尿液檢測醫(yī)院檢驗科

尿液檢測（Urine

Examination）1山東大學(xué)齊魯醫(yī)院檢驗科王

謙sUrine

Examination概述尿液檢驗的應(yīng)用、尿液檢驗的方法、尿液分析的標準化、尿液干化學(xué)和尿沉渣檢測的原理尿液理學(xué)檢驗?zāi)蛄俊⑼庥^、氣味、尿液化學(xué)檢驗?zāi)虻鞍住⒛蛱?、?/p>

、尿三膽、潛血、粒細胞酯酶、pH、亞硝酸鹽、維生素C尿液顯微鏡檢驗紅細胞、白細胞、上皮細胞、管型、結(jié)晶尿液檢驗的影響因素尿液

和處理儀器與試劑藥物對檢驗結(jié)果的影響23General

evaluation

of

healthDiagnosis

of

disease

or

disorders

of

theurinarytractDiagnosis

of

other

systemic

disease

that

affectkidney

functionMonitoring patients

with

diabetesdrug

monitor

or

inteventionOutlineApplication

of

urineexamination?Clinical

Application

of

Urine

Test4Urine

Testurine

dry

chemistry

ysisautomatic

urine

sedimentysisOutlineUrine

dry

chemistryyzermicroscopic

examautomatic

urine

sedimentyzermicroscopic

exam6detecting

principle7microscopic

examdetecting

principlemicroscopic

examMicroscope

re-examination10reportreporturine

sampleOutlinedry

chemistryurinary

sedimenturine

volumeurine

color（urine

appearance

）urin

rspecific

gravityPhysical

Examsfor

Urinephysical

exams

for

urine11111.

Urine

Volumeadult

：1000-2000ml/24hnewborn

：400ml/24hinfant

：400～600ml/24hpreschool

：600～800ml/24hschool

age

：800～1400ml/24h12The

normaldaily

urineoutput

depends

ontheamount

of

liquiddischarged

by

thedailyamount

of

waterdiverted

and

othermeans

.physical

exams

for

urineoliguriaanuria<100ml/24h13<400ml/24hor

17ml/hPrerenal

oliguria

：The

glomerular

filtration

wasdecreasedcaused

by

the

kidney

effective

hypovolemia.

EgShock,

heart

failure, dehydrationandso

on.Renal

parenchymal

oliguria

：

renal

parenchyma

disease.Egacute glomerulonephritis，tubular

mecrosis and

soon.Postrenal

oliguria

：caused

by

obstruction

ofurinarytract.physical

exams

for

urinepolyuria>2500ml/24hTemporary

polyuria:Endocrine

diseases：

Diabetes，diabetesinsipidus，pri ldosteronism

and

so

on.Kidney

disease：Function

of

tubular

reabsorptiondecreaseor,

renal

tubular

concentration

insufficiency.

eg.chronic

nephritis

，glomerulosclerosis，

chronicpyelonephritis，renal

tubular

acidosis

and

so

on.Spiritual

factor：Caused

by

psychentonia.physical

exams

for

urine142.1

Hematuriamacroscopic

hematuriamicroscopic

hematuriainfection,

renal

calculus,

urinary

calculus,tuberculosis

,

glomerular

disease,

tumor,

traumahemorrhagic

diseasephysical

exams

for

urine152

Urine

Appearance2.2

Hemoglobinuria,

MyoglobinuriaStrong

tea’s

color

or

dark-red

urine,

occult

blood

test+.physical

exams

for

urineSevere

intravascular

hemolysis，such

as

PNH，free

hemoglobin>1.3g/L;

hemolytic

anemia，favism,

hemolytic

transfusionreaction

and

so

on.such

ascrush

syndrome,Ischemicmuscle

necrosis.1616urinary

tract

infectious

disease2.3

Pyuria,

Bacteriuria2.4

Chyluria,Lipiduriafilariasis,tuberculosis,tumorphysical

exams

for

urine17crush

syndrome,nephrotic

syndromeobstructive

jaundicehepatocellular

jaundice2.5

Bilirubinuriaphysical

exams

for

urineconjugated

bilirubin183.Odorammoniacal

odor：interstitial

nephritis,

chronic

cystitis,

urine

retentionaceton

r：diabetic

ketoacidosisalliaceous

odor：organophosphorus

intoxicationrat

odor：phenylketonuriaphysical

exams

for

urine194.

Specific

Gravity20healthy

people：1.015~1.025fluctuation

range:

1.003~1.030Specific

gravity

is

the

ratio

of

the

density

of

urine

to

thedensity

of

water.(1)

Increased

urine

specific

gravity

：①

Physiological:

Excessive

sweating,

etc.;②

Pathological:

Acute

glomerulonephritis,

diabetes,high

fever,

proteinuria, nephrotic

syndrome,dehydration,

prerenal

oliguria

(peripheral

circulatorydisorders) and

so

on.physical

exams

for

urine(2)Urine

specific

gravity

reduce

：①

Physiological

dysfunction:

Drink

lots

of

water.②

Pathological:

Chronic

nephritis,

diabetes

insipidus,chronic

renal

failure,

pri

ldosteronism,pyelonephritis，

glomerulosclerosis

and

so

on.(3)

Isotonic

urine

was

mainly

seen

in

uremia,and

mainlycaused

by

the

serious

damage

of

renal

parenchyma

andits

specific

gravity

is

generally

fixed

in

the

1.010

or

so.physical

exams

for

urine21chemical

examProteinGlucoseKetonesBilirubinUrobilinogenBloodLeucocytespHNitriteVitamin

CPROGLUKETBILUROBLDLEUpHNITVTCchemical

exam1.

Urine

ProteinProteinuria：More

than

100mg

proteins

in urine

in24

hours

or

qualitative

positive.selective

proteinuria

;

non-selective

proteinuriaqualitative

test:

negativetative

test：0?100mg/24hchemical

exam23(2)

Mechanism

of

proteinuria

：24the

fracture

of

glomerular

capillary

wall

or

the

change

ofglomerular

charge

barrier:

Main

in

Proteinplasma.podocyte,

endothelial

cells,

VEGF,angt.Decreased

renal

tubular

reabsorption

：The

tubularfunction

damage

leads

to

disturbance

of

renal

proximaltubular

reabsorption

in

protein.

Such

as

β2-microglobin.Increased

protein

in

plasma:

Protein

in

plasma

throughthe

glomerular

filtration

barrier

was

more

than

tubularreabsorption.

Main

in

Bence-Jonesprotein,

Hb,

Mb.Increased

tubular

secretion

：The

T-H

glycoproteinsecreted

by

medullarythick

ascending

and

distal

convolutedtubule

was

increased.

Main

in

T-H.chemical

examClassification

according

to

the

characteristics

of

theproteinuriaFunctional

proteinuria:

fever,

sport,

cold,

nervous,temporary.Postural

proteinuria：出現(xiàn)于直立，尤其是脊柱前突，而臥位

。表現(xiàn)為輕中度蛋白尿。Pathologicalproteinuria：因各種腎臟及腎外疾病導(dǎo)致的蛋白尿。持續(xù)性蛋白尿。chemical

exam25Types

of

Pathological

Proteinuria26Classification

according

to

the

mechanism

of

theproteinuriaglomerular

proteinuriatubular

proteinuriamixed

proteinuriaoverflow

proteinuriahistic

proteinuriafalse

proteinuriachemical

examGolmerular

proteinuria:factors

leading

to

the

damage

ofglomerular

barrier

permeabilityand

charge

barrier

,

alot

of

plasma

protein

were

filtered

into

primaryurine,and

such

proteinexceeded tubular

reabsorption.Primary

kidney

damage

：Glomerulonephritis，nephrotic

syndrome，

latent

glomerulonephritisSecondary

kidney

damage

：Diabetes，

hypertension，27SLE.chemical

examTubular

proteinuria:28The

inflammation

orpoisoning

leading

to

the

insufficiency

of

proximaltubule

reabsorption

in

low-molecular

weightprotein.found

：

pyelonephritis，

interstitial

nephritis

，renal

tubular

acidosis；Gentamicin,

cadmium(Cd)

,

mercury

(Hg)

,

drug

poisoning.chemical

examMixed

proteinuria

:

The

renal

tubular

andglomerular

were

all

involved

,and

the

high,middle,

and

low-weight

protein

appeared

in

the

urine

atthe

same

time.29for

example,

chronic

nephritis

,

diabeticnephropathy

,

SLE

and

so

on.Overflow

proteinuria:

The

protein

in

plasmaincreased

more

than

tubular

reabsorption.Bence-Jonesprotein---MMchemical

examHistic

proteinuria:

The

large

component

were

low-weight

protein

,

caused

by

the

damage

of

renal

tissuesor

the

renal

tubular

secretion

increase.

Main

in

Tamm30－Horsfall.False

proteinuria：Mixed

with

a

lot

of

blood

,

pus

,mucus

and

other

ingredients

in

urine,

leading

toqualitative

test

of

urine protein

positive.Found

：cystitis，

urethritis,

hemorrhage，vaginitis.chemical

exam2.UrineGlucose31threshold

sugar

8.88mmol/Lcauses of

presenting

glycosuria

：Increased

degreeof

blood

glucose

>

thresholdsugar.Normal

blood

glucose but

low

threshold

sugar.chemical

examHyperglycemic

glycosuria：Diabetes，cushing

syndrome，

pheochromocytoma,hyperthyroidism,

acromegaly,

liver

cirrhosis,

pituitarytumor,

pancreatitis.Normoglycemic

glycosuria：

Also

named

renalglycosuria.

Found:

chronic

nephropathy，

nephroticsyndrome

，

interstitial

nephritis,

familial

glycosuria,

pregnancy.32chemical

examClinical

Application

of

Glycosuria

TestingTemporary

glycosuria

：

Physiologiclactose,glycosuria,

stress

glucosuria.Other glycosuria

：

Fructose,galactose,

pentose

and

sucrose.Pseudo-glycosuria

：

The

nonsugar

inurine

interfering the

test

of

glycosuria.chemicalexam333.

Urine

ketoneBodies34diabetic

ketonuriablood

glucose

>16.7mmol/Lblood

ketone

>4.8mmol/Lnon-

diabetic

ketonuriasevere

hunger,

severe

vomiting,

severe

diarrhea,dehydration,

hyperemesis

gravidarum,

strenuousexercise

and

so

on.chemical

exam4.

Urine

Bilirubin

and

Urobilinogenchemical

exam

When

the

conjugated

bilirubin

in

urine

was

more

than340～510μmol/L，the urine

bilirubin

happened

.The

urobilinogen

was

all

from

the

intestinal

reabsorption.尿三膽：urine

bilirubin,urobilinogen,

urobilin尿二膽：urinebilirubin,urobilinogenThe

qualitative

test

of

urine

bilirubin

wasnegative.The

qualitative

test

of

urobilinogen

was

negative

orweak

positive, tativetest<10mg/L.35chemical

examitemreferencerangeobstructivejaundicehepatocellularjaundicehemolyticjaundicecolorlightlyyellowdarkyellowdarkyellowdark

yellowbilirubinnegativepositivepositivenegativeurobilinogennegativeor

1:20negativepositivestrongpositiveurobilinnegativenegativepositivepositiveUrineysis

in

Various

Types

of

Jaundice365.

Clinical

Application

of

Blood

Testing37hematuriaThe

urine

BLDpositive

canbe

seeninurinary

tractinfection,

acuteglomerulonephritis,

stones,tuberculosis,

tumors,vascular

malformations,

andhemorrhagic

diseases.hemoglobinuriaHemoglobinuria

can

be

seen

inPNH,PCH, acute

hemolytic

disease,

sometimes in

viral

infection,malaria,

cardiopulmonary

bypass

surgery,

kidney

dialysisand

the

large

damage

of

redbloodcells

caused

byoperation.BLD

refers

to

the

red

blood

cells

in

urine

or/and

thehemoglobin

overflowed from

the

red

blood

cell

lysis,thus

the positive

BLDreport is

often

higher

than

the

redblood

cell

counted

by

microscopic

examination.chemical

exam6.

Clinical

Significance

of

LeucocytesTesting38①

The

increase of

the

WBC

is

mostly

seen

inacute

urinarytract

infection,

acuteand

chronic

glomerular

nephritis,prostatitis,

urolithiasis,

renal

tuberculosis,

urinary

tracttumors

with

active

SLE,

etc.;②

White

blood

cellscan

be

increasedin

any

periodofpregnancy;③The

increase

of

lymphocyteor

monocyte in

urine

weremostly

seen

in

chronic

inflammation,

interstitial

nephritisinduced

by

the

use

of

antibiotics

and

anti-cancer

drugs

and

soon.

In

theurine

of

patientswith

kidney

transplantrejection,lymphocyte

can

be

significantly

increased.

The

increase

ofeosinophilia

is

seen

in

allergic

diseasesof

the

urinarysystem,

such

as allergic

interstitial

nephritis

induced

by

drug.chemical

examThenormal

urine

was

weak

acidic(pH6.5),and

variation

range

are

4.5~8.0.397.

pHchemical

examClinical

Application

of

pH

Testing40chemical

exam①

The pH

increased

can

be

seen

in

alkalosis,the

bladder

urinary

tract

infections

and

pyelonephritisetc

(deformation

,Pseudomonas

)

.When

the

renaltubular

acidosis

(I,

II,

III

type)

happenedor

theinsufficiency

secretion

of

acid

by

kidney

,despite

the

acidosis

existing,

the

pH

was not

below

6.5.②The

pH

reduced

can

be

seen

in

metabolic

acidosis,gout,

diabetes,

type

IV

renal

tubular

acidosis,

scurvyand

so

on.chemical

exam41③

The

effects

of

drugs:

The

drugs

leading

to

pH

increased,such

as

sodium

bicarbonate,

sodium

citrate,

quinine,quinidine,

pyrimidine,

and

some

Chinese

herbal

medicine.Drugs

leading

to

pH

decreased,

such

as

ammoniumchloride,

calcium

chloride,

potassium

chloride

and

so

on.④

Drug

intervention:

NaHCO3,

NH4Cl.⑤

Determine

the

type

of

urinary

calculi

,and

guide

dietand

clinical

use

of

drugs.

For

example,

urate,

oxalate,cystine stones

are

more

common

in

acidic

urine,

however,phosphate

and carbonate

stones

are

more

commonin

alkaline

urine.Except

thepollution

factors,

the

positive

of

NIT

means

thepresence

of

bacteriuria.

It mainly

appeared in

urinarytractinfections

caused

bygram-negative

bacilli

Escherichiacoli

with

nitrate

redu e

monocytogenes.

However,

theother

pathogenic

cocci,mould

and

mycoplasma,

usually

cannot

produce

theenzymewhich

inducing

nitrate

into

nitrite,so

the

infection

caused

by

such

bacterium

was

still

negative.8.

Clinical

Application

of Nitrite

Testingchemical

exam429.

Vitamin

C43chemical

examVitamin

C

’s

effect

on

urine

dipsticksHigh

concentrations

of

vitamin

C

interferes

thedetermination

of

the

BLD,

GLU,

BIL

and

theNIT.尿液干化學(xué)檢測方法的局限性例如：白細胞：只能檢測含有酯酶的中性粒細胞紅細胞：通過檢測血紅蛋白中亞鐵血紅素的過氧化物樣活性來反映紅細胞，有許多因素會引起結(jié)果的假陽性和假細菌：只能檢測含有亞硝酸鹽還原酶的細菌不能檢測管型、上皮細胞…定性結(jié)果，難以用于療效的監(jiān)測chemical

exam44cellepitheliumMicroscopic

Exambacteriumcastcrystal45microscopic

examMicroscopic

Examination46Cell:

Erythrocyte,

leukocyte.Epithelium:

Renal

tubular

epithelium,

transitionalepithelium,

pavement

epithelium.Microorganisms:

Bacterium,

fungi，

yeast.Cast:

hyaline

cast,

granular

cast,

Cellular

cast,

waxy

cast,fatty

cast,

renal

failure

cast.Crystal:

Uric

acid

crystal,

bilirubin

crystal,

sulfa

drugcrystal,

ect.Other：mucus,

sperm，pollution.microscopic

examCells47red

blood

cellwhite

blood

cell

and

pyocyteepitheliumrenal

tubular

epitheliumtransitional

epitheliumpavement

epitheliummicroscopic

examred

blood

cell(

high

magnification)referencevalue

:0?3/HPmicroscopic

examfungi1.

Erythrocyte48多形性紅細胞metamorphicerythrocyte＞80%，常見于急性腎小球腎炎、急進性腎炎、慢性腎炎、紫癜性腎炎、狼瘡性腎炎等。glomerular

hematuriamicroscopic

exam多形性紅細胞<50%，見于腎小球以下部位

，如急性膀胱炎、急性腎盂腎炎、泌尿系、結(jié)核、腫瘤、畸形、外傷、血液病等。non-glomerular

hematuria49microscopic

examUrinary

red

blood

cell

deformation

mechanismInjury

of

lomerular mechanism

associated

withrenal

tubular

pH,

osmotic

pressure

The

role

ofdifferent

osmotic

pressure

in

tubular.Identification

of the

Source

of

Hematuria50LEU(high

magnification)microscopic

exam2.Leukocyte51pyocytemicroscopic

exam523.

Epithelium

Cell53small

round

epithelium

，

tail

epithelium，large

round

epithelium，pavementepithelium.microscopic

examrenal

tubular

epitheliummicroscopic

examfatty

granular

cell3.1

Renal

Tubular

Epithelial

Cells54large

round

epithelial

cellmicroscopic

examtailepitheliumtransitional

carcinoma

cells3.2

Transtitional

Epithelium55microscopic

exampavement

epithelium3.3 Pavement

Epithelium564.

Castsmicroscopic

examhyaline

castgranular

castcellular

castwaxy

castfatty

castrenal

failure

cast57Hyaline

castmicroscopic

exam58granular

castmicroscopic

exam59erythrocyte

castmicroscopic

exam60leukocyte

Castmicroscopic

exam61renal

tubular

epithelial

castmicroscopic

exam62Fatty

castmicroscopic

exam63waxy

castmicroscopic

examrenal

failure

cast64microscopic

examcomposite

casturic

acid

casthemosiderin

cast65microscopic

exammixture

or

pseudocast6603:5467Uric

acid

crystalmicroscopic

exam生理性結(jié)晶calcium

oxalate

crystalsmicroscopic

exam68Ammonium

urate

crystalmicroscopic

exam69microscopic

examamorphous

phosphatesamorphous

urate70calcium

phosphate

crystalsmicroscopic

exam71microscopic

examtriplephosphate

crystals72microscopic

examcholesterol

crystals病理性結(jié)晶73microscopic

exambilirubincrystals74microscopic

examhemosiderin

crystals75microscopic

examcystine

crystalstyrosine

crystalsleucine

crystals76sulfa

drug

crystalsmicroscopic

exam藥物性結(jié)晶77case，女性，29歲，已婚尿頻、尿急、3天。

3天前無明顯誘因尿頻、尿急、

骨弓上不適，低熱、腰痛，自服抗生素癥狀好轉(zhuǎn)。病程中。既往史:無結(jié)核病結(jié)核接觸史，無藥物過敏史眼瞼無水腫。咽部無紅腫。雙肺呼吸音清心率71次/分、血壓：

17.0/10.7Kpa

。腎區(qū)無叩擊痛，脊肋角及輸尿管點壓痛（?），雙下肢無水腫。Case78男，16歲高燒，血尿。半月前突然高燒，為化膿性扁桃體炎?，F(xiàn)水腫，以面部及下肢為重。尿量進