Result Normal Findings Interpretation Color brown brown Normal Consistency watery soft and bulky, small and

dry, depending on the diet Muscle fiber few Pus cells 6-8 None Infection Bacteria +++ None Infection Red cells 0-3 Creatinine 0.8 0.5-1.7 Normal Sodium 137.5 135-148 Normal Potassium 3.06 3.5-5.3 Low potassium

Complete Blood Count (CBC)

A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets. A CBC helps your health professional check any symptoms, such as weakness, fatigue, or bruising, you may have. A CBC also helps him or her diagnose conditions, such as anemia, infection, and many other disorders.

A CBC test usually includes:

White blood cell (WBC, leukocyte) count. White blood cells
protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or other organism causing it. White blood cells are bigger than red blood cells but fewer in number. When a person has a bacterial infection, the number of white cells rises very quickly. The number of white blood cells is sometimes used to find an infection or to see how the body is dealing with cancer treatment.

White blood cell types (WBC differential). The major types of

white blood cells are neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Immature neutrophils, called band neutrophils, are also part of this test. Each type of cell plays a different role in protecting the body. The

numbers of each one of these types of white blood cells give important information about the immune system. Too many or too few of the different types of white blood cells can help find an infection, an allergic or toxic reaction to medicines or chemicals, and many conditions, such as leukemia.

Red blood cell (RBC) count. Red blood cells carry oxygen from the
lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count is low (anemia), the body may not be getting the oxygen it needs. If the count is too high (a condition called polycythemia), there is a chance that the red blood cells will clump together and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry oxygen.

Hematocrit (HCT, packed cell volume, PCV). This test measures

the amount of space (volume) red blood cells take up in the blood. The value is given as a percentage of red blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's volume is made of red blood cells. Hematocrit and hemoglobin values are the two major tests that show if anemia or polycythemia is present.

Hemoglobin (Hgb). The hemoglobin molecule fills up the red blood

cells. It carries oxygen and gives the blood cell its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body.

Red blood cell indices. There are three red blood cell indices: mean
corpuscular volume (MCV), mean corpuscular hemoglobin(MCH), and mean corpuscular hemoglobin concentration (MCHC). They are measured by a machine and their values come from other measurements in a CBC. The MCV shows the size of the red blood cells. The MCH value is the amount of hemoglobin in an average red blood cell. The MCHC measures the concentration of hemoglobin in an average red blood cell. These numbers help in the diagnosis of different types of anemia. Red cell distribution width (RDW) can also be measured which shows if the cells are all the same

or different sizes or shapes.

Platelet (thrombocyte) count. Platelets (thrombocytes) are the

smallest type of blood cell. They are important in blood clotting. When bleeding occurs, the platelets swell, clump together, and form a sticky plug that helps stop the bleeding. If there are too few platelets, uncontrolled bleeding may be a problem. If there are too many platelets, there is a chance of a blood clot forming in a blood vessel. Also, platelets may be involved in hardening of the arteries (atherosclerosis). Your doctor may order a blood smear test to be done at the same time as a CBC but it is not part of the regular CBC test. In this test, a drop of blood is spread (smeared) on a slide and stained with a special dye. The slide is looked at under a microscope. The number, size, and shape of red blood cells, white blood cells, and platelets are recorded. Blood cells with different shapes or sizes can help diagnose many blood diseases, such as leukemia, malaria, or sickle cell anemia.
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Complete Blood Count (CBC)

Why It Is Done
A complete blood count may be done to:

(continued)

Find the cause of symptoms such as fatigue, weakness, fever, bruising, or weight loss. Find anemia. See how much blood has been lost if there is bleeding. Diagnose polycythemia. Find an infection. Diagnose diseases of the blood, such as leukemia. Check how the body is dealing with some types of drug or radiation treatment. Check how abnormal bleeding is affecting the blood cells and counts.

Screen for high and low values before a surgery. See if there are too many or too few of certain types of cells. This may help find other conditions, such as too many eosinophils may mean an allergy or asthma is present.

A complete blood count may be done as part of a regular physical examination. A blood count can give valuable information about the general state of your health.

How To Prepare
You do not need to do anything before having this test. How It Is Done Your health professional drawing blood will:

Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein. Clean the needle site with alcohol. Put the needle into the vein. More than one needle stick may be needed. Attach a tube to the needle to fill it with blood. Remove the band from your arm when enough blood is collected. Put a gauze pad or cotton ball over the needle site as the needle is removed. Put pressure to the site and then a bandage.

If this blood test is done on a baby, a heel stick will be done instead of a blood draw from a vein.

How It Feels
The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch.

Risks
There is very little chance of a problem from having a blood sample taken from a vein.

You may get a small bruise at the site. You can lower the chance of bruising by keeping pressure on the site for several minutes. In rare cases, the vein may become swollen after the blood sample is taken. This problem is called phlebitis. A warm compress can be used several times a day to treat this. Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medicines can make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medicine, tell your doctor before your blood sample is taken.

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Complete Blood Count (CBC) (continued)

Results
A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells,white blood cells, and platelets. A CBC helps your health professional check any symptoms, such as weakness, fatigue, or bruising, you may have. A CBC also helps him or her diagnose conditions, such asanemia, infection, and many other disorders.

Normal
Normal values can vary from lab to lab. Normal values for the complete blood count (CBC) tests depend on age, sex, how high above sea level you live, and the type of blood sample. Your health professional may use all the CBC values to check for a condition. For example, the red blood cell (RBC) count, hemoglobin (Hgb), and hematocrit (HCT) are the most important values needed to tell whether a person has anemia, but the red blood cell indices and the blood smear also help with

the diagnosis and may show a possible cause for the anemia. To see if the white blood cell (WBC, leukocyte) count is good and how the cells look on the smear, your health professional will look at both the number (WBC count) and the WBC differential. To see whether there are too many or too few of a certain type of cell, your health professional will look at the total count and the percentage of that particular cell. There are normal values for the total number of each type of white cell. Pregnancy can change these blood values. Your doctor will talk with you about normal values during each trimester of your pregnancy.

White blood cell (WBC, leukocyte) count Men:.............5,00010,000/microliter (mcL)3

.......................or 510 x 109/Liter (SI units)

Nonpregnant women:.........4,50011,000/mcL3 or 4.511.0 x 109/Liter

.........................(SI units) Pregnant women: ........................1st trimester: 6,60014,100/mcL ..............................or 6.614.1 x 109/L ........................2nd trimester: 6,90017,100/mcL ..............................or 6.917.1 x 109/L ........................3rd trimester: 5,90014,700/mcL ..............................or 5.914.7 x 109/L .......................Postpartum: 9,70025,700/mcL ..............................or 9.725.7 x 109/L

White blood cell types (WBC differential)

Neutrophils:..........55%70% Band neutrophils:...0%3% Lymphocytes:........20%40% Monocytes:............2%8%

Eosinophils:...........1%4% Basophils:..............0.5%1%

Red blood cell (RBC) count

Men:............4.76.1 million RBCs per microliter (mcL) .......................or 4.76.1 x 1012/Liter (SI units) Women:.....4.25.4 million RBCs per mcL or 4.25.4 x 1012/L Children:...4.05.5 million RBCs per mcL or 4.64.8 x 1012/L Newborn:...4.87.1 million RBCs per mcL or 4.87.1 x 1012/L

Hematocrit (HCT)
Men:.............42%52% or 0.420.52 volume fraction (SI units) Women:........37%47% or 0.370.47 volume fraction Pregnant women ........................1st trimester: 35%46% ........................2nd trimester: 30%42% ........................3rd trimester: 34%44% Postpartum:....30%44% Children:........32%44% Newborns:......44%64% Hemoglobin (Hgb) Men:.............1418 grams per deciliter (g/dL) ..........................or 8.711.2 millimoles per liter (mmol/L) (SI units) Women:........1216 g/dL ..........................or 7.49.9 mmol/L Pregnant women: ........................1st trimester: 11.415.0 g/dL ..............................or 7.19.3 mmol/L ........................2nd trimester: 10.014.3 g/dL ..............................or 6.28.9 mmol/L ........................3rd trimester: 10.214.4 g/dL ..............................or 6.38.9 mmol/L Postpartum:....10.418.0 g/dL or 6.49.3 mmol/L

Children:..........9.515.5 g/dL Newborn: 1424 g/dL In general, a normal hemoglobin level is about one-third the value of the hematocrit.

Red blood cell indices

Mean corpuscular volume (MCV): 8095 femtoliters (fL) Mean corpuscular hemoglobin (MCH): 2731 picograms (pg) Mean corpuscular hemoglobin concentration (MCHC): 3236 grams per deciliter (g/dL) or 32%36%

Red cell distribution width (RDW)

Normal: 11%14.5%

Platelet (thrombocyte) count

Normal: ...Children and adults 150,000400,000 platelets per mm3 .......................or 150400 x 109/Liter (SI units) ...Baby 200,000475,000 mm3 ...Newborn 150,000300,000 mm3

Blood smear
Normal: Blood cells are normal in shape, size, color, and number.

High values
Red blood cell (RBC) Conditions that cause high RBC values include smoking, exposure to carbon monoxide, long-term lung disease, kidney disease, some cancers, certain forms of heart disease, alcoholism, liver disease, a rare disorder of the bone marrow (polycythemia vera), or a rare disorder of hemoglobin that binds oxygen tightly. Conditions that affect the body's water content can also cause high RBC

values. These conditions include dehydration, diarrhea or vomiting, excessive sweating, severe burns, and the use of diuretics. The lack of fluid in the body makes the RBC volume look high; this is sometimes called spurious polycythemia. White blood cell (WBC, leukocyte) Conditions that cause high WBC values include infection, inflammation, damage to body tissues (such as a heart attack), severe physical or emotional stress (such as a fever, injury, or surgery), burns, kidney failure, lupus, tuberculosis (TB), rheumatoid arthritis, malnutrition, leukemia, and diseases such as cancer. The use of corticosteroids, underactive adrenal glands, thyroid glandproblems, certain medicines, or removal of the spleen can also cause high WBC values. Platelets High platelet values may be seen with bleeding, iron deficiency, some diseases like cancer, or problems with the bone marrow.

Low values
Red blood cell (RBC) Anemia lowers RBC values. Anemia can be caused by heavy menstrual bleeding, stomach ulcers, colon cancer, inflammatory bowel disease, tumors, Addison's disease, thalassemia, lead poisoning, sickle cell disease, or reactions to some chemicals and medicines. A low RBC value may also be seen if the spleen has been taken out. A lack of folic acid or vitamin B12 can also cause anemia, such aspernicious anemia, which is a problem with absorbing vitamin B12. The RBC indices value and a blood smear may help find the cause of a low RBC value.

White blood cell (WBC, leukocyte)

Conditions that can lower WBC values include chemotherapy and reactions to other medicines, aplastic anemia, viral infections,malaria, alcoholism, AIDS, lupus, or Cushing's syndrome. A large spleen can lower the WBC count.

Platelets
Low platelet values can occur in pregnancy or idiopathic thrombocytopenic purpura and other conditions that affect how platelets are made or that destroy platelets. A large spleen can lower the platelet count. LOOKING AT THE URINE ("Gross Examination")

The first part of the urinalysis is direct visual observation. Normal, fresh urine is clear and pale to dark yellow or amber in color. Cloudiness may be caused by excessive cellular material or protein in the urine or may reflect from crystallization or precipitation of salts upon standing at room temperature or in the refrigerator. Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of tubidity. A red or reddish-brown color could be from a food dye, consumption of beets, a drug, or the presence of either hemoglobin (from the breakdown of blood) or myoglobin (muscle breakdown). If the sample contains many red blood cells, it would be cloudy as well as red.

Reading The Dipstick

The dipstick yields valuable information which is available by direct observation after brief immersion of the urine specimen. Acid/Base (pH)

The dipstick yields the pH, a reflection of acid/base levels. The initial filtrate of blood plasma is usually acidified by the renal tubules and collecting ducts (microscopic structures in the kidneys of which there are millions) from a pH of 7.4 to about 6 in the final urine. in other words, the urine is acidified. However, depending on the acid-base status, urinary pH may range from as low as 4.5 to as high as 8.0. One task nature has assigned to the kidneys is to rid the body of acid. Specific Gravity Specific gravity measures urine density which reflects the ability of the kidney to concentrate or dilute the urine relative to the plasma from which it is filtered. Although dipsticks are available that also measure specific gravity in approximations, most laboratories measure specific gravity with a instrument call a refractometer. Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if kidney function is normal. Any measurement below 1.007 to 1.010 indicates hydration and any measurement above it indicates relative dehydration. Urine having a specific gravity over 1.035 is either contaminated, contains very high levels of glucose, or the patient may have recently received high density radiopaque dyes intravenously for radiographic studies or low molecular weight dextran solutions. Protein While the dipstick test has a portein measurement, more elaborate tests for urine protein should be performed since cells suspended in normal urine can produce a false high estimation of protein. Normal total protein excretion does not usually exceed 150 mg/24 hours or 10 mg/100 ml in any single specimen. More than 150 mg/day is considered proteinuria. Proteinuria greater than 3.5 gm/24 hours is severe and indicates the nephrotic syndrome. Dipsticks detect protein by production of color with an indicator dye, Bromphenol blue, which is most sensitive to albumin but detects globulins and Bence-Jones protein poorly. Precipitation by heat is a better semiquantitative method, but overall, it

is not a highly sensitive test. The sulfosalicylic acid test is a more sensitive precipitation test. It can detect albumin, globulins, and Bence-Jones protein at low concentrations. "Trace" protein is equivalent to 10 mg/100 ml or about 150 mg/24 hours (the upper limit of normal). 1+ corresponds to about 200-500 mg/24 hours; 2+ to 0.5-1.5 gm/24 hours, a 3+ to 2-5 gm/24 hours, and a 4+ represents 7 gm/24 hours or greater. Glucose Glycosuria (excess sugar in urine) generally means diabetes mellitus. Ketones Ketones (acetone, aceotacetic acid, beta-hydroxybutyric acid) may be present in diabetic ketosis or other forms of calorie deprivation (e.g. starvation). Ketones are easily detected using either dipsticks or test tablets containing sodium nitroprusside. Nitrite A positive nitrite test indicates that bacteria may be present in significant numbers. Gram negative rods such as E. coli are more likely to give a positive test. Leukocyte Esterase A positive leukocyte esterase test results from the presence of white blood cells either as whole cells or as destroyed cells. A negative leukocyte esterase test means that an infection is unlikely. Without additional evidence there is no need for culture.

MICROSCOPIC URINALYSIS

Genaral Considerations A sample of well-mixed urine (usually 10-15 ml) is centrifuged in a test tube at relatively low speed (about 2000-3,000 rpm) for 5-10 minutes which produces a concentration of sediment (cellular matter) at the bottom of the tube. The fluid on top is poured off to a volume of 0.2 ml to 0.5 ml left inside the tube. The sediment is resuspended in the remaining urine by flicking the bottom of the tube several times. A drop of resuspended sediment is poured onto a glass slide and a thin slice of glass (a coverslip) is place over it. The sediment is first examined under low power to identify crystals, casts, squamous cells, and other large objects. "Casts" are plugs of material which came from individual tubules. The numbers of casts seen are usually reported as number of each type found per low power field (LPF). For an example: "5-10 hyaline casts/L casts/LPF." Since the number of elements found in each field may vary considerably from one field to the next, several fields are averaged. Then, examination is carried out at high power to identify crystals, cells, and bacteria. The various types of cells are usually described as the number of each type found per average high power field (HPF). For example: "1-5 WBC/HPF." Red Blood Cells Hematuria is the presence of abnormal numbers of red cells in urine due to any of several possible causes, e.g. glomerular damage, tumors which erode the urinary tract anywhere along its length, kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and lower urinary tract infections, nephrotoxins, and physical stress (like a contact sport, or long distance running for example). Red cells may also contaminate the urine from the vagina in menstruating women or from trauma produced by bladder catherization. Theoretically, no red cells should be found, but that is not true because some are present even in healthy individuals. However, if one or more red cells can be found in every high power field, and if contamination is ruled out, the specimen reflects some abnormality. There are a few individuals who leak excessive numbers of red cells with no identifiable cause. This is

called "idiopathic hematuria." RBC's may appear normally shaped, swollen by dilute urine (in fact, only cell ghosts and free hemoglobin may remain), or crenated (deflated and wrinkled up) by concentrated urine. Both swollen, partly hemolyzed RBC's and crenated RBC's are sometimes difficult to distinguish from WBC's in the urine. In addition, red cell ghosts may simulate yeast. The presence of poorly shaped (dysmorphic) RBC's in urine suggests glomerulonephritis. Dysmorphic RBC's have odd shapes as a consequence of being distorted via passage through the abnormal glomerular drainage structures. White Blood Cells Pyuria refers to abnormal numbers of leukocytes (white cells) that may appear with infection in either the upper or lower urinary tract or with acute glomerulonephritis. Usually, the WBC's are granulocytes (a type of white cell which includes neutrophils and eosinophils). White cells from the vagina, in the presence of vaginal and cervical infections, or the external urethral meatus (opening) in men and women may contaminate the urine. If two or more leukocytes per each high power field appear in non-contaminated urine, the specimen is probably abnormal. Leukocytes have lobed nuclei and granular cytoplasm. Epithelial Cells Renal tubular (the microscopic tubes in the kidneys which lead to the drainage system) epithelial cells which are usually larger than granulocytes (again, a type of white cell which includes neutrophils and eosinophils) contain a large round or oval nucleus and normally appear in the urine in small numbers. However, with nephrotic syndrome and in conditions leading to tubular degeneration, the number sloughed into the urine is increased. When lipiduria (literally "fat in the urine") occurs, these cells contain endogenous fats. When filled with numerous fat droplets, such cells are called "oval fat bodies." Oval fat bodies exhibit a "Maltese cross" configuration by polarized light microscopy. Epithelial cells from the large drainage structures (the renal pelvis, ureter, or bladder) have more regular cell borders, larger nuclei, and

smaller overall size than squamous epithelium. Renal tubular (from the microscopic tubules in the kidneys) epithelial cells are smaller and rounder than transitional epithelium, and their nuclei occupy more of the total cell volume. Squamous epithelial cells from the skin surface or from the outer urethra can appear in urine. They represent possible contamination of the specimen with skin bacteria. Casts Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron). The proximal convoluted tubule (PCT) and loop of Henle do not produce casts. Hyaline casts are composed primarily of a mucoprotein (Tamm-Horsfall protein) secreted by tubule cells. Even with injury causing increased glomerular permeability to plasma proteins with resulting proteinuria, most of the matrix (glue) that cements urinary casts together is Tamm-Horsfall mucoprotein, although albumin and some globulins are also part of it. Low flow rate, high salt concentration, and low pH, all lead to protein denaturation and precipitation, particularly that of the Tamm-Horsfall protein. Protein casts with long, thin tails are formed at the junction of Henle's loop and the distal convoluted tubule and are known as cylindroids. Hyaline casts can be seen even in healthy patients. Red blood cells may stick together and form red blood cell casts. Such casts are indicative of glomerulonephritis, with leakage of RBC's from glomeruli, or severe tubular damage. White blood cell casts are most typical for acute pyelonephritis, but they may also be present with glomerulonephritis. Their presence indicates inflammation of the kidney, because such casts will not form except in the kidney. When cellular casts remain in the nephron for some time before they are flushed into the bladder urine, the cells may degenerate to present as a coarsely granular cast, later a finely granular cast, and ultimately, a waxy cast. Granular and waxy casts are be believed to come from renal tubular cell casts. Broad casts come from damaged and dilated tubules and are therefore seen in end-stage chronic renal disease. The so-called telescoped urinary sediment is one in which red cells, white cells, oval fat bodies, and all types of casts are found in more or less equal profusion. The conditions which may lead to a telescoped sediment are: (1) malignant hypertension (2) lupus nephritis, (3) diabetic glomerulosclerosis, and (4) rapidly progressive glomerulonephritis. In end-

stage kidney disease of any cause, the urinary sediment often becomes very scant because few remaining nephrons produce dilute urine. Bacteria Bacteria are common in urine specimens because of the abundant normal microbial flora of the vagina in the female and the the external urethral meatus in both sexes and because of their ability to rapidly multiply in urine standing at room temperature. Therefore, microbial organisms found in all but the most scrupulously collected urines should be interpreted and correlated with the condition of the patient. Diagnosis of bacteriuria in a case of suspected urinary tract infection requires culture. A colony count may also be done to see if significant numbers of bacteria are present. Generally, more than 100,000/ml of one organism reflects significant bacteriuria. The presence of multiple organisms reflect contamination. However, the presence of any organism in catheterized or suprapubic tap (needle directly into the bladder) specimens should be considered significant. Yeast Yeast cells may be contaminants or represent a yeast infection. They are often difficult to distinguish from red cells and amorphous crystals but are distinguished by their tendency to form buds (this is how they reproduce). Most often they are Candida, which can colonize bladder, urethra, or vagina. Crystals Common crystals seen even in healthy patients include calcium oxalate, triple phosphate crystals and amorphous phosphates. Rarely crystals of cystine (in urine of neonates with congenital cystinuria or severe liver disease), tyrosine crystals with congenital tyrosinosis or marked liver impairment, or leucine crystals in patients with severe liver disease or with maple syrup urine disease. Miscellaneous Findings

Unidentifiable objects (referred to as "crud") may find their way into a specimen, particularly those that patients bring from home. Spermatozoa can sometimes be seen. Rarely, pinworm ova may be seen the urine.