DJOKO HADIWIDODOBAGIAN PATOLOGI KLINIKFAKULTAS KEDOKTERAN UNS SURAKARTAUrine Analysis Surakarta, 19 April 2010

TUJUAN PEMERIKSAAN URINEUMUM :Membantu / menegakkan diagnosisFollow up & prognosisFungsi organ KHUSUS :Kelainan Traktus Urinarius / UrogenitalPenyakit ginjalPenyakit diluar ginjal

Specimen CollectionPertama - pagiTampungType of specimenAnalisis dalam 2 jam Bebas dari debris vaginal

Specimen CollectionMengapa urine pagiurine rutin ? Asam pengawet Kandungan tinggi Nilai Rujukan Perlakuan minimal

MacroscopicChemical Analysis (Urine Dipstick)MicroscopicCultureCytologicalTypes of Analysis

MacroscopicBau : Ammonia-like:(Urea-splitting bacteria) Foul, offensive:Old specimen, pus or inflammation Sweet: Glucose Fruity: Ketones Maple syrup-like: Maple Syrup Urine DiseaseWarna : Colorless Diluted urine Deep YellowConcentrated Urine, Riboflavin Yellow-GreenBilirubin / Biliverdin RedBlood / Hemoglobin Brownish-redAcidified Blood (Actute GN) Brownish-blackHomogentisic acid (Melanin)

Chemical AnalysisUrine Dipstick

Specific GravitySignificance- Diabetes insipidus

Limitations- Interference: alkaline urinepHSignificance- 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

GlucoseSignificanceDiabetes mellitus.Renal glycosuria.Glukosuria fisiologis

LimitationsInterference: reducing agents vit. C , buah2an, antibiotik

KetonesSignificance- 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 secretionsCauses of Proteinuria

Protein% of TotalDaily Maximum

Albumin40%60 mgTamm-Horsfall40%60 mgImmunoglobulins12%24 mgSecretory IgA3%6 mgOther5%10 mg

TOTAL100%150 mgProteins in Normal Urine

NitriteSignificance Limitations- Gram negative bacteriuria - Interference: bacterial overgrowth - Vitamin C negativ palsu

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

Limitations- Interference: menstrual contamination

BilirubinSignificance- 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 merahUrobilinogen

BloodSignificance- Hematuria (nephritis, trauma, etc)- Hemoglobinuria (hemolysis, etc)- Myoglobinuria (rhabdomyolysis, etc) - UTI, urolithiasis, hipertensi, terapi antikoagulan.

Limitations- Interference: reducing agents, microbial peroxidases

Microscopic ExaminationPer High Power Field (HPF) (400x)> 5 erythrocytes> 12 leukocytes> 2 renal tubular cells> 10 bacteriaPer 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 inclusionsPathological crystals (leucine, tyrosine, cystine)Large number of uric acid or calcium oxalate crystalsAbnormal

Bacterial CastsIndividual LeukocytesLeukocyte CastsIndividual ErythrocytesErythrocyte CastsIndividual BacteriaSignificance of Cellular Casts

Erythrocyte Casts:Glomerular diseases

Leukocyte Casts:Pyuria, glomerular disease

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

Urine microscopy castErythrocyte cast. Leukocyte castEpithelial cast. Hyaline Granula cast

pH unsur anorganik

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

KRISTAL URINEUmum - Asam urat, Ca Oxalat, Ca Phosphat - Makanan, dehidrasi, perubahan pH & suhu - Gagal ginjal akut : - Asam urat urat akut nephropaty - Calsium oxalat keracunan ethylen glycol

Patologi - Cholestrol, cystine, leucine, tyrosine

Obat - Overdosis, dehidrasi, pH, hypoalbuminemia

CRYSTAL PATOLOGICholesterolLeucineCysteinTyrosineKristaluria yang berhubungan dengan Gagal Ginjal Akut :

Uric acidCalsium oxalate

Cystine hexagonaltyrosineleucineKRISTAL PATOLOGI

MANIFESTASI KLINIK KRISTALURIA :

Tanpa gejalaHematuria & / leukosituriaObstruksi batuPresipitasi intratubular gagal ginjal akut

Urine syndromes

Urinary tract infectionGlomerulo-nephritisNephrosis(idiopathic)Bacterial infection of renal parenchymaStructural glomerular damageIncreased permeability to albumineLeucocytesbacteriaErythrocytes(dysmorphic) -(erythrocytes+/-)(leucocytes+/-)-(Protein+/-)Protein ++(0.5-1-2 g/day)Protein ++++(>3.5 g/day)Leucocyte casts(=Pyelonephritis)Erythrocyte casts(Hyaline/waxy casts)