1 Chapter 7 Urinalysis-3 Professor A. S. Alhomida Disclaimer The texts, tables, figures and images contained in this course presentation (BCH 376) are.

11

Chapter 7 Urinalysis-3

Professor A. S. Alhomida

Chapter 7 Urinalysis-3

Professor A. S. Alhomida

DisclaimerDisclaimer• The texts, tables, figures and images contained in this course The texts, tables, figures and images contained in this course

presentation (BCH 376) are not my own, they can be found on: presentation (BCH 376) are not my own, they can be found on: • References suppliedReferences supplied• Atlases orAtlases or• The webThe web

King Saud University

College of Science

Department of Biochemistry

22

Urine Screening for Urine Screening for Metabolic DisordersMetabolic Disorders

1.1. Urinary Inorganic ConstituentsUrinary Inorganic Constituents• ChlorideChloride• PhosphatesPhosphates• SulphurSulphur• SodiumSodium• PotassiumPotassium• CalciumCalcium• MagnesiumMagnesium

33

Urine Screening for Urine Screening for Metabolic Disorders, Metabolic Disorders,

Cont’dCont’d2.2. Urinary Organic ConstituentsUrinary Organic Constituents

• UreaUrea• AmmoniaAmmonia• Uric AcidUric Acid• CreatineCreatine• CreatinineCreatinine• Oxalic acidOxalic acid• Amino acidsAmino acids

44

Urine Screening for Urine Screening for Metabolic Disorders, Metabolic Disorders,

Cont’dCont’d3.3. Abnormal ConstituentsAbnormal Constituents

• ProteinProtein• Carbohydrates (Sugar) Carbohydrates (Sugar) • Urinary CalculiUrinary Calculi

55

• Most abundant Anion in ECFMost abundant Anion in ECF• Major contribution to Major contribution to

osmolarityosmolarity

• RolesRoles1.1. Formation of HClFormation of HCl

2.2. Chloride shiftChloride shift• COCO22 Loading/Unloading Loading/Unloading

3.3. Regulation of body pHRegulation of body pH

ChlorideChloride

66

Clinical and Biochemical Significance

Chloride

1. Excessive sweating

2. During fasting

3. Loss through extrarenal channels; diarrhea, vomiting

4. Edema

5. Diabetes insipidus

6. Infections; pneumonia

7. Adrenocortical hyperfuntion; Cashing’s syndrome

DecreaseDecrease

77

Chloride

IncreaseIncrease1. Excessive water drinking

2. Addison’s disease

3. Use of diuretics

Clinical and Biochemical Significance, Cont’d

88

• Relatively Concentrated IN ICFRelatively Concentrated IN ICF• RolesRoles

1.1. Components of bones Components of bones

2.2. Components of DNA and RNA Components of DNA and RNA

3.3. Components of phospholipids Components of phospholipids

4.4. Activate/deactivate some Activate/deactivate some

5.5. Buffer pH of body fluidsBuffer pH of body fluids

PhosphatesPhosphates

99

• Components ofComponents of• Nucleic acids (DNA, RNA)Nucleic acids (DNA, RNA)• NTPs AND dNTPs (ATP, dATP, GTP, dGTP, etc)NTPs AND dNTPs (ATP, dATP, GTP, dGTP, etc)• cAMPcAMP• PhospholipidsPhospholipids• Various others phosphorylated molecules Various others phosphorylated molecules

generated via ATP hydrolysis, etc generated via ATP hydrolysis, etc • Exist as mixture of three formsExist as mixture of three forms• POPO44

3-3- (phosphate ion)(phosphate ion)• HPOHPO44

2-2- (monohydrogen phosphate ion)(monohydrogen phosphate ion)• HH22POPO44

-- (dihydrogen phosphate ion(dihydrogen phosphate ion

Phosphates, Cont’dPhosphates, Cont’d

1010

1.1. Diet Provides Ample PhosphateDiet Provides Ample Phosphate2.2. Readily Absorbed by Small IntestineReadily Absorbed by Small Intestine3.3. RegulationRegulation

• Renal tubules site of regulationRenal tubules site of regulation• PTH increases phosphate excretionPTH increases phosphate excretion• Excretion rate affected by urine pHExcretion rate affected by urine pH

4.4. Phosphate ImbalancesPhosphate Imbalances• Phosphate Homeostasis NOT Very CriticalPhosphate Homeostasis NOT Very Critical• Body can Tolerate Wide Variations of Body can Tolerate Wide Variations of

Phosphate Concentration with Little EffectPhosphate Concentration with Little Effect

Phosphate HomeostasisPhosphate Homeostasis

1111

Phosphates


1. Diarrhea

2. Acute infections

3. Nephritis

4. Parathyroid hypofuntion

5. Pregnancy

6. Insulin administration

7. Certain inherited disorders; galactosemia, fructose intolerance

DecreaseDecrease

1212

Phosphate

IncreaseIncrease1. Bone diseases; rickets, osteomalcia, periostosis

2. Addison’s disease

3. Acidosis

Clinical and Biochemical Significance, Cont’d

1313

SulfurSulfur

1.1. Formation of Sulfur CompoundsFormation of Sulfur Compounds• Inorganic SOInorganic SO44 (80-85%) (80-85%)• Ethereal sulfates (organic esters) (5%)Ethereal sulfates (organic esters) (5%)• Organic sulfates (Neutral sulfur) (15-20%)Organic sulfates (Neutral sulfur) (15-20%)

2.2. Sources of SulfatesSources of Sulfates• Most of urinary sulfates arises from

metabolism of proteins, especially Cys, cystine, Met and GSH

• A small amount obtained from S-containing vitamins, B6, biotin, lipoic acid, coenzyme A

• Food proteins that contain on an average of 1% of sulfur

1414

Urinary Excretion of Urinary Excretion of SulfatesSulfates

• Urinary Sulfate Excretion Varies withUrinary Sulfate Excretion Varies with• Protein intake in dietProtein intake in diet• Rates of tissue protein breakdownRates of tissue protein breakdown

1515

DecreaseDecrease

Inorganic sulfatesInorganic sulfates

Clinical and Biochemical Clinical and Biochemical SignificanceSignificance

It is diminished on conditions of renal functional It is diminished on conditions of renal functional impairmentimpairmentIncreaseIncrease

1.1. On high protein dietOn high protein diet

2.2. In excessive tissue protein breakdownIn excessive tissue protein breakdown

1616

Ethereal sulfatesEthereal sulfates

1.1. Urinary excretion range from 0.06-1.2 g/dayUrinary excretion range from 0.06-1.2 g/day

2.2. It consists of Na, K salts of sulfuric acidIt consists of Na, K salts of sulfuric acid ester of ester of phenols, eg indoxal, skatoxyl, phenol and cresolphenols, eg indoxal, skatoxyl, phenol and cresol

3.3. These ether sulfates represent of detoxication These ether sulfates represent of detoxication compounds of phenols and are formed in livercompounds of phenols and are formed in liver

4.4. Some of the phenolic sulfates originate throughSome of the phenolic sulfates originate through• Bacterial action in the gastrointestinal (GI) Bacterial action in the gastrointestinal (GI)

tracttract• Some appears to be formed in tissue Some appears to be formed in tissue

metabolismmetabolism

1717

5.5. Indoxyl and skatoxyl are formed entirely by Indoxyl and skatoxyl are formed entirely by putrefactive decomposition of Trp in the GI putrefactive decomposition of Trp in the GI tract and phenol and cresol from Tyr tract and phenol and cresol from Tyr

6.6. Formation of indole and skatol from Trp are Formation of indole and skatol from Trp are esterified with Hesterified with H22SOSO44 in liver and excreted in in liver and excreted in urine as Na and K saltsurine as Na and K salts (urinary bile acid (urinary bile acid sulfates)sulfates)

Ethereal sulfates, Cont’dEthereal sulfates, Cont’d

1818

IncreaseIncrease1.1. In intestinal obstruction due to putrefaction and In intestinal obstruction due to putrefaction and

absorption of these products in carcinoma, liver absorption of these products in carcinoma, liver cholera, typhuscholera, typhus

2.2. In cholera and typhus, sufficient In cholera and typhus, sufficient indicanindican is is excreted to cause urine to assume a bluish tinge excreted to cause urine to assume a bluish tinge on standingon standing

3.3. Bacterial decomposition of Trp in pus any where Bacterial decomposition of Trp in pus any where in the body in pathological conditions increases in the body in pathological conditions increases the excretion of indicanthe excretion of indican


Ethereal sulfatesEthereal sulfates

1919

Urinary IndicanUrinary Indican

1.1. Insufficient gastric HCl, insufficient digestive Insufficient gastric HCl, insufficient digestive enzymes, adverse food reactions, parasitic enzymes, adverse food reactions, parasitic infection, fungal infection, overgrowth of bacteria infection, fungal infection, overgrowth of bacteria that metabolize specific proteins, hypermotility of that metabolize specific proteins, hypermotility of the small intestine, or other gastrointestinal the small intestine, or other gastrointestinal dysfunction can compromise protein digestiondysfunction can compromise protein digestion

2.2. The level of indican is an index of the efficiency The level of indican is an index of the efficiency of protein digestionof protein digestion

2020

Urinary IndicanUrinary Indican

3.3. Poor protein digestion also can result from the Poor protein digestion also can result from the dietary intake of protein from a group of food dietary intake of protein from a group of food proteins called lectins proteins called lectins

4.4. The Indican test uses a urine sample to test for The Indican test uses a urine sample to test for the presence of indole, a metabolic byproduct the presence of indole, a metabolic byproduct of the action of intestinal bacteria on the amino of the action of intestinal bacteria on the amino acid tryptophanacid tryptophan

2121

Conditions with Elevated Conditions with Elevated Levels of Urinary IndicanLevels of Urinary Indican

1.1. Inflammatory bowel diseaseInflammatory bowel disease

2.2. Celiac diseaseCeliac disease

3.3. HypochlorhydriaHypochlorhydria

4.4. AchlorhydriaAchlorhydria

5.5. Gastric ulcerGastric ulcer

6.6. Biliary and intestinal obstructionBiliary and intestinal obstruction

7.7. Jejunal diverticulosisJejunal diverticulosis

2222

Conditions with Elevated Conditions with Elevated Levels of Urinary Indican, Levels of Urinary Indican,

Cont’dCont’d8.8. SclerodermaScleroderma

9.9. PostgastrectomyPostgastrectomy

10.10. Hartnup's diseaseHartnup's disease

11.11. Pancreatic insufficiencyPancreatic insufficiency

12.12. Diminished peristalsisDiminished peristalsis

13.13. Blue diaper syndromeBlue diaper syndrome

14.14. Hypermotility of the small intestineHypermotility of the small intestine

2323

Urinary Indican TestUrinary Indican Test

• Trp is converted to Trp is converted to indole by intestinal indole by intestinal bacterial cleavage of Trp bacterial cleavage of Trp side chainside chain

• Following absorption, Following absorption, indole is converted to 3-indole is converted to 3-hydroxy indole (indoxyl hydroxy indole (indoxyl or indican) in the liver, or indican) in the liver, where it is then where it is then conjugated with conjugated with potassium sulfate or potassium sulfate or glucoronic acidglucoronic acid

• It is then transported It is then transported through the blood to the through the blood to the kidneys for excretion in kidneys for excretion in urineurine

2424

Results of Urinary Results of Urinary Indican TestIndican Test

Urine ColorUrine Color 0 (normal)0 (normal)

Light BlueLight Blue 1+ (Low Positive)1+ (Low Positive)

BlueBlue 2+ (Medium Positive)2+ (Medium Positive)

VioletViolet 3+ (High Positive)3+ (High Positive)

Jet BlackJet Black 4+ (Very high 4+ (Very high Positive)Positive)

2525

Neutral sulfatesNeutral sulfates

1.1. Urinary excretion range from 0.08 – 0.16 g/dayUrinary excretion range from 0.08 – 0.16 g/day2.2. It is composed of heterogeneous mixtures of It is composed of heterogeneous mixtures of

sulfur compoudssulfur compouds3.3. These includes cystine, Met, urochrome, These includes cystine, Met, urochrome,

throsulfates, oxyproteic acid, thiocyanates, bile throsulfates, oxyproteic acid, thiocyanates, bile acids and taurine and its derivativesacids and taurine and its derivatives

2626

IncreaseIncrease1.1. Inherited disorders like cystinuria, homocystinuriaInherited disorders like cystinuria, homocystinuria

2.2. Melanuria in melanomaMelanuria in melanoma

3.3. Hepato cellular jandiceHepato cellular jandice

4.4. Cyanide poisoning as cyanide is converted to Cyanide poisoning as cyanide is converted to thiocyanatesthiocyanates

5.5. Chloroform as an anesthesia Chloroform as an anesthesia


Neutral sulfatesNeutral sulfates

2727

Urinary Bile Acid Sulfate Urinary Bile Acid Sulfate

1.1. The enterohepatic circulation regulates bile acid The enterohepatic circulation regulates bile acid levelslevels

2.2. Under normal conditions, little leaks into the blood Under normal conditions, little leaks into the blood and is converted to sulfate and excreted in the and is converted to sulfate and excreted in the urineurine

3.3. Elevated bile acid sulfate levels in the urine are Elevated bile acid sulfate levels in the urine are associated with impaired liver function, associated with impaired liver function, hepatocellular damage, and a high specificity hepatocellular damage, and a high specificity toward hepatobiliary diseasestoward hepatobiliary diseases

4.4. Urinary bile acid sulfates test uses a urine sample Urinary bile acid sulfates test uses a urine sample to provide a direct assessment of liver functionto provide a direct assessment of liver function

2828

Urinary Lipid PeroxidesUrinary Lipid Peroxides

1.1. The level of lipid peroxides is an index of cellular The level of lipid peroxides is an index of cellular membrane damage caused by the action of free membrane damage caused by the action of free radicalsradicals

2.2. The membranes of the organelles within the cells The membranes of the organelles within the cells (mitochondria, lysosomes, peroxisomes, etc) can (mitochondria, lysosomes, peroxisomes, etc) can also be damagedalso be damaged

3.3. Membrane proteins, membrane lipids and Membrane proteins, membrane lipids and cholesterol can be damaged due to an insufficiency cholesterol can be damaged due to an insufficiency of antioxidants to deal with the level of oxidative of antioxidants to deal with the level of oxidative stress and free radicalsstress and free radicals

2929

Urinary Lipid Peroxides, Urinary Lipid Peroxides, Cont’dCont’d

4.4. Other associated diseases include coronary Other associated diseases include coronary artery disease and cancerartery disease and cancer

5.5. Normal Normal urinary lipid peroxide concentrations: 1.0 urinary lipid peroxide concentrations: 1.0 - 7.5 nmol/mg creatinine- 7.5 nmol/mg creatinine

3030

• Principal ECF CationPrincipal ECF Cation• 90 – 95% OF OSMOLARITY FROM SODIUM 90 – 95% OF OSMOLARITY FROM SODIUM

SALTSSALTS

• RolesRoles• Depolarization Depolarization

• Muscles, nervesMuscles, nerves

• Affect total body waterAffect total body water• Affect water distributionAffect water distribution• CotransportCotransport

• Glucose, amino acids, calcium, etc Glucose, amino acids, calcium, etc

SodiumSodium

3131

1.1. 0.5 g/day Dietary Requirement 0.5 g/day Dietary Requirement

2.2. Receive 3 – 7 g/day from Our DietReceive 3 – 7 g/day from Our Diet

3.3. Kidneys excrete excess (~5 g/day)Kidneys excrete excess (~5 g/day)

4.4. Excretion regulated by three hormonesExcretion regulated by three hormones• Aldosterone Aldosterone • Antidiuretic hormone (ADH)Antidiuretic hormone (ADH)• Atrial natriurtic factor (ANF)Atrial natriurtic factor (ANF)

Sodium HomeostasisSodium Homeostasis

3232

• Regulation by AldosteroneRegulation by Aldosterone• ““Salt-retaining hormoneSalt-retaining hormone

• Steroid HormoneSteroid Hormone• Aldosterone secretion stimulated by:Aldosterone secretion stimulated by:

• HyponatremiaHyponatremia• HperkalemiaHperkalemia• HypotensionHypotension

Sodium Homeostasis, Sodium Homeostasis, Cont’dCont’d

3333

• Regulated by AldosteroneRegulated by Aldosterone• Target CellsTarget Cells

• Distal convoluted tubule Distal convoluted tubule • Colleting ductColleting duct

• Transcribe gene for NaTranscribe gene for Na++-K-K++ pump pump• Sodium reabsortion increases Sodium reabsortion increases • HH++ and K and K ++ secretion increases secretion increases• Urine pH dropsUrine pH drops


3434

• Regulation by AldosteroneRegulation by Aldosterone• Average NaAverage Na++ excretion 5 g/day excretion 5 g/day• Aldosterone reduces to ~ 0Aldosterone reduces to ~ 0• Water reabsorbed proportionally Water reabsorbed proportionally • Sodium concentration in body unchangedSodium concentration in body unchanged• Inhibited by HypertensionInhibited by Hypertension

• Kidneys then Reabsorb little NaKidneys then Reabsorb little Na++

• Excretion increased to ~30 g/dayExcretion increased to ~30 g/day


3535

Action of AldosteroneAction of Aldosterone

3636

• Regulation by ADHRegulation by ADH• Independently modifies sodium and Independently modifies sodium and

water excretionwater excretion• Can Change sodium concentrationCan Change sodium concentration• High blood [Na+] High blood [Na+] ADH secretion ADH secretion

• Increases water reabsorptionIncreases water reabsorption• Sodium concentration decreasedSodium concentration decreased

• ADH also stimulates thirstADH also stimulates thirst• Also happens in reverseAlso happens in reverse


3737


• Regulation by ANF

• Hypertension Hypertension ANF secretion ANF secretion

• Inhibits ADH and renin secretionInhibits ADH and renin secretion

• Inhibits sodium and water reabsorptionInhibits sodium and water reabsorption

• More sodium and water excreted More sodium and water excreted

• Blood pressure decreasedBlood pressure decreased

3838


• Regulation by Other HormonesRegulation by Other Hormones

• Estrogens mimic aldosteroneEstrogens mimic aldosterone

• Water retention during pregnancyWater retention during pregnancy

• Menstrual water retentionMenstrual water retention

• ProgesteroneProgesterone

• Reduces sodium reabsorptionReduces sodium reabsorption

• GlucocorticoidsGlucocorticoids

• Promote sodium reabsorpiton, EdemaPromote sodium reabsorpiton, Edema

3939

• Relatively RareRelatively Rare• HypernatremiaHypernatremia

• Can result from IV salineCan result from IV saline• Causes water retention, hypertension, edemaCauses water retention, hypertension, edema

• Hyponatremia Hyponatremia • Generally from water excessGenerally from water excess• Hypotonic hydrationHypotonic hydration• Corrected by excretion of excess of waterCorrected by excretion of excess of water

Sodium Homeostasis Sodium Homeostasis ImbalancesImbalances

4040

• Principal intracellular cationPrincipal intracellular cation• Affects intracellular osmolarityAffects intracellular osmolarity• Affects cell volumeAffects cell volume

• RolesRoles• Produces resting and action potentialsProduces resting and action potentials• CotransportCotransport• ThermogenesisThermogenesis• Cofactor for protein synthesisCofactor for protein synthesis

PotassiumPotassium

4141

• Homeostasis Linked to that of NaHomeostasis Linked to that of Na++

• KK++ and Na and Na++ noregulated by aldosterone noregulated by aldosterone• 90% of K90% of K++ Reabsorbed in PCT Reabsorbed in PCT

• Remainder excreted in urineRemainder excreted in urine• Control Imparted in DCT and Collecting Control Imparted in DCT and Collecting

Duct (CD) Duct (CD) • High [KHigh [K++] ] Secrete more into filtrate Secrete more into filtrate• Low [KLow [K++] ] Secrete less into filtrate Secrete less into filtrate• Exchanged for NaExchanged for Na++

Potassium HomeostasisPotassium Homeostasis

4242

• Regulation by AldosteroneRegulation by Aldosterone• High [KHigh [K++] ] Aldosterone production Aldosterone production

• NaNa++-K-K++ pump produced pump produced• NaNa++ and K and K++ coregulated coregulated• Increase KIncrease K++ secretion secretion• Decrease NaDecrease Na++ secretion secretion

Potassium Homeostasis, Potassium Homeostasis, Cont’dCont’d

4343

• Most Dangerous Electrolyte ImbalancesMost Dangerous Electrolyte Imbalances• HyperkalemiaHyperkalemia

1.1. Effects depend on speed of concentration raiseEffects depend on speed of concentration raise2.2. Quick Rise Quick Rise Nerve/muscle cells very excitable Nerve/muscle cells very excitable3333 Cardiac arrestCardiac arrest

• E.G., K+ Released from injured cellsE.G., K+ Released from injured cells• E.G., Transfusion with old bloodE.G., Transfusion with old blood• E.G., Euthanasia, capital punishment lethal injectionE.G., Euthanasia, capital punishment lethal injection

• K+ has leaked from erythrocytesK+ has leaked from erythrocytes4.4. Slow Rise Slow Rise Nerve/muscle cells less excitable Nerve/muscle cells less excitable5.5. (Na+ channels inactivated) (Na+ channels inactivated)

• E.G., Aldosterone hyposecretion, renal failure, acidosis E.G., Aldosterone hyposecretion, renal failure, acidosis • E.G., Supplemental K+ to relieve muscle crampsE.G., Supplemental K+ to relieve muscle cramps

Potassium Homeostasis Potassium Homeostasis ImbalancesImbalances

4444

• HypokalemiaHypokalemia1.1. Nerve/muscle cells less excitableNerve/muscle cells less excitable

2.2. Muscle weakness, loss of muscle tone, Muscle weakness, loss of muscle tone, depressed reflexes, irregular heart activitydepressed reflexes, irregular heart activity

3.3. E.G., Heavy sweating, chronic vomiting or E.G., Heavy sweating, chronic vomiting or diarrhea, excessive laxatives, aldosterone diarrhea, excessive laxatives, aldosterone hypersecretion, alkalosishypersecretion, alkalosis

4.4. E.G., Depressed appetite, but rarely from E.G., Depressed appetite, but rarely from dietary insufficiencydietary insufficiency

Potassium Homeostasis Potassium Homeostasis Imbalances, Cont’dImbalances, Cont’d

4545

Potassium and Potassium and Membrane PotentialsMembrane Potentials

4646


1. Fasting or inadequate protein intake, in excessive tissue protein catabolism, with liberation of ICF resulting in an increase in urinary K and a change in Na : K ratio (in fasting, there is lack of NaCl intake

2. Mineralocorticoid, aldosterone, increases the reabsorption of Na and excretion of K

3. K excretion increases during alkalosis or ingestion of alkaline diet

4. K excretion decreases during acidosis or ingestion of acid diet

5. Decrease urinary excretion of both Na and K Through extrarenal channels; excessive sweating, vomiting, diarrhea

Sodium and Potassium

4747

• RolesRoles1.1. Strengthens boneStrengthens bone2.2. Muscle contractionMuscle contraction3.3. Second messenger for hormones Second messenger for hormones 4.4. Activated exocytosisActivated exocytosis5.5. Blood clottingBlood clotting

CalciumCalcium

4848

• Binds to Phosphate IonBinds to Phosphate Ion1.1. Can form CaCan form Ca33(PO(PO44))22

2.2. High concentrations of both ions will High concentrations of both ions will form precipitate crystalsform precipitate crystals

3.3. Intracellular [CaIntracellular [Ca2+2+] must be kept low] must be kept low

4.4. CaCa2+2+ pumped out and into endoplasmic pumped out and into endoplasmic reticulumreticulum

Calcium, Cont’dCalcium, Cont’d

4949

• Regulated by PTH and CalcitrolRegulated by PTH and Calcitrol• Also by calcitonin in childrenAlso by calcitonin in children

• Blood [CaBlood [Ca2+2+] Regulated via: ] Regulated via: 1.1. Bone deposition and reabsorptionBone deposition and reabsorption

2.2. Intestinal absorption Intestinal absorption

3.3. Urinary excretionUrinary excretion

Calcium HomeostasisCalcium Homeostasis

5050

• HypercalcemiaHypercalcemia1.1. Reduces membrane permeability to Na+ Reduces membrane permeability to Na+

2.2. Inhibits depolarization of nerve/musclesInhibits depolarization of nerve/muscles

3333 Muscular weakness, cardiac arrhythmi, Muscular weakness, cardiac arrhythmi, etc etc

4.4. Results fromResults from• AlkalosisAlkalosis• Hyperparathyroidism Hyperparathyroidism • HypothyroidismHypothyroidism

Calcium Homeostasis Calcium Homeostasis ImbalancesImbalances

5151

• HypocalcemiaHypocalcemia1.1. Increases membrane permeability to Na+ Increases membrane permeability to Na+ 2.2. Nerves/muscles overly excitableNerves/muscles overly excitable3333 Tetanus if concentration drops to lowTetanus if concentration drops to low4.4. Results fromResults from

• AcidosisAcidosis• Vitamin D deficiencyVitamin D deficiency• DiarrheaDiarrhea• Pregnancy or lactationPregnancy or lactation• HypoparathyroidismHypoparathyroidism• HyperthyroidismHyperthyroidism

Calcium Homeostasis Calcium Homeostasis Imbalances, Cont’dImbalances, Cont’d

5252

1.1. Principal method for removing ammonia Principal method for removing ammonia

2.2. Occurs primarily in liver; excreted by kidneyOccurs primarily in liver; excreted by kidney

3.3. HyperammonemiaHyperammonemia• Defects in urea cycle enzymes (CPS, OTC, etc.)Defects in urea cycle enzymes (CPS, OTC, etc.)• Severe neurological defects in neonatesSevere neurological defects in neonates

4.4. TreatmentTreatment• Stop protein intakeStop protein intake• DialysisDialysis• Increase ammonia excretion: Na benzoate, Na Increase ammonia excretion: Na benzoate, Na

phenylbutyrate, L-arginine, L-citrullinephenylbutyrate, L-arginine, L-citrulline

Urinary Organic Constituents

Urea Urea FormationFormation

53

The Urea Cycle

NH3+

NH-CHCH2CO2-

CO2-

+H2N=C-HNCH2CH2CH2CHCO 2

-

NH3+

NH2CONH CH2CH2CH2CHCO 2-

Citrulline

Arginosuccinate

Arginosuccinatesynthase

NH3+NH2

H2N=C-HNCH2CH2CH2CHCO 2-

+

Arginine

NH3+

H3NCH2CH2CH2CHCO 2-

+

Ornithine

CO2-

-O2C

H

H

Fumarate

TCA Cycle

Arginase

H2NCONH2

UreaArgino-succinase

OrnithineTranscarbamoylase(mitochondria)

NH3-CHCH2CO2-

CO2-

+ Asp

5454


1. In certain liver diseases; cirrhosis, acute yellow atrophy

2. In cases of severe acidosis

3. NephritisIncreaseIncreaseWhenever protein catabolism is increased as in fever, diabetes mellitus, excess of adrenocortical activity

Urea

DecreaseDecrease

5555

Ammonia


DecreaseDecrease1. In alkalosis

2. Administration of alkalis or base forming foods

3. Nephritis

IncreaseIncrease1. In cases of severe diabetic acidosis

2. Administration of acid forming foods

3. Copious water drinking

4. Bacterial infection of bladder as in cystitis

5656


Pathophysiolgical VariationsPathophysiolgical Variations

1. Urinary excretion of UA increase during gout

2. In leukemia where breakdown of large amount of nuclear materials

3. Administration of cortisone of ACTH

4. In Wilson’s disease

Uric acid

DietDietOn a purine free diet uric acid excretion may fall to

0.1 g/day, while on a high purine diet the excretion may raise to 2 g/day

57

Creatine and Creatinine Formation

NH3+NH2

+H2N=C-HNCH2CH2CH2CHCO 2

-

Arginine Glycine Ornithine

Arginine-glycinetransamidinase

(Kidney)NH2

H2N=C-HNCH2CO 2-

+

Guanidoacetate

NHPO3-2

CH3

+H2N=C-NCH2CO 2

-

GuanidoacetateMethyltransferase

(Liver)

SAM + ATP

S-Adenosyl-homocysteine + ADP

Phosphocreatine

N

NH

CH3

HN

O

Creatinine(Urine) Non-enzymatic

(Muscle)

NH2

CH3

H2N=C-NCH2CO 2-

+

Creatine kinase

(Muscle)

ATP

Creatine ADP + Pi

5858

Creatine

1.In children; reason probably lack of ability to convert creatine into creatinine

2.In pregnancy

3.In febrile conditions

Excretion of creatine in urine is called creatinuria for these causes:


5959

Creatine

4.In hypotoxicosis; probably associated with myopathies

5.In muscular dystrophyies

6.Lack of carbohydrates in diets in diabetes mellitus

7. In Wasting diseases; eg molignancies

8.In starvation

Clinical and Biochemical Clinical and Biochemical Significance, Cont’dSignificance, Cont’d

6060

Oxalic acidOxalic acid


1.Oxalic acid separates from urine as insoluble Ca-oxalate crystals which can be seen microscopically in centrifuged deposit urine. If passed in excessive amounts can form urinary calculus in urinary tract

6161

Oxalic acidOxalic acid

Clinical and Biochemical Clinical and Biochemical Significance, Cont’dSignificance, Cont’d

2.Increase:

• Diabetes mellitus

• Certain liver diseases

• In various conditions involving deficient tissue oxidation

3.Primary hyeroxaluria

• Oxaluric acid; a combination of oxalic acid and urea occasionally present in traces in normal urine

6262

Amino acidsAmino acids

Excretion of amino acids in urine is called aminoaciduria

• There is some metabolic defects; as a result there occurs an increase in plasma level of one or more of amino acids which exceeds the capacity of normal renal tubules to reabsorb them. It found in:

Over Flow Aminoaciduria


6363

1. Severe liver diseases; acute yellow atrophy, cirrhosis, etc

2. Wasting diseases 3. Metabolic amino acid disorders:

• Phenylkeptonuria• Tyrosyluria• Alkaptonuria• Melanuria• Maple syrup urine diseases

Over Flow Over Flow Aminoaciduria, Cont’dAminoaciduria, Cont’d

6464

• Plasma level of amino acids is normal, but because of defects in renal tubular reabsorption of amino acids, an increase amount of one or several or all amino acids escape in urine. The defect may be:

1. Specific to one reabsortion mechanism as in cystinuria in which there is failure to reabsorb Cys, Lys, Arg and Orn (a common transport defect)

Renal AminoaciduriaRenal Aminoaciduria

6565

2. Nonspecific mechanism as seen in:• Fanconi syndrome; in which there is failure to

reabsorb glucose, phosphates, ammonia and other organic acids, eg lactic acid

• Wilson’s disease; in which in addition to aminoaciduria (Ala, Asp, Glu) there is associated glycosuria, uric acid and phosphate excretion.

• Muscular dystrophies; Met, Val, Ile or Leu.• Heavy metal intoxication; Pb, Hg, Co, Ur

Renal aminoaciduria, Renal aminoaciduria, Cont’dCont’d

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ProteinProtein % of Total% of Total Daily MaximumDaily Maximum

AlbuminAlbumin 40%40% 60 mg60 mg

Tamm-HorsfallTamm-Horsfall 40%40% 60 mg60 mg

ImmunoglobulinsImmunoglobulins 12%12% 24 mg24 mg

Secretory IgASecretory IgA 3%3% 6 mg6 mg

OtherOther 5%5% 10 mg10 mg

TOTALTOTAL 100%100% 150 mg150 mg

Proteins in “Normal” Proteins in “Normal” UrineUrine

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ProteinuriaProteinuria

When protein appears in urine in detectable amounts, it is called misnomer “albuminuria”. Two types:Functional proteinuria It is not related to a diseased organ.

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Functional Proteinuria, Functional Proteinuria, Cont’dCont’d

CausesCauses1. Violent exercise2. Cold bathing3. Alimentary of protein ingestion4. Pregnancy5. Orthastatic or postural; in children or in

adolescents usually in age of 14 to 18 years

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Organic Organic ProteinuriaProteinuria

• It is classified into three major groups:

1. Prerenal

2. Renal

3. Postrenal protienuria

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Prerenal ProteinuriaPrerenal Proteinuria

1. Cardiac diseases2. Any abdominal tumors3. Fever and hypoxia conditions4. Cancers5. Collagen diseases

It is not related to kidneys

CausesCauses

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1.Acute glomerulophritis

2.Chronic glomerulophritis

3.Nephrosclerosis

4.Nephrotic syndrome

5.Renal tumor or infection

Renal ProteinuriaRenal Proteinuria

It is related to kidney diseases.

CausesCauses

7272

1.Urethritis or prostatitis

2.Bleeding in genito urinary tract

3.Cystitis

4.Contamination with vaginal secretions

Postrenal ProteinuriaPostrenal Proteinuria

CausesCauses

It is sometimes called “false proteinuria” because protein don’t pass through kidneys.

7373

GlucosuriaGlucosuria

When sugar (glucose) appears in urine in detectable amounts.

Two TypesTwo Types 1. Hyperglycemic glucosuria

• It is NOT related to kidney diseases

2. Renal glucosuria• It is related to kidney diseases

7474

CausesCauses1. Alimentary of ingestion of carbohydrates

2. Nervous or emotional conditions; (increases glycogenolysis)

3. Endocrine disorders:• Insulin, diabetes mellitus

• Hyperthyroidism

• Epinephrine

• Hyperactivity of anterior pituitary gland

• Adrenal cortex

• Glucagon

Hyperglycemic GlucosuriaHyperglycemic Glucosuria

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CausesCauses1. Hereditary

2. Acquired:

• Renal tubule diseases

• Heavy metal poisoning

• Lowering of renal threshold

• Renal tubular transport defects

• Renal tubular acidosis

• Hyperphosphaturia as in Fanconi syndrome

Renal GlucosuriaRenal Glucosuria

7676

Classification of Urinary Classification of Urinary CalculiCalculi

1.Calcium oxalate

It is the most commonly formed constituent of urinary calculi. It precipices at acid or neutral pH

2. Calcium phosphate

It forms calculi at the normal urinary pH 6 – 6.5

3. Magnesium ammonium phosphate

It forms calculi in an alkaline urine probably associated with bacterial infections

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4.Mixed calcium oxalate and calcium phosphate

It is the most common constituents (80 – 84%)

5.Mixed calcium phosphate, magnesium ammonium phosphate and uric acid

It is about 3 – 10%

Classification of Urinary Classification of Urinary Calculi, Cont’dCalculi, Cont’d

7878

6. Uric acid, cystine and xanthine

It precipitates in acid urine at pH < 6

7. Cystine

It is about 1 – 2%


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8. CarbonateIt is frequently detected in chemical analysis and probably

results from absorption of carbon dioxide to the calcium phosphate crystals

9. Organic matrixIt appears to be the one essential component of all urinary

calculi. This mixture is mucoid containing about 65% protein, 14% carbohydrates, 12% inorganic ash and 1% bound water


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Causes of Urinary Causes of Urinary CalculiCalculi

1. Consumption of animal proteins

2. Hyperparathyroidism

3. Hypervitaminosis D

4. Avitaminosis A (Deficiency)

5. Avitaminosis B6

6. Kidney stones

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Reporting ResultsReporting Results

1.1. Most urinalysis reports have a Most urinalysis reports have a standardized formstandardized form

1.1. Key to reporting is to be consistentKey to reporting is to be consistent

2.2. DocumentatioDocumentatio

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Laboratory Report: Laboratory Report: UrinalysisUrinalysis

8383

Urinalysis Automation Urinalysis Automation

• Several automated instruments are Several automated instruments are currently available to standardize:currently available to standardize:• Sample processingSample processing• Biochemical test strips analysisBiochemical test strips analysis• Microscopy analysisMicroscopy analysis• Report resultsReport results

8484

Urinalysis Automation Urinalysis Automation

• Automation Urinalysis Features:Automation Urinalysis Features:1.1. On-line computer capabilityOn-line computer capability

2.2. Bar codingBar coding

3.3. Manual entry of colorManual entry of color

4.4. ClarityClarity

5.5. Microscopic resultsMicroscopic results

8585

Urinalysis Automation, Urinalysis Automation, Cont’d Cont’d

• Automation Urinalysis Features:Automation Urinalysis Features:6.6. Flagging of abnormal resultsFlagging of abnormal results

7.7. Sorting of patients and control resultsSorting of patients and control results

8.8. Minimal calibrationMinimal calibration

9.9. CleaningCleaning

10.10. MaintenanceMaintenance

8686

• SemiautomationSemiautomation• It depends on an It depends on an

operator for specimen operator for specimen mixing mixing

• Test strip dippingTest strip dipping• In-putting physical and In-putting physical and

microscopic resultsmicroscopic results

• Fully automationFully automation• Add urine to reagent Add urine to reagent

stripsstrips

• WorkstationsWorkstations• Complete urinalysis Complete urinalysis

Major Automated Major Automated Biochemistry Urine Biochemistry Urine

Analyzers Analyzers

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Clinitek 50/100 Reagent Clinitek 50/100 Reagent StripsStrips

• It suited for small LabIt suited for small Lab• Reagent strips are Reagent strips are

manually dipped and manually dipped and placed into the strip placed into the strip readerreader

• Results are displayed Results are displayed or printedor printed

• Patients ID, specimen Patients ID, specimen color, clarity are color, clarity are manually enteredmanually entered

• Abnormal results are Abnormal results are flaggedflagged

8888

Distinguishes between Distinguishes between hemolyzed and intact hemolyzed and intact RBCs RBCs

BiochemistriesBiochemistries leukocytes, glucose, leukocytes, glucose,

Bilirubin, Ketone, Bilirubin, Ketone, specific gravity, nitrite, specific gravity, nitrite, phosphate, protein, phosphate, protein, Urobilinogen, bloodUrobilinogen, blood

Automatic urine color Automatic urine color determination determination

Multistix 10 SG Reagent Multistix 10 SG Reagent StripsStrips

8989

Clinitek 500 Reagent Clinitek 500 Reagent StripsStrips

• Distinguishes between Distinguishes between hemolyzed and hemolyzed and nonhemolyzed specimennonhemolyzed specimen

• Determine low SG and pHDetermine low SG and pH• Rapid entryRapid entry

• Specimen IDSpecimen ID• ColorColor• ClarityClarity

• Automatic featuresAutomatic features• Color determinationColor determination• Strips detectionStrips detection• CalibrationCalibration• ConfirmatoryConfirmatory• Microscopic analysisMicroscopic analysis

9090

Clinitek Microalbumin Clinitek Microalbumin Reagent Strips Reagent Strips

• Provide albumin, Provide albumin, creatinine and creatinine and albumin-to-creatinine albumin-to-creatinine ratio results in one ratio results in one minute minute

• useful to test for useful to test for microalbuminuria in microalbuminuria in patients with diabetes patients with diabetes or hypertension in or hypertension in order to detect early order to detect early kidney disease kidney disease

9191

• It designed for large LabIt designed for large Lab• Performs >12 tests Performs >12 tests

automaticallyautomatically• Walk-away capability (> Walk-away capability (>

225 specimen/hr)225 specimen/hr)• > 2 mL urine specimen > 2 mL urine specimen

requiredrequired• Flagging abnormal Flagging abnormal

specimenspecimen• Automatic featuresAutomatic features

• Color determinationColor determination• Strips detectionStrips detection• CalibrationCalibration• ConfirmatoryConfirmatory• Microscopic analysisMicroscopic analysis• etcetc

Clinitek AtlasClinitek Atlas

9292

Clinitek Status AnalyzerClinitek Status Analyzer

• Provides important Provides important markers to detect markers to detect early stages of many early stages of many disease states, such disease states, such as kidney disease and as kidney disease and urinary tract infectionsurinary tract infections

• Semi-quantitative Semi-quantitative results have proven to results have proven to be cost-effective and be cost-effective and virtually immediate virtually immediate

• Its readings eliminate Its readings eliminate the subjectivity of the subjectivity of color interpretationcolor interpretation

9393

Intended Use of Intended Use of Clinitek Clinitek Status AnalyzerStatus Analyzer

• The Analyzer is for in vitro use in the semi-The Analyzer is for in vitro use in the semi-quantitative detection of quantitative detection of • Albumin, bilirubin, blood (occult), creatinine, glucose, Albumin, bilirubin, blood (occult), creatinine, glucose,

ketone (acetoacetic acid), leukocytes, nitrite, pH, protein, ketone (acetoacetic acid), leukocytes, nitrite, pH, protein, specific gravity and urobilinogen in urine samplesspecific gravity and urobilinogen in urine samples

• The calculation of albumin-to-creatinine and The calculation of albumin-to-creatinine and protein-to-creatinine ratios in urine samples, when protein-to-creatinine ratios in urine samples, when Clinitek® Microalbumin and Multistix PRO® Clinitek® Microalbumin and Multistix PRO® Reagent Strips for Urinalysis are usedReagent Strips for Urinalysis are used

• The detection of human Chorionic Gonadotropin The detection of human Chorionic Gonadotropin (hCG) in urine samples, when Clinitest® hCG (hCG) in urine samples, when Clinitest® hCG cassettes are usedcassettes are used

9494

9595

Urinalysis WorkstationsUrinalysis Workstations

• Automatic analysis Automatic analysis (6 mL) at room (6 mL) at room temperaturetemperature• Biochemistry strip Biochemistry strip

teststests• Urine specific Urine specific

gravity (2 mL)gravity (2 mL)• Microscopy (4 mL Microscopy (4 mL

uncentrifuged urine uncentrifuged urine specimen)specimen)

9696

Urinalysis Workstations, Urinalysis Workstations, Cont’dCont’d

• Operator makes the Operator makes the final ID by touching on final ID by touching on monitor screen of monitor screen of touch buttons:touch buttons:• An appropriate areaAn appropriate area• CategoryCategory

• Contains body fluids:Contains body fluids:• Cerebrospinal fluidCerebrospinal fluid• Serous fluid (pleural, Serous fluid (pleural,

pericardial, peritoneal pericardial, peritoneal fluid)fluid)

• Seminal fluidSeminal fluid• Synovial fluidSynovial fluid

9797

Urine Pathology SystemUrine Pathology System

• Complete routine Complete routine urinalysis automationurinalysis automation• Fully automated Fully automated

biochemistry test strip biochemistry test strip resultsresults

• Urine SG, color, clarityUrine SG, color, clarity• Microscopic analysis Microscopic analysis

(uncentrifuged (uncentrifuged specimen)specimen)

• Automatically countsAutomatically counts• RBC, WBC, bateria, RBC, WBC, bateria,

yeasts, squamous yeasts, squamous epithelial cells, hyaline, epithelial cells, hyaline, nonhyaline casts, nonhyaline casts, sperm, mucus, etc sperm, mucus, etc

9898

Urine Pathology System, Urine Pathology System, Cont’dCont’d

• Operator interacts Operator interacts with the monitor towith the monitor to• Review and confirm Review and confirm

analyte imagesanalyte images• Edit the resultsEdit the results• Flag the abnormal Flag the abnormal

resultsresults

• Final report can be Final report can be printedprinted

9999

IRIS Flow IRIS Flow VideomicroscopyVideomicroscopy

• Urine is drawn through Urine is drawn through a flat chambera flat chamber

• Video snaps are sorted Video snaps are sorted by computerby computer

• Technician scans Technician scans images and deletes images and deletes dud onesdud onesComputer then adds Computer then adds up #/cmmup #/cmm

• These are RBCsThese are RBCs

100100

IRIS Flow IRIS Flow VideomicroscopyVideomicroscopy

• Squamous Squamous epithelial cells epithelial cells

101101

THE ENDTHE END

Any questions?

1 Chapter 7 Urinalysis-3 Professor A. S. Alhomida Disclaimer The texts, tables, figures and images contained in this course presentation (BCH 376) are.

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