Urinalysis

尿液分析

血液科

上聯(lián)：貧血便輸，輸一紅二白三小板，原來全系降低

下聯(lián)：發(fā)熱就查，查七血八尿九骨髓，結(jié)果是個感冒

橫批：開個玩笑

傳染科

上聯(lián)：常恐交流惹禍

下聯(lián)：還是隔離放心

橫批：改日再聊

腎內(nèi)科

上聯(lián)：前尿道，后尿道，有病難道

下聯(lián)：左腎臟，右腎臟，無尿易喪

橫批：關(guān)鍵是尿我科尿液常見檢查尿常規(guī)尿四樣24H尿白蛋白尿蛋白電泳尿輕鏈蛋白尿蛋白免疫固定電泳CollectionofurinespecimensThefirstvoidedmorningurine(themostcommon)第一次晨尿Randomurine(foremergency)隨機(jī)尿Clean-catch,midstreamurine(forurineculture)潔尿，中段尿Attention注意Needtobeexaminedwithin1hour需要在1小時內(nèi)送檢ContentsPhysicalexamination物理檢查Chemicalexamination化學(xué)檢查Microscopicexamination顯微鏡檢查PhysicalexaminationAppearance外觀Urinevolume尿量Specificgravity(SG)比重Appearance外觀Includingcolorandclarity顏色和澄清度Color:normally,paletodarkyellow(urochrome)

正常淺黃到深黃（尿色素）

Abnormalcolor:somedrugscausecolorchanges藥物導(dǎo)致顏色變化

1.redurine

:causes:hematuria血尿

hemoglobinuria血紅蛋白尿

myoglobinuria肌紅蛋白尿

2.yellow-brownorgreen-brownurine黃褐色或綠褐色尿液:bilirubin膽紅素

cause:obstructivejaundice阻塞性黃疸3牛奶樣的乳糜尿1.0001.0051.0101.0151.0201.0251.030X++Polymethylvinylether/maleicanhydride--------------->X+-Polymethylvinylether/maleicanhydride+H+H+interactswithaBromthymolBlueindicatortoformacoloredcomplex.ChemicalPrincipleReadupto2minutesRR:1.003-1.035TheUrineDipstick:SpecificGravityUrineSpecificGravityTesting

Specificgravitybetween1.002&1.035onarandomsampleisnormalifkidneyfunctionisnormal.SpecificgravityinBowman’scapsulefluidis@1.007Anyreadingbelowthisindicateshydration低于暗示水化Anyreadingabovethisindicatessomedegreeofdehydration高于暗示脫水UrineSpecificGravityTestingIncreasedurinespecificgravitymayindicate/beseenin:*Dehydration脫水*Diarrhea腹瀉*Excessivesweating大汗*GlucosuriaDM*Heartfailure(relatedtodecreasedbloodflowtothekidneys)*Renalarterialstenosis腎動脈狹窄*Syndromeofinappropriateantidiuretichormonesecretion(SIADH)*Vomiting嘔吐*Waterrestriction限水UrineSpecificGravityTestingDecreasedurinespecificgravitymayindicate/beseenin:*Excessivefluidintake過多的液體攝入*Diabetesinsipidus–centralornephrogenic尿崩*Renalfailure(thatis,lossofabilitytoreabsorbwater)腎衰*Pyelonephritis腎盂腎炎UrineSpecificGravityTestingSpecificgravity>1.035(refractometer)CouldhaveveryhighglucoselevelsCouldcontainradiographicdyeUrineSpecificGravityTestingInterferingsubstancesFalseelevationofresultsmaybeseeninsampleswithincreasedproteinconcentration.

尿蛋白增加尿比重Somereportsofreducedspecificgravityresultsonalkalinespecimens.堿性尿比重下降Lipidsmayalsoeffectresults脂肪影響結(jié)果RedUrineMicroscopicHematuria

鏡下血尿Urinarytractsource泌尿道來源Urethraorbladder尿道與膀胱Prostate前列腺Ureterorkidney輸尿管與腎臟Non-Urinarytract非尿道來源sourceVagina陰道Anusorrectum肛門或直腸

Pseudohematuria(non-hematuriarelatedredurine假性血尿)Myoglobinuria肌紅蛋白尿Hemoglobinuria血紅蛋白尿Phenolphthalein

Laxatives果導(dǎo)Phenothiazines酚噻嗪系Porphyria卟啉癥Rifampin利福平Pyridium尿路鎮(zhèn)痛藥Bilirubinuria膽紅素Phenytoin苯妥英Foods食品(Beets甜菜,Blackberries黑莓,Rhubarb大黃)RedUrineCausesofAsymptomaticGrossHematuriabyIncidence

無癥狀性肉眼血尿AcuteCystitis(23%)急性膀胱炎BladderCancer(17%)膀胱癌BenignProstaticHyperplasia(12%)良性前列腺增生(癥)Nephrolithiasis(10%)腎石病Benignessentialhematuria(10%)良性血尿Prostatitis(9%)前列腺炎Renalcancer(6%)腎癌Pyelonephritis(4%)腎盂腎炎ProstateCancer(3%)前列腺癌Urethralstricture(2%)尿道狹窄AppearanceClarity:normally,clear澄清

Abnormalcolor:cloudyurine渾濁

Causes:1.crystalsornonpathologicsalts結(jié)晶與鹽

phosphate,carbonateinalkalineurine在堿性尿中的磷酸鹽和碳酸鹽

(dissolve---addaceticacid加醋酸溶解)uricacidinacidurine酸性尿中的尿酸

(dissolve---warmingto60℃加熱60度溶解)2.variouscellularelements各種細(xì)胞組分:leukocytes粒細(xì)胞,RBCs紅細(xì)胞,epithelialcells上皮細(xì)胞UrinevolumeTheaverageadult:1000mlto2000ml/24hIncrease

polyuria多尿---morethan2000mlofurinein24hours1.physiologicalstates生理狀態(tài):waterintake,somedrugs,intravenoussolutions2.pathologicstates:diabetesmellitus,DMdiabetesinsipidus尿崩UrinevolumeDecrease

Oliguria少尿---lessthan400mlofurinein24hours

Anuria無尿---lessthan100mlofurinein24hours1.prerenal腎前:hemorrhage出血,dehydration脫水,congestiveheartfailure充血性心力衰竭

2.postrenal腎后:obstructionoftheurinarytract尿路梗阻(maybestones,carcinoma結(jié)石，腫瘤)3.renalparenchymaldisease:腎實(shí)質(zhì)疾病

acutetubularnecrosis急性腎小管壞死,chronicrenalfailure慢性腎衰ChemicalexaminationUrinePHProtein尿蛋白Glucose尿糖Ketones尿酮體Occultblood潛血Bilirubin膽紅素Urobilinogen尿膽素原NitritesUrineBloodTestingUrineBloodTestingTestingdipstickreactionUrineBloodTesting‘Blood’testdetectsFreeHemoglobin游離血紅蛋白RBCs–getlysedonthepad&theirhemoglobinreacts紅細(xì)胞細(xì)胞溶解劑血紅蛋白反應(yīng)Myoglobin–musclehemoglobin肌紅蛋白Principlebasedontheperoxidase-likeactivityofthehemeportionofthemoleculeUrineBloodTestingSensitivity–candetectatlevelsof5-10cells/uLInterferingsubstancesAscorbicacid維生素CNitrates硝酸鹽Oxidizingagents(iebleach)氧化劑漂白Contaminateblood(menstrual)污染標(biāo)本月經(jīng)等NegativeTrace(100mg/dL)+(250mg/dL)++(500mg/dL)+++(1000mg/dL)++++(2000+mg/dL)TheUrineDipstick:GlucoseGlucose+2H2O

+O2

--->GluconicAcid+2H2O2GlucoseOxidase3H2O2+KI--->KIO3+3H2OHorseradishPeroxidaseChemicalPrincipleReadat30secondsRR:NegativeGlucoseinurineReferencevalueQualitativemethod:negativeGlycosuria---qualitativetestispositive1.hyperglycemia高血糖:diabetesmellitusCushing’ssyndrom2.withouthyperglycemia非高血糖:renaltubulardysfunction,suchaspyelonephritis腎盂腎炎

SignificanceDiabetesmellitus.糖尿病Renalglycosuria.腎行糖尿LimitationsInterference:reducingagents還原劑,ketones.酮體Onlymeasuresglucoseandnotothersugars.只檢測葡萄糖Renalthresholdmustbepassedinorderforglucosetospillintotheurine.必須超過腎糖閾OtherTestsCuSO4testforreducingsugars還原糖.UsesandLimitationsofUrineGlucoseDetection

Sugar

Disease(s)-Galactose半乳糖

GalactosemiasFructose果糖

Fructosuria,FructoseIntolerance,etc.

果糖不耐癥;果糖尿癥-Lactose乳糖

LactaseDeficiency乳糖酶缺乏癥-Pentoses戊糖

EssentialPentosuria戊糖尿癥-Maltose麥芽糖

Non-pathogenic*NOTSucrosebecauseitisnotareducingsugarDetectionofReducingSugars*byCuSO4+++trace4006008001000200UrinalysisGlucoseResultBloodGlucose(mg/dL)UrineversusBloodGlucoseNegativeUrinePHNormalPHTheaverageisabout6平均值6Rangefrom5~9(dependsondiet)5-9波動HigherPH(greaterthan8.0):---alkalineurine堿性尿

1.drugs:sodiumbicarbonate碳酸氫鈉

2.classicrenaltubularacidosis經(jīng)典腎小管中毒3.alkalosis堿中毒(metabolic代謝orrespiratory呼吸性)LowerPH(lessthan4.5):---acidurine1.drugs:ammoniumchloride氯化銨

2.acidosis酸中毒(metabolic代謝orrespiratory呼吸)ProteininurineReferencevalue參考值

Qualitativemethod定性法:negative陰性

Quantitativemethod:lessthan150mgofproteinin24hoursUrineproteinscomefromplasmaproteinandTamm-Horsfall(T-H)glycoprotein

來源血漿蛋白與T-H糖蛋白

Protein %ofTotal DailyMaximumAlbumin 40% 60mgTamm-Horsfall 40% 60mgImmunoglobulins 12% 24mgSecretory

IgA 3% 6mgOther 5% 10mgTOTAL 100% 150mgProteinsin“Normal”UrineFunctional

RenalSeveremuscularexertion過度運(yùn)動 -GlomerulonephritisPregnancy懷孕 -Nephroticsyndrome-Orthostaticproteinuria直立蛋白尿 -RenaltumororinfectionPre-Renal

Post-Renal -Fever發(fā)熱 -Cystitis膀胱炎 -Renalhypoxia腎缺氧-Urethritisorprostatitis

尿道前列腺炎 -Hypertension高血壓 -Contaminationwithvaginal secretions婦科分泌物污染CausesofProteinuriaProteinuria---morethan150mgproteinsinurinein24hoursorqualitativetestispositiveProteinuriaquantification(dependontheamountofprotein)heavyproteinuria----＞4.0g/24hoursmoderateproteinuria----1.0~4.0g/24hoursminimalproteinuria----＜1.0g/24hoursQualitativecategoriesofproteinuria

Glomerularproteinuria小球性蛋白尿:1.glomerulardiseasesdamageglomerularbasementmembranebuttubularfunctionisnormal小球損傷，小管功能良好

2.selectiveproteinuria選擇性蛋白尿---chieflyalbumin主要為白蛋白

nonselectiveproteinuria非選擇性蛋白尿

3.heavyproteinuria大量蛋白尿

4.disease:腎病綜合征Tubularproteinuria小管性蛋白尿

1.Renaltubulardiseasedamagetubularfunctionbutglomerularisnormal2.Moderateproteinuria中等量蛋白尿

3.disease:pyelonephritis腎盂腎炎等Overflowproteinuria溢出性蛋白尿

Excesslevelsofaproteininthecirculation,hemoglobin,myoglobin,etc.循環(huán)中大量蛋白。OverflowCausesHemoglobinuria血紅蛋白尿Myoglobinuria肌紅蛋白尿MultipleMyeloma多發(fā)性骨髓瘤Amyloidosis淀粉樣變ProteinuriaCauses

GlomerularCauses(Increasedglomeruluspermeability)

PrimaryGlomerulonephropathyMinimalChangeDiseaseIgANephropathyIdiopathicmembranousGlomerulonephritis

FocalsegmentalGlomerulonephritis

MembranoproliferativeGlomerulonephritis

HeavymetalsTubularCauses(Decreasedtubularreabsorption)

HypertensivenephrosclerosisUricAcidnephropathyAcutehypersensitivityInterstitialNephritis

FanconiSyndrome

HeavymetalsSickleCellAnemia

NSAIDsAntibioticsSecondaryGlomerulonephropathyDiabetesMellitus(DiabeticNephropathy)SystemicLupusErythematosus(LupusNephritis)Amyloidosis

Preeclampsia(PregnancyInducedHypertension)InfectionHIVInfection

HepatitisB

HepatitisC

PoststreptococcalGlomerulonephritis

Syphilis

Malaria

EndocarditisLungCancer

GastrointestinalCancerLymphoma

RenaltransplantrejectionOverflowCauses(IncreasedlowMWproteinproduction)

Hemoglobinuria

血紅蛋白

Myoglobinuria肌紅蛋白MultipleMyelomaMMAmyloidosis

淀粉樣變蛋白尿的臨床診斷思路KetonesinurineIncludingthreeketonebodies:acetoaceticacid乙酰乙酸20%acetone丙酮2%β-hydroxybutyricacid78%Theproductsoffatmetabolism脂肪代謝至產(chǎn)物Referencevalue:qualitativemethod:negativeKetonuria---qualitativetestispositiveKetonuria1.diabeticketonuriaDM相關(guān)2.nondiabeticketonuria:非DM相關(guān)Hyperemesisofpregnancy妊娠嘔吐Patientsaccompaniedbyvomitingordiarrhea伴有嘔吐或腹瀉Negative+(weak)++(moderate)+++(strong)TheUrineDipstick:Bilirrubin膽紅素Bilirubin+Diazosalt--------->AzobilirubinAcidicChemicalPrincipleReadat30secondsRR:NegativeSignificance -Increaseddirectbilirubin(correlateswithurobilinogenandserumbilirubin)Limitations -Interference:prolongedexposureofsampletolight -Onlymeasuresdirectbilirubin--willnotpickupindirectbilirubinOtherTests -Ictotest(moresensitivetabletversionofsameassay) -SerumtestfortotalanddirectbilirubinismoreinformativeUsesandLimitationsofUrineBilirrubinDetection尿四樣意義

計算內(nèi)生肌酐清除率的計算估算24H尿白蛋白計算24H白蛋白判斷尿蛋白來源意義

計算內(nèi)生肌酐清除率的計算Ccr=U×V/P（ml/min）V：每分鐘尿量（ml/min）=全部尿量（ml）÷（24×60）minU：尿肌酐，umol/LP：血肌酐，umol/L24H尿白蛋白的計算或判定意義

尿蛋白來源定位尿微量白蛋白/B2微球蛋白比值-大于100:1考慮小球性蛋白尿-小于50：1考慮非小球性蛋白尿判定尿蛋白來源定位尿蛋白電泳血清蛋白質(zhì)為膠體物質(zhì)，在一定條件下帶有電荷并在電場中泳動。在堿性環(huán)境里，血清蛋白皆帶陰電荷，在電場中向陽極泳動，因各蛋白質(zhì)等電點(diǎn)和分子量有差異，分子量小、陰電荷多泳動最快；分子量大、陰電荷較少者泳動較慢。電泳后，從陽極開始，依次為白蛋白、a1球蛋白、a2球蛋白、β球蛋白和γ球蛋白五個區(qū)帶。正常值白蛋白0.60～0.71(60%～71%)。α1球蛋白0.03～0.04(3%～4%)。α2球蛋白0.06～0.10(6%～10%)。β球蛋白0.07～0.11(7%～11%)。γ球蛋白0.09～0.18(9%～18%)。增高①白蛋白同白蛋白，多見于脫水。②α1球蛋白肝硬化、肝癌、腎病綜合征、營養(yǎng)不良。③α2球蛋白膽汁性肝硬化、肝膿腫、營養(yǎng)不良。④β球蛋白阻塞性黃疸、膽汁性肝硬化、高脂血癥。⑤γ球蛋白慢性肝炎、肝硬化、急性腎炎、多發(fā)性骨髓瘤、結(jié)締組織疾病、急性血吸蟲病。減少①白蛋白同白蛋白，多見于肝病、營養(yǎng)不良、腎病。②α1球蛋白嚴(yán)重肝病。③α2球蛋白肝病。④β球蛋白嚴(yán)重肝病。⑤γ球蛋白慢性腎炎、腎病綜合征。意義：1尿蛋白定位：小球、小管2選擇性或非選擇性蛋白尿4估算蛋白定量3提示漿細(xì)胞疾?。篗帶缺陷：不能顯示輕鏈蛋白輕鏈蛋白輕鏈（lightchain，L）大約由214個氨基酸殘基組成，通常不含碳水化合物，分子量約為24kD。每條輕鏈含有兩個由鏈內(nèi)二硫鍵內(nèi)二硫所組成的環(huán)肽。L鏈共有兩型：kappa（κ）與lambda（λ），同一個天然免疫球蛋白分子上L鏈的型總是相同的。正常人血清中的κ：λ約為2：1。游離輕鏈的測定及其醫(yī)學(xué)意義：免疫球蛋白（Ig）輕鏈分為κ（ka