantitative method, but overall, it is

not a highly sensitive test. The sulfosalicylic acid test is a more sensitiveprecipitation test. It can detect albumin, globulins, and Bence-Jones protein at low

concentrations.

In rough terms, trace positive results (which represent a slightly hazy appearance in

urine) are equivalent to 10 mg/100 ml or about 150 mg/24 hours (the upper limit of

normal). 1+ corresponds to about 200-500 mg/24 hours, a 2+ to 0.5-1.5 gm/24

hours, a 3+ to 2-5 gm/24 hours, and a 4+ represents 7 gm/24 hours or greater.

URINE DIPSTICK CHEMICAL ANALYSIS

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RBCs

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Dysmorphic red blood cells from the urinary sediment of a patient with chronic glomerulonephritis.

Sternheimer stain, X400.

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Dysmorphic red blood cells from the urinary sediment of a patient with chronic glomerulonephritis.Sternheimer stain, X400.

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Isomorphic red blood cells from the urinary sediment of a patient with urolithiasis.

Sternheimer-Malbin stain, X400.

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Isomorphic red blood cells from the urinary sediment of a patient with hematuria of undetermined

origin. Sternheimer-Malbin stain, X400.

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LEUCOCYTES

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Squamous cells (superficial type) from the urinary sediment of a patient. Sternheimer-Malbinstain, X400.

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Squamous cells (parabasal and intermediate type) from the preceding patient.


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Renal tubular epithelial cells from the urinary sediment of a patient with acute tubular necrosis

caused by mercury poisoning. The patient took mercuric chloride in a suicide attempt. Thecells have degenerated greatly and are much larger than usual. Sternheimer stain, X400.

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Casts

Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting

duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle are not

locations for cast formation. Hyaline casts are composed primarily of a mucoprotein

(Tamm-Horsfall protein) secreted by tubule cells. The Tamm-Horsfall protein secretion

(green dots) is illustrated in the diagram below, forming a hyaline cast in the collecting

duct

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Clump of oval fat bodies from the urinary sediment of a patient with chronic gromerulonephritis

complicated with nephrotic syndrome. These oval fat bodies were fatty-degenerated renal

epithelial cells. This patient rapidly proceeded to renal failure, and started extracorporealdialysis therapy. Sternheimer stain, X400.

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Oval fat body and fatty cast from the urinary sediment of a patient with chronic

gromerulonephritis (nephrotic stage clinically). Background contains many dysmorphic red

blood cells. Sudan stain, X400

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Oval fat body from the urinary sediment of a patient with chronic gromerulonephritis

(nephrotic stage clinically). There are uric acid crystals around. Sternheimer stain, X400.

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Same field as the preceding one, but seen by polarized microscopy. Arrows show

Maltese cross image of lipoid droplets. Sternheimer stain, X400.

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Intact tubular epithelial cells laden with numerous refractile fat droplets.

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Under polarized light, oval fat bodies demonstrate the "Maltese cross"

appearance.

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This histologic section at medium power with trichrome stain highlights

red blood cells grouping together in tubules to form casts. The tubular

epithelium is also damaged, with a foamy appearance, and is the basis

for the appearance of oval fat bodies in urine in this case.

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The presence of this red blood cell cast in on urine microscopic

analysis suggests a glomerular or renal tubular injury.

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Red blood cell cast from the urinary sediment of another patient with chronic

glomerulonephritis. The matrix looks granular, but a part of the cast looks red

because of hemoglobin inside. Unstained, X200.

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Red blood cell cast from the urinary sediment of the preceding patient. The red blood

cells in the cast are granular and yellow. Unstained, X200.

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White blood cell cast from the urinary sediment of a patient with chronic

glomerulonephritis. The cast contains polynuclear white blood cells.


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Microscopic analysis reveals a protein cast containing white blood cells. Compared to RBC

casts, the WBC's are larger, have nuclei and contain cytoplasmic granules. The cast takes the

shape of the renal tubule.

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White blood cell cast from the urinary sediment of a patient with chronic glomerulonephritis.

The cast contains polynuclear white blood cells. Sternheimer-Malbin stain, X400.

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Casts which persist may break down, so that the cells forming it are

degenerated into granular debris, as has occurred in this granular cast.

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This is a broad, waxy cast. Note that the edges are sharp and there are

"cracks" in this cast.

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This section of renal cortex reveals tubules containing hyaline casts

that are bile stained in a patient with hyperbilirubinemia.

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Bence Jones protein cast (myeloma cast) from the urinary sediment of the preceding

patient. Note the characteristic appearance of yarn wound into a bundle. Identification of Bence

Jones protein casts is possible only by immunochemical staining with antiserum to the L-chain.

Sternheimer stain, X1000.

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Bilirubin cast from the urinary sediment of a patient with cancer of the liver. It is a

pigmented bile cast and yellowish brown, such as is often seen in patients with severe

bilirubinuria or jaundice. Bilirubin may stain cells or crystals as well. Unstained, X400

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Bilirubin cast from the urinary sediment of the preceding patient. Unstained, X400

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These are oxalate crystals, which look like little envelopes (or

tetrahedrons). Oxalate crystals are common.

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CALCIUM OXALATE

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Triple Phosphate CrystalsUrine Sediment Atlas

Jessie Hano, M.D

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These cystine crystals are shaped like stop signs. Cystine crystals are

quite rare.

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CYSTINE

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Cystine cristals - 6 sided of varying dimension, sharp edges

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Cholesterol crystals from the urinary sediment of a patient with cystic kidneys. Many fatty

degenerated white blood cells are seen in the background. Cholesterol crystals formed cysts

during the long-time inflammation, and when cysts broke, entered the urine. Unstained, X100.

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Same field as the preceding one, but seen by polarized microscopy. Cholesterol

crystals show weak monotone polarization. Unstained, X100.

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Sulfa crystals from the urinary sediment of a patient taking Sinomin (sulfamethoxazol).

These crystals resemble crystals of uric acid or calcium oxalate, but sulfa crystals are

soluble in acetone. Unstained, X400

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Rhomboid forms of uric acid dyhydrate

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Bacteria

• Bacteria are common in urine specimens because of the abundant

normal microbial flora of the vagina or external urethral meatus and

because of their ability to rapidly multiply in urine standing at roomtemperature. Therefore, microbial organisms found in all but the

most scrupulously collected urines should be interpreted in view of

clinical symptoms.

• Diagnosis of bacteriuria in a case of suspected urinary tract infection

requires culture. A colony count may also be done to see ifsignificant numbers of bacteria are present. Generally, more than

100,000/ml of one organism reflects significant bacteriuria. Multiple

organisms reflect contamination. However, the presence of any

organism in catheterized or suprapubic tap specimens should be

considered significant.

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Yeast

• Yeast cells may be contaminants or represent a trueyeast infection. They are often difficult to distinguish from

red cells and amorphous crystals but are distinguished

by their tendency to bud. Most often they are Candida,

which may colonize bladder, urethra, or vagina.

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Miscellaneous

• General "crud" or unidentifiable objects

may find their way into a specimen,

particularly those that patients bring from

home.• Spermatozoa can sometimes be seen.

Rarely, pinworm ova may contaminate the

urine. In Egypt, ova from bladderinfestations with schistosomiasis may be

seen.

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Summary

• To summarize, a properly collected clean-catch, midstream urineafter cleansing of the urethral meatus is adequate for completeurinalysis. In fact, these specimens generally suffice even for urineculture. A period of dehydration may precede urine collection iftesting of renal concentration is desired, but any specific gravity >1.022 measured in a randomly collected specimen denotes

adequate renal concentration so long as there are no abnormalsolutes in the urine.

• Another important factor is the interval of time which elapses fromcollection to examination in the laboratory. Changes which occurwith time after collection include: 1) decreased clarity due tocrystallization of solutes, 2) rising pH, 3) loss of ketone bodies, 4)loss of bilirubin, 5) dissolution of cells and casts, and 6) overgrowth

of contaminating microorganisms. Generally, urinalysis may notreflect the findings of absolutely fresh urine if the sample is > 1 hourold. Therefore, get the urine to the laboratory as quickly as possible.

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