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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2593_Библиотеки_им_академика_М_И_Перельмана
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leukocyte esterase, an enzyme found in most WBCs, is absent in
normal urine. The presence of elevated WBCs in the urine (pyuria)
and/or leukocyte esterase suggests an acute infection in the urinary
tract. Some noninfectious inflammatory diseases of the kidney,
ureter, or bladder may also contribute WBCs to the urine sediment.
Normal urine also contains chemicals called nitrates. When certain
bacteria like Escherichia coli enter the urinary tract, nitrates are
enzymatically converted to nitrites, suggesting that a UTI is present.
A urine sample finding that is positive for leukocyte esterase, but
negative for nitrites, may still indicate an infection.
Casts may be used to identify the location of disease in the
genitourinary tract. Casts are composed of proteinaceous or fatty
material that outlines the shape of the renal tubules where they are
deposited. The presence of casts must be interpreted in light of other
factors related to the kidney and its function; however, fatty casts,
RBC casts, and WBC casts are always significant. RBC casts
usually suggest glomerular injury, and WBC casts suggest tubular or
interstitial injury. Lipid casts with proteinuria are characteristic
findings in patients with nephrotic syndrome or hypothyroidism.
78
The finding of hyaline casts alone in the presence of proteinuria
suggests a renal origin for the protein. Hyaline or granular casts
alone, however, only suggest some defects in factors that affect cast
formation and are therefore difficult to interpret.
Crystals may originally appear as a cloud in the urine. Their
formation is pH dependent, and they often appear only as the urine
cools to room temperature or in concentrated urine. In acidic urine,
crystals may be uric acid or calcium oxalate; in alkaline urine, they
may be phosphates. Crystals per se are not highly significant,
although they may reflect a tendency toward the formation of renal
calculi.
CASE 2-6
QUESTION 1: S.T. is a 33-year-old female with type 1 diabetes who presents to
the urgent care clinic with a 3-day history of fever, malaise, dysuria, and flank
pain. Upon interview, you learn that over the past few days, S.T. has been
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unable to keep down any food because of feelings of nausea. Because of this,
she has not taken her insulin for 48 hours. Today, her finger-stick blood glucose
is 415 mg/dL, and a STAT midstream urinalysis and Gram stain indicate the
following:
pH: 5.2
Appearance: cloudy
Specific gravity: 1.033
Urine protein: 3+
Urine glucose: 4+
Urine ketones: positive
Urine bacteria: 4+
Urine WBC: too numerous to count (TNTC)
Squamous epithelial: few per HPF
Urine nitrite: positive
Gram stain: numerous gram-negative rods
What objective data from the urinalysis indicate a UTI?
The cloudy appearance of S.T.’s urine indicates the presence of
bacteria, protein, and WBCs, which is supported by the urinalysis
results. The lack of a significant amount of squamous epithelial cells,
the presence of a significant number of nitrite-producing bacteria,
and the Gram stain indicate a clean-catch urine specimen and a UTI
involving gram-negative organisms (most likely E. coli that causes a
majority of UTIs).
CASE 2-6, QUESTION 2: What objective data from the urinalysis indicate
uncontrolled diabetes?
Glucose is normally filtered in the glomerulus and a majority is
reabsorbed in the proximal tubule of the kidney. S.T.’s glycosuria (4+
glucose) and finger stick of 415 mg/dL indicate the filtered amount of
glucose exceeds the capacity for reabsorption (∼180 mg/dL). In
addition, the presence of positive ketones indicates the body is
utilizing fat, not glucose, for energy. High levels of ketones can
predispose S.T. to dehydration, resulting in diabetic ketoacidosis.
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THERAPEUTIC DRUG MONITORING
Many drugs have a wide dosing range that can achieve efficacy with
a low risk of toxicity. Drugs that have a narrow dosing range with a
high risk of toxicity (narrow therapeutic index) often have their blood
levels monitored. Results from therapeutic drug monitoring assist
clinicians with appropriate dosing adjustments to prevent toxicity and
achieve appropriate clinical outcomes. Pharmacokinetic parameters
and drug interactions may significantly impact the laboratory results
and must be integrated into the clinical assessment of the data.
Similarly, for certain drugs and drug classes, there are
recommended laboratory tests that should be performed to monitor
their potential adverse effects on organ systems. Ideally, blood level
monitoring should occur after the drug has reached steady state and
at a consistent time within the dosing interval.
PATIENT-DIRECTED MONITORING AND
TESTING
Often patient-directed self-monitoring is an essential component to
successful management of certain disease states such as blood
pressure monitoring for hypertension and blood glucose monitoring
for diabetes mellitus. When used appropriately, data obtained from
these monitoring devices can be used by health care providers and
consumers to initiate or modify therapies accordingly.
Additional laboratory, self-monitoring tests or devices are also
available for consumers to purchase for independent testing or
screening purposes at home. Tests that are designed specifically to
be used by the consumer without the involvement of a provider are
called direct-to-consumer (DTC) tests. Some products provide an
immediate result, whereas others require submitting a completed kit
to a laboratory for analysis. Samples may be obtained from various
sources, including urine, blood, saliva, stool, or hair samples. The
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incidence of consumers using these products has significantly
increased and likely will continue to climb because of increased
access via the Internet as well as additional tests becoming
available.
In the United States, some, but not all, DTC tests have been
approved by the U.S. Food and Drug Administration (FDA). A current
listing of approved products is available through the FDA’s Office of
In Vitro Diagnostic Device Evaluation and Safety (OIVD) and can be
accessed online at
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/I
nVitroDiagnostics/default.htm. Consumers should be cautioned
about the accuracy of tests that have not been approved and the
validity of all test results, especially for diagnostic purposes, because
many factors can impact or interfere with the sensitivity (probability
of obtaining a positive result when a sample is truly positive) and
specificity (probability of obtaining a negative result when the sample
is truly negative). Follow-up assessment with a health care provider
should be encouraged to confirm or refute patient-directed test
results.
KEY REFERENCES AND WEBSITES
A full list of references for this chapter can be found at
http://thepoint.lww.com/AT12e. Given here are the key references
and websites for this chapter, with the corresponding reference
number in this chapter found in parentheses after the reference.
Key References
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(2)
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Engl J Med. 2004;351:1548–1563. (1)
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1.
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Lee M. Basic Skills in Interpreting Laboratory Data. 6th ed. American Society of
Health-System Pharmacists; 2017. (3)
Key Websites
Mayo Medical Laboratories Mobile App. https://www.mayocliniclabs.com/
Merck Manual. http://www.merckmanuals.com/professional/appendixes/normal-
laboratory-values/normal-laboratory-values
COMPLETE REFERENCES CHAPTER 2
INTERPRETATION OF CLINICAL LABORATORY
TESTS
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