Urine R/M/E

Urine normal values are:

Urine Color :

Various odors of the urine:

Urine clarity variables:

Normal urine specific gravity :

• 1.003 to 1.030 (1.005 to 1.030).

1. Most urine fall in the range of 1.015 to 1.025.
2. Newborn = 1.012
3. Infants = 1.002 to 1.006
4. Adult = 1.002 to 1.030

• After 12 hours of fluid restriction = >1.025
• Urine 24 hours = 1.015 to 1.025
• The diluted urine range is 1.000 to 1.010.
• Concentrated urine is 1.025 to 1.030.

Low specific gravity urine (hyposthenuria) is seen in:

1. Diabetes inspidus (not go above 1.001 to 1.003. ADH hormone is lacking.
2. Pyelonephritis.
3. Glomerulonephritis.
4. The consistent low specific gravity of 1.010 is known as isosthenuria.
5. It is seen in chronic renal disease, where the capacity of concentrating urine is lost.

High specific gravity urine (hypersthenuria) is seen in:

1. Diabetes mellitus.
2. Congestive heart failure.
3. Dehydration due to sweating, fever, and vomiting or diarrhea.
4. Adrenal insufficiency.
5. Liver disease.Nephrosis.

Causes of acidic and alkaline urine:

1. Normal:
   1. 500 to 800 mOsm/ kg of water.
   2. Serum osmolarity = 275 to 300 mOsm.
   3. Urine osmolarity = 50 to 1400 mOsm.

1. Use of the osmolality/osmolarity:
   1. It can monitor renal concentration ability for the course of renal disease.
   2. It can monitor fluid and electrolyte therapy.
   3. It can differentiate between hypernatremia and hyponatremia.
   4. It evaluates the secretion and renal response to ADH.
   5. There is a need to get the osmolarity of the serum and the urine.

1. Normal:
   1. 1200 to 1500 mL/24 hours.
   2. The range of 600 to 2000 mL/24 hours may be considered normal.
   3. The average urine volume is 1200 ml.
2. Night urine volume is usually less in amount.
3. The ratio of day urine to night’s urine is  2: 1 to 4:1.

1. 2.Nocturnal polyuria:
2. 1. There is increased urine at night. This may be seen in diabetes mellitus and diabetes inspidus.
   2. This may be seen as diuretics, or intake of tea, coffee, or alcohol. These will suppress the ADH.
3. Polyuria is seen in:
   1. diabetes mellitus.
   2. Diabetes inspidus.
   3. Chronic renal disease.
   4. In the case of acromegaly.
   5. In the case of myxedema.
4. Oliguria:
   1. There is a decrease in the normal daily urine volume.
      1. Anuria or oliguria, where urine volume is <200 mL/day.
   2. This is seen in dehydration due to vomiting, diarrhea, perspiration, or severe burn.
   3. Nephritis.
   4. Urinary tract obstruction.
   5. Acute renal failure.
   6. Oliguria may lead to anuria.
   7. Drugs that have diuretic effects are:
      1. Thiazides.
      2. Alcohol.
      3. Caffeine.
   8. The drugs which decrease the volume and are nephrotoxic are:
      1. Analgesics like salicylates.
      2. Antibiotics like neomycin, penicillin, and streptomycin.

Clinical types of proteinuria are:

Prerenal proteinuria:

1. This is caused by  nonrenal diseases and is transient; it is seen in:
   1. Hemoglobinuria.
   2. Myoglobinuria.
   3. Acute phase proteinuria.
   4. This is usually not detected by the routine urine reagent strips.

Renal proteinuria:

1. This is due to renal diseases involving glomeruli or tubules.
2. Albumin appears in the urine in glomerular damage, followed by the WBCs and RBCs.
3. It is seen in:
   1. SLE.
   2. Streptococcal glomerulonephritis.
   3. Strenuous exercise  (reversible condition).
   4. Pre-eclampsia and hypertension. (reversible condition).
   5. Toxic heavy metals.
   6. Severe viral infection.

Postrenal proteinuria:

1. Proteins can be added as the urine passes through the ureter, urinary bladder, and urethra.
   1. Bacterial and fungal infection of the lower urinary tract,
   2. Menstrual contamination also contains proteins.
   3. Prostatic fluid and spermatozoa.

Orthostatic or postural proteinuria:

1. This is a persistent benign condition frequently seen in young patients.
2. It appears when the person is upright and disappears when the patient lies down.
3. Procedure to confirm the diagnosis:
   1. These patients are advised to empty their bladder before going to bed.
   2. Take the first urine sample when patients get up.
   3. Take another sample when patients are upright for several hours.
      1. The first sample will be negative.
      2. The second sample will be positive in orthostatic proteinuria.

Type and degree of proteinuria:

Renal glycosuria:

1. It is seen when the blood glucose level is normal and glucose appears in the urine.
   1. Renal tubules’ absorption of glucose by the tubules is compromised.
   2. It is usually seen in end-stage kidney diseases, osteomalacia, and Fanconi’s syndrome.
2. Glucose false tests are seen in the urine’s high specific gravity and contain a large amount of ascorbic acid.

Hyperglycemia of nondiabetic origin is seen in:

1. It is seen in the following conditions:
   1. Pancreatitis.
   2. Pancreatic cancer.
   3. Acromegaly.
   4. Cushing’s syndrome.
   5. Hyperthyroidism.
   6. Pheochromocytoma.
   7. The above conditions produce hormones like glucagon, epinephrine, cortisol, thyroxine, and growth hormone.
   8. These hormone acts against insulin and leads to glycogenolysis.

Indications for the ketone bodies:

1. Diabetic acidosis.
2. Starvation.
3. Vomiting.
4. Malabsorption syndrome.
5. Pancreatic disorders.
6. Insulin dosage monitoring.
7. Strenuous exercise.
8. Inborn error of amino acid metabolism.

Ketones are the intermediate products of fat metabolism, and these are:

1. acetone.
2. Acetoacetate.
3. β-hydroxybutyric acid.

Indications for urobilinogen in the urine:

1. Early detection of liver diseases.
2. Hemolytic diseases.
3. Hepatitis and Cirrhosis.
4. In carcinomas.

Increased level of urobilinogen is seen in:

1. Hemolytic anemia.
2. Pernicious (megaloblstic) anemia.
3. Malarial attack.
4. Excessive bruising.
5. Pulmonary infarction.
6. Cirrhosis.
7. Acute hepatitis.
8. Cholangitis.

A decreased level of urobilinogen is seen in:

1. Complete or partial obstruction of the biliary tract.
2. Cholelithiasis.
3. Biliary duct inflammation.
4. Cancer of the head of the pancreas.
5. Antibiotic therapy will suppress intestinal bacterial flora.

Normal bilirubin level in urine:

1. Urine bilirubin is negative (0 to 0.2 mg/dL (0 to 0.34 µmol/L).
2. Bilirubin can be detected in urine by the Foam test.

1. Increased bilirubin in the urine is seen in:
   1. Hepatitis and liver diseases.
   2. Obstructive biliary tract disease.
   3. Liver or biliary tract tumors.
   4. Septicemia.
   5. Hyperthyroidism.

1. Hemoglobinuria causes are:
   1. It may result from the hemolysis of RBCs in the urinary tract. This happens in the dilute and alkaline urine.
   2. This can also occur in intravascular hemolysis, where hemoglobin filters out through the glomeruli. No RBCs will be seen in the urine.
2. Pathogenesis:
   1. Under normal conditions, the complex of hemoglobin+haptoglobin complex can not filter out of the glomeruli.
   2. This happens when the free hemoglobin exceeds the haptoglobin e.g.
      1. Hemolytic anemia.
      2. Transfusion reactions.
      3. Infection.
      4. Severe burns.
      5. Strenuous exercise.
      6. Malarial infection.

1. Causes are:
   1. Crush syndrome.
   2. Muscle wasting diseases.
   3. Trauma.
   4. Alcoholism.
   5. Convulsion.
   6. Extensive exertion.
   7. Heroin abuse.

1. Indication for urinary 24 hours phosphorus:
   1. In hyperparathyroidism.
   2. In hypoparathyroidism.
   3. In case of renal losses.

Normal creatinine in urine:

1. 1.0 to 1.6 gm/24 hours.
2. Or 15 to 25 mg/ kg body weight / 24 hours.

1. Indications:
   1. To evaluate kidney diseases.

1. Indications:
   1. Cystitis.
   2. Pyelonephritis.
   3. Monitoring of the patients who are at high risk for urinary tract infection.
   4. Monitoring of antibiotic therapy.
   5. Screening of the urine culture specimens.

1. Indication for urinary sodium:
   1. Electrolytes imbalance.
   2. Acute renal failure.
   3. Hyponatremia.
   4. Oliguria.
   5. Na+ excreted for diagnosis of renal and adrenal imbalance. No preservative is needed for the collection for 24 hours ; only refrigerate during the collection.
2. Increased sodium in urine is seen in:
   1. Addison’s disease (adrenal failure, primary and secondary).
   2. Renal tubular acidosis.
   3. Diabetic acidosis.
   4. Tubulointerstitial disease.
   5. Salt losing nephritis.
   6. Barrter’s syndrome
3. A decrease in urinary sodium is seen in:
   1. Excessive sweating and diarrhea.
   2. Prerenal azotemia.
   3. Cushing’s syndrome.
   4. Primary aldosteronism.
   5. Congestive heart failure.
   6. Nephrotic syndrome with acute oliguria.

Normal potassium in urine:

1. Adult = 25 to 125 meq/24 hours urine (25 to 125 mmol/day).
2. Child = 10 to 60 meq/24 hours urine (10 to 60 mmol/day)
3. Values are diet-dependent.

1. Increased urinary K+ is seen in:
   1. Diabetic and renal tubular acidosis.
   2. Primary renal diseases.
   3. Cushing’s syndrome.
   4. Starvation.
   5. Primary and secondary aldosteronism.
   6. Fanconi’s syndrome.
   7. The onset of metabolic alkalosis.
2. The decreased urinary K+ value is seen in:
   1. Addison’s disease.
   2. In patients with K+ deficiency.
   3. Pyelonephritis and glomerulonephritis.
3. Indications:
   1. To evaluate the electrolyte imbalance.
   2. Renal disorders.
   3. Adrenal glands disorder.

Macroscopic hematuria:

1. It shows cloudy urine with a red to brown color.
2. This is seen in:
   1. Trauma.
   2. Acute infection.
   3. Inflammation.
   4. Coagulation disorders.

Microscopic hematuria is seen in:

1. Glomerular diseases.(AGN)
2. Malignancy of the urinary tract.
3. Renal calculi.
4. The possibility of menstrual contamination should be considered in females.

Normal WBCs number:

1. Normally few Neutrophils are seen.
2. Usually 4 to 5 /HPF.
3. >30 cells /HPF is considered an infection.
4. WBCs clumps are a sign of infection and must be reported

Increased neutrophils are seen in:

1. All renal inflammatory diseases.
2. Glomerulonephritis.
3. Cystitis and urethritis.
4. Chronic pyelonephritis.
5. Prostatitis.
6. Pyogenic infection.
7. Acute appendicitis.
8. Acute pancreatitis.
9. Tuberculosis.
10. Urinary bladder tumors.

Nonbacterial increased WBCs are seen in:

1. SLE.
2. Interstitial nephritis.
3. Glomerulonephritis.
4. Tumors.

Epithelial cell found in .....

1. Acute tubular necrosis.
   1. It is seen in heavy metal poisoning.
   2. Drug-induced toxicity.
   3. Hemoglobin and myoglobin toxicity.
   4. Viral infections like HBV.
   5. Pyelonephritis.
2. Viral infections.
3. Allergic reactions.
4. Acute allogenic Rejection phenomenon.
5. Malignant infiltration.

Hyaline casts found ....

1. Normally Hyaline casts are seen in :
   1. After severe exercise.
   2. Dehydration.
   3. Emotional stress.
   4. Heat exposure.
2. Pathologically hyaline casts are seen in:
   1. Acute glomerulonephritis.
   2. Chronic renal disease.
   3. Pyelonephritis.
   4. Congestive heart failure.
   5. > 20 / PHF is seen in moderate or severe renal disease.

1. Granular casts are seen in:
   1. Acute tubular necrosis.
   2. Pyelonephritis.
   3. Advanced glomerulonephritis.
   4. Malignant nephrosclerosis.
   5. The increased number indicates severe renal disease.

Red Blood Cell cast Found in.....

1. Subacute bacterial endocarditis
2. Goodpasture’s syndrome
3. Renal infarct
4. Acute glomerulonephritis
5. Lupus nephritis

• Epithelial cells cast Found in....

1. Transplant rejection
2. Tubular necrosis
3. Heavy metal toxicity
4. Salicylates toxicity
5. CMV infection