DJOKO HADIWIDODODJOKO HADIWIDODOBAGIAN PATOLOGI KLINIKBAGIAN PATOLOGI KLINIK

FAKULTAS KEDOKTERAN UNS FAKULTAS KEDOKTERAN UNS SURAKARTASURAKARTA

Urine AnalysisUrine Analysis

Surakarta, 19 Maret 2014Surakarta, 19 Maret 2014

TUJUAN PEMERIKSAAN URINETUJUAN PEMERIKSAAN URINE

UMUM :

1. Membantu / menegakkan diagnosis2. Follow up & prognosis3. Fungsi organ

KHUSUS :

1. Kelainan Traktus Urinarius / Urogenital2. Penyakit ginjal3. Penyakit diluar ginjal

Specimen Specimen CollectionCollection

– Pertama - pagi

– Tampung

– Type of specimen

– Analisis dalam 2 jam

– Bebas dari debris vaginal

Specimen CollectionSpecimen CollectionMengapa urine pagiMengapa urine pagiurine urine rutin ?rutin ?

o Asam pengawet

o Kandungan tinggi

o Nilai Rujukan

o Perlakuan minimal

MacroscopicChemical Analysis (Urine Dipstick)

Microscopic

CultureCulture

CytologicalCytological

Types of Types of AnalysisAnalysis

MacroscopicMacroscopicBau :− Ammonia-like: (Urea-splitting bacteria)− Foul, offensive: Old specimen, pus or inflammation− Sweet: Glucose− Fruity: Ketones− Maple syrup-like: Maple Syrup Urine Disease

Warna :− Colorless Diluted urine− Deep Yellow Concentrated Urine, Riboflavin− Yellow-Green Bilirubin / Biliverdin− Red Blood / Hemoglobin− Brownish-red Acidified Blood (Actute GN)− Brownish-black Homogentisic acid (Melanin)

ChemicalChemical AnalysisAnalysisUrine Dipstick

GlucoseGlucose

BilirubinBilirubin

KetonesKetones

Specific GravitySpecific Gravity

BloodBlood

pHpH

ProteinProtein

UrobilinogenUrobilinogen

NitriteNitrite

Leukocyte EsteraseLeukocyte Esterase

SpecificSpecific GravityGravity

Significance- Diabetes insipidus

Limitations- Interference: alkaline urine

pHpH

Significance- Acidic (> 4.5):

high-protein diet- Alkaline (> 8.0)

Limitations- Interference: bacterial

overgrowth (alkaline or acidic),

Other- Acidic sepanjang hari batu

asam urat- Alkaline sepanjang hari infeksi

GlucoseGlucose

SignificanceDiabetes mellitus.Renal glycosuria.Glukosuria fisiologis

LimitationsInterference: reducing

agents vit. C , buah2an, antibiotik

KetonesKetones

Significance- Diabetic ketoacidosis- Prolonged fasting

- Demam

Functional Renal- Severe muscular exertion - Glomerulonephritis- Pregnancy - Nephrotic syndrome- Orthostatic proteinuria - Renal tumor or infection

Pre-Renal Post-Renal- Fever - Cystitis- Renal hypoxia - Urethritis or prostatitis- Hypertension - Contamination with vaginal secretions

Causes of Causes of ProteinuriaProteinuria

Protein % of TotalDaily Maximum

Albumin 40%60 mg

Tamm-Horsfall 40%60 mg

Immunoglobulins 12%24 mg

Secretory IgA 3%6 mg

Other 5%10 mg

TOTAL 100%150 mg

Proteins in “Normal” UrineProteins in “Normal” Urine

NitriteNitrite

Significance Limitations- Gram negative bacteriuria - Interference: bacterial

overgrowth - Vitamin C negativ

palsuLeukocyte EsteraseLeukocyte EsteraseSignificance

- UTI- Infeksi sekitar Saluran kemih- Sumbatan saluran kemih bagian bawah

Limitations- Interference: menstrual contamination

BilirubinBilirubin

Significance- Increased direct bilirubin (correlates with urobilinogen and

serum bilirubin)

Limitations- Positif palsu : Obat2-an yang berwarna merah- Negatif palsu : vit. C

Significance- High: increased hepatic processing of bilirubin- Low: bile obstruction

Limitations- Positf palsu : Obat2-an yang berwarna merah

UrobilinogeUrobilinogenn

BloodBlood

Significance- Hematuria (nephritis, trauma, etc)- Hemoglobinuria (hemolysis, etc)- Myoglobinuria (rhabdomyolysis, etc)

- UTI, urolithiasis, hipertensi, terapi antikoagulan.

Limitations- Interference:

reducing agents, microbial peroxidases

Microscopic ExaminationMicroscopic Examination

Per High Power Field (HPF) (400x)– > 5 erythrocytes

– > 12 leukocytes

– > 2 renal tubular cells

– > 10 bacteria

Per Low Power Field (LPF) (100x)– > 3 hyaline casts or > 1 granular cast

– > 10 squamous cells (indicative of contaminated specimen)

– Any other cast (RBCs, WBCs)

Presence of:– Fungal hyphae or yeast, parasite, viral inclusions

– Pathological crystals (leucine, tyrosine, cystine)

– Large number of uric acid or calcium oxalate crystals

AbnormalAbnormal

Bacterial CastsBacterial Casts

Individual LeukocytesIndividual Leukocytes

Leukocyte CastsLeukocyte Casts

Individual ErythrocytesIndividual Erythrocytes

Erythrocyte CastsErythrocyte Casts

Individual BacteriaIndividual Bacteria

Significance of Cellular CastsSignificance of Cellular Casts

Erythrocyte Casts: Glomerular diseases

Leukocyte Casts: Pyuria, glomerular disease

Degenerating Casts:- Granular casts Nonspecific (Tamm-Horsfall protein)- Hyaline casts Nonspecific (Tamm-Horsfall protein)- Waxy casts Nonspecific- Fatty casts Nephrotic syndrome (oval fat body casts)

CastsCasts

Urine microscopyUrine microscopy cast cast

Erythrocyte cast. Leukocyte cast Epithelial cast.

Hyaline – Granula cast

Acid Urine pH Neutral Urine pH

Alkaline Urine pH

Calcium Oxalate Ammonium Biurate

Triple Phosphates

Uric Acid Calcium Carbonate

Ammonium Biurate

Calcium Oxalate Calcium Carbonate

Triple Phosphate Calcium Phosphate

Amorphous urates

Amorphous Phosphates

pH pH unsur anorganik unsur anorganik

KRISTAL URINEKRISTAL URINE

1. Umum - Asam urat, Ca Oxalat, Ca Phosphat - Makanan, dehidrasi, perubahan pH & suhu - Gagal ginjal akut : - Asam urat urat akut nephropaty - Calsium oxalat keracunan ethylen

glycol

2. Patologi - Cholestrol, cystine, leucine, tyrosine

3. Obat - Overdosis, dehidrasi, pH, hypoalbuminemia

CRYSTAL PATOLOGICRYSTAL PATOLOGI

1. Cholesterol2. Leucine3. Cystein4. Tyrosine

Kristaluria yang berhubungan dengan Kristaluria yang berhubungan dengan Gagal Ginjal Akut :Gagal Ginjal Akut :

1.Uric acid2.Calsium oxalate

Cystine hexagonal

tyrosineleucine

KRISTAL PATOLOGIKRISTAL PATOLOGI

MANIFESTASI KLINIK KRISTALURIA :MANIFESTASI KLINIK KRISTALURIA :

1.Tanpa gejala2.Hematuria & / leukosituria3.Obstruksi batu4.Presipitasi intratubular gagal ginjal akut

pH alkalis RBC lisis

Urine „syndromes”Urine „syndromes”

Urinary tract infection

Glomerulo-nephritis

Nephrosis(idiopathic)

Bacterial infection of renal

parenchyma

Structural glomerular

damage

Increased permeability to

albumine

Leucocytesbacteria

Erythrocytes(dysmorphic)

-

(erythrocytes+/-) (leucocytes+/-) -

(Protein+/-) Protein ++(0.5-1-2 g/day)

Protein ++++(>3.5 g/day)

Leucocyte casts(=Pyelonephritis)

Erythrocyte casts (Hyaline/waxy casts)