Glucose - in nearly all cases, glucosuria is a result of ...
Glucose - in nearly all cases, glucosuria is a result of prior (often, continuing) hyperglycemia to a level in excess of the renal threshold for reabsorption.
Glycosuria generally means diabetes mellitus
• Benign low renal glucose threshold
• Cushings syndrome
• False negatives are the worse, this is because you would miss something important
• Ascorbic acid can create lots of false negatives
• Levodopa, phenothiazines, tetracycline are others
• If you are peeing out sugar, you blood glucose is over 200, and you will never reach that level unless you are diabetic
Ketones - indicator of fat metabolism
• Beta-hydroxybutyric acid
• Either the patient is not eating or has diabetes, could be fasting, high protein diet, low carb diets
• Protracted vomiting
Nitrite
• Test for urinary tract infection (e. coli)
• Bacteria that changes nitrates to nitrite
• Tests for nitrite
• A negative result does not mean that the bug is not there
• Flase positives can occur in stale urine, and food dyes
Leukocytes
• Granulocytes counted and found by esterases
Bilirubin
• Conjugated - bilirubin that is bound to a protein by an enzyme
• Unconjugated - unbound bilirubin
• Hemoglobin is broken down to heme and globin
• Heme is converted to bilirubin, which is then carried by albumin in the blood to the liver.
• In th liver is where most of the bilirubin is conjugated with glucuronic acid before it is excreted in the bile
• Total bilirubin = DB(direct) + IB(indirect)
• If bile ducts are obstructed and it bilds up enough it can get in to the blood
• Hepatobiliary disease
• Results from conjugated bilirubin
• Bilirubinuria indicates cholestasis
• Intervascular hemolysis -rbc being destroyed in the cells
▪ Cholestasis
• Flase negatives can be caused by Large amounts of Vit C or Nitrite
Blood
• Looking for hemoglobin peroxidase, or any other peroxidase
Hematuria - results as a positive in the urine sample
Hemoglobinuria - peroxidase
Myoglobinuria - muscle protein released
Keep in mind about the FALS negative
When we find a positive ketone or blood there are many things that could cause it to be a false positive
Urine Microscopy
• You cannot detect parasites with a dip stick or test, but can be seen in a slide
• This can be debated to whether or not this is a thing that should be done
• Urine dipsticks are either negative or positive
Under normal conditions, the urine of healthy people contains a number of erythrocytes….
There is a concern that the concentration, speed and duration if centerfuge with sediment is not standardized enough between the labs.
500 erythrocytes
2000 leukocytes
126mg/dl is indicative of diabetes
It is hard to reproduce results over and over.
Collecting a 24 hr urine sample is the best way for testing
s
Erythrocytes
• The morphology of the RBC found in urinary sediment is extremely variable
• There are correlations between infections and cancers
• Biconcave disc - assed by phase contrast microscopy
• Damaged - tubular, interstial damage
• Fragmentation - vascular damage
• TNTC = too numerous too count (gross hematuria)
• Confused for RBCs
• Exercise induced hematuria - can cause RBC's in blood
• Yeast can be present and look whitish reddish
• Sodium carbonate crystals
• No crystals in plasma
• Small leukocytes -
Renal epithialicells - mostly found in renal
Casts - interstitial nephropaties, chronic pylonephritis
• Hyaline casts - one or two there is no significance
• Heart failure, hyperthermia, with or w/o protienuria (smooth)
• Granular - these are usually cellular debris, always have pathological significant if LARGE.
• Hemoglobin casts - these are significant, intervascular hemolysis, intravascular coagulation, hemolytic disease
• Red cell casts - significant findings - masses of RBCs (bleeding somewhere)
• Hematuria with this is even worse
• Waxy Casts - considered to be the final transformation of all kinds of casts
• The larger they are the more meaningful
▪ Small, Medium, and Large
• Epithelial casts - these are made up of epithelial cells
• Acute renal disorders
Crystals - uric acid crystals are characteristic of acidic urine
• Passing crystals due not normally hurt as you pass them, but can
• Calcium oxalate - characteristic of uric acid in urine
Generally there is no correlation between crystals and calculi if the person is otherwise normal.
Otherwise if there is a problem with the patient, and they are having pain, then there could be a correlation between the crystals and stones.
Phosphate crystals - Only magnesium ammonium phosphate is regarded as significant
Cystine Crystal - this is the most important and definite sign of stone. (urolisthiasis)
Tyrosine crystals - these are always pathologic and rare
• Indicative of tubular necrosis
Red cells, white cells, casts, crystals
• Overall the bigger they are and the more there are creates a higher or more severe significance
Fungal elements - represent severe problem or process taking place
• Must be cultured
Mucous thread - correlation of highly concentrated urine (no clinical significance)
The doctor decides what is clinically significant too.
Morpheus urates and phosphates - have very little clinical meaning and depends on pH
• Due to concentration and pH of urine
The art of evaluating urine microscopy. There is no standard in the evaluation
• 2-3 white cells no problem in asymptomatic person, however it could be a problem if the person is having symptoms.
• You could compare to the last urine test
• Overall it is difficult in the absence of other differential tests
This time you find out what is wrong with him. Over the 30 years of being a diabetic he has begun to get other problems.
…You can make him as sick as you want, but you must keep him alive
• Show he is anemic - What type
• Renal failure
• Angina
• UTI
• Liver failure
• Heart disease
• You do not need a differential
• We will go over them on thursday
LAB TESTS ARE LIMITED
• The good news is that Lab test is good for inflammation
• The bad news is that they are non specific
REVIEW
• Inflammation is not infection
• Itis - refers to inflammation and there is a downside
• Eliminates pathogenic ideology
• Leads to one of three possible outcomes
• The source is elimimnated - tissue is restored to functional ability
• Varying degrees of function are retained, but the architecture is damaged
▪ Sprained ankle
• Fails to eliminate insult, tissue is continually altered and function is lost.
▪ Alcoholic Liver disease
• Inflammation is always accompanied by some degree of cellular necrosis
• Inflammatory rxns are swelling, heat, redness, & pain.
• Systemis presentation of inflammation includes fever, tachycardia, malasia, and anorexia
• Depending on the site of inflammation (liver, kidney, muscle) a number of laboratory tests may be abnormal, and reflect the associated cellular necrosis
• How severe is it
• How long
• Is it getting better, worse or the same
• What tissue or where is it occuring
• Once a joint is ankylosed there is no turning back
• The inflammatory process with this can be from mild to severe
• CPK
• Increased due to tissue destruction
• LDH
• Increased due to tissue destruction
• ALT/AST
• Increased due to tissue destruction
• Despite the location or etiology of the inflammation there wil be information that supports the inflammatory cycle
• Increased WBC, ESR C-reactive protein
• Leukocytosis
• Inflammed tissue will be full of white cells,
• Acute inflammation - Neutrophils are present and are produced in the bone marrow with granulocytes, then taken through the blood stream to the spot where they are needed
• Reactive Leukocytosis - WBC increase is due to a reaction or need so the WBC's are put through the blood stream to the site where they are needed
▪ Associated with acute inflammation
• In a leukemia, all of the cells are of the same type
▪ 10,000 identical cell (more proliferative than reactive)
• Can be a FALSE positive for inflammation
▪ We can find elevated #'s in conditions that do not associate with inflammation
• Pregnancy
• Exercise - causes the kidney to release erythropoeitin and release of mature RBCs
• Acute bleeding
• Daily circadian fluctuation of about 2X
• Additionally some infections do not produce an elevation of WBCs
• Bacterial, Fungal, Parasitic, Rickettsial, Viral, typhoid, diptheria
• LEFT SHIFT
• An increase in the number of IMMATURE granulocytes
▪ Baso, Eosinophils, or neutrophils, Myelo, Meta, Band
▪ When these start increasing from normal this is a left shift
▪ The increase number of immature cells in the peripheral circulation occurs because cells are recruited out, before they have fully matured
• The blasts do not do anything, but the more mature the better able they are
• Right shift is increase in mononuclear cells
• Infectious mononucleousis (increase in lymphocytes)…NOT A RIGHT SHIFT
• Lymphocytes and Monocytes = mononuclear cells
▪ Bacterial - granulocytes
▪ Viral - mononuclear
• Sed Rate
• Let blood settle for an hour, then gravity will take over…
▪ Red cells fall, and the distance that they fall is the sed rate
▪ Males have usually a little higher sed rate
▪ An elevated sed rate (higher than 11-13 mm) is correlated with inflammation
• We are actually measuring (using the Stokes equation)
▪ Radius
▪ Density of sphere and fluid
▪ Viscosity
▪ Gravity
• Whats being measured…how far the RBC's settle in one hour
▪ We are measuring changes in the plasma protein composition
▪ Using the RBC's to do it.
• ZETA potential is a function of the sialic acid group, pH of medium, ionic strength of the medium,
• Macromolecular effect
• Decreased Zeta potential is when the RBCs settle faster
• Rouleaux formation - invitro artifact
• When the cells stack like coins
• Fibrinogen, gamma globulin……
• Acute phase proteins accumulate in the plasma and look as if they are forming on the RBC,s ad cause the Rouleaux formation
• Sed rate can be meaningless, when anemic…the sed rate will be elevated
▪ A person has a hematocrit of 30%, hemoglobin is a 10
▪ 36 mm an hour…but false positive
• Dehydrated
▪ Sed rate will be 5mm hr, and hematocrit of 60%
• Normal Hematocrit is 45%
• Anemic is 35% - less blood cells so it will settle quicker
• Polycythemia (dehydration) - hct of 60% - will settle slower
• MicroCV - falso positive
• Macro - False negative
• Pernicious anemia
• Poikilocytosis - shape issue
• Heart failure cell - cell full of lipofusion cells
• Remember never evaluate a SED rate result without knowing that there is no hematologic artifact (anemia, funny shaped cells, HCT, or morphilogical change)
• MEASURES ACUTE PHASE PROTEINS
▪ These are non specific indicators of inflammation
▪ They are everyday typical proteins
• C reactive
• A-1-Antitrypsin
• Fibrinogen
• C3
• C4
• Cerulplasmin
▪ C reactive protein - a risk factor for coronary heart disease, sensitive marker for inflammation and is sensitive in the ability to differentiate
• Can elevate up to 100 fold when being tested in about 6-10 hours
• Most often used….because it is most sensitive
• 100% sensitive, but not 100% specific
• Acute phase proteins
• Used in screening for organic disease
• Monitoring disease activity
Know normal values
|WBC |(5-10) |
|RBC |(4.2-6.0) |
|HgB |(12-15.5) F |
| |(12.5-17.5) M |
|HCT |(37-45) F |
| |(40-50) M |
|MCV |(80-99) |
|Fasting Glucose |(80-115)mg/dl |
|BUN |(7-27)mg/dl |
|Creatinine |(0.5-1.5)mg/dl |
|Sodium |(135-148)meq/l |
|Potassium |(3.4-5.3)meq/l |
|Chloride |(95-108)meq/l |
|Calcium |(8.1-10.7)mg/dl |
|Albumin |(3.3-5.5)g/dl |
|Uric Acid |(2.5-7.7)mg/dl |
|Magnesium |(1.8-2.6)mg/dl |
|Phosphate |(2.7-4.5)mg/dl |
|Bilirubin (total) |(0.2-1.2)mg/dl |
|Cholesterol (HDL) |(29-72)mg/dl |
|Cholesterol (LDL) |‹130 mg/dl |
Also know
Total protein -
Globulin -
Retics -
MCH -
UA-SpGr -
UA-24hr volume -
Also Know
Pg 164-178
Pg 178-221
Slides
UA & UA microscopic lecture slides
Inflammation Lecture slides
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