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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