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Interpretation of Renal Function Tests

May 18 | 3:30 PM

The kidneys are involved in the excretion of waste products and toxins like urea, creatinine, and uric acid, as well as the regulation of extracellular fluid volume, serum osmolality, and electrolyte concentrations, and the production of hormones like erythropoietin, 1,25 dihydroxy vitamin D, and renin. The nephron, which includes the glomerulus, proximal and distal tubules, and collecting duct, is the functional unit of the kidney. Renal function testing is crucial in the treatment of patients with kidney disease or diseases that impact renal function. Renal function tests are useful for detecting renal disease, monitoring the kidneys' response to treatment, and determining the development of renal illness. Join us live with Dr. Mahadev Desai in this super amazing #backtoschool series on basic investigations.

[Music] hi dr rucha welcome you all uh all the doctors on behalf of team netflix i'm glad you all could join us today uh to this amazing interesting session in the series of investigations part that mahadev said has started few months back uh we did amazing cbc a session on cbc then uh liver function test and we are back with renal function test now so welcome mahadev sir uh it's been really long after cutting edge but we are glad to see you again on the platform we have dr mahadeva with us who is senior consultant physician from zapat and uh sar has been in teaching for really long and he loves teaching uh so he will be covering interpretation of renal function test today so with this over to you sir yeah good evening dr rocha and all the members in the audience it has been a long time since we discussed about the interpretation series but incidentally netflix is already running many interpretation topics that is yeah maybe for yesterday there was interpretation of thyroid functions then his interpretation of ecg is due in a day or two so i think this is the right time that we discuss the interpretation of renal functions but before i proceed i let's have a quick round of quiz to know how much we know about the importance of renewal functions and important aspects about the real functions yeah so first in the evolution of renal functions what is very important good history taking green analysis serum creatinine and the yeah injustice created in gfr or all of the above so your time starts now all of the above is the majority still voting we have nine seconds left don't influence them okay so final results are here so 70 of the doctors here say all of the above and followed by serum creatinine and history taking an urine analysis right so i'm glad that most of the people agree with me the answer correct answer is all of the above it's everything is important you just can't evaluate or interpret one report and next is the morning sample of fuel is ideal for urine microscopic analysis is it a true state all statement or it doesn't matter whether it is the morning or random sample so you have 25 seconds so so 797 votes 78 percent for true and doesn't matter 18 and 12 3 the majority are right and we'll know we'll let you know why this is the case and last quest average 24 hour urine output in a healthy person with normal liquid intake is how much how much so yeah 500 to 750 750 to 1500 1500 to 2000 or 2000 to 2500 ml all day so four seconds left and i can see everyone going for 1500 to 22 000 ml and followed by lost option which is 2002. we'll talk but that's not correct in fact the very queer words included the normal liquid intake right and of course it's going to vary with the season and with the person's individual but its correct answer is between 750 and 1500 ml it's roughly 1 ml per minute we have got 1440 minutes in a day and roughly 1 ml per minute anyway so let me have put a disclaimer i am not a nephrologist or a pathologist i am a clear-cut intense intern nist and we try to be jack of all the master of none but what is important is that we have taken so much material from so different sources and the individuals in the textbooks and monograms that i am really grateful to all of them and very importantly medicine is an ever-changing science what i tell today may not stand to tomorrow it's very important that we interpret anything in real time and be ready to change if the things come out otherwise with that we begin what i intend to talk in the next 45 minutes is the very brief of what are the kidney functions what are the routinely order renal functions and i am going to stress more about the urine analysis for the entire talk and then we'll see whether the time permits for the other test numeral filters and rate and specific renewal functions which are occasionally ordered so first and foremost what are the functions of the kidney effect interpret general functions we should know what are the functions of the kitten those of you who have attended our medical mnemonics this was one of the neuronics that we put the kidney functions can be remembered as a mnemonic a wet bed right we know the kidneys are the main functions having the balance it balances the water it balances the electrolytes it maintains the balance delicate balance of acid and base then it also helpful in the toxic removal then blood pressure control and the blood pressure blood hemoglobin that is through erythropoietin and very importantly vitamin d metabolism so these are the main functions of the kidney and if you have to evaluate the this functions we need the help of the test so what are the tests that we ask for generally for the evaluation the renewal functions first and foremost is urine analysis then complete blood count with esr peripheral smear serum creatinine is very very important as somebody has rightly said put at the second part but not the only one and with serum creatinine we also estimate the pulmonary filtration rate blood urea nitrogen or blood urea depending on where you see some countries only measure bu and that is blood area nitrogen while majority like countries like us go for blood urea then electrolytes especially the potassium then the other ions like calcium phosphorus also sometimes ask for uric acid is another important order test we order for venous bicarbonates is another one and amongst the non blood tests are the sonography of the abdomen that is the routine test that we asked for but the odd test that we asked for in specific situations are the urine electrolytes urine or serum osmolality 24-hour urine protein estimations serum intact parathyroid levels hormone levels and vitamin d as a arterial blood gas analysis renal doppler or ct or mri of the abdomen then complement levels a a profile when we suspect some immunological disorders of the kidney and renal biopsy obviously renal biopsy being invasive is the last and required in very few cases so we begin with the test which is most important that we are going to discuss is urine analysis but this slide will summarize what are the most important tests and with maximum yield if you have to if you have a cost constrained economic constraint constrainer we are in practice then we go one by one so most of the time we ask for urine rn this rm stands for the routine as well as microscopy and especially one should look for the protein urea hematuria and detailed analysis of the microscopic examinations about the cells then serum creatinine and the estimated growing filtration rate we usually estimate and we do not actually measure the serum uh creatinine leading to creatine clearance or the gfr we have to estimate the gfr because that's easier and it's almost identical to actual measurement of the chromosome rate then serum potassium and if we are suspecting chronic kidney disease then additional tests that might help are the cbc calcium phosphorus parathyroid hormones and sonography so the most important being the urine analysis and that's what we are going to focus today but importantly when you screen the patients for renal functions ideally all persons who are at a high risk of the kidney impairment or kidney function rearrangement should be subjected to basic analysis for the kidney functions so all who are above the age of 60 years we know that glomerular filtration rate which is anything between 90 and 125 at the young patients start declining at least one ml per year after 60. so we expect a person's with the age of 60 gfr of around 60 or 70 that could be normal the patients having diabetes having hypertensions having cardiovascular diseases or autoimmune diseases patients having chronic liver disease patients who have been receiving long-term non-steroidal anti-fluid drugs patients having chromatological or osteoarthritis they are receiving the nsaids for a long time they need to be screened for the renal impairment persons having renal calculi those who are having recurrent unitec infections also need to go for the basic screening test for the neural functions persons having family history of chronic kidney disease or persons having an adult polycystic kidney disease which is an autosomal dominant disease and if there is a family history in one member the other members will also be screened persons having sickle cell disease are likely to have renal impairment and the sickle crisis so we have to keep that in mind persons having malignancy and hiv are also are likely to have some renal impairment moreover in all these patients when we have to give medications very importantly we should know the creatine clearance or the egfr so that we can adjust the dose accordingly so we before we go for the renal function ordering it's better we know and take the history in little more detail about the urinary symptoms as well as the other symptoms so that we know what to suspect clinically and what is to be ordered so always inquire about the quantity of the urine in a day and when in doubt right you can ask the patient to actually measure the urine output in the 24 hours then how what is the flow and frequency of urine especially whether the person is having nocturnal frequencies then whether the patient has painful maturations or disuria whether the patient says any of this urgency hesitancy or incontinence of the urine and very importantly whether the patient is having foamy or frothy or cloudy urine whenever the patients complain of this kind of urine one of the important possibilities and urinate infections or protein urea so he always insist about the color of the urine and whether it is turbid cloudy or frothy and what is the order of the urine also that will talk a little more detail and color of the urine you will be surprised to know that there are so many colors of the urine that can indicate the different kinds of diseases some of them are common some of them are uncommon will be dealing with that too then another important thing is to ask about the systemic symptoms whether the patient has fever vomiting flank pain weight loss anorexia whether the patient has any past or present coexisting illnesses like diabetes hypertension ischemic heart disease and which medication space it's better that we personally check whether a person is using the medicines and this includes the over-the-counter medicines as well as non-allopathic medicines because so many they have been consuming the heavy metals and so many of them that we have come across so many patients with chronic kidney diseases simply because we just inquire about what are the medications they take and when we ask for the lead levels of the arsenic levels or the mercury levels and they come very high and that's because they have been consuming the alternative medicines which contain such heavy metals so it's very important that we inquire about the over the counter medicines and the herbal represents that they might be taking because patients on their own may not feel it necessary or they have the general impression that the non-allopathic medicines are safe we only know because we are the ones who usually look after the patients who come with some problems so first and foremost thing is the urine collection it's very very important then we collect the urine the most ideal manner to avoid contaminations and get the right analysis so urine should be collected in a clean dry container patients should be asked to clean the external genitalia and provide a midstream specimen for analysis patients would discard first few ml of urine and then only the unit should be collected in a container sterile container and if the patient is catheterized with connecting directly from the catheter and not from the urometer or the uric back then specimen should be immediately analyzed ideally right and should be stored at the room temperature should be tested within two hours but that is not possible because of the logistic problems and it's better that we keep the urine sample in a regular freeze that is two to eight degree centigrade and when it is to be analyzed it should be reward it's very very important to take these small precautions and this here lies the questions why early morning sample the sample has to be in the morning because the morning sample is acidic in nature and this is one where it's little concentrated and if the urine is acidic concentrated it preserves the structures that is the cells and the other cast and all those things but if the urine is collected after the patient is tight they're taking water and if it is low specific gravity and ph it might distort some of these cast and the red blood cells and we may not get the correct picture so always always get the morning sample that is best for the microscopic analysis and this is what we usually see as a report the normal values of the urine analysis the color has to be pale yellow or amber color then the clarity it has to be clear or slightly hazy and both things depend on the patient's hydration in the water intake too that we have to take figure out then specific gravity is generally from 1.005 to 1.030 normally it is around 1.010 then the glucose is obviously negative the ketones are negative the ph is usually between 5 and 8 but it's mainly accepted as between 5 and 6 the ph also gate depends on the many other factors we'll be talking this blood ph we know is the neutral that is around 7 but the urine ph is usually on the acidic side in most of the patients and because if that is the very function of the it needs to acidify the util and to dispose of the h ions then the blood is obviously not expected the bilirubin is also is negative the euro billing region might be in this very small quantity because of the end products of the bilirubin metabolism then nitrite test will be talking more about it is negative and leukocyte stress is negative what i stress upon is that it's very very important that the weather whenever we are suspecting uridec infections always look at the leukocyte leukocyte asterisk as well as nitrite along with the microscopic picture so that we can say that whether there is a neurotic infections or there is a contaminations and if there is any tech infection could it be a particular kind of organisms that we might suspect if the patient has leukocyte leukocyte stress is positive nitrite is also positive and the microscopy shows more than tests then wbcs you can reasonably be sure that patients can have infections by the gram-negative organisms and if the patient is otherwise fine you may start with the drugs like the nitrofurantoin which so far has always been sensitive to gram-negative organisms in the eu right the microscopic examinations look for the bacteria in the high power field the wbc is normally expected to be only 0 to 2 and most of the wbcs are obviously polymorphs the red blood cells also less than two then the epithelial cells are usually look for in the low power field is hardly one or two the caste again we don't expect any cast or maybe a high line cast one per low power field the crystals we don't expect sometimes you might get a normally constituent of the urine like the calcium or phosphates as crystals but they are always very few so this is the normal urine analysis picture that we expect now we go to the different pathologies of the urine analysis we begin with the color of the urine as you can see that we can have plethora of colors which can give you different kinds of the pathologies in the from the urine color normally urine is pale or yellow and that's because of the euro billion that is again the end product of the metabolisms but it can be red whenever the urine is red it's we must centrifuge the urine sample and then see what turns red whether the whole entire samples is after centrifugation also is red or only the sediment is red or the superman atom is red and depending on that will come to that little in a minute then whether the urine is dark brown or cola colored right then whether the urine has reddish orange whether the urine is dark yellow that we see in the jaundice or most commoner than that is the consumption of b complex especially vitamin b1 then whether the urine could be green color then either the urine is blue white urine is also not very uncommon it could be because of the just turbid urine or because of the excess crystals or heavy protein area or it could be because of the child area again we'll be talking that black urine not very common but again can be part of the extension of the holocaust pink urine or the purple urine so it's very important that whenever we find different colors of the urine we try to find out what are the patients has been consuming whether it's drugs food the diets that we might be exposed to or whether placenta has pre-existing conditions like g6p deficiency this is very very important to know before we analyze the color of the urine the yellow urine as we said is either b complex or jaundice it's red urine which is very important and this is one where we must make sure whether we are dealing with hematuria hemoglobin urea myoglobin urea or it is just red color of the urine because of the pigments of the foods or vegetables that fruits that we eat with its because of the beet it can lead to bethuria right it's because of the betanine a pigment which gives the red color to the green otherwise it's a very very harmless conditions then blackberries carrots and rhubarb they all can give red color and it's seemingly harmless and within 24 hours that redness should disappear but what is important is whenever you come across a red urine as i discussed earlier we must centrifuge the urine sample and see what turns red it's a supernatant it is red or sediment which is red if the sediment is red obviously we are dealing with the hematuria because sediment is all rbc's but if the supernatant is red it's like we must check this with the one more method that is the dipstick method dipstick method picks up the hem part of the urine and that again will be talking about the distinct method and we'll talk more about that but what is important is if the district is also showing him and the supernatant is clear and there are only rbc then picture is very clear schematic but the whole sample remains red then we should also rely on the microscopy and if we find microscopic presence of rbcs it's a hematuria if the microscopy does not reveal rbc's and the urine is red then it is either hemoglobin or myoglobin area and that we need to analyze later with the further test dark brown or cola colored urine is usually because of certain foods and fair beans fair beans are what we call the bakla in the hindi or in gujarati and they can give rise to the dark brown color and especially if the person is having g6 period deficiency you can have the hemolysis which goes responsible for the dark brown color or cola colored urine persons taking metro azole or nitropharyntoid can also have a dark brown color colored urine and patients who are in the habit of taking the constipation relieving drugs like senna can also have the dark brown color the reddish orange color we quite often tell all our patients who receive the composition or the phenopyridine that is the unity analysis expired here right they definitely color the urine and we must warn otherwise the patient would come next day worrying that my urine has turned red and the medicine is very not tolerating but that's usually the color of the drug that is coming out and it's nothing pathological then the blue color urine is because of either the methylene blue or benign familiar hypercalcemia conditions not much significance to that the green colored urine is usually because of the urinary infections by the gram negative especially pseudomonas infections and again it can be because of the drugs like the nsaids or amitriptyline or methylene blue sometimes can also give the green color to the urine and sometimes give blue color then white urine is because of the phosphaturia or the crystals or because of the tile urea or persons who received the propofol after that he might get the white color urine sometimes they might get even pink color especially in the patient is also having uric acid nephropathy or uric acid crystals in the urine the black urine is because of the hemoglobin urea or myoglobin urea but melanoria or metastatic melanin melanoma is another conditions we should keep in mind one heretic conditions called phenylketonuria can also give black color to the urine because of the homogenic acid in the urine and that will not come up on a freshly avoided sample if the urine is allowed to stand for some time the homogenic acid gets the color later on likewise patients having acute intermittent porphyria might sometimes come out with the urine which understanding gives the pot wine color of the urine so very very important is always always asked for the color of the urine and gets repeated samples not one sample another important is the order of the urine we know normally the order of the urine is because of the ammonia and little pungent smell but not very strictly pungent or very annoying smells unless the patient has not consumed enough of the water or consumed more of the ammonical substances than only expectation but persons who've been taking asparagus give rise to very strong smell because of the sulphur containing compounds in it and it can come as early as 15 minutes after consumption of asparagus the drugs like pyridoxine can also do a strong smell we all know the sweets smell of the diabetic ketoacidosis because that smell is just typical like the nail polish remover same smell that we see because of the acetone in the urine the musty smell is because of the dead mouse mill that we may find because of the mercaptans in the liver diseases or phenylketonuria also we can give the same smell they sometimes we get a very foul smell because of the gross uridec infections or the renal failure and the typical ammonical smell we might see and the very rarely i have seen one patient's at least where the urine he says that the urine is smelling like his fecal smell and his urine also persistently sold the fecal matter first time we always suspect that it said contaminations but in the male patients it is unlikely to have this fecal contaminations right correctly collected sample but this was the patient who had the rectum vesicle fistula and it turned out to be a case of c rectum with fistula and the urine was showing the fecal matter the now we come to the dipstick analysis we know that most of the laboratories now use the heuristics for the analysis and the manual reading of all these states are virtually out in most of the metros it's still there in many of the laboratories but dipstick is a very reliable and easy to and quickly look for the most of the test in a given time it's a simple stick which has got multiple small different colors squares and each square represent a particular trace and everything is written in the bottle which has the sticks and as you can see from this the first here is a glucose then second is the bilirubin then the ketones specific gravity blood ph eurovirus and proteins all these things so for every test of a stress strip of a particular company that test might differ but what we need to see is we must correctly interpret by view of rightly dipping the whole strip into the test tube with the entering the urine and read it at the particular time that is mentioned on the bottle that if you have to measure in five seconds you have to see and that's usually the way the the squares are arranged in such a way that the first has to be tested uh seen very fast and that is how you can see the entire heuristics we can analyze in a matter of 10 minutes and the color generated in each pad has to be compared with the color which is seen and any of this test also give rough idea that is a semi-quantity method one plus two plus three plus depending on the severity of the change in the color so it's very very important and very quick rapid semi-quantity analysis what is most important is that we can get some of the test as i mentioned is the glucose leukocyte asterisk leukocyte asterisk are the enzymes that are present in the neutrophils and when the neutrophils are more in the urine and that these are released and this is what gives the dipstick analysis the leukocyte asterisk positive when it is present along with the pulse cells mean the wbc's in the urine definitely we are dealing with either the infection or inflammations then second is the nitrite test as i mentioned earlier the nitrate is converted into nitrite by the gram negative organism so if the nitrite test is positive leukocyte asterisk is positive and there are number of wbcs in the urine you can say that patient is having ram negative infections if it's not an immunocompromise or a diabetic and first-time infection you may straightaway start with the treatment like the nitrogen coin but otherwise repeated infections fluoride infections suspicion of pyelonephritis ideally you should go for the urine culture before starting the antibiotics uh point five taken then bilirubin can also be seen in the one of the dieptics analysis the eurovilinogen will also give idea about the presence of illumination and it's more likely when there is a hemolysis and higher will no chance conventionally we have been doing with the laboratory with the ariel's reagent and formula we are doing the other test and ketone easily we can see with the heuristics about the ketone and that can give you idea about whether we are dealing with diabetic ketosidosis but patients who have been fasting right the starvation ketosis also give rise to ketones ketones we know there are three types of ketones ketone bodies in the urine there's acetone acetic acid beta hydroxybutyric acid and the acetone of which it is the acetoacetic acid which is the true keto acid and acetone is the true ketone and it when it comes to diabetic ketosidosis we have to remember that diabetic ketosidosis it's mainly the beta hydroxybutyric acid which is in large quantity which is not what we measure in the urine when we measure in the urine with the nitric oxide test what measure is the acetoacetic acid mainly so it is likely that in the very initial part of the diabetic heterostatosis blood bites or large quantity of serum acetone because we measure beta hydroxybutyric acid but acetone may not be present or maybe a very small ring is present but once we correct diabetic is that beta hydro synthetic acid is mobilized and is converted into acetic acid and that will give the so the urine might start showing the ketones later on once the patient is being treated right and the urine starts coming and it may not be seen on the very initial part that's very important to remember dipstick analysis has its own drawbacks particularly when it comes to albumin the proteins the district measures only the albumin it does not measure all proteins urine dipstick present means albumin is present urine ft district is absent for protein does not mean there is no protein area protein area other than aluminum may still be present and it's very very important that if the heuristic not so proteins but we have a strong suspicion of proteinuria then we go for the conventional method of the urine being tested conventionally by heating and then adding sulphur silic acid ah we'll come to that lineability's time so remember heuristics is very specific only for albumin and it can give rise to one plus two plus up to four plus but that depends on the change of the color which again depends on the how much is the urine concentration right with the patient has consumed too much of water we may not be able to get the correct interpretation of the quantity of quantitative protein area the light chain proteins we know that the multiple myeloma and many other gamma globinopathies they said the light chains which are the globulins like kappa and lambda chains which cannot be picked up by dipsticks and that is one of the big flaw of the dipstick protein analysis and we have to go for the regular heating method for the dipstick for the light chain protein urea detections another part is you got to see that the dipsticks are not out of date right we have to use it before the expiry date and we must store it properly once we open the lead and we take out the stream this should be closed immediately because it they are all enzymes and they get degraded on repeated exposures and when there is a high dose of vitamin c which we have seen in decoy time people keep on taking large quantity of vitamin c with the patient consuming large quantity of vitamin c then it can give false report for the heme as well as glucose as well as the nitrates and leukocyte esters all can be falsely negative in spite of they are being present because of the ascorbic acid we may not get the report so it's a very important point to remember then we come to urine specific gravity again it's a very best way to see is through the districts method only and as said earlier its normal range is 1.003 to 1.030 we can also get the urine specific gravity correlated with the osmolality but urine osmolarity is not that we routinely ask for we'll talk at the end about it the importance of urine osmolarity when we are suspecting polyuria and the different types of polyuria the normal urine specific gravity is around 1.010 and it's if it is less than that there is a good hydration more than 1.020 is a relative dehydration and persons having a fixed 1.010 all the time we go for it that means patient has lose the ability to concentrate urine and it could be indicative of chronic kidney disease and important thing is for you specific gravity as mentioned in the manufacturer's instructions it should be dipped into the for at least two minutes and then wait for the results urine ph very important we know that the serum ph is 7.4 earlier i mean seven that was not that sleep of tongue is seven point four plus minus point zero four and normal urine ph is a wide range depending on the consumption of the food and what time you look for it and how much is the acidification is required so it ranges from 4.5 to alkaline side eight but generally it is between 5.5 and 6.5 so we can say that the normal urine ph is usually acidic and this mainly because of the secretion of the h ion and the absorption of the bicarbonates that maintain the urine acidity the urine acid it could be normal but persons who have been consuming cranberry fruits can also have acidic urine then persons who are taking cheese will also have acidic urine and meat eaters also acidic curing so when we analyze acidic urine we keep these factors in mind on the other side the alkaline ure is mainly in the citrus fruits legumes and vegetative diet as well as the non-cheese dairy products they all can give the alkaline urine for since having renal tubular acidosis male alkaline urine and the persons having urine tech infections mainly with the proteus organisms will have alkaline urine triple phosphate crystals or obstruction by the stones will also lead to alkaline urine so something to remember when we analyze the ph interpret the ph always see whether the patient is having infections and depending on the we have to either acidify the rib or alkenize the urine depending on what we see along with infections most important is the urine microscopic analysis we know that there are so many things we look for what is important is what we look for in the urine is the red blood cells the white blood cells the epithelial cells the crystals mainly the hyaline crystals then a cast that is the crystals are mainly whether the calcium oxalate or phosphate or uric acid or cysteine crystals then the cast then sometimes we also look for when we are suspecting the multiple myeloma we ask for pencils proteins generally what we need is a urine electrophoresis as a test and the general stain that is used for most of these structures analysis is the what's called stem henner malbin supravital stain which contains the crystal violet in saffron stains and it can be used as a general stain for most of the microscopic analysis what we see is the i just put one slide for all these my structures to see the relative size of the cells and the nuclei you can pinch and zoom in and zoom out and see the different size but we are going to talk about it individually also so this is all that will look for the rbc's wbc's epithelial cells crystals and the cast so first is red blood cells as we discussed persons having a red urine and who is having the supernatant as well as the sediments all is red and the heme also is present in the digestive method and the number of rvs is more than two per high power field as hematuria hematuria can be crossed when the rbc is really innumerable or there may be very few that is normally what we look for the microscopic imagery in case of infected endocarditis but the cross hematuria is indicative of damage anything from glomeruli to the urethra most common is the glomerular damage will lead to the gross hematuria but if the patient is having tumors patients having brain tumor infections upper and lower intake infections or stones they all can give to the hematuria important thing is whether it's maturia or hemoglobin area that we have to differentiate first and further test accordingly if it is herbicides the first and foremost thing if we have ruled out the attack infections or the infected endocarditis we should go for the sonography to look for the stones which is a very important common cause of the maturia normally if you look for the microscopy they do not mention past cells very few laboratories will mention the parcels ideally this will be writing wbc's only but when do we define pi urea well the urine microscopy shows 10 or more cells in a urine specimen or in an unspun or uncentric samples if you find three or more white cells or if on the dipstick we have got a leukocyte stress test positive or on a gram strain is positive right in unspun urine they all constitute pyruvia pyoria of course indicate not only your infections but it can be inflammations in the track or the interstitium can also give rise to pass past cells or wbc in the urine so pyria does not mean infections and persons who have been having the recurrent repeated detection of what we mean by unspawn uranus when we ideally the urine should be centrifuged at least for 5 minutes 200 to 1000 revolutions per minute speed for at least five minutes and what we have to remove all the superintendent and take the very small part of the remaining part sediment part over the cover sleep and then look it in the microscope that is the ideal centrifuge but if you just take the urine a drop of urine from the unspawn means uncentrifuge that is where we do not get all these cells in a more details or in more quantity that is the unsponsored what we look for is the wbcs wbcs as i mentioned earlier most of the wbcs are the neutrophils and neutrophils we know are size of around 10 micron right and they have got the nucleus and that can be seen that has to be con compared with the other cells we hardly see lymphocytes or eusenophils once in a while we might see the patient as drug induced interstitial nephritis right or if the patient has some say undergone renal transplantation and now we see the lymphocytes it could be the early sign of renal transplantation like that that not very common if the patient is having persistent muscles in the urine right and in the absence of bacteria on the culture we call it sterile pyoria in our setup if person is having repeatedly this it's not an uh catheterized samples or patient is not having insulin nephritis the disease that we keep in mind is tuberculosis the epithelial cells so often we find the wbcs and epithelial cells and as a knee jerk reaction we start the antibiotics which is not correct epithelial cells we know the entire lining of the kidneys and the aerator and the bladder and the urethra is the epi different kinds of epithelial cells and in female patients the urine which comes out from the urethra through the vagina and labia also as the epidural cells so it's very important we not only see look at the epithelial cells but whether there is mentioning of any specific type of epithelial cell these chromos epithelial cells are the largest objective cells and slide is little transparent and not easily seen but you can zoom out and see the relative size of the different kinds of epithelial cells epithelial cells these chromosomes are the largest and usually comes mainly from the external genitalia and the vagina and grit and more common in females if the urine sample is not correctly collected then you might find multiple epithelial cells as chromos epithelial cells as a part of contaminations and if it is there in absence of the wbcs in the urine again we may take the another samples rather than give attribute to it but if you have got the epithelial cells which like like renal tubular cells which are having a rounded nucleus and oval nucleus in a round border and it might be a renal tubular cells and if their history suggests or there is other features like the protein area better we give importance that of course they have to be large more than 15 in a high power field otherwise they can still be part of the normal urine sediments the transitional cells may be seen insulin the elderly patients and if they are in large number we have to keep in mind the transit cell carcinoma but routinely we don't look for it because we are not it's not there then very very important are the urinary cast the caste are the cylindrical structures as is shown in the first the urine itself the unit track particularly the proximal the tubules of the urine they synthesize a protein called the tom horseball proteins and this cast are these threading of these degenerated epithelial cells may be seen as the tubular structures in the urine uh usually they are seen one or two in the low power field there are many and if the patient has other symptoms or if these gibla structures uh otherwise normally are the high line or transparent structures right the high line cost do not indicate much but if this high line cast are also having the wbcs or rbcs within that cost then it becomes the wbc cost for rbc cost and whenever we get the wbc cost or rbc cost in the reports or there may be the granular cost as mentioned in the reports that granular cost usually indicates the cellular debris or the mix of the wbcc nervous is and all this cost other than the highline cost usually indicate a global disease so if the patient is rbc's wbcs they are not as important for indicative of the criminal disease as the caste whenever there are multiple caste in a report of particularly the wbc cars or rbc class always think of the global disease and tree try to lock one so crystals in the urine we know that the persons having the stone disease or ural lithius may have crystals the classical calcium oxide crystals are the envelope like crystals which are the diphosphate dioxide crystals then the cysteine is a typical hexagonal and uric acid crystals are the dimension crystals and all they can if you change the light right over the microscope they become biorefrigerant with a special type of microscope we can look for that important thing is all these crystals would be seen in an acidic urine then your diet is certain that you are dealing with the calcium oxide crystals but when in doubt we and if the patient passes the calcula in the urine it is better that let that calculus or the material whatever it is is subjected to the chemical analysis for the different types of the composition of the stone persons having an alkaline urine with the coffin lean type of the shape of the hexagonal crystals they are usually the calcium phosphates or triple phosphate crystals or the calcium carbon crystals so crystals are very important important thing is this would be many and they are the normal calcium oxalate one or two crystals may be present in the few pisces but if they are present with rbcs or patients having the history of real calculi or hematuria we give importance to crystals then the important part is the urine protein estimations we have been giving importance to the protein because protein area is one of the important uh part of the renal functions uh evaluation so as we said earlier if the urine dipstick shows positive we are dealing with the alpha but that is a semi-quantity we can't say exactly how much is the urine excretion per day so we need to go for the quantitative estimations but where in doubt about any protein area not only albin urea then it is better we go for the sulphur salicylic acid test because sulfoxylic acid can detect all types of proteins the globulins different kinds of globulins whether it's a kappa lambda chains mineral globulins or beta globulins which is a normal constituents in the blood right so what we do is we take the one part of the urine and the three parts of the sulphalic acid acid and see what happens to the turbidity of the urine and depending on the degree of turbidity it can be labeled as one plus two plus three plus and whenever you just when you collect the urine in the simple test tube and heat it if the patient has phosphaturia you can still have the white precipitates you add acetic acid and the the crystals disappear that means that was definitely phosphaturia and no more taste is required if you add sulphic acid and if you get the precipitates then definitely we are dealing with the protein urea and importantly it can be proteinary is not always pathological sometimes we might get transient protein there after the exercise or in certain people in the posturally also we can get osteotic urea and but important thing is a persistent protein area total protein excretion is very important is especially when dealing with the conditions like the nephron glomerulonephritis or nephrotic syndrome we know that the normal protein excretion is usually less than 150 milligram per day and generally it is not more than 80 milligram per day the protein amongst the protein albumin is generally around less than 20 milligram because albin is a very heavy molecule its molecular weight is around 69 000 kilodaltons so what we get in the urine as a protein area is usually the beta globulins small globulin that is a very small molecular weight around 15 000 so that is what we get but again not more than 150 milligram in entire 24 hours and person having persistent protein area 3 plus 4 plus and sulfuric acid bitter we go for the twenty four however in estimations if the twenty four urine estimation is more than three gram it is clear cut nephrotic syndrome we also look for the other features in the nephrotic syndrome in the form of patients having edema or hypercholesterolemia or cholesterols or lipids in the urine that's different isolated protein area as i said earlier is but the patient is having only protein no sediments no decrease in the abnormal filtration rate no rbc's no hypertension diabetes only feature is the protein area it and that quantity of the protein here is also not more than one or two grams usually it's a benign conditions can be because of as i said earlier exercise or certain postures my patients keep a particular poster for the whole day in the end of the day or personally you have done the march right you might get it and easiest way it is get the urine sample of the in the morning and get the urine sample in the evening and if urine sample in the morning does not so proteinuria and the evening and the urine sample source albumin i mean protein area it's an isolated protein area provided there are the urine sediments is negative but what is important is the 24 urine output is very cumbersome collection of the urine sample to have the exit 24 hours then only otherwise the values can differ in the patient discards one of the one hour sample so now what we do is the urine albumin to create in ratio and that is what is mentioned on spot urine you take first or the second morning samples and send it to the laboratory for uacr that is urine albin created in ratio which is measured as milligrams of albumin for gram of creatinine and it's measured as a milligram per gram or milligram per millimole and what we have been calling micro albino earlier right before last three years the terminology has changed we no longer use microbial urea we all that we say or the previously called microbial now we call it moderately increased albumin that is the person is having between 330 to 300 milligram per day alden excretion that is moderately increase albumin area or in terms of every minute that twenty two hundred microgram severely increased microalban area is uh she will increase albino area is more than three hundred milligram or more than two hundred microgram per minute so remember microalbumin area is no longer used the dipstick method usually picks up the albumin which is in a smaller quantity whenever there is a distinct method is positive that we have to go for the analysis of the on the basis of uacr the limitation of urine albumin creatine ratio is that the creatine expression is also phasic and also depends on the patient's food consumptions and it can vary but honestly it's not a big difference and particularly in pathological conditions or persons like diabetic patients when we follow up these patients by and large it is almost the values come consistent so we can go for unit albumin creatine ratio which is a much better and consistent results than going for the 24-hour tedious urine collections and the phase quality last part of it the urine osmolality generally as we said we not require this test and primarily as i said i started with the urine analysis and the routine test but since this is a part of the urine analysis i thought that we might talk for a minute the measures of the number of dissolved particles in the urine in the that is osmolality when we measure specific gravity we not only measure the particles we also see the size of the particles so specific gravity measures the size as well in number of particles while the osmolarity measures the dissolved particles in the urine and normal urine hospitality is again depending on the amount of for the food that the person consumes and what is important is the urine osmolality if it is very high since if the person is asked to withhold the water for 12 hours and if we then go for the urine osmolality it will be more than 850 milliosmol per kilogram of water right and the random samples vary is anything from 50 to 1200 because it depends on the water and the dilating capacity to the kidney is enormous and what is important is when we are suspecting polyurea that is the urine output for more than three liters per day right in adults or more than two liters of children that is called the polyurea there you have to go for the urine osmolarity and generally urinationality is increased when there is dehydration glycosyria sids syndrome of inappropriate ads secretions will be talking more next time and adrenal insufficiency all these tests will talk next time the decrease during osmolarities because of the diabetes incidence excessive fluid intake and patience on glucocorticoids the last part urine electrolytes again not a routinely ordered test generally we need it in icu when we are having a patient having acute kidney injury and we want to make sure that these acute kidney injuries because of the renal hypovolemia or because of the established atn that is acute tubular necrosis if we go order for urine electrolytes mainly the sodium the urine sodium is less than 20 milligram per liter it is pre-renal or hypovolemic acute kidney injuries but if the urine electrolyte so more than 40 milliliters of sodium excretion then it is the renal cause of acute kidney injury and maybe that patient has established a acute tubular necrosis again it can be seen by the fractional excretion of sodium same less than one percent is pre-renal more than one percent is atn and few books also mentioned about the trans tubular potassium gradient that's too much for us we don't want to discuss the urine protein electrophoresis as we mentioned if the urine district is negative but the sulphur salicylic acid is positive that means patient is having protein area but not alvin area that means it is probably one of the monoclonal proteins and there we go for the protein electrophoresis and we can see the typical band of the monoclonal gamma accumulations it could be multiple myeloma it could be valdestrone microglobulin or lymphoma and once we edit we hand over to the hematologist or the oncologist for the further treatment this is the last part of the today's talk and that is the urine pregnancy test we know that it is not a part of the renal functions but it is a part of the urine analysis and we know that it is very very important to go for the urine pregnancy test in all patients women who come in the child varying age when particularly when we are suspecting that could we possibly have conceived and we want to start certain drugs because we know that we are very careful about using the drugs in the first trimester which is a period of organogenesis so pregnancy test the fundamental basis is that the once there is the placenta is the is the fertilized egg implants in the uterus right the placenta is formed and that starts secreting the uh human chronic chronotrophin which is picked up in the urine usually as early as 10 days after the conception so once the patient has missed the period and sees herself feels that she is likely to be pregnant after 10 days right it's better to go for the pregnancy test and if it is positive definitely the pregnancy is confirmed and if you do it after two or three days the human coronary ground phase rises in a lip forms and that means the large number of hcg tests uh this this will be positive the method is very simple it can be self detected also this tests are available on the counter important thing is last you must have seen and received the whatsapp of the weather the urine pregnancy test done in a man and accidentally and it turned out to be positive is it possible that the men get the urine pregnancies positive or is there a false positive test for the urine pregnancy test yes if the woman is consuming the fertility medicines it might once in a while give a green pregnancy it is positive so we have to ensure before declaring somebody is pregnant that whether she is receiving the fertility drugs and urine technologies in men yes testicular tumors not very commonly but testicular tumors do secrete hcg so once in a while you might get a positive pregnancy test in the samples of the males and if it is positive you have to double check it and subject it to further test for the testicular tumors but it can be positive not necessarily false positives it can be indicative of the testicular tumors so i think we i will stop here because it's better that we leave it to the other renal functions especially the normal filtration test related test uh for the next time because already it's never and you might have many questions and it's better that we discuss the questions or the comments from the many members i know they are the experts and they know more than me probably so later i would ask them to come out with their suggestions or the comments about all the factors about the urinals that we talk about and we talk about the creatinine clearance taste and other taste whether it's calcium uric acid phosphorus vitamin d parathorma next time thank you so much sir uh so should i just stop this presentation yeah please please yeah thank you thanks a lot for your time and it was wonderful session uh you walked us starting from the uh microanalysis to differential diagnosis part so thank you so much we'll definitely have a few more uh analysis on uh renal function test in the next session so thanks a lot sir it was wonderful uh i'll just check if there are any questions uh for now i can see awesome sessions so it was fantastic thank you so much gem of medicine uh dr anamika is saying uh thank you so much uh so dr shahab is saying so you are the gem of medicine uh awesome sir it was wonderful session so i i can see one reason dr himani i'm accepting your request you can come on stage and ask your question you will see prom to turn on your audio video um [Music] so my question was that in the last slide levels are more in the morning but sir my question is that since it has started producing the hormone it should be the same amount throughout the day right no the problem of morning sample is probably that before other contaminants are less and the persons who consumes water after waking up right it will dilute so it is what we measure is the hcd value so if it's a dilated urine we might get a weak taste for the absentees in spite of present being actually platinum so that is probably the only reason that we go for the money okay thank you thank you sir thank you thank you man you can turn your audio video thank you uh so dr jayadi is asking for so which is the best urinary acr or egfr or both or perennial function status which is so basically the real function is now the gradation of the renal function that we'll be talking next time includes the both the protein urea part as well as the gfr when we analyze the grading the kidney failures right we take into account both the proteinuria part as well as the egfr both are to be included not it's only a pregnancy with uti so please suggest a safer antibiotic in this case it's very very important questions and definitely the normally the asymptomatic urinary utea is not is treated normally but in a pregnancy if the number of cells are more uh it's better that we pretend which trimester or the patient is if the pregnant lady is in the first trimester with the safest drugs are the amphisyllines and cephalosporins but the later part means all antibiotics are safer the urinary specific antibiotics are the nitrofuran joints because as we said if most common organisms are the e coli which is the in female business particularly e coli are one of the commonest right and there the ferentines are good if the patient is tolerating then better we go for the night differently because it is excreted exclusively in the urine but otherwise the safer antibiotics are definitely the ampicillins and cephalosporins and better never ever use prophylaxis or any of the quinoa ones because conventionally utility is either not flux acid or ciprofloxacin or floxacin definitely they are a big no and same is the bacterium group of drugs bactrimo sulphur groups we avoid not that we cannot give it we can give it after the first trimester we avoid at the end of the pregnancy because of the connectors in the newborn otherwise the it's also safe all right i hope this answers your question dr anuj uh and sir has already actually taken an interesting session on antibiotics so if you are interested in understanding more on this uh you can just go to replay section and check out it was an amazing interesting sentence somebody has mentioned anti-sas antibodies in the urine is a non-invasive and sensitive way i'm not honestly aware of it but if you have more details better come on the stage and enlighten all others also about the same whether it is done routinely or it's still at the expenditure level i am not sure yeah so uh doctor mythical if you have any insights on this you can come on stage or share or if you have any question which is like more specific towards this uh maybe uh we can try and answer that person's uh doctor pariksha the same person's undergoing alternative medicine treatment having heavy metals what's further treatment should be given uh see it all depends uh see please don't misunderstand me that all alternative treatment are bad or cause side effects no what means is when as physicians when we see the patients obviously these are patients who had some medical problems and they are usually the heavy metals mainly the lead or arsenic right and we can have the drugs like penicillin it can be used as a part of the removal of these drugs but again it depends on what is the level of these drugs and whether it has cause any side effect but definitely there are treatment in the form of the penicillin that we use it for the lead in the arsenic and maybe i am not sure about the bowel that we used to use for the coppers and the arsenic the people are using it we usually involve the nephrologist also or patients having the renal involvement and because of the heavy metals we do take their health and ask them but penicillin is what we routinely use it and it definitely helps and it's safe right okay thank you sir thanks for taking this uh dr rishi you can uh go to our replay section and watch this session again and again but uh you will have ppt in the session itself somebody's asked about the role of prophylactics in the usually no profile axis is required for the surgery other than this profile axis before the incision that is we normally what we see when we discuss in our antibiotic sessions the idea of giving prophylaxis before surgery is to prevent the contamination at the time of incision putting incisions right so that is why we give and that is why the communist organisms that are likely to cause surgical site infections because of the contaminations are the usually the gram positive infection like step two step alcohol so till today the best drugs is the cephalosporins right but if the institutions or the areas where cephalosporin are not is definitely soul resistant they might go for the second or third generation cephalosporins like cepheloxime or cephalaris themselves or with the combinations and only when we are doing on a surgery in a contaminated like an bust abdomen or something then we have to give the antibiotics then we have to both gram positive gram negative coverage but when we use the word profile axis it's usually one or maximum two dosages the first dose is one hour before this and incision so that there's a maximum concentration of the antibiotic at the time of putting the incisions and if the surgery is delayed beyond three to six hours maybe we give the second dose of antibiotics that is prophylaxis except in cabg bypass surgery usually you do not continue antibiotics beyond two dosages in bypass you might give it for up to 48 hours when we give antibiotics for a longer period it becomes a therapeutic when we are treating an infection but when you use the word prophylaxis it's one or maximum to those edges right so you are saying what are the antibiotics that are required uh for any surgery while giving normal incision are only prescribed here as well there is no separate antibiotic that is required right yeah now somebody is asking uh hey what is the nitroform is contacted it comes i i talked about the bacterium sulphur type of drugs because it can produce carbonic terrace nitrofurantoin is uh not and of course the patient is having g6p deficiency we should avoid all these drugs that is different otherwise it's not that the knight of friend iron is avoided during the at the time it is the sulphur trimethoprim combination that is what i meant there is one now what colony counter which would be generally the pathogenic level is 10 raised to 5 colony forming units are generally considered but again depends on the patient subject with the patient is diabetic and patient living symptomatic urine tech infractions even the lower counts also will be treated and once we have sent the urine for culture we have to give the antibiotics are modified according to the culture and sensitivity reports uh so you have answered dr anna's question as well sir uh so dr anuj is saying what about albumin infusion patients with nephrotic syndrome see in nephrotic syndrome protein urea is mainly responsible for the hypo albuminemia the liver it will try to manufacture proteins as much possible albumin infusion can be given temporarily when they are giving certain treatments but ultimately it is the drug like the steroids or immunosuppressants that has to reduce the proteinuria part we can give albumin for a short period because albin half-life is hardly 20 days it's a very expensive treatment so maybe as a short-term bridging therapy we can give it but it cannot be the treatment for a long period and after also a blood product it set its own hazards of the different kinds of the infections which might be transmitted but for a short period it can be cured right uh thank you sir so other than this so we have covered me all the questions that are there in the comment box uh so anyone has anything uh people wait for a minute or so or you can put it in the comment section or just freeze and i'll accept your request immediately see five to 10 arby's in urinary process uti or we should look for kinetic rbc's grenadier carbon renated rbc's the one which is once which are definitely if the patient is fraction or stones calculus also the rbcs can be created what is important if there are more than two different there is rbcs but all arbison alone will not give the diagnosis of utr stones we have to give look for the wbcs and we also look for the crystals and we may need further investigations right okay thank you sir so with this i guess uh we can wrap up the section uh we can thank you all for patient hearing and being with us for such a long time right and it's very important the creatine clearance egfr there are many concepts we need to be discussed so definitely we will discuss in detail thank you all good night thank you all take care thank you sir good night

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