updates in urinalysis

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UPDATE IN URINALYSISDiane Gaspari, SH(ASCP) Division Manager, Core Lab York Hospital, York, PA ggaspari@wellspan.org

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Program ObjectivesEnhance knowledge of CKD and the NKF’s guidelines for laboratory diagnosis & monitoring of CKD. Identify pre-analytic variables of urinalysis testing & analytic variables of manual urine sediment testing. Understand the technology, software features, and flagging parameters of the Sysmex UF-1000i automated urine sediment analyzer. Identify the benefits of automated urine sediment analysis.

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Did You Know . . .“Urinalysis is the most valuable single test of the anatomic integrity of the kidneys that is readily available to the clinician”Schreiner From J. Szwed, The Importance of Microscopic Examination of the Urinary Sediment, American Journal of Medical Technology, 48:2, Feb. 1982

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Functions of KidneyRemove waste products & drugs from body. Balance body’s fluid, release hormones to regulate blood pressure, and produce active vitamin D. Regulation of body’s salt, potassium, & acid content

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National Kidney Foundationhttp://www.kidney.org/kls/index/cfm http://www.kidney.org/professionals/kdoqi/guidelines New Guidelines February 2002 Addition to Guidelines in 2003, 2005, 2006, 2007, 2008, and 2012.

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Incidence and Prevalence of End-Stage Renal Disease in the U.S.

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CHRONIC KIDNEY DISEASECKD is a world-wide public health problem that is under-diagnosed and under-treated. Early diagnosis is critical as kidney disease is often silent in the early stages. Most common causes of CKD in North America is diabetes, hypertension, and glomerular disease.

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CHRONIC KIDNEY DISEASEPresence of excessive amounts of urine protein is most common clinical sign of early kidney dysfunction. Other markers of kidney damage abnormal urine sediment abnormal findings on imaging studies abnormal blood & urine chemistry results that identify renal tubular syndromes

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CHRONIC KIDNEY DISEASESymptoms fatigue difficulty concentrating poor appetite sleeplessness muscle cramping at night swollen feet and ankles

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CHRONIC KIDNEY DISEASESymptoms (cont.) Puffiness around the eyes, especially in the morning Dry, itchy skin Frequent urination, especially at night

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Complications of CKDResult of reduction of GFR, disorder of tubular function, or reduction in endocrine function of the kidney Hypertension Malnutrition Anemia Low serum albumin and serum calcium

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Complications of CKDHigh serum phosphate concentration and high serum parathyroid hormone concentration Reduced activities of daily living Lower quality of life Increased risk of cardiovascular disease and stroke

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Laboratory Diagnosis and Monitoring of CKDDefinitive diagnosis of the type of kidney disease is based on biopsy or imaging studies Biopsy and invasive imaging procedures are associated with a risk or serious complications and are usually avoided unless a definitive diagnosis would change treatment or prognosis

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Laboratory Diagnosis and Monitoring of CKDGFR is the best overall index of kidney function Decreased GFR precedes the onset of kidney failure and persistently reduced GFR is a specific indicator of CKD. Drug dosing in CKD is based on GFR levels

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Laboratory Diagnosis and Monitoring of CKDGFR cannot be measured directly Serum creatinine is used to measure GFR in most cases Use of an international standard or traceable standard for creatinine calibration is recommended. Creatinine clearance is considered too inaccurate due to difficulties in obtaining a correctly timed specimen.

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Laboratory Diagnosis and Monitoring of CKDThe NKF guidelines recommend that clinical labs report an estimate of GFR using the MDRD prediction equation in addition to the serum creatinine. Variables that will affect the estimation of GFR include: age, sex, race, diet, body build, medication, and pregnancy. If the variables are significant, use the creatinine clearance.

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Laboratory Diagnosis and Monitoring of CKDSerum creatinine is recommended at least yearly in patients with CKD. The rate of decline in GFR can be used to estimate the interval until onset of kidney failure and facilitate planning for therapy, diet, or kidney replacement. An acute decline in GFR may be superimposed on CKD and result in acute deterioration of kidney function.

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Laboratory Diagnosis and Monitoring of CKDMost common causes of deterioration of kidney function are: Reduced blood flow to the kidney, usually related to volume depletion. Toxic insult Obstruction from tumors, stones, or blood. Inflammation and infection

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Cystatin C13 kDa cysteine protease inhibitor constantly produced by all nucleated cells Advantages over creatinine Constant rate of production, freely filtered by the glomerulus Unaffected by muscle mass, diet or gender No renal tubular secretion Good assay precision (~3% CV throughout assay range) Assay unaffected by spectral interferences

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NKF Guidelines for Adults and ChildrenUnder most circumstances, untimed (“spot”) urine samples should be used to detect and monitor proteinuria. First morning urines preferred but random specimens are acceptable. Timed urine collection (overnight or 24 hr) is not necessary.

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NKF Guidelines (cont.)In most cases, screening with urine dipsticks is acceptable for detecting proteinuria Standard urine dipsticks are acceptable for detecting increased total urine protein. Albumin-specific dipsticks are acceptable for detecting albuminuria

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NKF Guidelines (cont.)Patients with a positive dipstick (1+ or greater): confirm proteinuria by a quantitative measurement (protein-to-creatinine ratio >200 mg/g or albumin-to-creatinine ratio >30 mg/g) within 3 mos. Patients with 2 or more positive quantitative tests temporally spaced by 1-2 weeks: diagnosed as persistent proteinuria; further evaluation needed

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NKF Guidelines (cont.)Monitoring proteinuria in patients with CKD should be performed using quantitative measurements. Children Without Diabetes: orthostatic proteinuria must be excluded by repeat measurement on a first morning specimen if the initial proteinuria was obtained on a random specimen.

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NKF Guidelines (cont.)Children Without Diabetes: Screen spot urine sample for total urine protein using either: standard urine dipstick or total protein-to-creatinine ratio When monitoring proteinuria for CKD, total protein-to-creatinine ratio should be measured in spot urine specimens.

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Last Updated: 8th March 2018

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