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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)