Urinalysis

尿液分析

血液科

上聯：貧血便輸，輸一紅二白三小板，原來全系降低

下聯：發熱就查，查七血八尿九骨髓，結果是個感冒

橫批：開個玩笑

傳染科

上聯：常恐交流惹禍

下聯：還是隔離放心

橫批：改日再聊

腎內科

上聯：前尿道，后尿道，有病難道

下聯：左腎臟，右腎臟，無尿易喪

橫批：關鍵是尿我科尿液常見檢查尿常規尿四樣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)隨機尿Clean-catch,midstreamurine(forurineculture)潔尿，中段尿Attention注意Needtobeexaminedwithin1hour需要在1小時內送檢ContentsPhysicalexamination物理檢查Chemicalexamination化學檢查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Phenothiazines酚噻嗪系Porphyria卟啉癥Rifampin利福平Pyridium尿路鎮痛藥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各種細胞組分:leukocytes粒細胞,RBCs紅細胞,epithelialcells上皮細胞UrinevolumeTheaverageadult:1000mlto2000ml/24hIncrease

polyuria多尿---morethan2000mlofurinein24hours1.physiologicalstates生理狀態: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結石，腫瘤)3.renalparenchymaldisease:腎實質疾病

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紅細胞細胞溶解劑血紅蛋白反應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)污染標本月經等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過度運動 -GlomerulonephritisPregnancy懷孕 -Nephroticsyndrome-Orthostaticproteinuria直立蛋白尿 -RenaltumororinfectionPre-Renal

Post-Renal -Fever發熱 -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.循環中大量蛋白。OverflowCausesHemoglobinuria血紅蛋白尿Myoglobinuria肌紅蛋白尿MultipleMyeloma多發性骨髓瘤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脂肪代謝至產物Referencevalue:qualitativemethod:negativeKetonuria---qualitativetestispositiveKetonuria1.diabeticketonuriaDM相關2.nondiabeticketonuria:非DM相關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為膠體物質，在一定條件下帶有電荷并在電場中泳動。在堿性環境里，血清蛋白皆帶陰電荷，在電場中向陽極泳動，因各蛋白質等電點和分子量有差異，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、營養不良。③α2球蛋白膽汁性肝硬化、肝膿腫、營養不良。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、多發性骨髓瘤、結締組織疾病、急性血吸蟲病。減少①白蛋白同白蛋白，多見于肝病、營養不良、腎病。②α1球蛋白嚴重肝病。③α2球蛋白肝病。④β球蛋白嚴重肝病。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提示漿細胞疾病：M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二硫鍵內二硫所組成的環肽。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學意義：免疫球蛋白（Ig）輕鏈分為κ（ka