Graffs Urine Analysis

Graffs

Textbook of RoutineUrinalysis and BodyFluids

S E C O N D E D I T I O N

Lillian A. Mundt, EdD, CLS(NCA)SpH, MT(ASCP)SHAdventist Health Systems, Hinsdale HospitalHinsdale, IL

Kristy Shanahan, MS, CLS(NCA), MT(ASCP)Assistant ProfessorRosalind Franklin University of Medicine and ScienceNorth Chicago, IL

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Acquisitions Editor: John GoucherProduct Manager: Renee ThomasArt Director: Jennifer ClementsProduction Manager: Kevin JohnsonManufacturing Coordinator: Margie OrzechMarketing Manager: Allison PowellDesign Coordinator: Joan WendtProduction Service: Aptara, Inc.

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All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including pho-tocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner, except forbrief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their ofcialduties as U.S. government employees are not covered by the above-mentioned copyright.

Printed in China

Library of Congress Cataloging-in-Publication Data

Mundt, Lillian A.Graff's textbook of routine urinalysis and body uids / Lillian A.

Mundt, Kristy Shanahan. 2nd ed.p. ; cm.

Rev. ed. of: A handbook of routine urinalysis / Laurine Graff. c1983.Includes bibliographical references and index.ISBN 978-1-58255-875-2 (alk. paper)1. UrineAnalysisHandbooks, manuals, etc. 2. UrineExaminationHandbooks, manuals, etc. I. Shanahan, Kristy. II. Graff, Laurine. Handbook of routine urinalysis. III. Title. IV. Title:Textbook of routine urinalysis and body uids. [DNLM: 1. Urinalysismethods. 2. Body Fluidschemistry.

3. Urinechemistry. QY 185 M965g 2010]RB53.G73 2010616.07'566dc22

2009042587

Care has been taken to conrm the accuracy of the information presented and to describe generally accepted practices. However, theauthors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the informationin this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of thepublication. Application of the information in a particular situation remains the professional responsibility of the practitioner.

The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accor-dance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in govern-ment regulations, and the constant ow of information relating to drug therapy and drug reactions, the reader is urged to check the pack-age insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly importantwhen the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use inrestricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device plannedfor use in their clinical practice.

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We dedicate this book to our families who were patient and

encouraged us while we spent valuable time away from

them working on this project.

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vSister Graff s A Handbook of Routine Urinalysis has servedthe clinical laboratory profession as a classic referencetext of urine testing and atlas of urinary sediment since1983. Our goal in revising this book has been to preservethe integrity and importance of Sister Graff s work whilebringing it into the 21st century and expanding its use fromreference to textbook. Thus, this long-awaited second edi-tion has been substantially revised and enhanced not onlyto bring the content up-to-date but also to include analysisof other body uids. Moreover, we have added ChapterObjectives, Key Terms, Study Questions, Case Studies, anda Glossary to make the text more user-friendly in the class-room. These updates and additions are reected in the newtitle, Graffs Textbook of Routine Urinalysis and Body Fluids.

The urinalysis and body uids coverage in this text iscomprehensive, clearly presented, and explained in easy-to-understand language. Continuing the standard set by SisterGraff, the book uses numerous color photomicrographs tofamiliarize readers with both the normal and abnormalstructures found in the urinary sediment and body uidswhile tables and illustrations help clarify concepts.

The text progresses from introductory informationabout clinical laboratory operations (Chapter 1) to founda-tional concepts of renal anatomy and physiology, as well asurine formation (Chapter 2) and on to the practical meth-ods of urinalysis such as collection and physical examina-tion (Chapter 3), chemical analysis (Chapter 4), and micro-scopic examination (Chapter 5).

The central chapter and jewel of Graffs Textbook of RoutineUrinalysis and Body Fluids is the atlas of urinary sediment(Chapter 6). This chapter contains 190 full-color images30

more than in the rst editioncategorized by cells, crystalsfound in acidic urine, crystals found in alkaline urine, casts,and miscellaneous images. Instructors, students, and clini-cians will nd that no other text includes a comparable atlas.

The latter half of the book presents urinary and meta-bolic diseases (Chapter 7) and then moves on to introduceother body uids (Chapter 8) before going into depth abouteach one: cerebrospinal uid (Chapter 9), serous body uids(Chapter 10), synovial uid (Chapter 11), semen (Chapter12), fecal matter (Chapter 13), and miscellaneous body u-ids (Chapter 14.) Chapter 14 also includes key informationon pregnancy testing.

The book wraps up with a chapter on automated meth-ods and equipment (Chapter 15); three Appendixes provid-ing answers to the study and case questions, historically rel-evant urinalysis information from the rst edition of thetext, and reagent strip color charts; a glossary of terms thatis ideal for study and review; and for those who rely on thetext as a reference, a complete index.

We note that the information concerning reactions ofthe various reagent strip methods is up-to-date at the timeof publication, but because manufacturers continuallyimprove their products, the reagents, sensitivities, detectionranges, and timings may change. Therefore, following man-ufacturers most recent directions is of utmost importance.

We are grateful for the thoughtful suggestions of ourreviewers and readers, to which we have given considerationwhen revising and updating the current text to meet theneeds of our audience. Graffs Textbook of Routine Urinalysisand Body Fluids will continue to serve the clinical laboratoryprofession into the new millennium.

PrefacePreface

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vii

W e thank our reviewers for their insightful sugges-tions for improving the second edition of this text.We greatly appreciate the expertise, cooperation, and

patience of the publisher and editing managers whoassisted us.

AcknowledgmentsAcknowledgments

In addition, we thank the various manufacturers forimages of their instruments.

Finally, we thank the Pathology Laboratory at HinsdaleHospital, Hinsdale, IL, for supplying specimens from whichnew images were created.

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ix

Kay HannaStark State College of TechnologyNorth Canton, Ohio

Liz JohnsonApollo CollegeAlbuquerque, New Mexico

Julie HammerlingFlorida Gulf Coast UniversityFort Myers, Florida

Danyel AndersonOzarks Technical Community CollegeSpringeld, Missouri

Janice MillerNorthcentral Technical CollegeWausau, Wisconsin

Sherry ParsonsWichita Area Technical CollegeWichita, Kansas

Sondra SutherlandJefferson Community CollegeSteubenville, Ohio

ReviewersReviewers

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xi

1-1. Common safety symbols. 51-2. NFPA symbol. 72-1. Male urinary tractlateral view. 122-2. Female urinary tractlateral view. 122-3. The urinary system. 132-4. Structures of the urinary tract. 142-5. The kidney. 142-6. The sectioned left kidney. 152-7. The nephron. 162-8. Different sections of the tubule and reabsorption

of sodium and water. 172-9. Renal arterial and venous blood ow through the

kidney. 172-10. The renal pyramid with corresponding blood

vessels. 182-11. Bowman capsule, the glomerular tuft, and the

juxtaglomerular apparatus. 182-12. The glomerulus (renal corpuscle) and the

ltration barrier of the glomerulus. 182-13. Formation of urine via ltration, reabsorption,

secretion, and hormonal effects. 192-14. Filtration and tubular processing of the

glomerular ultraltrate. 192-15. The countercurrent mechanism and antidiuretic

hormone in urine concentration. 202-16. The reninangiotensinaldosterone cycle and

hypertension. 212-17. Renal cell becoming an oval fat body. 223-1. Cloth bers (160). 263-2. Urine specimens of varying color. 293-3. Schematic diagram of the Total Solids

refractometer. 323-4. Schematic representation of the refractometer

scales of measurement. 323-5. Specic gravity color chart. 334-1. Illustration of Multistix 10 SG. 364-2. pH color chart. 374-3. Protein color chart. 384-4. Glucose color chart. 404-5. Clinitest color chart. 414-6. Ketone color chart. 424-7. Acetest color chart. 434-8. Blood color chart. 44

4-9. Bilirubin color chart. 474-10. Ictotest color reactions. (A) negative, (B)

moderate, and (C) large. 474-11. Urobilinogen color chart. 484-12. Nitrite color chart. 504-13. Leukocyte esterase color chart. 505-1. Amorphous phosphates and hyaline cylindroid

(200). 575-2. Red blood cells. The eld also contains a white

cell and several ghost cells (400). 585-3. RBCs and WBCs (A). Charging the focus causes the

red cells to appear as black circles (B) (400). 585-4. White blood cells in a hypotonic urine

(800). 595-5. White cell clumps (200). 605-6. Numerous white cells (400). 605-7. Transitional cell (A), Renal epithelial cells (B) and

WBCs (C) (800). 615-8. Transitional epithelial cells (500). 615-9. Transitional epithelial cell, several squamous

epithelial cells, and white cells (200). 625-10. Squamous epithelial cells (160). 625-11. Crystals frequently found in acidic urine. 645-12. Other crystals found in acidic urine. 655-13. Uric acid crystals. (500). 665-14. Uric acid crystals in rosette formation (500). 665-15. Six-sided uric acid crystal (400). 665-16. Polarized uric acid crystal (400). 675-17. Calcium oxalate crystals (400). 675-18. Calcium oxalate crystals (500). 675-19. Amorphous urates (200). 695-20. Hippuric acid crystal (400). 695-21. Sodium urate crystals (400). 695-22. Cystine crystal (1000). 705-23. Cystine crystals. Several have laminated

surfaces (160). 705-24. Leucine spheroid (400). 705-25. Tyrosine crystals (160). 715-26. Tyrosine crystals (1000). 715-27. Cholesterol crystal with typical notched

edges (250). 715-28. Sulfonamide crystals, yeast, and WBCs

(400). 72

List of FiguresList of Figures

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xii List of Figures

5-29. X-ray dye crystals (Hypaque) (160). 725-30. X-ray dye crystals (Renogran) (400). 725-31. X-ray dye crystals (Hypaque) (160). 735-32. Polarized x-ray dye crystals (160). 735-33. Bilirubin crystals (500). 745-34. Crystals found in alkaline urine. 755-35. Triple phosphate crystals (200). 755-36. Amorphous phosphates (400). 765-37. Calcium carbonate crystals (400). 765-38. Calcium phosphate crystals (400). 765-39. Calcium phosphate plate or phosphate

sheath (200). 775-40. Ammonium biurate crystals (500). 775-41. Ammonium biurate crystals without

spicules (500). 775-42. Sequence of urinary cast degeneration. 785-43. Hyaline cast and red blood cells (400). 795-44. Red cell cast and RBCs (400). 805-45. White cell cast and WBCs (500). 815-46. Finely granular casts (500). 815-47. Broad coarsely granular cast (200). 815-48. Epithelial cell cast (200). 825-49. Waxy cast and WBCs (200). 825-50. Waxy cast, WBCs, and bacteria (400). 825-51. Fatty cast (400). 835-52. Bacteria (rods, cocci, and chains) (500). 845-53. Yeast cells (1000). 845-54. Cylindroid (400). 845-55. Spermatozoa (500). 855-56. Mucous threads. Viewed with an 80A

lter (100). 855-57. Oval fat body and a ber (500). 865-58. Fat droplets (500). 865-59. Polarized anisotropic fat droplets (160). 875-60. Starch crystal (500). 885-61. Polarized starch crystals (400). 885-62. Cloth bers (160). 885-63. Fibers (200). 895-64. Fiber (400). 895-65. Oil droplet. Field also contains WBCs and

squamous epithelial cells (400). 905-66. Hair and a coarsely granular cast. Viewed with an

80A lter (400). 905-67. Glass fragments (400). 915-68. Air bubble and amorphous urates (160). 915-69. Talcum powder particles (160). 915-70. Fecal contamination. Field also contains triple

phosphate crystals (100). 925-71. Trichomonas vaginalis (1000). 925-72. Enterobius vermicularis ovum and

WBCs (500). 935-73. Head of the Enterobius vermicularis adult female

worm (100). 935-74. Schistosoma haematobium ovum. 945-75. Image for Case Study 5-1. 955-76. Image for Case Study 5-2. 96

5-77. Image for Case Study 5-2. 965-78. Image for Case Study 5-3. 965-79. Image for Case Study 5-4. 975-80. Image for Case Study 5-4. 975-81. Image for Case Study 5-5. 976-1. Hypotonic urine containing an RBC, several

WBCs, two renal epithelial cells, and atransitional epithelial cell (500). 100

6-2. Renal epithelial cells, WBCs, RBCs, and bacteria(500). 100

6-3. Many RBCs and a squamous epithelial cell(160). 101

6-4. SM-stained RBCs, some crenated (400). 1016-5. SM-stained RBCs, some crenated, under phase

contrast microscopy (400). 1026-6. WBCs, a few RBCs, and bacteria (500). 1026-7. SM-stained WBCs and bacteria under phase

contrast microscopy (400). 1036-8. Large clump of WBCs and many squamous

epithelial cells (400). 1036-9. SM-stained RBCs, WBCs, and squamous

epithelial cells (400). 1046-10. Distorted WBCs (400). 1046-11. Clump of WBCs, stained by bilirubin

(200). 1056-12. WBCs and squamous epithelial cells

(400). 1056-13. Renal epithelial cells (500). 1066-14. Sheet of squamous epithelial cells (160). 1066-15. Numerous WBCs and few transitional cells.

(200). 1076-16. SM-stained WBCs and transitional epithelial

cells (200). 1076-17. Squamous epithelial cells. 1086-18. WBCs and bacteria. 1086-19. SM-stained WBCs and bacteria (400). 1096-20. SM-stained WBCs, and bacteria, under phase

contrast microscopy (400). 1096-21. Amorphous urates (100). 1106-22. Amorphous urates (100). 1106-23. Uric acid crystals, diamond or rhombic form

(400). 1116-24. Uric acid crystals in the urine of a patient with a

kidney stone (400). 1116-25. WBC cast and uric acid crystals (400). 1126-26. Uric acid crystals in rosette formation

(400). 1126-27. Uric acid crystals, atypical form (400). 1136-28. Uric acid crystals, layered formation

(500). 1136-29. Uric acid crystals, thick rosette formation

(200). 1146-30. Uric acid, thick rosette formation under higher

power (500). 1146-31. Uric acid and calcium oxalate crystals

(500). 115

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6-32. Uric acid crystals under polarized light (400). 115

6-33. Uric acid under polarized light (400). 1166-34. Uric acid crystals (100). 1166-35. Uric acid crystals under polarized light

(100). 1176-36. Uric acid crystals in pseudocast formation

(400). 1176-37. Uric acid, barrel shape, and yeast in the

background (200). 1186-38. Sodium urate crystals (400). 1186-39. Sodium urates and a WBC (400). 1186-40. Sodium urate crystals (400). 1196-41. Uric acid, needle shape under polarized light with

red compensator (400). 1196-42. Calcium oxalate crystals (200). 1206-43. Calcium oxalate crystals (160). 1206-44. Calcium oxalates, amorphous urates, and a piece

of debris (200). 1216-45. Calcium oxalate crystals clustered around a piece

of debris (100). 1216-46. Calcium oxalates and amorphous urates

(100). 1226-47. Hippuric acid crystals (400). 1226-48. Cystine crystals (160). 1226-49. Cystine crystal with unequal sides (1000). 1236-50. Cystine crystals (160). 1236-51. Cystine crystal with layered or laminated surface

(1000). 1246-52. Cystine crystals and a squamous epithelial cell

(400). 1246-53. Leucine crystals. 1256-54. Leucine crystals under interference contrast

microscopy. 1256-55. Tyrosine crystals (160). 1256-56. Tyrosine crystals (1000). 1266-57. Tyrosine crystals (1000). 1266-58. Tyrosine crystals under polarized light. 1276-59. Tyrosine crystals (1000). 1276-60. Cholesterol crystals from kidney uid

(200). 1286-61. Same specimen as the previous gure under

polarized light. 1286-62. X-ray dye crystals (160). 1296-63. X-ray dye crystals (400). 1296-64. X-ray dye crystals under polarized light

(160). 1306-65. Bilirubin crystals and bilirubin-stained WBC and

granular cast (500). 1306-66. Bilirubin crystals and bilirubin-stained sediment

(500). 1316-67. Bilirubin crystals. 1316-68. Sulfonamide crystals (400). 1326-69. Sulfonamide crystals under polarized light with

red compensator. 1326-70. Triple phosphate crystals (200). 133

6-71. Triple phosphate crystals and amorphousphosphates (200). 133

6-72. Triple phosphate crystals (400). 1346-73. Triple phosphate crystals (500). 1346-74. Triple phosphates crystal and amorphous

phosphates (200). 1356-75. Triple phosphate crystals under polarized

light. 1356-76. Triple phosphates crystal and amorphous

phosphates (200). 1366-77. Triple phosphates crystal and amorphous

phosphates (200). 1366-78. Triple phosphates crystal and mucus (400). 1376-79. Triple phosphate crystal (400). 1376-80. Triple phosphate crystals under polarized light

with red compensator (200). 1386-81. Calcium phosphate crystals (400). 1386-82. Calcium phosphate plates and amorphous

phosphates (200). 1396-83. Calcium phosphate plate (or phosphate sheath)

and amorphous phosphates (200). 1396-84. Ammonium biurate crystals (200). 1406-85. Ammonium biurate crystals (200). 1406-86. Ammonium biurate crystals (500). 1416-87. Ammonium biurate crystals (500). 1416-88. Ammonium biurate crystals (500). 1426-89. Ammonium biurate crystal and a squamous

epithelial cell (500). 1426-90. Ammonium biurate crystals (500). 1436-91. Ammonium biurate crystals. Spheroid form

without spicules (400). 1436-92. Ammonium biurate crystals (500). 1446-93. Hyaline cast, WBCs, RBCs, and bacteria

(500). 1446-94. Hyaline casts (200). 1456-95. Hyaline cast that is bent back upon itself and

many RBCs (400). 1456-96. Hyaline casts and many RBCs (100). 1466-97. Hyaline casts (400). 1466-98. Hyaline casts using phase contrast

microscopy. 1476-99. Many hyaline casts and WBC casts, and rare RBC

(200). 1476-100. Hyaline, WBCs, RBCs, and epithelial cells

(200). 1486-101. Hyaline cast with a few granular inclusions

(500). 1486-102. Convoluted red blood cell cast (500). 1496-103. Red blood cell cast and many RBCs (500). 1496-104. Red blood cell cast (500). 1506-105. Red blood cell cast (200). 1506-106. Red blood cell cast and amorphous urates

(500). 1516-107. White blood cell cast, WBCs, squamous epithelial

cells, and mucus (400). 1516-108. White blood cell cast (500). 152

List of Figures xiii

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xiv List of Figures

6-109. SM-stained WBC cast (400). 1526-110. White blood cell cast (400). 1536-111. Bilirubin-stained casts, bers, and sediment

(200). 1536-112. Mixed cell cast, WBCs, and RBCs (500). 1546-113. Bilirubin-stained WBC cast (500). 1546-114. Many WBC casts and many WBCs (200). 1556-115. SM-stained mixed cellular cast including renal

tubular epithelial cells (400). 1556-116. Epithelial cell cast (500). 1566-117. Mixed cast. This cast is half hyaline and half

granular (400). 1566-118. Mixed cast, yeast, and a WBC (500). 1576-119. Mixed cast (500). 1576-120. Many casts, WBCs, RBCs, and amorphous

sediment (200). 1586-121. Broad mixed granular and RBC cast, and a broad

granular cast (500). 1586-122. SM-stained hyaline cast, granular cast, mixed

cellular cast, and partially degenerated RTE cells(200). 159

6-123. Broad granular cast (400). 1596-124. Fine granular cast, WBCs, and RBCs (500). 1606-125. Fine granular casts and WBCs (500). 1606-126. SM-stained granular cast (200). 1616-127. Fine granular casts and WBCs (400). 1616-128. Coarse granular cast (500). 1626-129. Coarse granular cast (400). 1626-130. Coarse granular cast, calcium phosphate plate,

and amorphous phosphates (200). 1636-131. Broad and narrow coarse granular casts

(200). 1636-132. Coarse granular cast (400). 1646-133. Bilirubin-stained granular cast (500). 1646-134. Fine granular cast (400). 1656-135. Fine granular cast, WBCs, and bacteria

(400). 1656-136. Waxy cast and amorphous urates (500). 1666-137. Bilirubin-stained waxy cast, granular cast,

WBCs, and amorphous sediment (500). 1666-138. Long waxy cast, WBCs, and an epithelial cell

(200). 1676-139. Fine granular cast becoming a waxy cast

(500). 1676-140. Convoluted waxy cast. This eld also contains

WBCs, rare RBC, and bacteria (500). 1686-141. Convoluted waxy cast (500). 1686-142. SM-stained waxy cast (100). 1696-143. SM-stained waxy cast using phase contrast

microscopy (100). 1696-144. SM-stained waxy-granular cast (200). 1706-145. Granular cylindroid (500). 1706-146. Hyaline cylindroid (160). 1716-147. Fine granular cast and yeast (400). 1716-148. Bacteria. This eld contains rods, cocci, and

chains (500). 172

6-149. Yeast, WBCs, rare RBC, and bacteria (500). 172

6-150. Yeast (1000). 1736-151. SM-stained yeast with pseudohyphae and

WBCs (200). 1736-152. Yeast under phase contrast microscopy

(400). 1746-153. Pinworm ovum and WBCs (100). 1746-154. Enterobius vermicularis or pinworm ovum

(400). 1756-155. Tail of the adult female pinworm (40). 1756-156. Pinworm ovum and WBCs (500). 1766-157. Schistosoma haematobium ovum under interference

contrast microscopy. 1766-158. Trichomonas vaginalis with mixed cellular

background viewed under phase contrastmicroscopy. 177

6-159. Sperm and epithelial cells (500). 1776-160. SM-stained sperm. 1776-161. Mucus. 1786-162. Mucus containing WBCs and RBCs

(200). 1786-163. Fat droplets and epithelial cells (160). 1796-164. Oval fat body, granular cast, and amorphous

urates (500). 1796-165. Oval fat body (400). 1806-166. Oval fat body (500). 1806-167. Oval fat bodies and WBCs (500). 1816-168. Oval fat body (400). 1816-169. Oval fat body (400). 1826-170. Oval fat body (400). 1826-171. Sudan III stained fat droplets. 1836-172. Starch granules (200). 1836-173. Starch crystals (500). 1846-174. Starch granules. 1846-175. Starch crystals under polarized light

demonstrating the typical Maltese-crossformation (400). 185

6-176. Talcum powder particles and a few squamousepithelial cells (160). 185

6-177. Debris from a diaper (400). 1866-178. A. Fine granular cast and WBCs. B. Fiber

(200). 1861876-179. Fiber (400). 1876-180. Fiber (400). 1886-181. Fiber (400). 1886-182. Debris from a diaper (200). 1886-183. Fibers (400). 1896-184. Fibers (400). 1896-185. Fiber (400). 1906-186. Fibers (500). 1906-187. Fiber, calcium oxalate crystals, and amorphous

urates (400). 1916-188. Fiber, calcium oxalate crystals, and

amorphous urates, but on a different focal plane (400). 191

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6-189. Air bubbles, phosphate plate, and amorphousphosphates (200). 192

6-190. Coverslip defects. 1927-1. The normal metabolic pathway of phenylalanine

and tyrosine. 2037-2. Increased formation of phenylalanine

metabolites. 2047-3. Biosynthesis of heme. 2107-4. RBC cast: urine sediment; 400. 2137-5. Broad nely granular cast becoming waxy cast

with mixed cellular background. 2147-6. Fatty casts, urine sediment; 400. 2147-7. Fatty casts; POL; urine sediment; 400. 2147-8. Granular casts, urine sediment. SM stain;

200. 2147-9. WBC cast, urine sediment. SM stain; 400. 2157-10. Direct Gram stain of urine showing gram-

negative rod bacteria and three WBCs(neutrophils); 1000. 215

7-11. Cystine crystal. Urine sediment, SM stain; 200. 215

7-12. Cystine crystal. Urine sediment; 200. 2167-13. Cystine crystal; POL. Urine sediment; 200. 2167-14. Cystine crystals. Urine sediment; 100. 2168-1. Forces governing the exchange of uid at the

capillary level. 2208-2. Exchanges through capillary membranes in the

formation and removal of interstitial uid. 2218-3. Neubauer hemocytometer diagrams. 2228-4. Cytocentrifuge. 2238-5. Cytocentrifugation method of body uid

concentration. 2238-6. Cytocentrifuge-prepared smears are marked

with a wax pencil to outline the area of celldeposit. 223

9-1. Anatomy of the central nervous system. 2299-2. Detail of meninges. 2299-3. Placement of the needle for CSF collection. 2309-4. Specimen containers for cerebral spinal uid

specimens. 2309-5. Comparison of cerebral spinal uid

appearance. 2319-6. Cells that can normally be found in cerebral

spinal uid (Wright stain 1000). 2319-7. Neutrophilic pleocytosis in cerebral spinal uid

(Wright stain 1000). 2329-8. Lymphocytic pleocytosis in cerebral spinal uid

(Wright stain 1000). 2329-9. Plasma cells in cerebral spinal uid (Wright

stain 1000). 2329-10. Eosinophils in cerebral spinal uid (Wright

stain 1000). 2329-11. Cerebral spinal uid with mixed pleocytosis

(Wright stain 1000). 2349-12. Macrophage in cerebral spinal uid (Wright

stain 1000). 234

9-13. Macrophage demonstrating erythrophagocytosisin cerebral spinal uid (Wright stain 1000). 234

9-14. Macrophage with iron inclusions (siderophage) incerebral spinal uid (Wright stain 1000). 235

9-15. Macrophage with hematin inclusions in cerebralspinal uid. 235

9-16. Macrophage with possible fat inclusions(lipophage) in cerebral spinal uid. 235

9-17. Ependymal cells in cerebral spinal uid (Wrightstain 1000). 235

9-18. Nucleated red blood cells in cerebral spinal uid(Wright stain 1000). 235

9-19. Clumped choroid plexus in cerebral spinal uid(Wright stain 1000). 235

9-20. Comparison of Wright stained and Gram stainedbacteria in cerebral spinal uid. 237

9-21. Positive india ink stain. 2379-22. Wright stained cytocentrifuged CSF. 2409-23. CSF specimen tubes one, two, and three. 2409-24. Wright stained cytocentrifuged CSF. 24010-1. Mesothelial lining of serous body cavities. 24210-2. Cytospin preparation of pleural uid containing

RBCs and lymphocytes in acute inammation.Wright stain 400. 243

10-3. Cytospin preparation of pleural uid containingRBCs, neutrophils, and a mesothelial cell inbacterial infection. Wright stain 200. 243

10-4. Cytospin preparation of peritoneal uidcontaining RBCs, lymphocytes, monocytes, andmesothelial cells. Wright stain 200. 243

10-5. Cytospin preparation of pericardial uidcontaining RBCs, WBCs, and cells resemblingadenocarcinoma. Wright stain 200. 243

10-6. Cytospin preparation of peritoneal uidcontaining RBCs, WBCs, and many bacteria.Identied by culture as Escherichia coli. Wrightstain 1000. 244

10-7. Cytospin preparation of peritoneal uidcontaining WBCs and few bacteria. Identied by culture as Staphylococcus. Wright stain1000. 244

10-8. Cholesterol crystals in pleural uid. Bright light(400). 245

10-9. Cholesterol crystals in pleural uid (400). 24610-10. The heart and pericardium. 24610-11. Aspirating pericardial uid. 24710-12. The pleural cavity with effusion. 24810-13. Thoracentesis. 24810-14. The organs of the abdomen. 24910-15. Paracentesis of the abdominal cavity in

midline. 24910-16. Wright stain of ascites uid. 25010-17. Pleural uid. 25111-1. Articulated joint. 25411-2. Synovial membrane from a normal knee joint. 254

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11-3. Bulge test of joint for the detection of synovialeffusion. 254

11-4. Placement of needle in arthrocentesis of (A) elbowand (B) knee joints. 255

11-5. Synovial uid. 25511-6. Synovial uid inclusions. 25611-7. String test showing normal synovial uid

viscosity. 25611-8. Mucin clot test of normal synovial uid. 25711-9. Normal cellular elements found in synovial uid

(WrightGiemsa). 25711-10. Synovial uid with acute inammation

(WrightGiemsa). 25811-11. LE cell is a neutrophil containing a phagocytized

homogeneous nucleus (WrightGiemsa). 25811-12. Tart cell: a macrophage containing a

phagocytized nucleus that retains some nucleardetail (WrightGiemsa). 258

11-13. Reiter cell is a macrophage that has phagocytosedone or more neutrophils. 258

11-14. Lipid-laden macrophage in synovial uid(WrightGiemsa). 259

11-15. Synovial uid with acute inammation andmonosodium urate crystals (WrightGiemsa stainand polarized light). 259

11-16. Synovial uid with acute inammation andmonosodium urate crystals (WrightGiemsa stainand polarized/compensated light). 259

11-17. Synovial uid with acute inammation andcalcium pyrophosphate dihydrate crystals(WrightGiemsa stain and polarized light). 259

11-18. Synovial uid with acute inammation andcalcium pyrophosphate dihydrate crystals(WrightGiemsa stain and polarized/compensatedlight). 259

11-19. Image A for Case Study 11-1 26111-20. Image B for Case Study 11-1. 26211-21. Image A for Case Study 11-2. 26211-22. Image B for Case Study 11-2. 26212-1. Detail of the male reproductive system. 26412-2. The process of spermatogenesis in the

seminiferous tubules. 26512-3. Stages of transformation from human spermatid

into spermatozoon. 26512-4. Normal semen viscosity test. 26612-5. Inclusion criteria of counting cells. 26712-6. Wet mount of semen. Many sperm are present

(450). 26712-7. Wet mount of semen (450). 26712-8. Viable sperm do not take up the eosin stain and

remain colorless, thus appearing white(eosin/nigrosin stain 1000). 268

12-9. Nonviable sperm take up the eosin stain andappear various shades of red (eosin/nigrosin stain1000). 268

12-10. Features of a normal spermatozoon. 269

12-11. Normal sperm (Papanicolaou stain, 1000). 269

12-12. Normal sperm (Papanicolaou stain, 1000). 270

12-13. Normal sperm, side view (Papanicolaou stain,1000). 270

12-14. Double-headed sperm (Papanicolaou stain,1000). 270

12-15. Double-tailed sperm (Papanicolaou stain,1000). 270

12-16. Coiled-tailed sperm (Papanicolaou stain, 1000). 270

12-17. Flat-headed sperm (Papanicolaou stain, 1000). 271

12-18. Various sperm head sizes (Papanicolaou stain,1000). 271

12-19. Normal sperm shown with sperm at arrow thathas a constricted (or pinched) head and excessivecytoplasmic membrane (Papanicolaou stain,1000). 271

12-20. Various sperm anomalies (Papanicolaou stain,1000). 271

12-21. Sperm with bent neck pieces (Papanicolaou stain,1000). 272

12-22. Sperm with round heads rather than oval(Papanicolaou stain, 1000). 272

12-23. Sperm with tapered heads rather than oval(Papanicolaou stain, 1000). 272

12-24. Sperm with heads containing vacuoles(Papanicolaou stain, 1000). 272

12-25. The necks of these sperm have excessivecytoplasmic membrane remaining (Papanicolaoustain, 1000). 273

12-26. Immature spermatids (Papanicolaou stain,1000). 273

12-27. Figure for review questions 1214. 27513-1. Fecal leukocytes. 27913-2. Guiac fecal occult blood test. 28013-3. Steatorrhea with fecal fat Sudan III stain for

neutral fats. 28013-4. Steatorrhea with fecal fat Sudan III stain for

fatty acids. 28013-5. Creatorrhea. Undigested meat ber. 28113-6. Creatorrhea. Undigested meat bers

tangled. 28114-1. Schematic drawing of the amniotic

cavity. 28514-2. Spectrophotometric scan of amniotic uid

indicating bilirubin and oxyhemoglobin peaks. 286

14-3. Liley graph for assessment of fetal risk. 28814-4. Wet mount showing characteristic clue

cells. 28914-5. Gram stain (1000). Lactobacillus

predominating in a healthy vagina withsquamous epithelial cells. 289

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14-6. Trophozoites of T. vaginalis obtained from in vitroculture, stained with Giemsa. 289

14-7. Wet preparation of Candida albicans yeast andpseudohyphae with white blood cells. Yeast(including pseudohyphae), RBCs, and WBCs(200). 290

14-8. Candia albicans with germ tube development in acalcouor white preparation. 291

14-9. Cell block preparation of BAL showing cysts of P. jiroveci, GMS-P stain (1000). 291

14-10. Cell block preparation of BAL showing cysts of P. jiroveci, GMS-P stain (1000). 292

14-11. Histopathologic changes indicating aspergillosisof the lung caused by Aspergillus fumigatus. 293

14-12. Methenamine silver stain. 29314-13. Bronchial washing cell block. H&E stain

(1000). 29314-14. Bronchial washing cell block. GMS-C

stain (1000). 29414-15. Bronchial washing cell block. PAP stain

(1000). 294

15-1. A. Iris Diagnostics Division iQ200 AutomatedUrinalysis System (AUTION plus iQ200). B. IrisDiagnostics close-up of the AUTION barcodereader and tube carrier. 297

15-2. Iris Diagnostics iChemVelocityTM. 29715-3. Iris Diagnostics iQ200ELITETM. 29815-4. Iris Diagnostics iQ200SELECTTM. 29815-5. Iris Diagnostics iQ200SPRINTTM. 29815-6. Siemens Medical Solutions Diagnostics

manufactures the Clinitek Status. 29815-7. Siemens Medical Solutions Diagnostics

manufactures the Clinitek Atlas. 29815-8. Sysmex UF-100 Urine Cell Analyzer. 29815-9. Sysmex UF-100 Flow Cell Diagram. 29815-10. Sysmex UF-100 Lateral Fluorescent Light

System Diagram. 29915-11. Sysmex XE-5000 Automated Hematology

System. 29915-12. SQA-V Sperm Analyzer. 300

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xix

Preface vAcknowledgments viiReviewers ixList of Figures xi

CHAPTE R 1 Urinalysis Clinical Laboratory Operations 1Regulations and Regulatory Agencies Governing the Clinical Laboratory 2Safety in the Clinical Laboratory 5

CHAPTE R 2 Renal Anatomy and Physiology and Urine Formation 11Renal Anatomy 12The Formation of Urine 16

CHAPTE R 3 Collection and Physical Examination of Urine 25Specimen Collection Methods 26Specimen Preservation 26Examination of Physical Characteristics 28Examination Methods 31

CHAPTE R 4 Chemical Analysis of Urine 35Urinary pH 36Protein 37Glucose and Other Reducing Substances 39Ketones 41Occult Blood 43Bilirubin and Urobilinogen 45Nitrite 49Leukocyte Esterase 50Additional Parameters Available on Dipsticks 51

CHAPTE R 5 Microscopic Examination of Urinary Sediment 55Microscopy 56Sediment Preparation and Use of the Microscope 56Cells 57

ContentsContents

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Crystals 62Casts 78Miscellaneous Structures 83Artifacts and Contaminants 87Other Artifacts 90Parasites 92

CHAPTE R 6 Atlas of Urinary Sediment 99Cells 100Crystals Found in Acidic Urine 110Crystals Found in Alkaline Urine 133Casts 144Miscellaneous Images 170

CHAPTE R 7 Urinary and Metabolic Diseases and Related Urinalysis Findings 193Anatomical Variations Affecting the Urinary Tract 194Infections of the Lower Urinary Tract 194Diseases of the Kidney 194Common Diseases of the Kidney: Vascular Disease and Diabetes 195Diseases Affecting the Glomerulus 196Tubular Disorders 198Tubulointerstitial Disease 199Renal Failure 200Metabolic Disorders 200Aminoacidurias 203Pophyrinurias, Porphyrins, and Porphobilinogen 210Mucopolysaccharide Disorders 211Carbohydrate Disorders of Metabolism 211

CHAPTE R 8 Introduction to Body Fluids 219Body Fluid Composition 220Types of Body Fluids 220Accumulation of Excess Body Fluids 220Body Fluid Collection 221Cell Counts in Body Fluids 222Cellular Morphologies and Differentials 222Crystal Analysis Microscopy 223

CHAPTE R 9 Cerebrospinal Fluid Analysis 227Cerebrospinal Anatomy 228Specimen Collection 229Laboratory Examination 230Chemical Analyses 236Microbiology Procedures 237

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CHAPTE R 10 Serous Body Fluids 241Serous Fluid Physiology 242Laboratory Testing of Serous Fluids 242Categorization of Effusions 244Types of Serous Fluids 245

CHAPTE R 11 Synovial Fluid 253Physiology and Composition 254Specimen Collection 254Laboratory Testing 255

CHAPTE R 12 Semen Analysis 263Semen Composition 264Sperm Formation 264Specimen Collection and Handling 265Macroscopic Examination 266Microscopic Examination 266Chemical Analysis 270Immunology 273Microbiology 273

CHAPTE R 13 Fecal Analysis 277Gastrointestinal Tract Physiology and Fecal Formation 278Disorders of the Gastrointestinal Tract 278Fecal Specimen Collection 278Fecal Analysis Methods 279

CHAPTE R 14 Miscellaneous Body Fluids 283Urine Pregnancy Testing 284Amniotic Fluid 284Vaginal Secretions 288Bronchoalveolar Lavage and Bronchial Washings 290Other Body Fluids 291

CHAPTE R 15 Automation of Urinalysis and Body Fluids Examination 295Rationale for Automating Urinalysis and Body Fluids 296Automated Urinalysis Systems 296Automated Body Fluid Analysis Systems 299

AP P E N DIX A Answers to Study Guide Questions and Case Studies 301AP P E N DIX B Historically Relevant Urinalysis Information 307

Bilirubin 307Blood 307

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Ketone 308Protein 309Bence-Jones Protein 310Reducing Substances 311Specic Gravity 312

AP P E N DIX C Reagent Strip Color Chart 315Glossary 317Index 325

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C H A P T E R

1Urinalysis ClinicalLaboratory OperationsUrinalysis ClinicalLaboratory Operations

Key TermsACCREDITATIONANALYTICAL ERRORSCENTERS FOR DISEASE CONTROL AND

PREVENTION (CDC)CENTERS FOR MEDICARE & MEDICAID SERVICES

(CMS)CHAIN OF CUSTODYCHEMICAL HYGIENE PLANCLIA 88CLINICAL LABORATORY STANDARDS INSTITUTE

(CLSI)COLLEGE OF AMERICAN PATHOLOGISTS (CAP)COMMISSION ON OFFICE LABORATORY

ACCREDITATION (COLA)COMPLIANCECONFIDENTIAL INFORMATIONCONTROLSCRITICAL VALUESDELTA CHECKDEPARTMENT OF HEALTH AND HUMAN SERVICES

(HHS)DEPARTMENT OF TRANSPORTATION (DOT)ENVIRONMENTAL PROTECTION AGENCY (EPA)EXPOSURE CONTROL PLANFOOD AND DRUG ADMINISTRATION (FDA)HAZARDOUS MATERIALS (HAZMATS)HEALTH INSURANCE PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA)HIGH-COMPLEXITY TESTING (HCT)INFORMED CONSENTJOINT COMMISSION ON ACCREDITATION OF

HEALTHCARE ORGANIZATIONS (JCAHO)MATERIAL SAFETY DATA SHEETS (MSDS)MODERATE COMPLEXITY TESTING (MCT)NUCLEAR REGULATORY COMMISSION (NRC)OCCUPATIONAL SAFETY AND HEALTH

ADMINISTRATION (OSHA)PERSONAL PROTECTION EQUIPMENT (PPE)PHYSICIAN OFFICE LABORATORIES (POLs)POINT OF CARE TESTING (POCT)PREANALYTICAL, ANALYTICAL, AND

POSTANALYTICAL SOURCESPROFICIENCY TESTINGPROVIDER-PERFORMED MICROSCOPY (PPM)PUBLIC HEALTH SERVICE ACTQUALITY ASSESSMENTQUALITY CONTROLSTANDARD OF CARESTANDARD PRECAUTIONSSTANDARDSWAIVED TESTING (WT)WAIVED TESTS

Learning ObjectivesClinical Laboratory Regulation and Management

1. Dene compliance and discuss how it relates to urinalysis and body uidanalysis.

2. List the four categories of clinical laboratory testing under CLIA 88 and listwhich personnel may perform laboratory tests in these categories.

3. Write a synopsis of the federal regulations and federal regulatory agenciesthat govern activities of the clinical laboratory and state their correspondingjurisdictions.

4. Discuss external accreditation and CLSI standards and their importance inlaboratory management and compliance.

5. Describe additional legal and ethical concerns related to the clinical labora-tory.

6. Write a summary of the scope of and importance of quality assessment.7. Evaluate each of these components of quality assessment: establishing a pro-

gram for quality assessment, establishing critical values, monitoring labora-tory results issued, using delta check monitoring of patient test results, qual-ity control, and prociency testing.

Safety in the Clinical Laboratory

8. Explain the responsibility of laboratories to develop and publicize safety poli-cies and procedures.

9. Identify and describe six types of safety risks that exist in the clinical labora-tory and discuss the effective management of these safety concerns in the clin-ical laboratory.

10. Dene standard precautions and discuss proper disposal of hazardous wastesand sharps in the laboratory.

11. Dene HAZMATS and discuss measures needed for larger incidents involvingHAZMATS.

1

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2 Graffs Textbook of Routine Urinalysis and Body Fluids

Urinalysis and body uid analysis are performed in theclinical laboratory, which is a part of the healthcareorganization. Both healthcare organizations and clin-ical laboratories have differing organizational congura-tions and offer a variety of services to physicians andpatients with the goal of providing the best possible patientcare. Providers of healthcare services must continuallyassess, update, and adjust their services to achieve optimaloutcomes for the patients they serve. This requires man-agers and leaders in laboratory medicine to have knowledgeand expertise in scientic, medical, and technical matters aswell as comprehension of related government regulationsand safety issues. It is part of the duties of laboratory man-agers and leaders to disseminate this knowledge to the lab-oratory staff and to monitor and ensure compliance togovernment regulations and adherence to established insti-tutional policies and procedures.

REGULATIONS AND REGULATORYAGENCIES GOVERNING THECLINICAL LABORATORY

Various federal, state, county, and city regulations apply tothe clinical laboratory. In addition to federal and nationalprofessional groups that inspect the clinical laboratory,states have additional laboratory inspections as well astheir own penalties for noncompliance to their regula-tions.

FEDERAL REGULATIONS AND REGULATORY ORGANIZATIONS

1. CLIA 88Clinical Laboratory Improvement Amend-ments of 1988.Most hospital laboratories, physician ofce laborato-ries (POLs), and reference labs for clinical testing aswell as point of care testing (POCT) are regulated byCLIA 88. An exception is that federal laboratories,such as veterans hospitals and medical centers, arenot covered by these requirements. The regulationsgovern how clinical laboratories perform their work.These regulations were put in place to ensure that lab-oratory test results are of high quality regardless ofwhere the tests are performed. Included are mandatesfor quality control, prociency testing, quality assess-ment, external inspections, site visits, consultations,and minimum personnel requirements. Also estab-lished are regulations that vary with the level of test-ing. All clinical laboratory testing is divided into oneof the following categories: Provider-Performed Microscopy (PPM)This cate-

gory includes brighteld or phase microscopy testsperformed by physicians, dentists, or other midlevel

practitioners under physician supervision. Includedare wet mounts, KOH preps, fern tests, postcoitalexaminations, urine sediment examinations, andmicroscopic examinations for WBCs. PPM allowsphysicians to obtain results on labile samples thatmust be tested immediately.

Waived Testing (WT)These tests are approved by theFood and Drug Administration (FDA) for home useand are designed to minimize performance errorsand pose no reasonable risk of harm to patientswhen performed inaccurately.

Moderate Complexity Testing (MCT)These tests aremore difcult to perform than the waived tests inthe POL. For MCT, high-complexity testing (HCT),and PPM, instrument calibration, training docu-mentation, prociency testing, and on-site inspec-tions are required under CLIA 88. In the hospitalsetting, both MCT and WT must adhere to moder-ate complexity test standards. Most hematology,clinical chemistry, and automated or semiauto-mated urinalysis and urine microscopic analysis fallinto this category.

High-Complexity Testing (HCT)These tests require ahigh degree of interpretative knowledge and skilland must be performed by more experienced per-sonnel and/or more complex instrumentation.Many tests performed in the cytology, microbiol-ogy, immunology, and immunohematology depart-ments fall into this category.

2. Public Health Service Act. To receive payment fromMedicare or Medicaid a laboratory must be licensedunder this act. This act mandates adherence to CLIA 88.

3. The Centers for Medicare & Medicaid Services (CMS)(formerly the Health Care Financing Administration[HCFA]) is under the Department of Health and HumanServices (HHS). This federal agency has establishedregulations to implement CLIA 88 and has also estab-lished Commission on Ofce Laboratory Accreditation(COLA) for accrediting POLs. COLA-accredited labora-tories are surveyed every 2 years.

4. Occupational Safety and Health Administration (OSHA).This government agency regulates issues of workersafety for the clinical laboratory. As a laboratoryworker you have the right to a safe working environ-ment and can report unsafe work practice concerns toOSHA. The employer is not to retaliate in any way forsuch reporting and will be penalized for any suchactions.

5. Environmental Protection Agency (EPA). This agencyensures that healthcare providers follow the MedicalWaste Tracking Act. The act denes medical wasteand establishes acceptable practices for treatment anddisposal of this waste.

6. Food and Drug Administration (FDA). This governmen-tal agency is responsible for the approval of medicaland diagnostic equipment, pharmaceuticals, reagents,


and diagnostic tests before these can be marketed.The FDA also regulates content labeling require-ments. Prior to product approval, the FDA evaluatesthe safety, efcacy, and medical need for medicalproducts and devices.

7. Centers for Disease Control and Prevention (CDC). Thisagency implements public health regulations andreporting requirements for the clinical laboratory andother healthcare providers. CDC is responsible forcategorizing newly developed laboratory tests as WT,MCT, or HCT and also performs CLIA-related studies.

8. Department of Transportation (DOT). This agency hasrequirements for the safe packaging and transport ofbiologically hazardous and other hazardous materials(HAZMATS).

9. Nuclear Regulatory Commission (NRC). This agency reg-ulates handling and disposal of radioactive materials.Although the clinical laboratory tries to minimize theuse of these agents, there are still some tests involvingthese substances.

EXTERNAL ACCREDITATION AND INSPECTION

In order for a healthcare organization to engage in andreceive payment from federal Medicare or Medicaid pro-grams, it must be certied by CMS as complying with theConditions of Participation set forth in federal regulations.CMS may grant the accrediting organization deemingauthority so it may deem an accredited healthcare organ-ization as meeting the Medicare and Medicaid certicationrequirements. This healthcare organization would thenhave deemed status and would not be subject to theMedicare survey and certication process.

The three main external laboratory accreditation agen-cies are as follows:

College of American Pathologists (CAP)This profes-sional organization has deemed status to provide thisservice for the federal government.

Commission on Ofce Laboratory Accreditation (COLA)This commission is administered through the CMS.This ofce is under the HHS.

Joint Commission on Accreditation of Healthcare Organi-zations (JCAHO)This organization also has deemed sta-tus to provide this service for the federal government.

Other organizations that inspect or accredit laboratoriesinclude state agencies, American Society for Histocompati-bility and Immunogenetics (ASHI), American Associationof Blood Banks (AABB), and American Osteopathic Associ-ation (AOA).

These organizations provide a valuable service to labora-tories by regular assessment, through the inspectionprocess, of compliance to regulations and evaluation of anindividual laboratorys policies and practices.

LABORATORY STANDARDS

The Clinical Laboratory Standards Institute (CLSI) (formerlythe National Committee for Clinical Laboratory Standards[NCCLS]) is a nonprot, private educational organizationthat develops and publishes national and international lab-oratory standards on a variety of clinical laboratory testingprocedures and policies. These guidelines assist clinical lab-oratories in the development of acceptable procedures andpolicies for their institutions. CLSI recommendations andstandards follow the CLIA 88 mandates and assist the clin-ical laboratory in adhering to federal regulations.

ADDITIONAL LEGAL AND ETHICAL CONCERNS

In addition to laws regulating clinical laboratories, lawsalso protect patients rights in many instances related tomedicine and to the clinical laboratory. Beyond establishedlaw, healthcare professionals have ethical obligations totreat patients as they would like to be treated if under theircare. These rights and obligations are discussed in this sec-tion.

Informed Consent

The laboratory has an obligation to ensure that the patientunderstands the testing to be performed and that thepatient gives consent to this testing. The patient has theright to refuse testing. If the patient does not speak English,efforts should be made to nd an interpreter, or a guardianmay be needed for minors or patients with certain disabili-ties. For certain complex procedures or procedures withimportant risks, a written informed consent form may berequired.

Standard of Care

Laboratory employees have the responsibility to know andfollow the accepted standards of care. An acceptable stan-dard of care for the laboratory is the care that a reasonablelaboratory professional would provide. Implied in this de-nition is the knowledge and use of acceptable proceduresand patient care. If a laboratory provider does not providethis standard of quality care and serious complication ordeath results, medical negligence may be charged. Continu-ing education is important for laboratory personnel to keepabreast of changes in acceptable practices for the labora-tory.

Condentiality

The Health Insurance Portability and Accountability Act(HIPAA) of 1996 mandates the privacy of patient informa-tion. Patient information, the tests they are having done

Chapter 1Urinalysis Clinical Laboratory Operations 3



and their laboratory results, must be kept strictly conden-tial. This condential information is not to be shared withinsurance companies, lawyers, or relatives of the patientunless they are authorized to have this information.

Specimens for Legal Cases

When a specimen is collected for a case that may involve liti-gation, special safeguards are recommended to protect therights of all those involved. Laboratory workers are requiredto know and adhere to the established policies of their facilityfor these specimens for legal cases. These types of specimensinclude bloodalcohol levels, specimens from rape cases,specimens in paternity cases, and medical examiners speci-mens. If a laboratory professional does not know the policiesfor these samples, he or she will be negligent in his or her dutyto the patient. With specimens for legal cases, chain of custodymust be maintained. This means that the specimen must becollected and handled in a particular manner with the namesof all individuals obtaining, handling, and testing the speci-men documented. These specimens should be kept in alocked or secure refrigerator to prevent specimen tampering.

Ethical Considerations

Most often, minor problems will not result in legal action.Nonetheless, laboratory professionals have a moral and eth-ical obligation to treat patient as they would want to betreated. Be respectful toward the patient, keep informed,follow established procedures and policies, and incorporatecompassion and concern for the patient into your decisionsand actions. An incident report should be led in the event

of any occurrence that might have legal or ethical implica-tions for patients or employees.

QUALITY ASSESSMENT

CLIA 88 mandates that quality assessment activities be acontinual process in the laboratory and that these efforts bedocumented. Results from quality assessment activities mustbe evaluated and communicated in order to make gains fromthe assessment work done and to reduce medical errors.

Variables Affecting the Quality of Laboratory Testing

Errors can occur throughout the testing process and includeerrors from preanalytical, analytical, and postanalyticalsources. Quality control is used to monitor the analytical (ortesting) process. This is critical to ensure the accuracy andprecision of laboratory test results. It is not sufcient, how-ever, as steps must also be taken to reduce preanalytical(pretesting) errors and postanalytical (posttesting) errors. Astesting procedures are now very sensitive and specic, thesepreanalytical and postanalytical errors are more prevalentthan analytical errors. Table 1-1 provides examples of behav-iors that can lead to preanalytical, analytical, and postana-lytical errors.

Establishing a Quality Assessment Program

Quality assessment should include a process of maintainingqualied personnel, establishment of written policies, a pro-cedure manual with appropriate methods, establishment of

Table 1-1 Examples of Laboratory Testing Errors

PREANALYTICAL ERRORS ANALYTICAL ERRORS POSTANALYTICAL ERRORS

Patient identication errors Technologist error Computer result entry error

Improper patient preparation Instrument Calibration Test interpretation errorserror

Inappropriate test orders Reagent deterioration Illegible report

Incorrect container/additives Pipetting errors Failure to deliver report

Specimen labeling errors Instrument bias or failure Incorrect patient information

Improper specimen Test procedure steps Transcription errorscollection or handling not followed

Improper timing of collection Timing errors while Delayed reportrunning test

Hemolyzed or contaminated Instrument not operated Failure to phone specimen correctly critical results


procedures for specimen collection and handling, an equip-ment maintenance program, established quality control andquality assurance programs, and methods to ensure accu-rate test ordering and reporting. Issues of patient service andwait times are other examples of quality issues that may bestudied in quality assessment.

Essentially, effective management of communication, ofadherence to policies, and of documentation must governlaboratory practice. This consists of clearly written labora-tory policies and procedures and established policies thatare known and followed by all. Proper laboratory resultreporting requires establishing and rapid reporting of criti-cal values. The documentation of results that are tele-phoned to the physician is also required. To avoid errors inlaboratory result reporting, the delta check is used to moni-tor changes in individual patient results and to assesswhether these changes are biologically possible. The prac-tice of review of results prior to release and cosigning servesto reduce reporting errors. Most laboratories have estab-lished a critical values list, with test results that are impor-tant enough to be called to the physician immediately.Despite the greatest efforts, errors will still occur. It isimportant that errors are acknowledged promptly, properlydocumented, and follow-up measures are taken.

Quality Control

Quality control is a set of procedures and practices that mon-itor the testing process and those procedures that verify thereliability, accuracy, and precision of testing. Standards andcontrols are used in this process. Standards contain a knownamount of the analyte being tested and are used to calibratethe test. Controls are materials of the same matrix as thesample (composed of serum for serum tests and composedof urine for urine tests) that have an established acceptablerange for the analyte being tested. The controls are alwaysrun with the test, and control values are monitored statisti-cally to assess the validity of the test results. If the controlsdo not fall in acceptable range, the test results may be inval-idated. By monitoring the control values daily or with eachshift, the accuracy and precision of the test method can beobserved. Controls are usually in the normal patient leveland in the clinically signicant abnormal level(s) (usuallyhigh and possibly also low levels). Quality control must berecorded and analyzed to be of any benet. Abnormal qual-ity control results must be noted by the technologist per-forming it and the supervision must be notied as well. Thesupervisor and laboratory administrators also have the obli-gation to review the quality control records to look for bothrandom problems and trends or repeat problems. Most uri-nalysis and body uid procedures are qualitative, but ifquantitative testing is performed, monitoring with a sys-tematic statistical analysis such as through the use of West-guard rules should be performed as well.

Other components of quality assessment include valida-tion of new procedures, establishing practices to minimize


Figure 1-1. Common safety symbols.1 (Courtesy of McBride L. Text-book of Urinalysis and Body Fluids. Philadelphia: Lippincott, 1998.)

human error, and correlation of an individual patients lab-oratory results.

Prociency Testing

External prociency testing is mandated by CLIA 88. Anagency such as CAP or other approved laboratories issueunknown samples for each of the tests that your laboratoryissues. The laboratory is to run these samples as it would apatient sample and then report the results to the issuingagency. The laboratory results of each participating agencyare compared with the results of designated reference labo-ratories. Internal prociency testing is also useful to detectproblems within your laboratory. A supervisor may includean internal sample without the knowledge of the laboratorystaff and check the results against known results or resultsfrom another laboratory. These exercises point out areas oftesting deciencies for the participating laboratories.

SAFETY IN THE CLINICALLABORATORY

Regulations at all levels of government and employer poli-cies mandate safe practices to protect everyone involved inhealthcareemployees, patients, and visitors. It is critical tofamiliarize yourself with potential risks in your laboratory.Such risks should be identied whenever possible. One wayto achieve this is through labeling of potential hazardsthrough the use of signage. Laboratory workers should rec-ognize common safety symbols (Fig. 1-1).

Laboratories must also develop their own safety policiesand must create safety manuals that are accessible to all



personnel. A designated safety ofcer is integral to theimplementation of a laboratory safety program. The safetyofcer holds responsibility for compliance with existingsafety regulations and adherence to safety policies. Employ-ees should le an incident report if there is any event involv-ing safety of a patient or for themselves.

PHYSICAL HAZARDS

As in many workplace environments, the laboratory con-tains many mechanical devices which cause accidents ifthey malfunction or are used improperly. Commonsenseprecautions also apply to the laboratory; avoid running orrushing, watch for wet oors, avoid dangling jewelry, tieback long hair, operate laboratory equipment as recom-mended by the manufacturer, and maintain an organizedand clean workspace. It is also important to get enoughhelp when lifting heavy items and remember to bend yourknees when lifting anything awkward or heavy. Try to createa workspace that is ergonomically friendly to avoid long-term health problems.

ELECTRICAL HAZARDS

Electrical burns, shocks, and electrocution are avoided bythe prevention of electrical potentials across laboratory per-sonnel. Fuses, circuit breakers, and ground fault inter-rupters are used to prevent overloaded circuits that couldcause re or explosion.

Three pronged grounded plugs provide protection froma possible short between one side of the power line and theinstrument or the person touching the instrument. Do notuse equipment that has just had liquid spilled on it or withwet hands. If equipment is damaged, malfunctions, smellsunusual, or makes a loud noise it should be turned off. Inaddition, electrical cords should not be stretched andshould not be used if frayed or damaged.

FIRE AND EXPLOSIVE HAZARDS

Every effort should be made to prevent re and explosion. Cir-cuit overload, misuse of chemicals, lack of training, and care-lessness are causes of res and explosions in the laboratory. Asafety committee should be formed to set policies and to forman evacuation plan in case of re. Employees need to be trainedin the proper use of chemicals and equipment and they need toknow hospital policies in case of re. Fire extinguishers mustbe readily available and employees must also be trained in theiruse. (See Table 1-2 on classes of re extinguishers and theiruses.) In case of re, remember to rescue those who needimmediate help, pull the alarm or phone in the alarm, containthe re as much as possible, and extinguish if possible. Allshould be evacuated from the area of the re quickly. Partici-pation in re drills assist in speeding the process in the event ofa real re. Remember to RACE (Rescue, Alarm, Contain, andExtinguish) and to evacuate as needed.

RADIOACTIVE HAZARDS

Laboratories have made an effort to avoid using radioactivematerial whenever possible. There are, however, still sometests using radioactive components. If you work regularlywith these tests, you must wear a lm badge or use adosimeter to monitor your exposure to radiation. You mustalso use barrier protection and limit the time you areexposed to radioactive materials.

CHEMICAL HAZARDS

OSHA mandated that every laboratory must develop andimplement a chemical hygiene plan and an exposure controlplan in 1991. State right to know documents and OSHAdocument 29 CFR 1910 set standards for chemical hazardcommunication (HAZCOM).3

Table 1-2 Classes of Fire Extinguishers and Their Uses2

WATER DRYCLASS USE EXTINGUISHER EXTINGUISHER

A Ordinary combustible YES YESmaterials, paper

B Flammable liquids NO (spreads liquid YESand gases and re)

C Electrical equipment NO (risk of shock) YES

D Combustible metals NO (intensies re) NO (sand or specialextinguishing agents)

Remember PASS when using the extinguisherPull, Aim, Squeeze, and Sweep the base of the re.


Material safety data sheets (MSDS) should be available toemployees so that they can be aware of any risks posed bychemicals present in the workplace and can utilize the rec-ommended protective equipment.

Chemical Hygiene Plan

The chemical hygiene plan is to be available to all employeesto guide them on OSHA requirements, give chemicalhygiene ofcer contact information, list chemicals on site,list standard procedures related to chemical storage anduse, appropriate work practices including the use of per-sonal protective equipment, engineering controls includinghoods and safety cabinets, special precautions for particu-larly hazardous chemicals, waste disposal procedures, andemployee training materials and training schedules, pro-vide the location of MSDS, and describe medical examina-tion requirements. MSDS provide workers with a summaryof the chemicals characteristics, re, explosion, reactivity,and health risks associated with the chemical, and methodsfor safe handling. By law, chemical suppliers are required tosupply these sheets to purchasers and the facility is respon-sible for keeping these MSDS available to employees.

Chemical Labeling

Chemicals need to be properly labeled with the contents ofthe container, the date of purchase or preparation, and theinitials of the preparer. OSHA recommends that all chemi-cally HAZMATS be labeled with each hazardous compo-nent designated and marked regarding the level of risk witha hazard symbol. The hazards identication system devel-oped by the National Fire Protection Agency (NFPA) is themost commonly used and recognized by laboratory person-nel (Fig. 1-2). The red quadrant of the diamond indicatesthe degree of ammability hazard of the chemical. The bluequadrant indicates the level of hazard the chemical poses to

health. The yellow quadrant indicates the chemicals reac-tivity or stability at certain temperatures. The white quad-rant may contain symbols that refer to addition hazards.The degree of hazard in each quadrant is indicated by num-bers ranging from 0 (not harmful under normal circum-stances) to 4 (most severe risk). The white diamond maycontain abbreviations for special risks such as COR for cor-rosive, OXY for an oxidizer, or W for do not add water.2 Inaddition, a radioactive symbol will be present if the chemi-cal also has a radioactivity hazard.

Chemical Handling

When acid is to be added to a reaction, it should be added towater and not water added to acid, to avoid suddensplashes. Use glassware of appropriate size for careful han-dling. Pipetting by mouth is unacceptable in the laboratory.Personal protection equipment (PPE) and engineering con-trols should be used as needed. State and federal regula-tions must be observed in the storage of and in the disposalof chemicals. Compressed gas cylinders must be chained tothe wall and chained properly in a handcart if transported.Great care must be taken to avoid dropping gas cylinders asthey can have explosive pressure.

Chemical Spills

If an accident causes chemical contact with skin or eyes, thebest rst aid is immediate ushing with large amounts ofwater. For this reason, it is important to know the locationof emergency showers and eye washes. Contaminated cloth-ing should be removed as soon as possible. Chemical spillkits should be available to quickly neutralize and minimizeexposure to chemical spills on surfaces in the laboratory.

Chemical Exposure Limits

Many toxic, carcinogenic, and teratogenic chemicals cur-rently have exposure limits set forth in OSHA regulations.These are designated as threshold limit values (TLVs) andpermissible exposure limits (PELs). TLVs are designatedlimits of safe maximum exposure set by federal regulation.PELs are regulatory limits on the concentration of a sub-stance in air or on skin, set to protect workers from toxicchemical exposures. Formaldehyde, benzene, and xylene areexamples of such regulated substances.

BIOHAZARD RISKS

Many of the risks related to analysis of urine and other bodyuids fall into the category of biological hazards. As statedpreviously, OSHA mandated that healthcare organizationshave an exposure control plan that is reviewed annually by allemployees as well as by all new employees upon hire, with thegoal of reducing workplace exposures to infectious agents.


Flammability

SpecificHazard

1

Reactivity2

HealthHazard

3

W

Figure 1-2. National Fire Protection Agency (NFPA) symbol.



STANDARD PRECAUTIONS

In 1996, the CDC issued the currently used Standard pre-cautions guidelines.4 These guidelines stress safe work prac-tices to prevent disease transmission that include the fol-lowing as well as guidelines on handling biological waste.

1. PPE/barrier protectiona) Wearing gloves and gowns and the use of bandages

on cuts or abrasions are proposed to prevent directcontact with infectious agents. Gloves should bechanged between patients. Nonlatex gloves mustbe available for employees or patients who areallergic to latex. Generally these allergies are mild,but they can be life threatening and exposure tolatex should be avoided with these allergies.

b) Facial barriers (splash shields) are used for protec-tion against splashes to mucosal surfaces of theface and mouth.

c) Respiratory protection in the form of tted masksis required in some circumstances to prevent theinhalation of airborne pathogens.

2. Hand washing is of critical importance to break thechain of infection and halt the spread of organismsthroughout the healthcare facility. Hands shouldbe washed frequently, after any accidental expo-sure, between patients, and upon leaving your workarea.

3. Decontamination of work surfaces and instrumentsmust be performed frequently and whenever contami-nation occurs with an antimicrobial liquid such as10% sodium hypochlorite. The EPA recommends theuse of registered products for decontamination agentsas they have demonstrated performance as disinfec-tants, rather than chlorine bleach from the grocerystore.

4. Specimens containing infectious agents must beproperly labeled regarding the hazards they containthrough use of a biological hazard label.

5. Spills of infectious samples must also be decontami-nated with care. Use proper PPE as the samples maybe mixed with broken glass. Do not handle glassdirectly, but rather scoop up the material with card-board or special spill kits scoopers. Remove as muchof the contaminated material as possible and thendecontaminate the area with a disinfectant.

6. Pipetting aids and other engineering controls mustbe used to prevent direct contact or ingestion ofinfectious material.

7. Immunizations, screening tests for antibody titer lev-els, and monitoring tests such as the PPD for expo-sure to Mycobacterium tuberculosis are used to protectboth employees and their patients.

8. Employees must be cognizant of the need for protec-tion from the aerosolization of infectious material inorder to block droplet exposure to infectious agents.

In some cases, M. tuberculosis might be in a specimenor specimens may even contain suspected bioterror-ism agents and in these instances special protectivemeasures are needed to avoid the risk of inhalingthese organisms.

9. Exposures to infectious agents must be dealt withpromptly as preventative measures and prophylactictreatment can be administered, so report all expo-sures promptly.

10. Specimen transport and shipping must be doneproperly to avoid public hazards. Samples must beproperly packaged and labeled. When shipping sam-ples, DOT packaging and labeling guidelines mustbe employed to be compliant with federal regula-tions.

BIOLOGICAL WASTE

Sharps hazards are an omnipresent safety risk for the clini-cal laboratory. Percutaneous injury gives infectious organ-isms immediate access to the blood and tissues. Rigid,puncture-proof, red plastic containers must be available inall patient rooms and in all laboratory work areas for sharpsdisposal. These containers are marked with the biohazardlabel and they must not be overlled. Moreover, please keepchildren away from these containers. Needlestick must beprevented in practice both by use of engineered safetydevices such as one-handed needle covering devices orretractable needles and through employee practice policies.Of course, recapping of needles is not permitted.

POLICIES FOR HAZARDOUS MATERIALS

Each healthcare facility must develop and disseminate poli-cies and plans for handling hazardous materials (HAZMATS).Hospitals are environments that have many very hazardouschemicals, organisms, materials, procedures, and equip-ment. Regulatory agencies require that personnel be ori-ented to and educated about this environment. There aremany levels of training required for hospital personneldepending upon their employment duties and employmentrisks. For routine tasks, hospital will have policies and prac-tices established for their personnel to follow. With largerincidents, a HAZMAT team may need to be called in to han-dle a large spill or an exposure affecting many people. Spe-cial policies, training, and exercises are developed for com-munity HAZMAT exposures as well.

EXPOSURE CONTROL PLAN

The exposure control plan is designed to protect workersfrom potential pathogens and to guide them in safe man-agement of biohazardous waste. The OSHA-mandatedOccupational Exposure to Bloodborne Pathogens programwas enacted in 1992.3


OTHER SAFETY ISSUES SPECIFICALLYRELATED TO URINALYSIS AND BODY FLUIDS

Many infectious agents, including, but not limited to,human immunodeciency virus, hepatitis C virus, and hepa-titis B virus, can be transmitted through the handling ofblood and body uids. Urine may contain infectious agentsas well, including Cytomegalovirus, which is a potential riskto pregnant women. For this reason, wear gloves and usestandard precautions when handling these samples and pro-tect your patients from exposures to infectious agents as well.

STUDY QUESTIONS1. All are reasons for participating in a prociency testing

program except:a. to ensure the best quality of laboratory resultsb. to compare your laboratorys results with other labo-

ratories resultsc. it is mandated by CLIA 88d. it will justify higher charges for laboratory analyses

2. This government agency is responsible for oversight ofemployee safety:a. HHSb. HIPAAc. OSHAd. CMC

3. CLIA 88 delineates the following categories oflaboratory testing except:a. waived testingb. high-complexity testingc. low-complexity testingd. physician-performed microscopy

4. A control sample should be all of the following except:a. material of the same matrix as your test samplesb. used to calibrate the testc. have an established acceptable ranged. be run along with your test samples and monitored

statistically

5. TLVs are:a. exposure levels permitted for employeesb. tracing lower volumec. a biohazard riskd. threshold limit values

6. Complete the table below for the NFPA diamond shown(Fig. 1-3).a. Identify the color that should appear in each

quadrant of the diamondb. Indicate what category corresponds to each

quadrant/colorCASE STUDIES


QUADRANT COLOR HAZARD CATEGORY

A

B

C

D

CASE STUDIES

Case 1-1 A new instrument is purchased for the St ThereseHospital clinical laboratory. This instrument needs a compressed

nitrogen gas tank attached to it. The laboratory manager is planning

the space for this new instrument adjacent to the urinalysis bench.

The laboratory manager will be ordering the nitrogen tanks and is

deciding where to store the spare tank as there is limited space in the

instrument area.

1. How must the nitrogen tank that will be in use and thebackup nitrogen tanks be stored?

2. What precautions must be taken when handling andchanging tanks?

3. What dangers are associated with compressed gastanks?

Case 1-2 As a technologist was opening a rubber-stopperedurine collection tube, the specimen splashed into the face of the

technologist and the student with her. Embarrassed, the technologist

noticed that the student was busy and had not even noticed the

splash and she said nothing to the student. They continued working

without addressing the splash.

A

CB

D

Figure 1-3.

LWBK461-c01_p1-10.qxd 07/12/2009 01:04 PM Page 9 Aptara


1. What possible infectious agents might this technologistand student now be exposed to?

2. What are the proper steps for handling this incident?

3. What should have been done to prevent this incidentfrom happening?

4. What ethical issues were not addressed by the techno-logist?

REFERENCES

1. McBride LJ. Textbook of Urinalysis and Body Fluids: A ClinicalApproach. Lippincott, 1998.

2. Davis D. An Overview of Clinical Laboratory Safety. Educational Mate-rials for Health Professionals, 2007.

3. Turgeon M. Linne and Ringsruds Clinical Laboratory Science: TheBasics and Routine Techniques. 5th Ed. Mosby, 2007.

4. Strasinger SK, DiLorenzo MS. Urinalysis and Body Fluids. 5th Ed. FADavis, 2008.


C H A P T E R

2Renal Anatomy andPhysiology and Urine Formation

Renal Anatomy andPhysiology and Urine Formation

Key TermsADRENAL GLANDALDOSTERONEANGIOTENSIN-CONVERTING ENZYMEANGIOTENSIN I AND II ANTIDIURETIC HORMONE (ADH) (VASOPRESSIN)ANURIABOWMAN CAPSULE (GLOMERULAR CAPSULE)CARBONIC ANHYDRASECOLLECTING DUCTSCORTEXCOUNTERCURRENT MULTIPLICATION CYSTITISDIABETES INSIPIDUSDISTAL CONVOLUTED TUBULEESTIMATED GLOMERULAR FILTRATION RATE (EGFR)GLOMERULAR FILTRATEGLOMERULAR FILTRATION RATEGLOMERULONEPHRITISGLOMERULUS (RENAL CORPUSCLE)HILUSJUXTAGLOMERULAR APPARATUSLOOP OF HENLEMACULA DENSA CELLSMAJOR CALYXMEDULLA MINOR CALYXNEPHRITISNEPHRON NEPHROSIS (NEPHROTIC SYNDROME)OLIGURIAOVAL FAT BODIESPERITUBULAR CAPILLARIESPODOCYTESPOLYURIAPROXIMAL CONVOLUTED TUBULEPYELONEPHRITISREABSORPTIONRENAL COLUMNSRENAL PELVISRENAL PYRAMIDSRENAL SINUSRENIN SECRETIONSHIELD OF NEGATIVITY SYNDROME OF INAPPROPRIATE ANTIDIURETIC

HORMONE (SIADH)THRESHOLD SUBSTANCESULTRAFILTRATEURETERURETHRA VASA RECTA

Learning Objectives1. Sketch the urinary tract, labeling each of the four basic anatomical compo-

nents.2. Diagram the kidney and the structures it contains.3. Identify the main functional unit of the kidney.4. Identify the structures and components of the nephron.5. Describe the functions of the glomerulus, the tubule, and the loop of Henle.6. Sketch the structures of Bowman capsule and the glomerulus.7. Summarize the blood ow through the kidney from the renal artery through

the renal vein, including the glomerulus. 8. Describe the process of glomerular ltration and list what is ltered and what

is not ltered from blood.9. Discuss the glomerular ltration rate and how ltration is affected by blood

ow and by the dilation and contraction of the afferent arteriole.10. Describe what happens to the glomerular ultraltrate as it becomes the urine

that is excreted.11. Dene renal threshold and countercurrent mechanism. State the renal

threshold range for glucose. 12. Discuss the reabsorption process and what is reabsorbed.13. Summarize the process of tubular secretion in the nephron.14. Explain the role of the kidney in ion secretion and acidbase balance and

identify the roles of (a) hydrogen ions, (b) bicarbonate ions, and (c) ammo-nium ions in accomplishing this balance.

15. Describe the process of formation of urine.16. Describe the effect of each of the following and their effect on urine produc-

tion: (a) aldosterone, (b) renin, and (c) vasopressin (antidiuretic hormoneADH).

17. List the major organic and inorganic constituents of urine.18. List and sketch the three types of epithelial cells that can be found in a routine

urinalysis, name their source, and explain their clinical signicance.

11



The urinary system is composed of four main compo-nents: the kidney, where urine is formed from the l-tration of blood; the ureters that carry the urine tothe bladder; the bladder that stores the urine produced;and the urethra that delivers the urine for excretion outsidethe body (Figs. 2-12-4 (page 14)). The kidneys are pairedorgans that are located inside the small of the back. Theyare essential for maintaining homeostasis including theregulation of body uids, acidbase balance, electrolyte bal-ance, and the excretion of waste products. They are alsoconcerned with the maintenance of blood pressure and ery-thropoiesis. Renal function is inuenced by the blood vol-ume, pressure, and composition, as well as by hormonesfrom the adrenal and pituitary glands.

The importance of blood ow to the kidneys in theprocess of urine formation cannot be underestimated.Waste products of metabolism are moved from the circula-tory system to the urine and excreted from the body via thekidney. Without the proper blood volume and pressure,urine cannot be formed. The circulatory system is crucialfor the retention of water and key organic molecules fromthe initial renal ltrate to prevent dehydration and loss ofessential nutrients.

The formation of urine involves the complex processesof blood ltration, the reabsorption of essential substancesincluding water, and the tubular secretion of certain sub-stances. After formation in the kidney, the urine passes

down the ureter into the bladder, where it is temporarilystored before being excreted through the urethra.

RENAL ANATOMY

The two kidneys are situated on the posterior wall of theabdominal cavity, with one on each side of the vertebral col-umn. Because of the anatomical location of the liver, theright kidney is slightly lower than the left kidney. The kid-ney is a bean-shaped organ and its medial border containsan indentation, the renal hilus, through which the renalartery enters the kidney and the renal vein and the ureterleave the kidney. Each kidney is covered by a capsule andcapped with an adrenal gland, which is an endocrine gland(Figs. 2-5 (page 14) and 2-6 (page 15)).

The internal structure of the kidney consists of threeregions: the cortex, the medulla, and the renal pelvis. Thecortex is the outer layer of the kidney, located just below therenal capsule. Regions of the cortex, called renal columns,extend into the renal medulla or middle areas of the kidney.Blood vessels that supply the cortex and the medulla passthrough the renal columns. Also within the medulla arethe triangular renal pyramids, located between the renalcolumns. The tips of the renal pyramids, the papillae, proj-ect into a funnel-shaped space, a minor calyx, and severalminor calyces join together to form a major calyx. The major

Kidney

Ureter

Bladder

Rectum

Prostate

Urethra

Figure 2-1. Male urinary tractlateral view. (Adapted by permissionfrom Anatomical Chart Company, Inc., Skokie, IL, USA)

Kidney

Ureter

Uterus

Rectum

Cervix

Bladder

Vagina

Urethra

Figure 2-2. Female urinary tractlateral view. (Adapted by permissionfrom Anatomical Chart Company, Inc., Skokie, IL, USA)


Chapter 2Renal Anatomy and Physiology and Urine Formation 13

Esophagus

Left inferior phrenic and suprarenal arteries

Suprarenal glandMedullaCortex

Left middle suprarenal arteryFibrous capsule

Minor calyxMajor calyxCortexRenal sinusRenal pelvisMedulla (pyramid)Papilla of pyramidBase of pyramid

Renal column(of Bertin)

Infundibulum

Left gonadal (testicular or ovarian)artery and vein

Superior mesenteric arteryInferior mesenteric artery

Inferior vena cavaAbdominal aorta

Renalpelvis

Rightkidney

Renal arteryand vein

Ureter

Right gonadal(testicular or ovarian)

artery and vein

Right and leftcommon iliac

artery and vein

Right and leftinternal iliac

artery and vein

Urinary bladderFundus of bladder

Interureteric foldOpening of ureter

Trigone of urinary bladderNeck of bladder

Urethra

Celiac trunk

Anterior view

Minor calyx

Hilus

Major calyx

Right suprarenalgland

Common hepatic artery

Left gastric artery

Splenic arteryLeft inferiorphrenic vein

Figure 2-3. The urinary system. (Asset provided by Anatomical Chart Co.)



calyces join with one another to form the renal pelvis, whichis an expansion of the upper ureter. The hilus opens intothis space, the renal sinus, in which the renal pelvis and therenal blood vessels are located.

The renal cortex and medulla contain the renal tubules,which include the nephrons tubules and the collectingducts. There are approximately 1 million or slightly morenephrons in each kidney. The nephron is the main func-tional unit of the kidney.

Within the cortex of the kidney, the cells of the afferentarteriole make contact with the macula densa cells of the

distal tubule to form the juxtaglomerular apparatus. Thejuxtaglomerular apparatus and the macula densa cells ofthe distal convoluted tubule maintain the blood pressure ata relatively constant rate regardless of uctuations in thesystemic blood pressure through regulation of the dilationand constriction of the afferent arteriole. Renin, an enzymeproduced by the juxtaglomerular cells, is secreted and reactswith the precursor angiotensinogen in the blood to pro-duce angiotensin I. Angiotensin I passes through the lungswhere the enzyme angiotensin-converting enzyme changes itto the active angiotensin II. Angiotensin II corrects renal

Diaphragm

Supra-renalglandRightkidneyRightureter

Urinarybladder

Prostategland Urethra

Inferiorvena cava

Hepatic veins

Abdominalaorta

Renalvein

Renalartery

Commoniliac veinCommoniliac arteryInternaliliac veinInternaliliac artery

Externaliliac vein

Externaliliac artery

Renalpelvis

Calyx

Ureter

Renalcortex

Nephrons

Renalmedulla

Pyramidsof medullaRenal capsule

Gonadalartery andvein

A BFigure 2-4. Structures of the urinary tract (A), and cross-section of the kidney (B).

Figure 2-5. The kidney.


blood ow by dilating the afferent arteriole and constrict-ing the efferent arteriole, by stimulating sodium reabsorp-tion in the proximal convoluted tubule, and by trigg

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